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Background: Incisional hernia (IH) is common after major abdominal surgery; however, the incidence after hepatectomy for cancer has not been described. We analyzed incidence of and risk factors for IH after hepatectomy for colorectal liver metastases (CLM). Methods: Patients who underwent open hepatectomy with midline or reverse-L incision for CLM at a single institution between 2010 and 2018 were retrospectively analyzed. Postoperative CT scans were reviewed to identify IH and the time from hepatectomy to hernia. Cumulative IH incidence was calculated using competing risk analysis. Risk factors were assessed using Cox proportional hazards model analysis. The relationship between IH incidence and preoperative body mass index (BMI) was estimated using a generalized additive model. Results: Among 470 patients (median follow-up: 16.9 months), IH rates at 12, 24, and 60 months were 41.5%, 51.0%, and 59.2%, respectively. Factors independently associated with IH were surgical site infection (HR: 1.54, 95% CI 1.16–2.06, P = 0.003) and BMI > 25 kg/m2 (HR: 1.94, 95% CI 1.45–2.61, P < 0.001). IH incidence was similar in patients undergoing midline and reverse-L incisions and patients who received and did not receive a bevacizumab-containing regimen. The 1-year IH rate increased with increasing number of risk factors (zero: 22.2%; one: 46.8%; two: 60.3%; P < 0.001). Estimated IH incidence was 10% for BMI of 15 kg/m2 and 80% for BMI of 40 kg/m2. Conclusion: IH is common after open hepatectomy for CLM, particularly in obese patients and patients with surgical site infection. Surgeons should consider risk-mitigation strategies, including alternative fascial closure techniques. [ABSTRACT FROM AUTHOR]

The aims of this study were to assess the effect of known gene alterations (RAS, TP53, APC, SMAD4, BRAF, and FBXW7) on pathologic response (PR) and their combined association with survival in patients with colorectal liver metastases (CLM). From a prospectively maintained database, we collected data on 458 patients who underwent curative-intent hepatectomy after receiving the first-line preoperative chemotherapy between 2004 and 2020. Major PR was defined as tumor viability of less than 50% in all tumors. Multivariate logistic regression revealed that oxaliplatin-containing regimen (OR: 2.54, 95% CI: 1.58–4.07, P < 0.001), bevacizumab-containing regimen (OR: 2.15, 95%CI: 1.36–3.39, P = 0.001), and TP53 alteration (OR: 0.42, 95%CI: 0.27–0.66, P < 0.001) were independently associated with major PR. Multivariate Cox regression also revealed that patients with TP53 wild-type and major PR (HR: 0.49, 95%CI: 0.31–0.77, P = 0.002) and those with TP53 alteration and major PR (HR: 0.70, 95%CI: 0.49–1.00, P = 0.048) had significantly better overall survival compared to those with minor PR. Further studies targeting the association of TP53 with PR and survival can help clarify the role of TP53 in CLM. [ABSTRACT FROM AUTHOR]

Background: The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator (ACS-NSQIP SRC) has been designed to predict morbidity and mortality and help stratify surgical patients. This study evaluates the performance of the SRC for patients undergoing surgery for colorectal liver metastases (CRLM). Methods: SRC was retrospectively computed for patients undergoing liver or simultaneous colon and liver surgery for colorectal cancer (CRC) in two high tertiary referral centres from 2011 to 2020. C-statistics and Brier score were calculated as a mean of discrimination and calibration respectively, for both group and for every level of surgeon adjustment score (SAS) for liver resections in case of simultaneous liver-colon surgery. An AUC ≥ 0.7 shows acceptable discrimination; a Brier score next to 0 means the prediction tool has good calibration. Results: Four hundred ten patients were included, 153 underwent simultaneous resection, and 257 underwent liver-only resections. For simultaneous surgery, the ACS-NSQIP SRC showed good calibration and discrimination only for cardiac complication (AUC = 0.720, 0.740, and 0.702 for liver resection unadjusted, SAS-2, and SAS-3 respectively; 0.714 for colon resection; and Brier score = 0.04 in every case). For liver-only surgery, it only showed good calibration for cardiac complications (Brier score = 0.03). The SRC underestimated the incidence of overall complications, pneumonia, cardiac complications, and the length of hospital stay. Conclusions: ACS-NSQIP SRC showed good predicting capabilities only for 1 out of 5 evaluated outcomes; therefore, it is not a reliable tool for patients undergoing liver surgery for CRLM, both in the simultaneous and staged resections. [ABSTRACT FROM AUTHOR]

Introduction: Colorectal cancer is a leading cause of cancer-related death worldwide. Metastatic liver disease develops in 50% of cases and drives patient outcomes. Although the ideal treatment for colorectal cancer liver metastases (CRLM) is resection, only a third of patients are suitable for this approach. Reports of liver transplantation in selected patients with unresectable CRLM have shown encouraging results compared to conventional forms of therapy. No study to date has examined the utility of liquid biopsy circulating tumor DNA (ctDNA) for evaluation of residual disease in this cohort of patients. We report a small series of liver transplantation in patients with CRLM in whom ctDNA was assessed peri-operatively. Methods: Five patients underwent liver transplantation for unresectable CRLM or liver failure following CRLM treatment from 2018 to 2022. Clinical data, cross-sectional imaging, and serum biomarkers including peri-operative ctDNA were reviewed from electronic medical records. Results: All patients are alive without radiologic evidence of disease at time of this publication. Median time of follow-up was 32 months (IQR 6.6–40 months). ctDNA was assessed before (4 patients) and after transplant (6 patients). One patient experienced a pulmonary recurrence that was resected, for whom pre-recurrence ctDNA was not available; the remaining patients have not experienced recurrence. Four patients are without evidence of ctDNA following transplant, and two demonstrate persistent ctDNA positivity post-transplant. Three of four patients with positive pre-transplant ctDNA remain ctDNA-negative post-transplant. Conclusions: Liver transplantation for liver-confined unresectable CRLM is emerging as a valid surgical option in selected patients. The significance of liquid biopsy in this population remains elusive due to lack of data. The clearance of ctDNA after transplant in these patients with metastatic disease and despite their immunosuppression is notable. The significance and usefulness of liquid biopsy in patient selection, surveillance, and as an indication for treatment warrant further investigation. [ABSTRACT FROM AUTHOR]

Background: The best surgical approach to treat synchronous colorectal liver metastases (CRLM) remains unclear. Here, we aimed to identify prognostic factors associated with limited survival comparing patients undergoing primary-first resection (PF) and simultaneous resection (SR) approaches. Methods: We retrospectively reviewed clinical data of 217 patients who underwent resection for synchronous CRLMs between January 1, 2011, and December 31, 2021. There were 133 (61.2%) PF resection and 84 (38.8%) SRS. The two groups of patients were compared using propensity score matching (PSM) analysis and cox analysis was performed to identify prognostic factors for overall survival (OS). Results: After PSM, two groups of 71 patients were compared. Patients undergoing SR had longer operative time (324 ± 104 min vs 250 ± 101 min; p < 0.0001), similar transfusion (33.3% vs 28.1%; p = 0.57), and similar complication rates (35.9% vs 27.2%; p = 0.34) than patients undergoing PF. The median overall survival and 5-year survival rates were comparable (p = 0.94) between patients undergoing PF (48.2 months and 44%) and patients undergoing SR (45.9 months and 30%). Multivariate Cox analysis identified pre-resection elevated CEA levels (HR: 2.38; 95% CI: 1.20–4.70; P =.01), left colonic tumors (HR: 0.34; 95% CI: 0.17–0.68; P =.002), and adjuvant treatment (HR: 0.43; 95% CI: 0.22–0.83; P =.01) as independent prognostic factors for OS. Conclusions: In the presence of synchronous CRLM, right colonic tumors, persistent high CEA levels before surgery, and the absence of adjuvant treatment identified patients characterized by a limited survival rate after resection. The approach used (PF vs SR) does not influence short and long-term outcomes. [ABSTRACT FROM AUTHOR]

Keywords: Laparoscopy; Liver Resection; Hepatectomy; Posterosuperior Lesions; Margin; Parenchyma Sparing EN Laparoscopy Liver Resection Hepatectomy Posterosuperior Lesions Margin Parenchyma Sparing 790 793 4 04/06/23 20230401 NES 230401 Introduction Laparoscopic parenchyma-sparing resection (LPSR) is the mainstay of laparoscopic liver resection (LLR) cases to provide a chance of repeat liver resection in case of liver recurrence and improve cancer-related outcomes[1]. Laparoscopy, Liver Resection, Hepatectomy, Margin, Parenchyma Sparing, Posterosuperior Lesions. [Extracted from the article]

Background: Liver venous deprivation (LVD) is a recent radiological technique performed to induce hypertrophy of the future liver remnant. Medium-term results of major hepatectomy after LVD have never been compared with the actual standard of care, portal vein embolization (PVE). Methods: We retrospectively compared data from 33 consecutive patients who had undergone LVD (n = 17) or PVE (n = 16) prior to a right hemi-hepatectomy or right extended hepatectomy indicated for colorectal liver metastases (CRLM) between May 2015 and December 2019. Results: The 1-year and 3-year overall survival (OS) rates in the LVD group were 81.3% (95% confidence interval [CI]: 72–90) and 54.7% (95% CI: 46–63), respectively, against 85% (95% CI: 69–101) and 77.4% (95% CI: 54–100) in the PVE group; the differences were not statistically significant (p = 0.64). The median disease-free survival (DFS) rate was also comparable: 6 months (95% CI: 4–7) in the LVD group and 12 months (95% CI: 1.5–13) in the PVE group (p = 0.29). The overall intra-operative and post-operative complication rates were similar between the two groups. The mean daily kinetic growth rate (KGR) was found to be higher after LVD than after PVE (0.2% vs. 0.1%, p = 0.05; 10 cc/day vs. 4.8 cc/day, p = 0.03), as was the mean increase in future liver remnant volume (FLR-V) (49% vs. 27%, p = 0.01). Conclusions: The LVD technique is well tolerated in patients undergoing right hemi-hepatectomy or right extended hepatectomy for CRLM. When compared with the PVE technique, the LVD technique has similar peri-operative and medium-term outcomes, but higher KGR and FLR-V increase. [ABSTRACT FROM AUTHOR]

A difference in OS among patients who underwent LDLT versus DDLT was also observed, depicted by a flat hazard curve for LDLT versus a multi-peak curve for DDLT. Keywords: Liver transplantation; Colorectal liver metastases; Hazard function EN Liver transplantation Colorectal liver metastases Hazard function 1720 1722 3 08/11/23 20230801 NES 230801 Introduction Few studies regarding liver transplantation (LT) for unresectable colorectal liver metastases (urCRLM) have been published.[1]-[3] Due to the paucity of literature, dynamic changes in risk of death and recurrence have been poorly documented. Although undoubtedly multifactorial, this difference in OS may have been attributable to patients undergoing DDLT who had a longer waitlist duration; however, the data do not inform which type of LT (i.e., LDLT vs. [Extracted from the article]

Background: Colorectal liver metastases (CRLM) involving two or three main hepatic veins pose a surgical challenge. For these lesions, compelled surgical strategies have usually included major and/or extended liver resections according to the two-stage hepatectomy (TSH) strategy. More recently, a one-stage transversal hepatectomy resecting the posterosuperior liver segment (7,8,4 superior) along with one or more hepatic veins has been described, such as showed herein in a didactical video. Methods: The patient is a 78-year-old woman with two large CRLMs located into segment 2 and into segment 8. Magnetic resonance imaging and computed tomography showed tumour stability after chemotherapy. The lesion of segment 2 is close to the left hepatic vein while the lesion of segment 8 infiltrates the middle (MHV) and the right hepatic veins (RHV). Results: Under intermittent pedicular clamping, resection of the segment 7, 8, 4 superior along with the right and middle hepatic veins is performed. Reconstruction of the veins was performed with 2 cryopreserved autologous saphenous grafts. Postoperative course was uneventful and postoperative CT scan showed patency of the two venous graft reconstructions. Conclusions: Surgery for CRLM has evolved over the last two decades shifting from large anatomical resections to parenchymal-sparing resections. Sparing liver parenchyma allows surgical radicality while reducing the risk of liver failure and allowing repeated liver resection. Associating vascular reconstruction to parenchymal-sparing surgery reduces the risk of venous congestion of the spared liver parenchyma. [ABSTRACT FROM AUTHOR]

Background: Surgical resection for patients with hepatic and extrahepatic colorectal metastases remains controversial. This study aimed to determine the efficacy of curative resection of distant extrahepatic metastatic lesions in patients with colorectal liver metastases (CRLM). Methods: From 2007 to 2019, 377 patients with CRLM were treated; of these, 323 patients underwent hepatectomy, and 54 patients with extrahepatic metastases (EHM) had received only chemotherapy. Survival and recurrence were compared between patients with and without EHM. Variables potentially associated with survival were analyzed in univariate and multivariate analyses. Results: Among patients who underwent hepatectomy, the median, 3-, and 5-year overall survival rates for patients with EHM (n = 60) were 32 months, 47%, and 28%, respectively, while those for patients without EHM (n = 263) were 115 months, 79%, and 66%, respectively (p < 0.001). Furthermore, outcomes were similar in R2 patients with EHM and those with unresectable tumors. However, outcomes were significantly better in the R0/1 group than in the R2 and unresectable groups (p < 0.001). Among patients with EHM, multivariate analysis revealed that higher clinical risk score, incomplete resection of all EHM, extrahepatic disease detected intraoperatively, and previous treatment with neoadjuvant chemotherapy were independently associated with worse survival. Conclusions: In patients with CRLM with EHM (liver + one organ), gross curative resection is necessary when surgical treatment is contemplated, and resection of liver metastases should be performed in patients with CRLM with smaller and fewer tumors (e.g., H1). [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to assess the impact of frailty on short-term outcomes after hepatectomy for colorectal liver metastasis (CRLM). Methods: Patients were identified using the National Surgical Quality Improvement Program (NSQIP). Patients were divided into 3 categories using the 5-item Modified Frailty Index (mFI). Results: There were 5230 patients included. 52%, 35%, and 13% had mFI scores of 0, 1, and ≥ 2 respectively. Patients with a ≥ 2 mFI score were more likely to experience minor complication (OR 1.34, 95% CI 1.06–1.69), major complication (OR 1.56, 95% CI 1.15–2.12), readmission (OR 1.55, 95% CI 1.12–2.14), unfavorable discharge (OR 2.48, 95% CI 1.62–3.80), 30-day mortality (OR 3.02, 95% CI 1.02–8.95), prolonged length of stay (OR 1.47, 95% CI 1.18–1.83), and bile leak (OR 1.51, 95% CI 1.02–2.24). Conclusion: Frailty is associated with increased post-operative complications. The 5-item mFI can guide risk stratification, optimization, and counseling. [ABSTRACT FROM AUTHOR]

Background: Liver resection for colorectal metastases is affected by a non-negligible recurrence rate. The earlier the recurrence, the worse the prognosis. We analyzed an unexplored topic, i.e., the incidence, predictive factors, and prognostic impact of very early recurrence (≤ 3 months after hepatectomy). Methods: All consecutive liver resections for colorectal metastases performed between 2004 and 2017 were retrospectively reviewed. Inclusion criteria were available recurrence status at 3 months after resection and follow-up ≥ 12 months. Results: Overall, 484 patients were analyzed; 56 (11.6%) had very early recurrence. Independent predictors were number of metastases (very early recurrence in 3.7% of patients with solitary metastasis, 8.1% of those with 2–9 metastases; 20.0% of those with 10–14 metastases; 44.4% of those with ≥ 15 metastases, p < 0.001) and extrahepatic disease (very early recurrence in 23.2% of patients with vs. 10.1% of those without extrahepatic disease, p = 0.017). Very early recurrence rate in patients with ≥ 15 metastases and simultaneous extrahepatic disease was 71.4%. Patients with very early recurrence had poor survival (5-year survival 17.3% vs. 44.5% of non-very early recurrence patients, p < 0.001), worse than patients with 3-to-6 months recurrence (p = 0.070), and no different from unresected patients (p = 0.114). Fifteen patients with very early recurrence (26.8%) underwent repeated treatment with adequate survival (at 3 years 42.2%), but seven had a further recurrence within 3 months. Conclusions: Very early recurrence occurs in about 12% of patients undergoing aggressive surgery for colorectal metastases. The risk is increased in patients with numerous metastases or extrahepatic disease. Very early recurrence is associated with very poor prognosis, similar to that of unresected patients, and a low chance of effective repeated treatment. [ABSTRACT FROM AUTHOR]

Background: The past 20 years have seen advances in colorectal cancer management. We sought to determine whether survival in patients undergoing resection of colorectal liver metastases (CLM) has improved in association with three landmark advances: introduction of irinotecan- and/or oxaliplatin-containing regimens, molecular targeted therapy, and multigene alteration testing. Methods: Patients undergoing CLM resection during 1998–2014 were identified and grouped by resection year. The influence of alterations in RAS, TP53, and SMAD4 was evaluated and validated in an external cohort including patients with unresectable metastatic colorectal cancer. Results: Of 1961 patients, 1599 met the inclusion criteria. Irinotecan- and/or oxaliplatin-containing regimens and molecular targeted therapy were used for more than 50% of patients starting in 2001 and starting in 2006, respectively, so patients were grouped as undergoing resection during 1998–2000, 2001–2005, or 2006–2014. Liver resectability indications expanded over time. The 5-year overall survival (OS) rate was significantly better in 2006–2014, vs. 2001–2005 (56.5% vs. 44.1%, P < 0.001). RAS alteration was associated with worse 5-year OS than RAS wild-type (44.8% vs. 63.3%, P < 0.001). However, OS did not differ significantly between patients with RAS alteration and wild-type TP53 and SMAD4 and patients with RAS wild-type in our cohort (P = 0.899) or the external cohort (P = 0.932). Of 312 patients with genetic sequencing data, 178 (57.1%) had clinically actionable alterations. Conclusion: OS after CLM resection has improved with advances in medical therapy and surgical technique. Multigene alteration testing is useful for prognostication and identification of potential therapeutic targets. [ABSTRACT FROM AUTHOR]

Patients with low TBS had the best long-term prognosis (low TBS, 52.4% vs. medium TBS, 39.2% vs. high TBS, 40.6%, I p i < 0.001). Keywords: CRLM; Tumor Burden Score; Prognosis EN CRLM Tumor Burden Score Prognosis 404 406 3 03/02/23 20230201 NES 230201 Introduction Surgery remains the curative-intent treatment of choice for colorectal liver metastases (CRLMs) with a 40-60% 5-year survival.[1] The tumor burden score (TBS) utilizes lesion size and number to generate a composite score that has been validated to stratify the prognosis of patients with CRLM accurately.[2] However, the incorporation of CRLM spread (i.e., unilateral, bilateral) in TBS, termed the modified TBS (mTBS), may provide more accurate prognostic information.[3] Therefore, the objective of the current study was to characterize the prognostic impact of TBS relative to unilateral or bilateral CRLM, as well as to define the performance of mTBS to predict long-term survival. [Extracted from the article]

Colorectal cancer (CRC) is one of the most common cancers in the world. The most important determinant of survival and prognosis is the stage and presence of metastasis. The liver is the most common location for CRC metastasis. The only curative treatment for CRC liver metastasis (CRLM) is resection; however, many patients are ineligible for surgical resection of CRLM. Locoregional treatments such as ablation and intra-arterial therapy are also available for patients with CRLM. Assessment of response after chemotherapy is challenging due to anatomical and functional changes. Antiangiogenic agents such as bevacizumab that are used in the treatment of CRLM may show atypical patterns of response on imaging. It is vital to distinguish patterns of response in addition to toxicities to various treatments. Imaging plays a critical role in evaluating the characteristics of CRLM and the approach to treatment. CT is the modality of choice in the diagnosis and management of CRLM. MRI is best used for indeterminate lesions and to assess response to intra-arterial therapy. PET-CT is often utilized to detect extrahepatic metastasis. State-of-the-art imaging is critical to characterize patterns of response to various treatments. We herein review the imaging characteristics of CRLM with an emphasis on imaging changes following the most common CRLM treatments. [ABSTRACT FROM AUTHOR]

Background: Recent studies suggest that lymph node ratio (LNR) has significantly better prognostic power than N-status in patients with colorectal cancer, in particular when the number of evaluated lymph nodes (LNs) was insufficient. The aim of this study was to assess the prognostic value of LNR in patients with resected synchronous colorectal liver metastases (SCLMs) and less than 12 examined LNs. Methods: A prospectively maintained database of patients with resected SCLMs was queried for patients with less than 12 LNs evaluated at the time of surgery. X-tile software was used to determine the LNR cutoff value able to divide the patients in two subgroups with distinct prognosis. Overall survival (OS) and disease-free survival (DFS) rates were compared by log-rank test. A multivariate Cox regression analysis identified independent prognostic factors. Results: A cutoff LNR value of 0.22 divided patients into Low-LNR group (35 patients) and High-LNR group (36 patients). Both OS and DFS rates were significantly higher in Low-LNR group than those in High-LNR group. Independent predictors of poor OS were High-LNR (HR: 2.841, 95% CI: 1.480–5.453, p value = 0.002), bilobar SCLMs (HR: 2.253, 95% CI: 1.144–4.437, p value = 0.019) and lack of adjuvant chemotherapy (HR: 2.702, 95% CI: 1.448–5.043, p value = 0.002), while the only independent predictor of poor DFS was High-LNR (HR: 2.531, 95% CI: 1.259–5.090, p value = 0.009). Conclusions: LNR > 0.22 was independently associated with poor OS and DFS in patients with resected SCLMs and less than 12 evaluated LNs. [ABSTRACT FROM AUTHOR]

Results Colon Cancer A total of 33,038 colon cancer patients with isolated liver metastases were included (31.3% academic, 68.7% community). Keywords: Colorectal cancer; Liver metastases; Survival EN Colorectal cancer Liver metastases Survival 209 213 5 01/17/22 20220101 NES 220101 Introduction Colorectal cancer is the third leading cause of cancer-related deaths in the USA. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. [Extracted from the article]

Aim: Defining sensitivity, specificity, diagnostic accuracy for detection of colorectal liver metastases in imaging compared to intraoperative assessment. Defining a cutoff, where accuracy of detection is impaired. Methods: Prospective single-institution clinical trial (clinicaltrials.gov: NCT01522209). Patients underwent CEUS, MDCT, and 3 Tesla EOB-MRI within 2 weeks preoperatively. Intraoperative palpation, IOUS, and CEIOUS were performed. A patient and lesion-based database was analyzed for accuracy of detection of CEUS, CT, MRI, and Palp/IOUS/CEIOUS combined read. Histology was standard of reference. Results: Forty-seven high tumor load (mean 5, 4 lesions) patients were analyzed. Histopathology confirmed 264 lesions (245 malignant: 19 benign). Accuracy for detection of all lesions: CEUS 63%, CT 71%, MRI 92%, and PALP/IOUS/CEIOUS 98%. ROC analysis for lesion size showed severe impairment of accuracy in lesion detection smaller than 5mm. Intraoperative imaging was not impaired by lesion size. Patient-based analysis revealed a change of resection plan after IOUS/CEIOUS in 35% of patients. Conclusion: At 5-mm lesion size, preoperative imaging shows a drop in accuracy of detection. In patients with multiple lesions, addition of MRI to MDCT seems useful. Accuracy of intraoperative ultrasound is not impacted by lesion size and should be mandatory. CEIOUS can improve intraoperative decision-making. Trial Registration: Study registered with clinicaltrials.gov: NCT01522209 [ABSTRACT FROM AUTHOR]

Background: The survival benefit of and indications for adjuvant chemotherapy (AC) for colorectal liver metastases (CRLM) remain unclear.Methods: Patients who were diagnosed with liver-limited CRLM between 2005 and 2007 and subsequently underwent R0 resection without preoperative chemotherapy were identified in a Japanese nationwide survey. This overall cohort was divided into synchronous and metachronous CRLM cohorts. In each of the three cohorts, the patients that were given AC were matched with those treated with surgery alone via 1:1 propensity score (PS) matching. Recurrence-free survival (RFS) and overall survival (OS) after the initial hepatectomy were compared.Results: The median follow-up period was 79.4 months and the overall, synchronous, and metachronous cohorts included 1145, 498, and 647 patients, respectively. After the PS matching, the patients' demographics were well balanced. AC was effective in terms of both RFS and OS in the overall cohort (RFS hazard ratio [HR] 0.784, p = 0.045; OS HR 0.716, p = 0.028) and synchronous cohort (RFS HR 0.677, p = 0.027; OS HR 0.642, p = 0.036), whereas AC was not effective in the metachronous cohort (RFS HR 0.875, p = 0.378; OS HR 0.881, p = 0.496). However, in the metachronous cohort, AC was effective in terms of OS in the subgroup that exhibited disease-free intervals of ≤ 1 year after primary tumor resection (RFS HR 0.667, p = 0.068; OS HR 0.572, p = 0.042).Conclusion: Adjuvant chemotherapy has a survival benefit for patients with resected CRLM. Synchronous CRLM is a favorable indication for AC, whereas in metachronous CRLM, the use of AC should be individualized according to each patient's risk factors. [ABSTRACT FROM AUTHOR]

Technological advances and investigation into tumor biology have enhanced treatments of patients with colorectal liver metastases (CLM). This article briefly summarizes paradigm shifts in treatments of this disease in the following 4 sections. (1) Small metastases: The treatment of multiple and small CLM has evolved from anatomic resection to parenchyma-sparing hepatectomy. Survival after parenchyma-sparing hepatectomy was similar to or better than anatomic resection. The use of preoperative chemotherapy may cause tumor disappearance. However, the use of fiducial markers may aid in intraoperative localization. Post-resection completion ablation is a new useful treatment concept. It was defined as percutaneous ablation under cross-sectional imaging guidance to eradicate CLM which were intentionally unresected during latest surgery. (2) Bilateral (bilobar) metastases: Two-stage hepatectomy (TSH) is a well-established approach for treating multiple bilateral CLM. The use of hybrid operating room accelerates this sequence because it allows first-stage hepatectomy, portal vein embolization, and computed tomography in one hospitalization. This accelerated TSH sequence enables the second-stage hepatectomy within 4 weeks compared to 8 weeks using conventional TSH sequence. (3) Synchronous lung metastases: For patients with synchronous liver and lung metastases, simultaneous surgical approach is feasible. Specifically, a transdiaphragmatic approach enables simultaneous resection of liver and lung metastases via one abdominal incision. (4) Multiple mutation: Somatic gene mutation testing is increasingly used to evaluate tumor biology. Mutations in TP53, RAS, and SMAD4 affect prognosis through three different signaling pathways of colorectal carcinogenesis. This information can be used to change clinical decision-making regarding surveillance intensity and treatments for liver recurrence. [ABSTRACT FROM AUTHOR]

Background: Parenchymal-sparing hepatectomies (PSH) are liver resections with preservation of as much liver parenchyma as possible. PSH can be performed laparoscopically (LPSH), but access to the posterosuperior segments is difficult and they are challenging when there are multiple bilobar lesions; the procedure may require repositioning and may be long and cumbersome. The objective of this systematic review is to analyze the feasibility and limitations of laparoscopic PSH in the literature.Methods: A systematic review of the literature was performed by searching Medline/PubMed, Scopus, and Cochrane databases. Resections were categorized by segment(s), and data regarding operative time, blood loss, length of hospital stay, complications, and R0 resection were analyzed.Results: Of 351 studies screened for relevance, 48 studies were reviewed. Ten publications fulfilled inclusion criteria, reporting data from 579 patients undergoing LPSH. The most common indication was CRLM (58%) followed by hepatocellular carcinoma (16%). Only 92 patients were reported to have resections of more than one tumor; the maximum number of lesions resected was seven. Of resected lesions, 21.5% were located in the cranial segments. Mean operating time was 335.2 min, estimated blood loss was 462 cc, and hospital stay was 7.6 days. Conversion rate was 9.7%, and complications occurred in 19.4% of cases. No perioperative mortality was reported. R0 resections were achieved in 87.7% of cases.Conclusion: Laparoscopic PSH is performed and reported, but the data quality is low so far. The main limitation of LPSH is the low number of lesions resected, especially for bilobar, metastatic disease. Prospective reports with tumor-specific oncological data are desirable. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to examine the merits of the anterior approach, if any, in colorectal liver metastasis (CRLM) resection.Methods: Data of patients who underwent partial hepatectomy for CRLM were reviewed. Patients treated by the anterior approach were compared with patients treated by the conventional approach.Results: Ninety-eight patients had right hepatectomy, extended right hepatectomy, or right trisectionectomy. Among them, 71 patients underwent the conventional approach (CA group) and 27 underwent the anterior approach (AA group). The two groups were comparable in demographic, pathological, and perioperative characteristics except that the AA group had higher levels of aspartate transaminase (median, 41 vs. 31 U/L; p = 0.006) and alanine transaminase (median, 27 vs. 22 U/L; p = 0.009), larger tumors (median, 7 vs. 4 cm; p = 0.000), and more extensive resections (p < 0.001). The median overall survival was 40 months (range, 0.69-168.6 months) in the CA group and 33.7 months (range, 0.95-99.8 months) in the AA group (p = 0.22), and the median disease-free survival was 9.7 months (range, 0.62-168.6 months) in the CA group and 6.2 months (range, 0.72-99.8 months) in the AA group (p = 0.464). Univariate and multivariate analyses identified 4 independent prognostic factors for overall survival: lymph node status of primary tumor (HR 1.352, 95% CI 0.639-2.862, p = 0.034), intraoperative blood loss (HR 1.253, 95% CI 1.039-1.510, p = 0.018), multiple liver tumor nodules (HR 1.775, 95% CI 1.029-3.061, p = 0.039), and microvascular invasion (HR 2.058, 95% CI 1.053-4.024, p = 0.035).Conclusions: The two approaches resulted in comparable survival outcomes even though the AA group had larger tumors and more extensive resections. The anterior approach allows better mobilization and easier removal of large tumors once the liver is opened up. [ABSTRACT FROM AUTHOR]

Introduction: Colorectal liver metastases develop in 50% of patients diagnosed with colorectal cancer. Surgical resection for colorectal liver metastasis typically involves either anatomical resection (AR) or parenchymal-sparing hepatectomy (PSH). The objective of the current study was to analyze data on parenchymal versus non-parenchymal-sparing hepatic resections for CLM.Methods: A systematic review of the literature regarding parenchymal-sparing hepatectomy was performed. MEDLINE/PubMed, Cochrane, and EMBASE databases were searched for publications containing the following medical subject headings (MeSH): "Colorectal Neoplasms," "Neoplasm Metastasis," "Liver Neoplasms" and "Hepatectomy". Besides, the following keywords were used to complete the literature search: "Hepatectomy," "liver resection," "hepatic resection," "anatomic/anatomical," "nonanatomic/ nonanatomical," "major," "minor," "limited," "wedge," "CRLM/CLM," and "colorectal liver metastasis." Data was reviewed, aggregated, and analyzed.Results: Two thousand five hundred five patients included in 12 studies who underwent either PSH (n = 1087 patients) or AR (n = 1418 patients) were identified. Most patients had a primary tumor that originated in the colon (PSH 52.2-74.4% vs. AR 53.9-74.3%) (P = 0.289). The majority of studies included a large subset of patients with only a solitary tumor with a reported median tumor number of 1-2 regardless of whether the patient underwent PSH or AR. Median EBL was no different among patients undergoing PSH (100-896 mL) versus AR (200-1489 mL) for CLM (P = 0.248). There was no difference in median length-of-stay following PSH (6-17 days) versus AR (7-15 days) (P = 0.747). While there was considerable inter-study variability regarding margin status, there was no difference in the incidence of R0 resection among patients undergoing PSH (66.7-100%) versus AR (71.6-98.6%) (P = 0.58). When assessing overall survival, there was no difference whether resection of CLM was performed with PSH (5 years OS: mean 44.7%, range 29-62%) or AR (5 years OS: mean 44.6%, range 27-64%) (P = 0.97).Conclusion: PSH had a comparable safety and efficacy profile compared with AR and did not compromise oncologic outcomes. PSH should be considered an appropriate surgical approach to treatment for patients with CLM that facilitates preservation of hepatic parenchyma. [ABSTRACT FROM AUTHOR]

Objective: This study was conducted to evaluate recurrence and survival among patients who underwent intraoperative margin re-resection for colorectal cancer liver metastases (CRLM). Background: Among patients who receive intraoperative margin re-resection, the relation between final margin status, pattern of recurrence, and survival is largely unknown. Methods: Three hundred thirty-two patients who underwent hepatic resection for CRLM between 2000 and 2013 were identified. Demographics, operative data, pathologic margin status, site of recurrence, and long-term survival data were collected and analyzed. Patients were stratified in three groups based on their margin status: R0, R1, and R1 → R0. Results: R0 resections were achieved in 247 (74.4 %) patients, 61 (18.4 %) patients had an R1 resection, whereas 24 (7.2 %) had an R1 → R0. Median survival for patients undergoing R0 resections was 50.2 (95 % confidence interval (CI) 49.2-66.2) months versus 63.0 (95 % CI 50.3-70.5) months for patients undergoing R1 resections versus 49.2 (95 % CI 29.9-NA) months for patients undergoing intraoperative margin re-resection ( P > 0.05). Differences in recurrence rate and pattern were not significant between the three groups ( P > 0.05). Conclusion: In the era of modern systemic chemotherapy, it seems that the impact of margin status on outcomes may be minimal compared to that of patient and tumor factors. In this scenario, margin re-resection to achieve R0 status does not improve long-term outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Following curative intent surgery (CIS) for colorectal liver metastasis (CRLM), repeat CIS for recurrence improves survival. The factors associated with repeat CIS are not widely reported. Methods: An institutional database (January 2002-December 2012) was reviewed to evaluate factors influencing repeat CIS. Results: One hundred sixty-three patients with colorectal liver metastasis (CRLM) underwent successful CIS. Median follow-up and disease-free interval (DFI) was 33 and 16 months, respectively. After initial CIS, 102 patients (63 %) recurred. Fifty-three patients (52 %) underwent a repeat CIS. After repeat CIS, 33 patients (62 %) developed a second recurrence, and in 13 patients (39 %), a third CIS was possible. DFI decreased following initial CIS (first CIS vs. second CIS vs. third CIS [20 vs. 15 vs. 8.5 months], p < 0.001). Overall 5-year survival in all patients was 55 %; patients who recurred had a 5-year survival of 67 % if they underwent repeat CIS vs. 7.8 % if they were managed palliatively. Second CIS was less likely with a postoperative complication, other/multifocal recurrence, or DFI <12 months. Conclusion: Despite high recurrence and decreasing DFI, repeat CIS provides a survival benefit. Postoperative complications, DFI, number, and pattern of recurrence influence the decision to pursue repeat CIS. [ABSTRACT FROM AUTHOR]

Introduction: The role of ablation for hepatic colorectal metastases (HCM) continues to evolve as ablation technology changes and systemic chemotherapy improves. Our aim was to evaluate the therapeutic efficacy of radiofrequency ablation (RFA) of HCM compared to surgical resection.Methods: A retrospective review of our 1,105 patient prospective hepatic database from August 1995 to July 2007 identified 192 patients with only hepatic resection or only ablation for HCM.Results: Patients who underwent RFA were similar to resection patients based on a similar Fong score (1.8 vs. 2.1 p = 0.28), presence of extrahepatic disease (15% vs. 9% p = 0.19), mean number of hepatic lesions (2.8 vs. 2.1 p = 0.14), and prior chemotherapy (67% vs. 60% p = 0.33). Median time to recurrence was shorter with ablation than resection (12.2 vs. 31.1 months; p < 0.001). Recurrence at the ablation-resection site was more common with ablation than resection occurring 17% vs. 2% (p < or = 0.001) of the time, respectively. Distant recurrence in the liver was also more common with ablation occurring in 33% of patients vs. 14% for resection (p = 0.002).Conclusions: Surgical resection is associated with a lower chance of recurrence and a longer disease-free interval than RFA and should remain the treatment of choice in resectable HCM. [ABSTRACT FROM AUTHOR]