TY - JOUR
AU - Gayet, B
AB - Abstract Background Despite the gradual diffusion of laparoscopic liver resection, the feasibility and results of laparoscopic two-stage hepatectomy (TSH) for bilobar colorectal liver metastases (CRLM) have not been described frequently. This study aimed to evaluate the feasibility, safety and oncological outcomes of laparoscopic TSH for bilobar CRLM. Methods All patients eligible for laparoscopic TSH among those treated for bilobar CRLM from 2000 to 2013 were included. Demographics, tumour characteristics, surgical procedures, and short- and long-term outcomes were analysed. Results Laparoscopic TSH was planned in 34 patients with bilobar CRLM, representing 17·2 per cent of all 198 patients treated for bilobar CRLM. Thirty patients received preoperative chemotherapy, and 20 had portal vein occlusion to increase the volume of the remnant liver. Laparoscopic resection of the primary colorectal tumour was integrated within the first-stage hepatectomy in 11 patients. After a median interval of 3·1 months, 26 patients subsequently had a successful laparoscopic second-stage hepatectomy, including 18 laparoscopic right or extended right hepatectomies. The mortality rate for both stages was 3 per cent (1 of 34), and the overall morbidity rate for the first and second stages was 50 per cent (17 of 34) and 54 per cent (14 of 26) respectively. Mean length of hospital stay was 6·1 and 9·0 days respectively. With a median follow-up of 37·8 (range 6–129) months, 3- and 5-year overall survival rates in patients who completed TSH were 78 and 41 per cent respectively. The 3- and 5-year disease-free survival rates were 26 and 13 per cent respectively. Conclusion Laparoscopic TSH for bilobar CRLM is safe and does not jeopardize long-term outcomes in selected patients. Introduction The majority of patients with colorectal liver metastases (CRLM) present with unresectable disease at the time of diagnosis, and only 15–25 per cent can be offered complete resection of metastases1. Although hepatectomy remains the only potentially curative treatment and provides long-term survival, extensive bilobar CRLM still remain a therapeutic challenge for both oncologists and surgeons. In this situation, two-stage hepatectomy (TSH) has emerged as a valuable curative strategy when marginally resectable bilateral CRLM cannot be removed by a single hepatectomy owing to the risk of liver failure. TSH has improved resectability rates by 10–50 per cent in such patients2–5. However, the two main concerns of this strategy are considerable morbidity and a high risk of progression after the first stage, leading to a reported drop-out rate of 15–30 per cent6. Recent development of laparoscopic devices and accumulation of expertise in laparoscopic liver resection have gradually extended the indications for laparoscopy from minor7–10 to major11–21 hepatectomies during the past decade, with potential advantages over open surgery22,23. Although TSH by an open approach is now considered the standard of care for patients with multiple bilobar CRLM in specialized hepatopancreatobiliary centres, the feasibility of and long-term survival following laparoscopic TSH are still under scrutiny, with few procedures reported so far24,25. The aim of this study was, therefore, to evaluate the feasibility, safety and long-term results of laparoscopic TSH for bilobar CRLM. Methods All consecutive patients who underwent surgery for bilobar CRLM with curative intent at Institut Mutualiste Montsouris, between January 2000 and December 2013, were analysed retrospectively from a prospectively maintained database. Patients were considered for laparoscopic TSH when removal of all CRLM with tumour-free margins was deemed impossible using a single laparoscopic liver procedure (even in combination with additional techniques). Patients requiring laparoscopic TSH for reasons other than insufficient volume and those undergoing associating liver partition and portal vein ligation for staged hepatectomy were excluded from the study. All included patients gave informed consent for analysis of data for scientific purposes. Preoperative evaluation before first-stage hepatectomy Patients with bilobar CRLM routinely underwent induction chemotherapy with or without targeted therapy before the first hepatectomy, except the subgroup with a symptomatic primary tumour. The response to chemotherapy and potential resectability were assessed every 2 months by CT using the Response Evaluation Criteria in Solid Tumours (RECIST)26. The decision to perform a hepatectomy was taken when the overall surgical strategy could achieve complete tumour resection and the disease was controlled by chemotherapy. Only patients who exhibited adequate downstaging or stable disease were considered for TSH. Patients with disease progression while receiving chemotherapy were excluded. Two-stage hepatectomy During the first stage, non-anatomical liver resections were performed mainly with or without radiofrequency ablation (RFA), regardless of the number of CRLM in the future remnant liver. RFA was used only in combination with surgery to treat unresectable deeply located remnant lesions smaller than 25 mm. In patients presenting with synchronous CRLM, laparoscopic clearance of liver metastases was achieved simultaneously during resection of the primary tumour. Portal vein occlusion (PVO) was carried out if the anticipated R0 resection would not have left at least 30 per cent of the liver volume with adequate inflow and outflow, estimated by CT after the first stage6,27. PVO included portal vein embolization and/or laparoscopic portal vein ligation, which could be performed during the first-stage procedure. After recovery, the decision to administer systemic chemotherapy to control tumour progression while awaiting liver regeneration was made on an individual basis. Surgical procedures Resection of the CRLM was conducted with the intention of obtaining a 1-cm tumour-free margin, when possible. During liver transection, the central venous pressure was maintained at less than 5 mmHg by strict control of intravenous fluid administration to reduce venous bleeding from the liver. Briefly, laparoscopic liver resection was performed using five or six ports20,21. The main hepatic pedicle was clamped only in the event of bleeding. The resected specimen was placed in a plastic bag and retrieved preferably through a suprapubic incision without muscle sectioning. Abdominal drainage was used only if there was concern about intraoperative bile control or haemostasis, regardless of the approach. Combined colorectal resections were performed by the same surgical team. Even if conversion to open surgery was required during the first stage, the laparoscopic approach was attempted for the second-stage hepatectomy. Postoperative outcomes and data collection Liver failure was defined according to the ‘50–50 criteria’ on postoperative day 528, and biliary leakage was defined by a bilirubin concentration in the drainage fluid more than threefold higher than that in serum29. Postoperative complications were stratified according to the Dindo–Clavien classification30, which defines major complications as those graded IIIB or more. Both complications and operative mortality were considered as those occurring within 90 days of surgery, or at any time during the postoperative hospital stay. The pathological surgical margin was categorized as either macroscopically positive (R2), microscopically positive (R1) or negative (R0). In patients previously treated with prolonged chemotherapy, administration of adjuvant chemotherapy was discussed on an individual basis. After discharge, patients were seen at the outpatient clinic for clinical examination, assessment of biological markers (carcinoembryonic antigen, carbohydrate antigen 19-9) and CT 1 month after discharge, every 3 months for the first 2 years and every 6 months until 5 years after surgery. Overall survival and disease-free survival (DFS) were the main endpoints of the study, and were calculated from the date of the first hepatectomy to the first recurrence. Statistical analysis Continuous data are presented as mean(s.d.) or median (i.q.r. or range) depending on the normality of distribution, and were compared by means of Student's t test or Wilcoxon test, as appropriate. Qualitative variables were analysed using χ2 test. Survival curves were calculated according to the Kaplan–Meier method and compared using the log rank test. All tests were bilateral, and P < 0·050 was considered statistically significant. All statistical analyses were performed with SPSS® version 20.0 (IBM, Armonk, New York, USA). Results Among the 39 patients considered for TSH, the strategy was not performed fully by a laparoscopic approach in five owing to insufficient future remnant liver volume. A total of 34 patients were scheduled for a completely laparoscopic TSH, and 26 completed the second-stage hepatectomy; the overall feasibility rate of the whole strategy was 67 per cent (26 of 39). Eight patients failed to complete the second procedure because of diffuse intrahepatic disease progression after the first hepatectomy, including three who developed concomitant extrahepatic metastases. All these patients died within 2 years after surgery. Patient characteristics Characteristics of the 34 patients scheduled for laparoscopic TSH for bilobar CRLM are detailed in Table 1. The mean number of metastases was 6·0(7·1), and metastases were synchronous with the primary colorectal tumour in 25 patients. Mean size of the largest metastasis was 40(70) mm at diagnosis. Concomitant extrahepatic disease was present in two patients, located in the lungs in one patient and the para-aortic lymph nodes in the other. Compared with patients in whom both resections were completed laparoscopically, those with failed procedures had similar tumour characteristics, except for a larger number of lesions in the right liver (mean 9·2 versus 6·4; P = 0·028). Table 1 Baseline data for patients scheduled for laparoscopic two-stage hepatectomy for bilobar colorectal metastases . No. of patients* . Patient Age (years)† 62(8) Sex ratio (M : F) 23 : 11 Body mass index (kg/m2)† 26(4) Primary tumour Site Colon 23 Rectum 11 Tumour category T2 2 T3 24 T4 8 Node-positive 25 Liver metastases Synchronous presentation 25 Total no. of lesions† 6·0(7·1) No. of lesions in left liver† 3·1(1·7) Largest nodule > 30 mm 19 Baseline CEA (ng/ml)† 32(100) Chemotherapy Before first hepatectomy 30 Before second hepatectomy 15 After second hepatectomy 12 . No. of patients* . Patient Age (years)† 62(8) Sex ratio (M : F) 23 : 11 Body mass index (kg/m2)† 26(4) Primary tumour Site Colon 23 Rectum 11 Tumour category T2 2 T3 24 T4 8 Node-positive 25 Liver metastases Synchronous presentation 25 Total no. of lesions† 6·0(7·1) No. of lesions in left liver† 3·1(1·7) Largest nodule > 30 mm 19 Baseline CEA (ng/ml)† 32(100) Chemotherapy Before first hepatectomy 30 Before second hepatectomy 15 After second hepatectomy 12 * Unless indicated otherwise; † values are mean(s.d.). CEA, carcinoembryonic antigen. Open in new tab Table 1 Baseline data for patients scheduled for laparoscopic two-stage hepatectomy for bilobar colorectal metastases . No. of patients* . Patient Age (years)† 62(8) Sex ratio (M : F) 23 : 11 Body mass index (kg/m2)† 26(4) Primary tumour Site Colon 23 Rectum 11 Tumour category T2 2 T3 24 T4 8 Node-positive 25 Liver metastases Synchronous presentation 25 Total no. of lesions† 6·0(7·1) No. of lesions in left liver† 3·1(1·7) Largest nodule > 30 mm 19 Baseline CEA (ng/ml)† 32(100) Chemotherapy Before first hepatectomy 30 Before second hepatectomy 15 After second hepatectomy 12 . No. of patients* . Patient Age (years)† 62(8) Sex ratio (M : F) 23 : 11 Body mass index (kg/m2)† 26(4) Primary tumour Site Colon 23 Rectum 11 Tumour category T2 2 T3 24 T4 8 Node-positive 25 Liver metastases Synchronous presentation 25 Total no. of lesions† 6·0(7·1) No. of lesions in left liver† 3·1(1·7) Largest nodule > 30 mm 19 Baseline CEA (ng/ml)† 32(100) Chemotherapy Before first hepatectomy 30 Before second hepatectomy 15 After second hepatectomy 12 * Unless indicated otherwise; † values are mean(s.d.). CEA, carcinoembryonic antigen. Open in new tab Before the first hepatectomy, 30 patients received systemic chemotherapy with a median of 1 (i.q.r. 1–3) regimens (Table 1). The remaining four patients received adjuvant chemotherapy after resection of the primary tumour. Response and stabilization of the disease were observed in 16 and 18 patients respectively. Fifteen patients received chemotherapy between the two procedures. Chemotherapy was continued after the second hepatectomy in 12 patients, with a median interval before starting of 23 (i.q.r. 18–37) days. Laparoscopic procedures First-stage laparoscopic liver resections consisted of minor hepatectomies in 29 patients, including non-anatomical resections in 26 (Table 2). During the first stage, five patients underwent laparoscopic major hepatectomy, including three left or extended left hepatectomies. These three patients had reverse TSH, with major hepatectomy in the first stage followed by multiple atypical resections of the contralateral liver in the second stage because of multiple lesions in segments II, III and IV, and several peripheral lesions in the right lobe. One patient required an intraoperative blood transfusion, and two had conversion to open surgery owing to intraoperative bleeding and a T4 rectal cancer. Abdominal drains were placed in four patients at the end of the first hepatectomy; the indication for this was a low rectal anastomosis in three of these patients. The median interval between the two liver resections was 3·1 (range 0·9–10·0) months. This time interval was justified by major complications after the first hepatectomy in four patients, adjuvant chemotherapy in four additional patients who did not receive chemotherapy before the first step, and unsatisfactory hypertrophy after PVO in two patients. PVO was used in 20 patients to increase the volume of the remnant liver. This procedure was carried out either during or after the first hepatectomy in five and 15 patients respectively. Table 2 Comparison of operative data between first and second hepatectomy . First hepatectomy (n = 34) . Second hepatectomy (n = 26) . P† . Pure laparoscopy 34 26 – Major hepatectomy (≥ 3 segments) 5 21 < 0·001 Type of resection < 0·001 Anatomical 8 22 Non-anatomical 25 0 Both 1 4 Tumour location 0·002 Anterior segments 13 19 Posterior segments 3 16 Left lobe 29 2 Inflow clamping 2 2 0·505 Duration (min)* 10 14 > 60 min 0 0 Associated RFA 3 2 0·784 Combined primary resection – Right colectomy 3 0 Left colectomy 1 0 Sigmoidectomy 4 0 Rectal excision 3 0 Combined portal vein ligation 5 – – Duration of surgery (min)* 210(114) 250(139) 0·217‡ Blood loss (ml)* 150(143) 250(203) < 0·001‡ Transfusion 1 4 0·021 Conversion to open surgery 2 4 0·052 Abdominal drainage 4 3 0·108 . First hepatectomy (n = 34) . Second hepatectomy (n = 26) . P† . Pure laparoscopy 34 26 – Major hepatectomy (≥ 3 segments) 5 21 < 0·001 Type of resection < 0·001 Anatomical 8 22 Non-anatomical 25 0 Both 1 4 Tumour location 0·002 Anterior segments 13 19 Posterior segments 3 16 Left lobe 29 2 Inflow clamping 2 2 0·505 Duration (min)* 10 14 > 60 min 0 0 Associated RFA 3 2 0·784 Combined primary resection – Right colectomy 3 0 Left colectomy 1 0 Sigmoidectomy 4 0 Rectal excision 3 0 Combined portal vein ligation 5 – – Duration of surgery (min)* 210(114) 250(139) 0·217‡ Blood loss (ml)* 150(143) 250(203) < 0·001‡ Transfusion 1 4 0·021 Conversion to open surgery 2 4 0·052 Abdominal drainage 4 3 0·108 * Values are mean(s.d.). RFA, radiofrequency ablation. † χ2 test, except ‡ Student's t test. Open in new tab Table 2 Comparison of operative data between first and second hepatectomy . First hepatectomy (n = 34) . Second hepatectomy (n = 26) . P† . Pure laparoscopy 34 26 – Major hepatectomy (≥ 3 segments) 5 21 < 0·001 Type of resection < 0·001 Anatomical 8 22 Non-anatomical 25 0 Both 1 4 Tumour location 0·002 Anterior segments 13 19 Posterior segments 3 16 Left lobe 29 2 Inflow clamping 2 2 0·505 Duration (min)* 10 14 > 60 min 0 0 Associated RFA 3 2 0·784 Combined primary resection – Right colectomy 3 0 Left colectomy 1 0 Sigmoidectomy 4 0 Rectal excision 3 0 Combined portal vein ligation 5 – – Duration of surgery (min)* 210(114) 250(139) 0·217‡ Blood loss (ml)* 150(143) 250(203) < 0·001‡ Transfusion 1 4 0·021 Conversion to open surgery 2 4 0·052 Abdominal drainage 4 3 0·108 . First hepatectomy (n = 34) . Second hepatectomy (n = 26) . P† . Pure laparoscopy 34 26 – Major hepatectomy (≥ 3 segments) 5 21 < 0·001 Type of resection < 0·001 Anatomical 8 22 Non-anatomical 25 0 Both 1 4 Tumour location 0·002 Anterior segments 13 19 Posterior segments 3 16 Left lobe 29 2 Inflow clamping 2 2 0·505 Duration (min)* 10 14 > 60 min 0 0 Associated RFA 3 2 0·784 Combined primary resection – Right colectomy 3 0 Left colectomy 1 0 Sigmoidectomy 4 0 Rectal excision 3 0 Combined portal vein ligation 5 – – Duration of surgery (min)* 210(114) 250(139) 0·217‡ Blood loss (ml)* 150(143) 250(203) < 0·001‡ Transfusion 1 4 0·021 Conversion to open surgery 2 4 0·052 Abdominal drainage 4 3 0·108 * Values are mean(s.d.). RFA, radiofrequency ablation. † χ2 test, except ‡ Student's t test. Open in new tab At the second-stage operation, major resections were performed in 21 patients, including 18 laparoscopic right or extended right hepatectomies. Minimal adhesions were found in the second-stage procedure in 18 patients, whereas the remaining eight patients had moderate adhesions (including the 2 whose operations were converted during the first hepatectomy). Intraoperative blood transfusion was required in one patient during the first resection and in four during the second procedure (P = 0·021) (Table 2). Pathology and postoperative outcomes The rate of R0 margin clearance was similar between the first and the second stages: 96 per cent (89 of 93 resected tumours) versus 92·4 per cent (122 of 132) (P = 0·908). The rates of overall postoperative complications were comparable between the first- and second-stage hepatectomies: 50 per cent (17 of 34) and 54 per cent (14 of 26) respectively (P = 0·895). However, after exclusion of the 11 patients who had concomitant primary resection, the morbidity was significantly higher after the second stage: 54 per cent (14 of 26) versus 26 per cent (6 of 23) (P = 0·002). Major complications did not occur more frequently after the second hepatectomy: 27 per cent (7 of 26) versus 12 per cent (4 of 34) (P = 0·103). One patient died within 2 months after the second-stage hepatectomy. This patient developed progressive liver failure and died 49 days after right hepatectomy. Reoperation was necessary in two patients after the first hepatectomy for small bowel occlusion or anastomotic leakage, and in one patient after the second hepatectomy for a non-drained biliary leak. All reoperations were performed laparoscopically. Finally, hospital stay was longer after the second-stage hepatectomy compared with the first stage (mean 9·0 versus 6·1 days; P = 0·022) (Table 3). Table 3 Comparison of postoperative outcomes between first and second hepatectomy . First hepatectomy (n = 34) . Second hepatectomy (n = 26) . P‡ . Postoperative death 0 1 0·718 Overall complications 17 14 0·895 Liver-specific complications† 5 8 0·003 Biliary leakage 2 4 Liver failure 1 4 Ascites 1 2 Intra-abdominal abscess 1 4 General complications† 13 6 0·020 Fever 3 2 Cardiopulmonary 1 2 Ileus 3 0 Urinary infection 2 0 Anastomotic leakage 3 – Other 2 2 Postoperative major complication 4 7 0·103 Biliary leakage 2 3 Liver failure 0 2 Severe respiratory insufficiency 1 1 Anastomotic leakage 1 – Other 1 1 Reoperation 2 1 0·830 Length of hospital stay (days)* 6·1(5·2) 9·0(8·2) 0·022§ . First hepatectomy (n = 34) . Second hepatectomy (n = 26) . P‡ . Postoperative death 0 1 0·718 Overall complications 17 14 0·895 Liver-specific complications† 5 8 0·003 Biliary leakage 2 4 Liver failure 1 4 Ascites 1 2 Intra-abdominal abscess 1 4 General complications† 13 6 0·020 Fever 3 2 Cardiopulmonary 1 2 Ileus 3 0 Urinary infection 2 0 Anastomotic leakage 3 – Other 2 2 Postoperative major complication 4 7 0·103 Biliary leakage 2 3 Liver failure 0 2 Severe respiratory insufficiency 1 1 Anastomotic leakage 1 – Other 1 1 Reoperation 2 1 0·830 Length of hospital stay (days)* 6·1(5·2) 9·0(8·2) 0·022§ * Values are mean(s.d.). † Some patients had both liver-specific and general complications. ‡ χ2 test, except § Student's t test. Open in new tab Table 3 Comparison of postoperative outcomes between first and second hepatectomy . First hepatectomy (n = 34) . Second hepatectomy (n = 26) . P‡ . Postoperative death 0 1 0·718 Overall complications 17 14 0·895 Liver-specific complications† 5 8 0·003 Biliary leakage 2 4 Liver failure 1 4 Ascites 1 2 Intra-abdominal abscess 1 4 General complications† 13 6 0·020 Fever 3 2 Cardiopulmonary 1 2 Ileus 3 0 Urinary infection 2 0 Anastomotic leakage 3 – Other 2 2 Postoperative major complication 4 7 0·103 Biliary leakage 2 3 Liver failure 0 2 Severe respiratory insufficiency 1 1 Anastomotic leakage 1 – Other 1 1 Reoperation 2 1 0·830 Length of hospital stay (days)* 6·1(5·2) 9·0(8·2) 0·022§ . First hepatectomy (n = 34) . Second hepatectomy (n = 26) . P‡ . Postoperative death 0 1 0·718 Overall complications 17 14 0·895 Liver-specific complications† 5 8 0·003 Biliary leakage 2 4 Liver failure 1 4 Ascites 1 2 Intra-abdominal abscess 1 4 General complications† 13 6 0·020 Fever 3 2 Cardiopulmonary 1 2 Ileus 3 0 Urinary infection 2 0 Anastomotic leakage 3 – Other 2 2 Postoperative major complication 4 7 0·103 Biliary leakage 2 3 Liver failure 0 2 Severe respiratory insufficiency 1 1 Anastomotic leakage 1 – Other 1 1 Reoperation 2 1 0·830 Length of hospital stay (days)* 6·1(5·2) 9·0(8·2) 0·022§ * Values are mean(s.d.). † Some patients had both liver-specific and general complications. ‡ χ2 test, except § Student's t test. Open in new tab Recurrences After a median follow-up of 37·8 (range 6–129) months, disease recurrence was observed in 21 patients, at isolated hepatic and extrahepatic sites in ten and six patients respectively. Combined intrahepatic and extrahepatic recurrences developed in the five remaining patients. Recurrences were treated with curative intent in eight patients: six patients had a third hepatectomy (including 1 with combined totally thoracoscopic lung wedge resection and 1 with para-aortic lymphadenectomy), one patient had totally thoracoscopic lung wedge resection for an isolated lung recurrence, and the final patient had surgery for local pelvic recurrence. At last follow-up, 17 of the 34 patients were alive, of whom six were free from disease. The other 17 patients had died from disease progression. Overall, the 26 patients who completed the two-stage procedure underwent 58 hepatectomies, seven extrahepatic resections and 11 RFA procedures, giving a total of 76 procedures (2·9 per patient). Overall and disease-free survival The 5-year overall survival rate for the 34 patients, calculated from the time of first hepatectomy, was 31 per cent. Three- and 5-year overall survival rates for patients in whom both hepatectomies were completed were 78 and 41 per cent respectively after the first hepatectomy. Overall survival was significantly better than in the eight patients who did not complete the two-stage strategy (P < 0·001). Median survival for these eight patients was 9·7 months while it was 55 months in the group that did complete the two-stage strategy. In the whole population, 3- and 5-year DFS rates were 26 and 13 per cent respectively. Discussion Advances in both chemotherapy efficacy and surgical techniques have led to more aggressive surgical management of patients with bilobar CRLM. Even though many series2–6 in the literature have reported favourable results after open TSH, publications on the laparoscopic approach to TSH have remained limited24,25. The acceptable short-term outcomes in the present study, such as low conversion rate, small amount of blood loss and limited morbidity, suggest that this complex surgery is feasible and safe using the laparoscopic approach in expert centres. Additionally, the laparoscopic approach does not have a negative effect on the oncological course of patients treated with TSH for bilobar CRLM. Although the feasibility of completion of both stages of hepatectomy has been of some concern, in the present study the second stage was completed in almost 80 per cent of patients (26 of 34). This high success rate can be explained partly by the stringent patient selection for laparoscopic TSH, including a very limited number of patients with extrahepatic disease. Furthermore, the fact that no patient was alive at 3 years if the second stage could not be achieved emphasizes that only patients who successfully completed the TSH could benefit from this strategy6,31. As this strategy requires both limited and major resections, in anterior but also in posterior segments of the liver, laparoscopic TSH obviously requires a high degree of expertise in both advanced laparoscopy and hepatobiliary surgery. In addition, the second-stage procedure is technically more demanding than a standard right hepatectomy, as the operation is often complicated by dense abdominal and perihepatic adhesions, anatomical alteration in the hypertrophied remnant liver and chemotherapy-induced liver injury. In this setting, the present series suggests that the laparoscopic approach minimizes the formation of adhesions, which facilitates the second stage. The potential surgical morbidity associated with TSH has also been an area of ongoing concern with the laparoscopic approach. Although it may be expected that laparoscopy would decrease postoperative complications, the considerable morbidity after first-stage hepatectomy may have been the result of a high rate of general complications related to combined resection of the primary tumour. Interestingly, the 3- and 5-year overall survival rates for patients in whom laparoscopic TSH was completed in the present series were comparable to those reported in recent series4,6,31 that included patients operated on by an open approach. These results suggest that the laparoscopic approach does not negatively affect the oncological course of patients treated with TSH for bilobar CRLM. Although the role of perioperative chemotherapy in improving DFS in patients with resectable CRLM has been demonstrated clearly32, only one-third of patients received adjuvant chemotherapy in the present series. All these patients with bilobar CRLM had been treated previously with prolonged chemotherapy, including one or two different lines. In this setting, the administration of chemotherapy was decided according to the cumulative toxicity of oxaliplatin and the tumoral response on the specimen. Adjuvant chemotherapy was also reserved to be given at the time of recurrence, given the high risk of relapse in this subgroup of patients with advanced disease. This study has several limitations. First, it is a retrospective analysis, with a limited sample size and a clear selection of patients. The selected population is heterogeneous, given that some patients underwent combined colorectal resection, patients were treated for either synchronous or metachronous CRLM, and some procedures were associated with RFA. 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TI - Laparoscopic two-stage hepatectomy for bilobar colorectal liver metastases
JO - British Journal of Surgery
DO - 10.1002/bjs.9945
DA - 2015-11-12
UR - https://www.deepdyve.com/lp/oxford-university-press/laparoscopic-two-stage-hepatectomy-for-bilobar-colorectal-liver-FpqpEgZddK
SP - 1684
EP - 1690
VL - 102
IS - 13
DP - DeepDyve
ER -