Liver metastases from colorectal cancer. Different strategies and outcomes

Patients with colorectal liver metastases (CRLM) increasingly undergo liver resections. The belief is that the resection or ablation of a tumor, when possible, is the only possibility of a cure. The classical strategy is where the primary colorectal tumor is resected as the first intervention, followed by resection of the liver metastasis at a second stage. The liver-first strategy is where preoperative chemotherapy is given, followed by resection of the liver metastases and then resection of the colorectal primary tumor at a second stage. The third option is the simultaneous strategy where the patient undergoes both liver and primary tumor resection during the same operation. The patient selection and drop-out from the planned intervention are poorly known. None of the three strategies have demonstrated any clear advantage or disadvantage in terms of survival. A repeated hepatectomy, for patients with recurrent CRLM, is increasingly performed with mostly unknown postoperative functional liver volume (FLV). Specific aims to investigate:I. Why do patients scheduled for the liver-first strategy not complete both the planned liver and primary resections? II. Compare the liver-first to the classical strategy for patients presenting with synchronous CRLM (sCRLM). III. Compare the simultaneous strategy with the classical strategy for patients presenting with sCRLM, focusing on patients undergoing major liver resections. IV. Measure liver regeneration and survival data after a repeated liver procedure (resection or ablation) for recurrent CRLM. Results and conclusions:I. Up to 35% of patients with sCRLM do not complete the planned treatment. II. The liver-first and the classical strategy did not show any overall survival difference. III. Simultaneous resections appeared to have more complications, shorter total length-of-stay but similar overall survival as patients chosen for the classical strategy. IV. We found a small change in FLV after two hepatic procedures but with a considerable inter-individual variation. Patients selected for a repeated hepatic procedure for recurrent CRLM had an acceptable survival.When choosing different strategies for sCRLM patients, our results imply that we should select according to treatment logistics, tumor symptoms, and surgical feasibility. When patients present with recurrent CRLM, a high variance in liver volume after repeated resection can be expected when planning future repeated resections

Acute pancreatitis–can evidence-based guidelines be transferred to an optimized comprehensive treatment program?

Acute pancreatitis is a common cause of hospitalization and has an incidence of about 300 per 1,000,000 inhabitants. A majority of patients with acute pancreatitis have mild disease, with an absence of local and systemic complications [1]. The clinical, translational, and experimental research in the field of acute pancreatitis is enormous and various guidelines exist. The guidelines have improved, and now increasingly use evidence-based grading, although expert opinion is still part of numerous recommendations.A persistent problem, however, is the uptake of and compliance with these guidelines. For every guideline recommendation, we should need an implementation plan and an audit. This was pointed out in an editorial in the Scandinavian Journal of Gastroenterology in 2008 [2]. It is reasonable to assume that adherence to existing management recommendations improves clinical outcomes for patients with acute pancreatitis

Repeat procedures for recurrent colorectal liver metastases : Analysis of long-term liver regeneration and outcome

Background and aim: Repeat hepatectomy is increasingly performed for the management of recurrent colorectal liver metastases (CRLM). The aim of this study was to evaluate longterm functional liver volume (FLV) after a second hepatic procedure and to measure survival outcome. Methods: In this retrospective cohort study, patients treated for recurrent CRLM in the years 2005-2015 at two liver centers were included. Total FLV was calculated before the first procedure and before and after the second procedure. Overall survival was calculated. Results: Eighty-two patients were identified. The median follow-up was 53 (40-71) months from the first procedure. The median interval between first and second procedure was 13 (8-22) months. The initial FLV was 1584 (1313-1927) mL. The FLV was 1438 (1204-1896) mL after the first procedure and 1470 (1172-1699) mL after the second procedure (P<0.001). After the second procedure, a total of ten patients (12%) had a residual liver volume of less than 75% of the initial liver volume. The 5-year overall survival was 37 (26-54)% after the second procedure. Conclusion: Small changes in FLV were found after two hepatic procedures but with considerable inter-individual variation. Patients selected for a repeated hepatic procedure for recurrent CRLM had an acceptable survival

Liver-first strategy for synchronous colorectal liver metastases : an intention-to-treat analysis

Background The liver-first strategy signifies resection of liver metastases before the primary colorectal cancer. The aim of the present study was to compare failure to complete intended treatment and survival in liver-first and classical strategies. Methods All patients with colorectal cancer and synchronous liver metastases planned for sequential radical surgery in a single institution between 2011 and 2015 were included. Results A total of 109 patients were presented to a multidisciplinary team conference (MDT) with un-resected colorectal cancer and synchronous liver metastases. Seventy-five patients were planned as liver-first, whereas 34 were recommended the classical strategy. Twenty-six patients (35%) failed to complete treatment in the liver-first group compared to 10 patients in the classical group (P = 0.664). Reason for failure was most commonly disease progression. A total of 91 patients had the primary tumor resected before the liver metastases of which 67 before referral and 24 after allocation at MDT. Median survival after diagnosis in this group was 60 (48–73) months compared to 46 (31–60) months in the group operated with liver-first strategy (n = 49), (P = 0.310). Discussion Up to 35% of patients with colorectal cancer and synchronous liver metastases do not complete the intended treatment of liver and bowel resections, irrespective of treatment strategy

Outcomes of liver-first strategy and classical strategy for synchronous colorectal liver metastases in Sweden

Background: Patients with synchronous colorectal liver metastases (sCRLM) are increasingly operated with liver resection before resection of the primary cancer. The aim of this study was to compare outcomes in patients following the liver-first strategy and the classical strategy (resection of the bowel first) using prospectively registered data from two nationwide registries. Methods: Clinical, pathological and survival outcomes were compared between the liver-first strategy and the classical strategy (2008-2015). Overall survival was calculated. Results: A total of 623 patients were identified, of which 246 were treated with the liver-first strategy and 377 with the classical strategy. The median follow-up was 40 months. Patients chosen for the classical strategy more often had T4 primary tumours (23% vs 14%, P = 0.012) and node-positive primaries (70 vs 61%, P = 0.015). The liver-first patients had a higher liver tumour burden score (4.1 (2.5-6.3) vs 3.6 (2.2-5.1), P = 0.003). No difference was seen in five-year overall survival between the groups (54% vs 49%, P = 0.344). A majority (59%) of patients with rectal cancer were treated with the liver-first strategy. Conclusion: The liver-first strategy is currently the dominant strategy for sCRLM in patients with rectal cancer in Sweden. No difference in overall survival was noted between strategies

Outcomes of Simultaneous Resections and Classical Strategy for Synchronous Colorectal Liver Metastases in Sweden : A Nationwide Study with Special Reference to Major Liver Resections

Background About 20% of patients with colorectal cancer have liver metastases at the time of diagnosis, and surgical resection offers a chance for cure. The aim of the present study was to compare outcomes for patients that underwent simultaneous resection to those that underwent a staged procedure with the bowel-first (classical) strategy by using information from two national registries in Sweden. Methods In this prospectively registered cohort study, we analyzed clinical, pathological, and survival outcomes for patients operated in the period 2008–2015 and compared the two strategies. Results In total, 537 patients constituted the study cohort, where 160 were treated with the simultaneous strategy and 377 with the classical strategy. Patients managed with the simultaneous strategy had less often rectal primary tumors (22% vs. 31%, p = 0.046) and underwent to a lesser extent a major liver resection (16% vs. 41%, p &lt; 0.001), but had a shorter total length of stay (11 vs. 15 days, p &lt; 0.001) and more complications (52% vs. 36%, p &lt; 0.001). No significant 5-year overall survival (p = 0.110) difference was detected. Twenty-five patients had a major liver resection in the simultaneous strategy group and 155 in the classical strategy group without difference in 5-year overall survival (p = 0.198). Conclusion Simultaneous resection of the colorectal primary cancer and liver metastases can possibly have more complications, with no difference in overall survival compared to the classical strategy

Hepatopancreatoduodenectomy -a controversial treatment for bile duct and gallbladder cancer from a European perspective

Background: Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. Method: Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. Results: In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. Conclusion: HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome