One-Stage Total Laparoscopic Treatment for Colorectal Cancer With Synchronous Metastasis. Is It Safe and Feasible?

Abstract

Liver is the main target organ for colorectal cancer (CRC) metastases. It is estimated that ~25% of CRC patients have synchronous metastases at diagnosis, and about 60% of CRC patients will develop metastases during the follow up. Although several teams have performed simultaneous laparoscopic resections (SLR) of liver and colorectal lesions, the feasibility and safety of this approach is still widely debated and few studies on this topic are present in the literature. The purpose of this literature review is to understand the state of the art of SLR and to clarify the potential benefits and limitations of this approach. Several studies have shown that SLR can be performed safely and with short-term outcomes similarly to the separated procedures. Simultaneous laparoscopic colorectal and hepatic resections combine the advantages of one stage surgery with those of laparoscopic surgery. Several reports compared the short-term outcomes of one stage laparoscopic resection with open resections and showed a similar or inferior amount of blood loss, a similar or lower complication rate, and a significant reduction of hospital stay for laparoscopic surgery respect to open surgery but much longer operating times for the laparoscopic technique. Few retrospective studies compared long term outcomes of laparoscopic one stage surgery with the outcomes of open one stage surgery and did not identify any differences about disease free survival and the overall survival. In conclusion, hepatic and colorectal SLR are a safe and effective approach characterized by less intraoperative blood loss, faster recovery of intestinal function, and shorter length of postoperative hospital stay. Moreover, laparoscopic approach is associated to lower rates of surgical complications without significant differences in the long-term outcomes compared to the open surgery.

Keywords: colorectal cancer; liver synchronous metastasis; one stage treatment; outcomes; simultaneous laparoscopic resection; timing.

Figure 1

Three different strategies in case of synchronous liver metastases and colorectal cancer. CRC, Colorectal cancer; CRLM, colorectal liver metastases; H, hospital stay; CHT, chemotherapy.

Figure 2

Example of trocar placement to perform a combined resection. From Rocca et al. (31).

Figure 3

(A) The surgical trocar sites. The dotted line indicates the incision line used for the hand-assisted laparoscopic procedure, which was 7-cm long. (B) Liver scheme. Arrowhead, a tumor measuring 5 mm was found in the right hepatic lobe (segment 7); Double arrowhead, another tumor was detected in the right hepatic lobe (segment 6); Arrow, a third metastatic tumor was observed in the left hepatic lobe (segments 2/3). From Ito et al. (32).

Figure 4

(A) Parenchymal transection during a left hepatectomy, performed with a thermofusion device. (B) The hepatic vein previously controlled with a vessel loop (black arrow) is sectioned at the end of liver division. From Tranchart et al. (34).

Figure 5

Controversial issues involving mini-invasive (laparoscopic and robotic) surgical strategies for colorectal cancer with synchronous resectable liver metastases. LR, Liver resection; TSH, Two-stage hepatectomy; ALPPS, Associating liver partition and portal vein ligation for staged hepatectomy; CRLM, Colorectal liver metastases; PSLR, Parenchymal-sparing liver resection. From De Raffele et al. (35).

Figure 6

Scheme of open liver resection (A), laparoscopic liver resection [regular caudal approach, (B)], laparoscopic liver resection [lateral approach, (C)] and thoracoscopic liver resection (D). Red arrows indicate the directions of view and manipulation in each approach. (A) In the open approach, the subcostal cage containing the liver is opened with a large subcostal incision and instruments are used to lift the costal arch, after which the liver is dissected and mobilized (lifted) from the retroperitoneum; (B) In the regular laparoscopic caudal approach, the laparoscope and forceps are placed into the subcostal cage from the caudal direction, and the surgery is performed with minimal alteration and destruction of the associated structures; (C) In the laparoscopic lateral approach, the intercostal (transdiaphragmatic) ports combined with total mobilization of the liver from the retroperitoneum can allow the direct lateral approach into the cage and to the posterosuperior tumors; (D) Thoracoscopic approach is employed for lesions in segment 8, with direct exposure of the tumor into the pleural cavity upon incision on the diaphragm adjacent to the tumor, with the endoscope placed in the pleural cavity. From Morise and Wakabayashi (49).