Abstract
Background
Proctectomy after hepatectomy, or the reverse approach, is an alternative to traditional sequencing for advanced liver metastases with asymptomatic colorectal primary tumors. We sought to evaluate the surgical morbidity of proctectomy for colorectal cancer after previous liver surgery.
Methods
A single-institution colorectal database was queried for patients treated with proctectomy after previous hepatectomy from 2003 to 2011. Reverse-approach patients (n = 31) were matched 1:2 with a cohort of standard proctectomy patients (n = 62) using operation, age, gender, and surgeon. Perioperative factors were analyzed by univariate/multivariate models for associations with complications graded by Dindo–Clavien criteria.
Results
Thirty-one patients with adenocarcinoma ≤20 cm from the anal verge underwent proctectomy after hepatectomy. Median time from hepatectomy to proctectomy was 5.1 months. Median tumor distance was 8.5 cm. Before proctectomy, patients underwent 28 (90 %) major hepatectomies and 7 (22 %) portal vein embolizations. There were no perioperative deaths. Reverse-approach patients did not differ from control patients in operation, demographics, body mass index (BMI), comorbidities, tumor distance, operative time, estimated blood loss, length of stay, or complication rates (p > 0.05). Grade 2 or higher complications developed in 42 % of reverse-approach and 27 % of standard proctectomies (p = 0.17). Grade 3 or higher complications developed in 10 % and 8 %, respectively (p = 1.00). Independent predictors of complications of grade 2 or higher were BMI ≥30 kg/m2 (p = 0.007), operative time ≥300 min (p = 0.012), intraoperative transfusion (p = 0.044), concurrent procedures (p = 0.024), and age ≥50 years (p = 0.030).
Conclusions
Risk factors for morbidity of staged proctectomy are similar to those for standard proctectomy. In selected patients, the reverse-approach proctectomy is safe with acceptable morbidity.
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References
Brouquet A, Mortenson MM, Vauthey JN, et al. Surgical strategies for synchronous colorectal liver metastases in 156 consecutive patients: classic, combined or reverse strategy? J Am Coll Surg. 2010;210:934–41.
Mentha G, Majno PE, Andres A, Rubbia-Brandt L, Morel P, Roth AD. Neoadjuvant chemotherapy and resection of advanced synchronous liver metastases before treatment of the colorectal primary. Br J Surg. 2006;93:872–8.
Verhoef C, van der Pool AE, Nuyttens JJ, Planting AS, Eggermont AM, de Wilt JH. The “liver-first approach” for patients with locally advanced rectal cancer and synchronous liver metastases. Dis Colon Rectum. 2009;52:23–30.
van der Pool AE, de Wilt JH, Lalmahomed ZS, Eggermont AM, Ijzermans JN, Verhoef C. Optimizing the outcome of surgery in patients with rectal cancer and synchronous liver metastases. Br J Surg. 2010;97:383–90.
de Jong MC, van Dam RM, Maas M, et al. The liver-first approach for synchronous colorectal liver metastasis: a 5-year single-centre experience. HPB (Oxford). 2011;13:745–52.
Mentha G, Roth AD, Terraz S, et al. “Liver first” approach in the treatment of colorectal cancer with synchronous liver metastases. Dig Surg. 2008;25:430–5.
Poultsides GA, Servais EL, Saltz LB, et al. Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment. J Clin Oncol. 2009;27:3379–84.
Aloia TA, Zorzi D, Abdalla EK, Vauthey JN. Two-surgeon technique for hepatic parenchymal transection of the noncirrhotic liver using saline-linked cautery and ultrasonic dissection. Ann Surg. 2005;242:172–7.
Smith DL, Arens JF, Barnett CC Jr, Izzo F, Curley SA. A prospective evaluation of ultrasound-directed transparenchymal vascular control with linear cutting staplers in major hepatic resections. Am J Surg. 2005;190:23–9.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.
Greenblatt DY, Rajamanickam V, Pugely AJ, Heise CP, Foley EF, Kennedy GD. Short-term outcomes after laparoscopic-assisted proctectomy for rectal cancer: results from the ACS NSQIP. J Am Coll Surg. 2011;212:844–54.
Widdison AL, Barnett SW, Betambeau N. The impact of age on outcome after surgery for colorectal adenocarcinoma. Ann R Coll Surg Engl. 2011;93:445–50.
Warschkow R, Steffen T, Thierbach J, Bruckner T, Lange J, Tarantino I. Risk factors for anastomotic leakage after rectal cancer resection and reconstruction with colorectostomy. A retrospective study with bootstrap analysis. Ann Surg Oncol. 2011;18:2772–82.
Suding P, Jensen E, Abramson MA, Itani K, Wilson SE. Definitive risk factors for anastomotic leaks in elective open colorectal resection. Arch Surg. 2008;143:907–11.
Brouquet A, Abdalla EK, Kopetz S, et al. High survival rate after two-stage resection of advanced colorectal liver metastases: response-based selection and complete resection define outcome. J Clin Oncol. 2011;29:1083–90.
Aloia TA, Vauthey JN. Management of colorectal liver metastases: past, present, and future. Updates Surg. 2011;63:1–3.
Reddy SK, Pawlik TM, Zorzi D, et al. Simultaneous resections of colorectal cancer and synchronous liver metastases: a multi-institutional analysis. Ann Surg Oncol. 2007;14:3481–91.
Hillingso JG, Wille-Jorgensen P. Staged or simultaneous resection of synchronous liver metastases from colorectal cancer—a systematic review. Colorectal Dis. 2009;11:3–10.
Chun YS, Vauthey JN, Ribero D, et al. Systemic chemotherapy and two-stage hepatectomy for extensive bilateral colorectal liver metastases: perioperative safety and survival. J Gastrointest Surg. 2007;11:1498–504.
Acknowledgment
The authors thank Sa Nguyen for her management of our colorectal cancer patient database.
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Tzeng, CW.D., Aloia, T.A., Vauthey, JN. et al. Morbidity of Staged Proctectomy After Hepatectomy for Colorectal Cancer: A Matched Case–Control Analysis. Ann Surg Oncol 20, 482–490 (2013). https://doi.org/10.1245/s10434-012-2620-z
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DOI: https://doi.org/10.1245/s10434-012-2620-z