Early and Long-Term Outcomes of Patients Undergoing Liver Resection and Diaphragm Excision for Advanced Colorectal Liver Metastases

Abstract

Ann RC oll Surg Engl 2009; 91:4 83-488 483Colorectal carcinoma is common in the Western world. 1,2 Approximately 50% of patients diagnosed with the disease develop liver metastases. 3,4 Currently,f or patients with colorectal liver metastases, liver resection offers the only potential chance for cure. However,t he proportion of patients with colorectal liver metastasese ligible for liver resection remains low (20-30%), 5,6 although there has been asteady increase over the past 10-15 years, [1][2][3][4] largely due to improvements in pre-operative assessment and selection and the use of neo-adjuvant chemotherapy.Studies have reported factors that influence early and long-term survival. 7-10Over the past 10 years in our unit, it was felt that diaphragm invasion and subsequent diaphragm excision at the time of liver resection predicted an adverse outcome. To the authors' knowledge there have not been any reports in the literature focusing on diaphragm excision with liver resection for colorectal liver metastases.Therefore, this study was undertaken to compare those patients who had liver resection and diaphragm excision with those who had liver resection alone, for colorectal liver metastases. Patients and MethodsAtotal of 285 consecutive completed liver resections for colorectal liver metastases in asingle unit over a10-year period (September 1996 to November 2006) were studied. Of these, 27 patients underwent liver resection and diaphragm excision simultaneously and 258 underwent liver resection At present, liver resection offers the best long-term outcome and only chance for cure in patients with colorectal liver metastases. However,t here are no large series that report the early and long-term outcomes of patients who require simultaneous diaphragm excision. This study was designed to investigate these patients.

Surgical outcome of extended liver resections for colorectal liver metastasis compared with standard liver resections

“…Currently, most institutions conduct a preoperative examination with CT and MRI, and these imaging modalities have been improved; nevertheless, it remains difficult to determine whether a hepatic tumor has invaded an adjacent organ or not. Previously, the rate of proven pathological invasions into adjacent organs associated with colorectal liver metastasis has ranged from 15 to 44% (8,24), and the rate of confirmed pathological invasions in this study was within that range. Previous studies have identified several indicators for supporting a preoperative diagnosis of invasion into an adjacent organs (24)(25)(26).…”

“…Around 2010, several authors reported that liver resections combined with a simultaneous diaphragm excision resulted in high morbidity (44%) but relative low mortality (3-7%) compared to a liver resection alone for advanced colorectal liver metastases (8,9). In contrast, conscerning about hepatectomy combined with a IVC resection, several studies reported high morbidity and mortality (40-43 and 8-11% respectively) (11,18,19).…”

“…Only a few studies have reported on long-term outcomes for a hepatectomy combined with either a diaphragm excision or IVC resection. Lordan et al reported that a liver resection with a simultaneous diaphragm resection had a worse long-term outcome than a liver resection alone (5-year overall survival rate, 19.6 vs. 62%; 3-year diseasefree survival rate, 22.1 vs. 50.7%, respectively (8). However, those authors stated that the prognosis for an extended resection was superior to chemotherapy alone.…”

“…Adjacent organs involved with metastatic liver tumors are mainly the diaphragm and inferior vena cava (IVC). Previously, a liver resection with a simultaneous diaphragm excision was associated with a greater incidence of perioperative morbidity and a significantly worse longterm outcome than liver resection alone (8,9). In addition, the only treatment modality for curing a primary or metastatic liver tumor that invaded IVC was an aggressive hepatectomy combined with resection and reconstruction of IVC, which is a challenging treatment with high morbidity and mortality rates (10,11).…”

‘Close Shave’ in liver resection for colorectal liver metastases

“…We adopted a policy in 1996 of standard neo-adjuvant chemotherapy followed by liver surgery for synchronous and early (<2years) metachronous CRLM, and for late metachronous (>2years) CRLM who were considered to have potentially threatened resection margins on pre-operative imaging [20][21][22][23] . The aim of this study was to analyse the effects of width of resection margin as a predictor of outcome in this setting.…”