Surgical management of patients with synchronous colorectal liver metastasis: a multicenter international analysis

Abstract

Background: The goal of this study was to investigate the surgical management and outcomes of patients with primary colorectal cancer (CRC) and synchronous liver metastasis (sCRLM).

Study design: Using a multi-institutional database, we identified 1,004 patients treated for sCRLM between 1982 and 2011. Clinicopathologic and outcomes data were evaluated with uni- and multivariable analyses.

Results: A simultaneous CRC and liver operation was performed in 329 (33%) patients; 675 (67%) underwent a staged approach ("classic" staged approach, n = 647; liver-first strategy, n = 28). Patients managed with the liver-first approach had more hepatic lesions and were more likely to have bilateral disease than those in the other 2 groups (p < 0.05). The use of staged operative strategies increased over the time of the study from 58% to 75% (p < 0.001). Liver-directed therapy included hepatectomy (90%) or combined resection + ablation (10%). A major resection (>3 segments) was more common with a staged approach (39% vs 24%; p < 0.001). Overall, 509 patients (50%) received chemotherapy in either the preoperative (22%) or adjuvant (28%) settings, with 11% of patients having both. There were 197 patients (20%) who had a complication in the postoperative period, with no difference in morbidity between staged and simultaneous groups or major vs minor hepatectomies (p > 0.05). Ninety-day postoperative mortality was 3.0%, with no difference between simultaneous and staged approaches (p = 0.94). The overall median and 5-year survivals were 50.9 months and 44%, respectively; long-term survival was the same regardless of the operative approach (p > 0.05).

Conclusions: Simultaneous and staged resections for sCRLM can be performed with comparable morbidity, mortality, and long-term oncologic outcomes.

Figure 1

Surgical management of 1,004 patients with synchronous colorectal liver metastasis over time. The use of staged operative strategies (colorectal primary→liver, and liver→colorectal primary) increased over time as compared with simultaneous resections of both the primary and liver disease (p < 0.001). Operative strategy: red bar, simultaneous; blue bar, liver first (liver→colorectal cancer); green bar, colorectal cancer first (colorectal cancer→liver).

Figure 2

Postoperative complications (Clavien Grade) by simultaneous vs staged operative approaches in 1,004 patients with synchronous colorectal and hepatic metastasis. There was no difference between the groups (all p > 0.05). Clavien Grade ≥ IIIa indicates severe complication. Complications after major and minor resections refer to overall complications. CRLM, colorectal liver metastasis. Postoperative complications: blue bar, overall complications; red bar, severe complications; green bar, after minor resection; tan bar, after major resection.

Figure 3

(A) Overall Kaplan-Meier survival of 1,004 patients with synchronous primary colorectal (CRC) and colorectal liver metastasis (CRLM) managed with resection of both primary and liver disease (median survival 50.9 months; 95% CI 44.8 to 56.9 months). (B) Overall survival of 1,004 patients after surgical management of synchronous colorectal liver metastasis stratified by timing and sequence of operations (p = 0.520, log-rank overall).