Clinico-pathological prognostic factors in hematogenously disseminated colorectal cancer

Background: Ekberg`s criteria for liver resections (LR) of colorectal cancer liver metastases (CRCLM) have been accepted as a `dogma` and the procedure - as a `gold standard` since 1986. There are many wellknown predictive factors for the early and long-term results in this field of surgery. However, some of them are still a matter of debate.Aim: Study on the possible prognostic value of some clinical-pathological factors for the early and late results after major LR (≥ 2 segments) of CRCLM.Material and methods: A total of 143 radical (R0) major LR (≥ 2 segments) of synchronous and metachronous CRCLM were performed between 01.01.20007 - 31.12.2014 in the Clinic of Liver, Biliary, Pancreatic and General Surgery, Tokuda Hospital Sofia. The design of the study was `a single center` and `retrospective`. We analyzed the data with possible predictive value - demography, comorbidity, liver function, ASA group, neoadjuvant chemotherapy, type and characteristics of the surgical procedure, pathological data (T,N,G,H) and time of detection of metastases (synchronous or metachronous). The early postoperative morbidity and mortality rates were compared with these factors looking for correlation. The long-term follow-up period was ≥ 12 months for 86 patients (60.1%).Results: The early postoperative mortality rate was 2.8% (4 cases) for the whole series. The specific morbidity rates were significantly higher in patients above 65 years of age, with ≥ 3 comorbid conditions, multivisceral resections in cases of synchronous metastases and atypical (non-anatomical) LR. The majority of CRCLM cases were ≥ Т2, N (+) positive and G2-3. Unfavorable prognostic factors were the detection of metachronous lesions earlier than 12 months after a curative previous resection especially on the basis of adequate chemotherapy.Conclusions: The knowledge on prognostic factors in patients with CRCLM as well as on indications and contraindications helps the correct preoperative judgment on choosing the right and appropriate type and volume of surgical procedures

Comparative analyses between the early postoperative results after major liver resections of colorectal and noncolorectal cancer liver metastases

Background: Liver resections (LR) are an obligatory element in the multimodal treatment scheme of colorectal cancer liver metastases (CRCLM). Nowadays still there are debates about the benefit of any aggressive surgical approach in noncolorectal cancer liver metastases (NCRCLM) because many authors report desperately high rates of early specific post-resection complications (SPRC) followed by unsatisfactory long term results.Aim: Comparative analyses between the SPRC after major liver resections (MLR), i.e. ≥ 2 segments of CRCLM and NCRCLM for confirming or denying the hypothesis of higher risk in the group of NCRLM.Material and methods: A total of 331 MLR of benign and malignant tumors were performed between 01.01.2007 - 31.12.2014 in the Clinic of Liver, Biliary, Pancreatic and General Surgery, Tokuda Hospital Sofia. Radical resections received 143 CRCLM patients and 58 NCRCLM patients, both synchronous and metachronous. The design of the study was `a single center` and `retrospective`. The perioperative data of these 201 patients were analyzed and finally 59 cases of CRCLM (Group 1) and 36 cases of NCRCLM (Group 2) were included in the study. All the metastases were metachronous and no significant differences in demography, comorbidity, liver function, ASA group, neoadjuvant chemotherapy and surgery specificity were detected between the two groups. Cases that were indicated for MLR were those under 65 years of age, with preserved liver function, without serious pulmonary and cardiac concomitant diseases, and estimated as ASA group ≤ III. Data about SPRC were collected and analyzed. Results: The entire early postoperative mortality rate was 3.2% (3 fatal outcomes) - 1/59 (1.7%) in group 1 and 2/36 (5.5%) in group 2. The cause of death was liver failure, sepsis and pulmonary embolism. The rate of SPRC was significantly higher in group 2, affecting 16/36 patients (44.4%) while only 18 out of all the 59 patients (30.5%) in group 1 suffered specific complications. However only 5.1% and 8.3% of the SPRC necessitated reoperations in group 1 and group 2 respectfully. The comparative analysis denied any prognostic value for the early SPRC played by the time of metastases detection, adjuvant chemotherapy, the duration of liver resection procedure and the necessity of blood transfusion. Conclusions: Both mortality and specific morbidity after MLR affected patients with ≥3 comorbid conditions which proved to be the only predictive factor for SPRC. SPRC were more frequent in group 2 (NCRCLM) but the great majority of them were solved by conservative measures, less often by interventional procedure and reoperations were indicated very rarely

Anatomical Versus Atypical Liver Resections - Advantages and Disadvantages

Background: Liver resections (LR) are a daily practice rather than exception with the aim of radicalism (sometimes `radicalism` is the excuse and justification of the surgeon). From a different point of view, an aggressive approach may predispose to specific post-resection complications (SPRC). There still are debates about the most proper procedure - anatomical versus atypical LRs. Aim: The aim of this article is an analysis of the structure and rate of SPRC (acute liver failure=ALF, biliary leakage, bleeding) with a focus on a possible correlation to the surgical technique. Materials and Methods: 344 liver resections in total were performed at the authors` institution from January 1, 2007 to December 31, 2015. All the procedures were indicated by benign tumors as well as by primary and metastatic malignancies. The study design was single-center, retrospective and randomized. Inclusion criteria were the following: (1) Age ≤ 70 years; (2) Presence of ≤ 3 cormobid conditions; (3) Major LR, i.e. removal of ≥ 2 segments or ≥ 30% of liver parenchyma; (4) No synchronous (Н1) liver metastases or metachronous metastases + local recurrence necessitating a single-stage multivisceral resections. We collected all the data from the medical records. Finally, 102 cases were selected according to the above-formulated criteria and they were divided into 2 groups: (A) Anatomical LR (AnatLR) - 44 patients; (B) Atypical LR (AtypLR) - 58 patients. The incidence rate and other characteristics of SPRC were analyzed and a possible correlation between SPRC and the group affiliation was investigated. Results: The early mortality and SPRC rates were 2.8% (3 cases) and 19.4% (21 complications in 20 patients), respectively. Fatal outcome was caused by ALF after right hepatectomy (2 cases) and sepsis leading to MODS and MOF (1 case). Four patients (3.7%) received reoperation due to biliary leakage and/or bleeding from the resection surface. The remaining 17 SPRCs were overcome by conservative treatment. There was no statistically significant difference in mortality and morbidity rates in group A and group B. Conclusions: A successful outcome after a major LR depends on many factors: preserved preoperatively liver function, definitive bilio- and hemostasis on the resection surface, as minimal as possible blood loss and prevention of postoperative biliary hypertension. In our study, we found that an AnatLR is an aggressive and risky procedure for acute liver failure, while a precise AtypLR may guarantee also a low rate of SPCR. The advantages and disadvantages of both techniques must be researched based on late results in oncologic cases

Non-Colorectal Liver Metastases - Where Are the Limits of a Reasonable Aggressive Surgical Approach in the Multimodal Treatment Scheme?

Background: Resection of non-colorectal liver metastases (NCRLM) is one of the recent fields in hepatic surgery. It was just 10-12 years ago when those procedures were totally denied as `risky` and `useless` and therefore, they were performed as an exception. Aim: The aim of this paper is to present analyses of early and late postoperative results in our series of resections of NCRLM, discussion of the indications for surgery and evaluation of the possible benefit of surgery as an element of multimodal treatment scheme. Materials and Methods: The study design was a single-center retrospective and prospective for a 9-year period (January 1, 2007-December 31, 2015). A total of 62 patients received R0 resections of metachronous and synchronous NCRLM. Metastatic pancreatic and gastric cancer cases predominated (n=49, 80.3%). The indications for aggressive surgery included age ≤ 60(65) years, absence of serious concomitant diseases, ASA ≤ III, no data of other distant organ involvement, no peritoneal lesions, no local recurrence (in metachronous cases) and resectable primary tumor (in synchronous cases). The early postoperative results were analyzed and outpatient follow-up was done every 3 months. Disease-free survival (DFS) and overall survival (OAS) rates were studied. Results: The early postoperative mortality rate was 4.2% in the whole series (2 fatal outcomes in gastric and 1 in pancreatic NCRLM). The specific morbidity rate was very high (N=33, 54.1%) and more often ascertained after multivisceral resections of synchronous NCRLM but 84.8% of them were treated by conservative or interventional methods. Reoperation was performed on 5 patients (15.2%). Fifty-six patients (91.8%) were followed for ≥12 months or until the patient`s death was registered. DFS (8.9-22.4 months) and OAS rates (10.7-57.3 months) varied in broad range and demonstrated statistical dependence on the primary tumor location, time of detection and „N`, „G` and `R` categories. Conclusion: Indicated and reasonable resections of synchronous and metachronous NCRLM had morbidity and mortality rates comparable to that of other multivisceral resections and they lead to a positive impact on the survival rates and the quality of life