Minor Hepatectomy Safe During Colorectal Cancer Surgery

Selected patients with colorectal cancer metastasized to the liver can undergo a single procedure to remove lesions at both locations, according to a multicenter study presented at the Society of Surgical Oncology in Washington.

The traditional approach has been to remove the primary tumor and then place the patient on chemotherapy prior to doing a hepatic resection, said Dr. Bryan Clary, chief of hepatobiliary surgery Duke University, Durham, N.C.

“The rationale for that approach has been the perception that simultaneous hepatic and colorectal surgery is excessively morbid, but a growing body of evidence has called this strategy into question,” Dr. Clary said in an interview.

In about a third of patients newly diagnosed with colorectal cancer, disease already has spread to the liver, he added.

The Duke University researchers teamed with investigators from Johns Hopkins Medical Institutions in Baltimore and the University of Texas M.D. Anderson Cancer Center in Houston to conduct a retrospective outcomes study of 610 patients who had undergone either simultaneous (135) or separate (475) procedures for removal of synchronous colorectal and liver cancer.

Data for the years 1985 through 2006 were drawn from three large-volume hepatobiliary centers.

“We found that for patients who require a minor hepatectomy in conjunction with their colorectal operations, the risk does not seem to be increased in comparison with those undergoing staged liver resection,” Dr. Clary said.

In the minor hepatectomy cohort, defined as the removal of fewer than three liver segments, 99 were done simultaneously with colorectal surgery and 184 were staged procedures. Measures of intraoperative red blood cell transfusion, blood loss, positive resection margins, mortality, and morbidity were statistically similar. However, in the major hepatectomy group, mortality, overall morbidity, and severe morbidity were significantly higher for the simultaneous procedure, compared with the staged approach (8% vs. 1%, 44% vs. 27%, and 36% vs. 15%, respectively).

Simultaneous resection resulted in a significantly shorter median length of hospital stay (8.5 vs. 14 days) at the single institution where hospital time was calculated for both procedures, Dr. Clary explained.

Survival data were similar for simultaneous and staged resection. However, posthepatectomy chemotherapy significantly prolonged survival for patients with synchronous hepatic metastases, regardless of whether the resection was done simultaneously with or separate from colorectal procedure.

The 1-, 3-, and 5-year survival rates following posthepatectomy chemotherapy were 98%, 75%, and 55%, respectively. When no chemotherapy was given, those rates fell to 95%, 60%, and 41%.

“There is no compelling evidence that giving chemotherapy beforehand makes a difference, so in general, patients whose disease is resectable should have a resection, whereas marginal medical patients with a lot of comorbidities should be given chemotherapy prior to a complex operation,” Dr. Clary said in an interview, adding that these complex cases need to be much more carefully selected because in general, severe morbidity rates are increased with the simultaneous approach.

Chemotherapy is appropriate in patients whose liver disease is not resectable, in cases where hepatic resection has a low likelihood of achieving a negative margin, and where disease is suspected elsewhere in the body, he said.

Dr. Clary stressed the importance of early patient evaluation by a multidisciplinary team that includes a surgeon experienced in doing hepatic surgery.

Patients with obstructing colon cancers in urgent need of removal and those with significant bleeding from their primary tumors should not undergo this procedure, he said.

“The bottom line is that a single surgery should be considered in the patient who likely would require a minor hepatectomy for extirpation of their liver disease following early evaluation by a competent hepatic surgeon,” Dr. Clary said.

Selected patients with colorectal cancer metastasized to the liver can undergo a single procedure to remove lesions at both locations, according to a multicenter study presented at the Society of Surgical Oncology in Washington.

The traditional approach has been to remove the primary tumor and then place the patient on chemotherapy prior to doing a hepatic resection, said Dr. Bryan Clary, chief of hepatobiliary surgery Duke University, Durham, N.C.

“The rationale for that approach has been the perception that simultaneous hepatic and colorectal surgery is excessively morbid, but a growing body of evidence has called this strategy into question,” Dr. Clary said in an interview.

In about a third of patients newly diagnosed with colorectal cancer, disease already has spread to the liver, he added.

The Duke University researchers teamed with investigators from Johns Hopkins Medical Institutions in Baltimore and the University of Texas M.D. Anderson Cancer Center in Houston to conduct a retrospective outcomes study of 610 patients who had undergone either simultaneous (135) or separate (475) procedures for removal of synchronous colorectal and liver cancer.

Data for the years 1985 through 2006 were drawn from three large-volume hepatobiliary centers.

“We found that for patients who require a minor hepatectomy in conjunction with their colorectal operations, the risk does not seem to be increased in comparison with those undergoing staged liver resection,” Dr. Clary said.

In the minor hepatectomy cohort, defined as the removal of fewer than three liver segments, 99 were done simultaneously with colorectal surgery and 184 were staged procedures. Measures of intraoperative red blood cell transfusion, blood loss, positive resection margins, mortality, and morbidity were statistically similar. However, in the major hepatectomy group, mortality, overall morbidity, and severe morbidity were significantly higher for the simultaneous procedure, compared with the staged approach (8% vs. 1%, 44% vs. 27%, and 36% vs. 15%, respectively).

Simultaneous resection resulted in a significantly shorter median length of hospital stay (8.5 vs. 14 days) at the single institution where hospital time was calculated for both procedures, Dr. Clary explained.

Survival data were similar for simultaneous and staged resection. However, posthepatectomy chemotherapy significantly prolonged survival for patients with synchronous hepatic metastases, regardless of whether the resection was done simultaneously with or separate from colorectal procedure.

The 1-, 3-, and 5-year survival rates following posthepatectomy chemotherapy were 98%, 75%, and 55%, respectively. When no chemotherapy was given, those rates fell to 95%, 60%, and 41%.

“There is no compelling evidence that giving chemotherapy beforehand makes a difference, so in general, patients whose disease is resectable should have a resection, whereas marginal medical patients with a lot of comorbidities should be given chemotherapy prior to a complex operation,” Dr. Clary said in an interview, adding that these complex cases need to be much more carefully selected because in general, severe morbidity rates are increased with the simultaneous approach.

Chemotherapy is appropriate in patients whose liver disease is not resectable, in cases where hepatic resection has a low likelihood of achieving a negative margin, and where disease is suspected elsewhere in the body, he said.

Dr. Clary stressed the importance of early patient evaluation by a multidisciplinary team that includes a surgeon experienced in doing hepatic surgery.

Patients with obstructing colon cancers in urgent need of removal and those with significant bleeding from their primary tumors should not undergo this procedure, he said.

“The bottom line is that a single surgery should be considered in the patient who likely would require a minor hepatectomy for extirpation of their liver disease following early evaluation by a competent hepatic surgeon,” Dr. Clary said.

Selected patients with colorectal cancer metastasized to the liver can undergo a single procedure to remove lesions at both locations, according to a multicenter study presented at the Society of Surgical Oncology in Washington.

The traditional approach has been to remove the primary tumor and then place the patient on chemotherapy prior to doing a hepatic resection, said Dr. Bryan Clary, chief of hepatobiliary surgery Duke University, Durham, N.C.

“The rationale for that approach has been the perception that simultaneous hepatic and colorectal surgery is excessively morbid, but a growing body of evidence has called this strategy into question,” Dr. Clary said in an interview.

In about a third of patients newly diagnosed with colorectal cancer, disease already has spread to the liver, he added.

The Duke University researchers teamed with investigators from Johns Hopkins Medical Institutions in Baltimore and the University of Texas M.D. Anderson Cancer Center in Houston to conduct a retrospective outcomes study of 610 patients who had undergone either simultaneous (135) or separate (475) procedures for removal of synchronous colorectal and liver cancer.

Data for the years 1985 through 2006 were drawn from three large-volume hepatobiliary centers.

“We found that for patients who require a minor hepatectomy in conjunction with their colorectal operations, the risk does not seem to be increased in comparison with those undergoing staged liver resection,” Dr. Clary said.

In the minor hepatectomy cohort, defined as the removal of fewer than three liver segments, 99 were done simultaneously with colorectal surgery and 184 were staged procedures. Measures of intraoperative red blood cell transfusion, blood loss, positive resection margins, mortality, and morbidity were statistically similar. However, in the major hepatectomy group, mortality, overall morbidity, and severe morbidity were significantly higher for the simultaneous procedure, compared with the staged approach (8% vs. 1%, 44% vs. 27%, and 36% vs. 15%, respectively).

Simultaneous resection resulted in a significantly shorter median length of hospital stay (8.5 vs. 14 days) at the single institution where hospital time was calculated for both procedures, Dr. Clary explained.

Survival data were similar for simultaneous and staged resection. However, posthepatectomy chemotherapy significantly prolonged survival for patients with synchronous hepatic metastases, regardless of whether the resection was done simultaneously with or separate from colorectal procedure.

The 1-, 3-, and 5-year survival rates following posthepatectomy chemotherapy were 98%, 75%, and 55%, respectively. When no chemotherapy was given, those rates fell to 95%, 60%, and 41%.

“There is no compelling evidence that giving chemotherapy beforehand makes a difference, so in general, patients whose disease is resectable should have a resection, whereas marginal medical patients with a lot of comorbidities should be given chemotherapy prior to a complex operation,” Dr. Clary said in an interview, adding that these complex cases need to be much more carefully selected because in general, severe morbidity rates are increased with the simultaneous approach.

Chemotherapy is appropriate in patients whose liver disease is not resectable, in cases where hepatic resection has a low likelihood of achieving a negative margin, and where disease is suspected elsewhere in the body, he said.

Dr. Clary stressed the importance of early patient evaluation by a multidisciplinary team that includes a surgeon experienced in doing hepatic surgery.

Patients with obstructing colon cancers in urgent need of removal and those with significant bleeding from their primary tumors should not undergo this procedure, he said.

“The bottom line is that a single surgery should be considered in the patient who likely would require a minor hepatectomy for extirpation of their liver disease following early evaluation by a competent hepatic surgeon,” Dr. Clary said.