Two-stage hepatectomy: A planned strategy to treat irresectable liver tumors

Abstract

Objective: To assess feasibility, risks, and patient outcomes in the treatment of colorectal metastases with two-stage hepatectomy.

Summary background data: Some patients with multiple hepatic colorectal metastases are not candidates for a complete resection by a single hepatectomy, even when downstaged by chemotherapy, after portal embolization, or combined with a locally destructive technique. In two-stage hepatectomy, the highest possible number of tumors is resected in a first, noncurative intervention, and the remaining tumors are resected after a period of liver regeneration. In selected patients with irresectable multiple metastases not amenable to a single hepatectomy procedure, two-stage hepatectomy might offer a chance of long-term remission.

Methods: Of consecutive patients with conventionally irresectable colorectal metastases treated by chemotherapy, 16 of 398 (4%) became eligible for curative two-stage hepatectomy combined with chemotherapy and adjuvant nonsurgical interventions as indicated.

Results: Two-stage hepatectomy was feasible in 13 of 16 patients (81%). There were no surgical deaths. The postoperative death rate (2 months or less) was 0% for the first-stage procedure and 15% for the second-stage one. Postoperative complication rates were 31% and 45%, respectively, with only one complication leading to reoperation. The 3-year survival rate was 35%, with four patients (31%) disease-free at 7, 22, 36, and 54 months. Median survival was 31 months from the second hepatectomy and 44 months from the diagnosis of metastases.

Conclusions: Two-stage hepatectomy combined with chemotherapy may allow a long-term remission in selected patients with irresectable multiple metastases and increases the proportion of patients with resectable disease.

Figure 1. The 13 cases of two-stage hepatectomy, showing the liver status at the first hepatectomy, the second hepatectomy, and the remnant liver after the two-stage procedure. Gray areas represent the parts of liver resected. The segments are numbered according to the Couinaud system. (8*) means partial resection of segment 8; (8) means 8 segmentectomy.

Figure 2. Comparative abdominal computed tomographs of patient 2, treated by neoadjuvant chemotherapy and two-stage hepatectomy. (A) Before chemotherapy. (B) Just before hepatectomy. (C) After the first stage (right hepatectomy). (D) After the second stage (left lobectomy). Only segments 1 and 4 remain. This patient subsequently underwent repeat pulmonary resections for lung metastases and was disease-free 54 months after the two-stage procedure.

Figure 3. Comparative abdominal computed tomographs of patient 13, treated by a two-stage hepatectomy. Liver sections (A, B) illustrate the multinodular bilobar lesions before the first hepatectomy (12 metastases). (C, D) Liver after multiple partial resection. This patient was free of recurrence 7 months after the two-stage hepatectomy.

Figure 4. Kaplan-Meier survival of patients after two-stage hepatectomy.