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Two-stage hepatectomy in resection of colorectal liver metastases – a single-institution experience with case-control matching and review of the literature

Spela Turk
Spela Turk
, 
Irena Plahuta
Irena Plahuta
, 
Tomislav Magdalenic
Tomislav Magdalenic
, 
Tajda Spanring
Tajda Spanring
, 
Kevin Laufer
Kevin Laufer
, 
Zan Mavc
Zan Mavc
, 
Stojan Potrc
Stojan Potrc
 and 
Arpad Ivanecz
Arpad Ivanecz
   | Jun 21, 2023
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Article Category: Research Article
Published Online: Jun 21, 2023
Page range: 270 - 278
Received: Mar 18, 2023
Accepted: May 15, 2023
DOI: https://doi.org/10.2478/raon-2023-0026
Keywords
© 2023 Spela Turk et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

FIGURE 1.

The study flowchart. The study period covers 1 January 2000 to 31 December 2020.ALPPS = associating liver partition and portal vein ligation for staged hepatectomy; CCM-OSH = case-control matching one-stage hepatectomy; CLMs = colorectal liver metastases; OSH = one-stage hepatectomy; PVE = portal vein embolization; PVL = portal vein ligation; RFA = radiofrequency ablation; TSH = two-stage hepatectomy
The study flowchart. The study period covers 1 January 2000 to 31 December 2020.ALPPS = associating liver partition and portal vein ligation for staged hepatectomy; CCM-OSH = case-control matching one-stage hepatectomy; CLMs = colorectal liver metastases; OSH = one-stage hepatectomy; PVE = portal vein embolization; PVL = portal vein ligation; RFA = radiofrequency ablation; TSH = two-stage hepatectomy

FIGURE 2.

Overall survival after case-control matching (TSH vs. case-control matching-OSH groups), P = 0.575.CCM-OSH = case-control matching one-stage hepatectomy; TSH = two-stage hepatectomy
Overall survival after case-control matching (TSH vs. case-control matching-OSH groups), P = 0.575.CCM-OSH = case-control matching one-stage hepatectomy; TSH = two-stage hepatectomy

Survival analysis

Overall OSH (n = 151) TSH (n = 15) P value
Median OS (months) [95% CI] 35 [30–40] 35 [31–39] 21 [17–25] 0.063
3-year OS 48% 49% 33% 0.107
5-year OS 26% 27% 13% 0.107
RFS (months) [95% CI] 11 [8–14] 11 [9–13] 5 [2–8] 0.138
3-year RFS 14% 15% 13% 0.070
5-year RFS 10% 10% 7% 0.070
After case-control matching
Overall CCM-OSH (N=14) TSH (N=15) P value
Median OS (months) [95% CI] 23 [19–27] 23 [5–41] 21 [17.0–25.0] 0.575
3-year OS 34% 36% 33% 0.743
5-year OS 17% 21% 13% 0.743
RFS (months) [95% CI] 7 [4–10] 8 [1–15] 5 [2–8] 0.888
3-year RFS 14% 14% 13% 0.498
5-year RFS 3% 0% 7% 0.498

Clinical characteristics and perioperative outcomes of the 166 patients

Clinical characteristics OSH (n=151) TSH (n=15) P value
Male sex a 109 (72.2%) 13 (86.7%) 0.365
Age (years) b 62 (34–84; 14) 64 (45–75; 12) 0.819
ASA score ≥ 3 a 32 (21.2%) 2 (13.3%) 0.701
Primary tumour location c
  Right colon 27 (17.9%) 1 (6.7%) 0.166
  Left colon 61 (40.4%) 6 (40.0%)
  Rectum 61 (40.4%) 7 (46.7%)
  > 1 primary tumour 2 (1.3%) 1 (6.7%)
Primary tumour nodal invasion a 99 (66.0%) 10 (66.7%) 1.000
Synchronous liver metastases a 81 (53.6%) 11 (73.3%) 0.179
Number of liver metastases b 3 (1–19; 3) 5 (2–12; 6) 0.001
Size of liver metastases (cm) b 4 (0.6–20; 3) 5 (1.5–11; 5.5) 0.183
Neoadjuvant chemotherapy a 79 (52.3%) 13 (86.7%) 0.013
Preoperative CEA level (ng/mL) b 14 (1–1359; 47.5) 12 (2–1312; 60) 0.464
Extrahepatic disease a 27 (17.9%) 3 (20.0%) 1.000
Clinical risk score 3–5 a 92 (60.9%) 10 (66.7%) 0.875
Major liver resection a 58 (38.4%) 15 (100%) <0.001
  Atypical resection 29 (19.2%) 0 (0.0%) /
  Segmentectomy/segmentectomy & atypical resection 3 (2.0%)/14 (9.3%) 0 (0.0%) /
  Bisegmentectomy/bisegmentectomy & atypical resection 10 (6.6%)/37 (24.5%) 0 (0.0%) /
  Right/extended right hepatectomy 28 (18.5%)/6 (4.0%) 13 (86.7%)/2 (13.3%) /
  Left/extended left hepatectomy 6 (4.0%)/3 (2.0%) 0 (0.0%) /
  Trisegmentectomy 6 (4.0%) 0 (0.0%) /
  Trisegmentectomy & atypical resection 5 (3.3%) 0 (0.0%) /
  Central resection 4 (2.6%) 0 (0.0%) /
R0 resection a 118 (78.1%) 10 (66.7%) 0.492
CD ≥ 3a a 31 (20.5%) 6 (40.0%) 0.161
90-day mortality a 7 (4.6%) 2 (13.3%) 0.189
ISGLS haemorrhage grade C a 2 (1.3%) 0 (0.0%) 1.000
ISGLS bile leakage grade C a 5 (3.3%) 1 (6.7%) 1.000
ISGLS liver failure – any grade a 40 (26.5%) 12 (80.0%) <0.001
  Grade A a 16 (10.6%) 5 (33.3%) 0.034
  Grade B a 19 (12.6%) 6 (40.0%) 0.014
  Grade C a 5 (3.3%) 1 (6.7%) 1.000
Hospital stay (days) b 10 (5–63; 7) 14 (8–158; 11) 0.028

Clinical characteristics of the matched groups

Clinical characteristics CCM-OSH (n = 14) TSH (n = 15) P value
Male sex a 11(78.6%) 13(86.7%) 1.000
Age (years) b 60 (53–78; 13) 64 (45–75; 12) 0.463
ASA score ≥ 3 a 2 (14.3%) 2 (13.3%) 1.000
Primary tumour in right colon a 2 (14.3%) 1 (6.7%) 1.000
Primary tumour in left colon a 10 (71.4%) 6 (40%) 0.125
Primary tumour in rectum a 2 (14.3%) 7 (46.7%) 0.063
> 1 primary tumour a 0 (0.0%) 1 (6.7%) 1.000
Primary tumour nodal invasion a 10 (71.4%) 10 (66.7%) 1.000
Synchronous liver metastases a 11(78.6%) 11(73.3%) 1.000
Number of liver metastases b 5 (2–12; 6) 5 (2–12; 6) 0.317
Size of liver metastases (cm) b 4.6 (1–20; 7) 5 (1.5–11; 5.5) 0.463
Neoadjuvant chemotherapy a 13 (92.9%) 13 (86.7%) 1.000
Preoperative CEA level (ng/mL) b 9 (1–261; 76) 12 (2–1312; 60) 0.975
Extrahepatic disease a 1 (7.1%) 3 (20.0%) 1.000
Clinical risk score 3–5 a 13 (92.9%) 10 (66.7%) 0.250
Major hepatectomy a 14(100%) 15 (100%) 1.000
  Right/extended right hepatectomy 8 (57.1%)/2 (14.3%) 13 (86.7%)/2 (13%) /
  Left hemihepatectomy 1 (7.1%) 0 (0.0%) /
  Trisegmentectomy & atypical resection 3 (21.4%) 0 (0.0%) /
R0 resection a 8 (57.1%) 10 (66.7%) 1.000
CD ≥ 3a a 4 (28.6%) 6 (40.0%) 0.688
90-day mortality a 1 (7.1%) 2 (13.3%) 1.000
ISGLS haemorrhage grade C a 0 (0.0%) 0 (0.0%) 1.000
ISGLS bile leakage grade C a 1 (7.1%) 1 (6.7%) 1.000
ISGLS liver failure – any grade a 10 (71.4%) 12 (80%) 1.000
  Grade A a 4 (28.6%) 5 (33.3%) 1.000
  Grade B a 5 (35,7%) 6 (40.0%) 1.000
  Grade C a 1 (7.1%) 1 (6.7%) 1.000
Hospital stay (days) b 16 (6–63; 13) 14 (8–158; 11) 0.406

Literature review of surgical outcomes and survival after two-stage hepatectomy for colorectal liver metastases

Authors Year Study period N of patients Major liver resection (%) R0 resection (%) Morbidity (%) Mortality (%) Median follow-up (months) Median RFS (months) 3-y RFS (%) 5-y RFS (%) Median OS (months) 3-y OS (%) 5-y OS (%)
Adam et al., France4 2000 1992–1999 13 62 NR 45 15 22 NR 31 31 44 35 NR
Tanaka et al., Japan17 2007 1992–2004 22 67 87 23 0 NR NR 6 NR NR 33 NR
Wicherts et al., France24 2008 1992–2007 41 76 NR 59 7 24 NR 26 13 39 60 42
Narita et al., France25 2011 1996–2009 61 95 NR 54 0 30 NR 15 8 40 59 32
Turrini et al., France26 2012 2000–2010 34 91 100 20 6 41 NR 24 14 44 59 35
Omichi et al., Japan27 2022 2013–2019 32 NR 78 22 0 17 6 NR NR 41 61 NR
The present study, Slovenia 2023 2000–2020 15 100 67 40 13 174 7 13 7 21 33 13
Multicentre studies
Tsai et al., USA and Portugal28 2010 1994–2008 35 80 NR 26 5 NR NR NR NR 16 58 NR
Regimbeau et al. LiverMetSurvey registry5 2017 2000–2014 625 NR 58 25 9 84a 41a 43 23 40a 45 23
Petrowsky et al. ALPPS registry29 2020 2009–2019 510 100 73 21 5 38 11 19 12 37 52 27
Chavez et al. Five centres in the USA22 2021 2000–2016 196 76 92 23 5 28 NR 19 18 50 64 44
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