| Colorectal cancer is one of the most common malignant tumors, and about 700,000 new cases emerge every year around the world. Metastatic disease is the main cause of death. Nearly half of the patients develop liver metastases during the course of disease, with 15% - 25% having liver metastases at the time of primary diagnosis. Many strategies are introduced to treat colorectal liver metastases and surgical therapy is regarded as the only potential curative option. With the development of minimally invasive techniques, tumor ablative therapy have been playing more and more important role in treating patients with colorectal liver metastases, especially those with unresectable tumors. There is still no randomized clinical trial up to date comparing the effectiveness between surgical resection and local tumor ablative therapy. Although surgical treatment can provide long-term survival for these patients, postoperative recurrence was seen in 70% of the patients, and about one third of recurrence was limited to the liver. It is very important to evaluate the effect of re-resection for liver recurrence. There also exist some controversies in surgical therapy, such as the width of surgical margin, the timing of liver resection for synchronous liver metastases of colorectal origin, and the patients who are suitable for surgical treatment. To study the surgical treatment for colorectal liver metastases, 225 patients of CLM from Jan. 1996 to Apr. 2004 managed in our hospital were analyzed retrospectively.1 Surgical treatment for colorectal liver metastases(1) Comparison between hepatectomy and minimally invasive therapy for the treatment of colorectal liver metastases.Objective:To analyse the effect of hepatectomy and minimally invasive therapy on colorectal liver metastases. Methods: A total of 225 colorectal liver metastasis patients were divided into two groups named surgical group (n=195) and minimally invasive group (n=30). The clinical data of patients were collected. Comparison was performed between the two groups. Results:No patient died within 1 month in both groups. The operative morbidity was 15.4% in surgical group, versus 3.3% in minimally invasive group( P<0.05). The 1-, 3- and 5- year cumulative survival rates for patients who received hepatectomy were 87.7%,49.9% and 23.2%, respectively, compared with 77.42%,20.22% and 0% in minimally invasive group. Patients who underwent hepatectomy had significantly higher survival rates than those who did not (P<0.01). The 1-year survival and 1-year disease-free survival were similar in two groups (P>0.05). The average period of hospital stay was 22.2 days in surgical group, which is longer than that(15.9 days) in minimally invasive group (P<0.05). Conclusion:The superiority of hepatectomy to minimally invasive therapy further supports its status as the preferred choice of treatment for colorectal liver metastases. Minimally invasive therapy is more suitable for patients with operative contraindication or patients who refuse operation.(2)Repeat hepatectomy for post-operative recurrence of colorectal liver metastasesObjective:To explore the effect of repeat hepatectomy on post-operative recurrence of colorectal liver metastases. Methods: A consecutive 195 colorectal liver metastases were followed up after initial hepatectomy. Post-operative recurrence was seen in 153 patients. Repeat hepatectomy was performed in 20 of them, while non-surgical treatment was given to the other 133 patients. The influence of repeat hepatectomy on survival was analysed. Results:No patient died within 1 month after repeat hepatectomy, and the operative morbidity was 20%, versus 15.4% after initial hepatectomy (P>0.05). The 1-, 3- and 5- year cumulative survival rates for patients who received repeat hepatectomy were 89.5%,44.7% and 16.0%, respectively, which were similar to those seen after initial hepatectomy (P>0.05). When measured from the time of initial hepatic resection, the median survival was 43.2 months, with 1-, 3- and 5-year survival rates of 100%, 54.2% and 48.8%, respectively, which were significantly higher than those of patients who had received hepatectomy only once (P<0.05). When measured from the time of primary colorectal resection, patients who received repeat hepatectomy had significantly prolonged survival than those who received hepatectomy only once, with 5-year survival rate of 55.3% versus 35.1% (P<0.05). When re-resection was not performed, no patient survived five years from the onset of recurrence after initial hepatectomy, the result was worse than that of patients who received repeat hepatectomy. Conclusion:The benefit of repeat hepatectomy observed in selected patient further support its status as the preferred choice of treatment for post-operative recurrence of colorectal liver metastases, when all hepatic recurrent tumors can be removed with safety.(3)Surgical margin of hepatectomy for colorectal liver metastasesObjective:To explore the width of surgical margin of hepatectomy for colorectal liver metastases. Methods:A consecutive 195 colorectal liver metastases received hepatectomy with potentially curative intent, 14 patients were exclude from study for concomitant extra-hepatic disease. All 181 patients were divided into four groups according to the width of surgical margin: group A (width<2mm), group B (2mm≤width<5mm), group C (5mm≤width<10mm), and group D (≥10 mm). Survival was compared in different groups. Results: All surgical margins were confirmed negative tumor invasion with pathology. The 1-, 3- and 5- year cumulative survival rates in group A were 82.9%,34.2% and 15.7%, respectively; 94.4%,60.6% and 28.3% in group B; 96.7%,59.1% and 35.6% in group C; 93.7%,67.5% and 28.2% in group D. The survival rates in group A were much lower than those in other three groups (P<0.05). When surgical margin width exceeds 2mm, the survival rates of the three group were similar (P>0.05). Conclusion:Hepatectomy with surgical margin width less than 2 mm may result in a bad prognosis. When surgical margin width exceeds 2mm, the width exerts no significant influence on survival."Two millimeter surgical margin"was recommended to hepatectomy for patients with colorectal liver metastases.(4)Timing of hepatectomy for synchronous colorectal liver metastasesObjective:To explore the timing of hepatectomy for synchronous colorectal liver metastases. Methods: A consecutive 74 patients with synchronous colorectal liver metastases were divided into two groups. Forty-seven patients who received hepatectomy and primary colorectal resection simultaneously were defined as synchronous group, and the other 27 patients who received hepatectomy and primary resection separately were defined as metachronous group. Comparison was performed between the two groups. Results:No patient died within 1 month in either group. The operative morbidity was 19.1% in synchronous group, which is similar to that in metachronous group (11.1%, P>0.05). The 1-, 3- and 5- year cumulative survival rates in synchronous group were 89.4%,42.4% and 11.4%, respectively, versus 81.5%,50.4% and 19.6% in metachronous group (P>0.05). Blood transfusion needed in synchronous group is more than that in metachronous group (P<0.05). Conclusion: Liver metastases and primary colorectal tumor can be resected simultaneously due to the similar survival in both groups.2 Indicators of prognosis after hepatectomy for colorectal liver metastasesObjective:To identify factors that influence patient's survival following hepatectomy for colorectal liver metastases. Methods: A total of 195 colorectal liver metastases patients who received hepatectomy were enrolled in this study. Twelve factors which were likely to influence survival after hepatectomy were collected. Univariate analysis uses log-rank comparisons, Kaplan-Meier survival curves, and multivariate analysis uses Cox proportional hazards regression. Results:Among the 12 factors likely to influence survival after hepatic resection, 8 were significantly associated to outcome at univariate analysis: the size of largest metastatic tumor, the number of liver metastases, extra-hepatic disease, timing of hepatic metastases, preoperative level of CEA, blood transfusion, and some pathologic factors such as tumor differentiation and tumor envelope. Multivariate analysis uses COX proportional hazards regression. Six factors were independently associated to decreased survival: size of the largest tumor > 50mm, the number of liver metastases more than 4, presence of extra-hepatic disease, synchronous liver metastases, preoperative CEA level > 15μg/L, and absence of tumor capsule. Conclusion:Current clinical prognostic factors might be used to predict outcome, but not to exclude patients from surgery, because many patients with negative prognostic factors can also enjoy long-term survival after complete resection. In this subgroup of patients, resection should be considered individually.
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