Simultaneous Laparoscopic Resection of Primary Colorectal Cancer and Metastatic Liver Tumor: Initial Experience of Single Institute

Introduction

Approximately 20%–25% of patients with colorectal cancer have synchronous liver metastasis at the time of diagnosis.^1,2 Without treatment of liver metastasis the majority of patients will not survive for more than 12 months. ³ Recent improvements in surgical techniques of liver resection have resulted in improved survival. ⁴ Simultaneous resection of metastatic hepatic lesions combined with colorectal surgery or staged resections is the treatment of choice in colorectal cancer with resectable liver metastases. Currently, one-stage resection of both malignancies is considered effective and safe and it does not increase mortality and surgical morbidity.^5–7

Because of the clinical benefits of minimally invasive surgery, conventional open surgery has been replaced in many surgical areas. With respect to colorectal cancer surgery, the laparoscopic approach has become a popular treatment as it offers short-term clinical benefits and acceptable long-term oncological results.^8–10 The indications for laparoscopic surgery are now considered the same as those for open surgery on colon and rectal cancer. ¹¹ Initially, the laparoscopic approach to liver surgery was limited to the excision of superficially located benign tumors. With improvements in technology and the accumulation of laparoscopic experiences, laparoscopic liver resection of malignant disease, including major hepatectomy, is technically feasible and can be performed safely.^12–15 The potential benefit of a minimally invasive approach for primary colorectal cancer and metastatic liver lesions is the possibility to perform a radical operation with small incisions and earlier recovery. Unfortunately, the role of laparoscopic one-stage colorectal surgery and liver resection has been poorly investigated and the efficacy of the procedure remains controversial.

The aim of the present study was to report our initial experience with simultaneous laparoscopic colorectal surgery and liver resection. We hope that our initial experiences will support large-scale studies determining whether this procedure is a safe and technically feasible option for patients with colorectal cancer with resectable liver metastases.

Patients and Methods

From August 2004 to August 2009, 10 cases of simultaneous laparoscopic colorectal surgery and liver resection were performed. Pathological confirmation, colonoscopy, barium enema, computed tomography (CT), liver ultrasound, and chest X-ray were performed for diagnosis and staging in all patients with colorectal cancer preoperatively. Patients with liver metastases were diagnosed by CT and F-18 dexoyfluoroglucose positron emission tomography CT. No patients received neoadjuvant chemoradiation therapy in the present study. Laparoscopic liver resection was considered after discussion between colorectal surgeons and liver surgeons for the patients when R0 resection of colorectal cancer and laparoscopic exposure of metastatic liver tumor was anticipated. All patients with colorectal cancer admitted to our clinic were considered for laparoscopic surgery. Exclusion criteria for laparoscopic colorectal surgery were as follows: (1) patients with obstructive colorectal cancer and failure of stent insertion, (2) patients with colorectal cancer perforation, (3) patients with T4 colorectal cancer, and (4) patients with compromised cardiopulmonary function. With respect to liver metastasis, (1) metastatic tumor that is adjacent to major vessels, (2) metastatic tumor located in the caudate lobe, (3) large metastatic tumor with local extension or large lymph node involvement, which is considered difficult to have a margin-free resection, or (4) patients with compromised cardiopulmonary function were excluded from laparoscopic surgery. Colorectal surgery was performed by a colorectal surgical team and liver surgery by a liver surgical team. All procedures were performed after obtaining informed consent from the patients.

Results

During the study period, a total of 540 cases of laparoscopic colorectal cancer surgery were performed, of which 59 cases (11%) had liver metastasis. Of 59 cases of liver metastasis, 23 cases (13 cases of conventional open surgery, 10 cases of laparoscopic surgery) underwent simultaneous liver surgery and 21 cases underwent conventional open-staged liver surgery. A total of 10 cases of laparoscopic simultaneous colorectal cancer surgery and metastatic liver resection were reviewed in the present study. The mean age of the patients was 63.7 ± 9.4 years (range, 48–75 years) and mean body mass index was 23.5 ± 2.1 kg/m² (range, 20–27.4 kg/m²). The average operation time was 401 minutes (range, 230–620 minutes) and average estimated blood loss was 500 mL (range, 60–1000 mL) (Table 1). Seven cases were colon cancer and 3 cases were rectal cancer. Six cases had single metastatic liver tumor and 4 cases had two or more liver tumors. Lateral segmentectomy was performed in 6 cases, nonanatomical tumorectomy in 5 cases, anatomical segmentectomy in 1 case, right hepatectomy in 1 case, and Pringle maneuver was applied in 5 cases. The average tumor size of colorectal cancer was 5.3 ± 1.5 cm (range, 3–8 cm) and that of metastatic liver tumor was 3.9 ± 2.0 cm (range, 0.6–6 cm) (Table 2). The average number of harvested lymph node was 22.0 ± 8.1 (range, 11–34). The time to pass first flatus was 2.4 ± 1.0 day (range, 2–5 days) and time to start diet was 3.6 ± 0.8 day (range, 2–5 days). The mean hospital stay was 10.5 ± 2.7 days (range, 7–15 days). In the present study, no patient underwent preoperative chemotherapy or chemoradiation therapy. The 9th case was converted to open surgery during laparoscopic liver resection because of uncontrolled bleeding from a hepatic vein, and in that case anastomotic leakage developed on postoperative day 8 and subsequently underwent ileostomy. There was no surgical mortality in the present study.

Discussion

Since the first report of laparoscopic colon resection,^16,17 several controlled randomized studies demonstrated short-term benefits of laparoscopic surgery for colorectal cancer.^8–10 Now laparoscopic surgery is accepted as an alternative to open surgery for colon cancer. ¹¹ In the case of laparoscopic liver surgery, it was considered promising because liver surgery is characterized by resection alone and does not need reconstruction. However, adoption of laparoscopic liver surgery was slower than that of colorectal surgery because of technical difficulties, anticipated complications such as bleeding or gas embolism, and the uncertainty of long-term oncologic safety. Recently, improved technology and accumulation of laparoscopic experience has made liver surgery for malignancy technically feasible and safe but reproducibility and routine feasibility of laparoscopic liver resection remain in doubt.

Approximately 20%–25% of colorectal cancer patients have synchronous liver metastasis at presentation and the most common site of hematogenous dissemination is to the liver. In colorectal cancer with liver metastasis, the only chance for cure is to resect both the primary colorectal cancer and the metastatic liver tumor. Recently, several studies have demonstrated that simultaneous resection of primary colorectal cancer and liver metastasis is technically feasible, with acceptable short-term outcomes compared with a staged operation.^18,19 Combined colorectal and liver surgery requires a long incision from the xiphoid process to the symphisis pubis to obtain appropriate exposure. Such a big incision could cause more pain, increase surgical morbidity, and delay the recovery of patients. The application of laparoscopy for simultaneous colorectal and liver resection could reduce the length of surgical incision, reduce pain, and lead to earlier recovery of patients. In the present study, there was no surgical site infection and wound dehiscence or hematoma, and the return of bowel function and time to start diet were acceptable. In the present study, the length of hospital stay was 7–15 days, which is comparable to open surgery, because some patients had adjuvant chemotherapy at about 7–8 days after surgery. In addition, because of specific medical environment, Korean patients tend not to leave the hospital quickly because hospital charges are inexpensive and largely covered by the Korean medical insurance system.

In liver surgery, preoperative mapping of tumor lesions in the liver is very important. CT and liver ultrasound are frequently used preoperatively, and during the surgery, intraoperative ultrasound is used. Sietses et al. reported 38% disconcordance between pre- and intraoperative findings of colorectal liver metastasis in 117 patients and suggested that intraoperative ultrasound could alter the surgical strategy. ²⁰ In the present study, we used CT and liver ultrasound preoperatively and intraoperative ultrasound during surgery, but we did not find any disconcordance between pre- and intraoperative mapping of liver metastasis and the preoperative surgical plan was not altered during the surgery.

Simultaneous resection of colorectal cancer and liver metastasis might have some potential adverse effects on anastomosis. In liver surgery, Pringle's maneuver is needed, which could induce transient portal hypertension and intestinal edema, a risk factor of anastomotic leakage.^21,22 Another major adverse effect on anastomosis might be the large amount of blood loss during liver surgery. A large amount of intraoperative blood loss could induce transient hypovolemic shock and ischemic injury to the anastomosis. In the present study, 1 case of anastomotic leak was encountered on the 8th postoperative day; in that case we used Pringle's maneuver and about 1000 mL of intraoperative blood loss occurred during liver resection. In that case we did not make a diverting stoma. A large amount of intraoperative bleeding or prolonged Pringle's maneuver during liver surgery may be an indication for a diverting stoma. In the present study, we preferred performing colorectal surgery before liver surgery. If large blood loss or Pringle's maneuver during liver surgery may be anticipated, there could be other option for the sequence of procedure—performing hepatic treatment first rather than colorectal surgery. This might be less harmful to anastomosis, because anastomosis will be made after recovery from transient hypovolemic shock.

In the present study, only one case was major hepatectomy and No. 7 segmentectomy. The others were lateral segmentectomy and tumorectomy. Tumors that are located superficially and peripherally and require limited resections are most amenable to laparoscopic surgery. Tumors in segments 2, 3, 4b, 5, and 6 are less complex lesions and good candidates for laparoscopic surgery. ¹³ On the other hand, tumors located in segments 4a, 7, 8, and 1, which require full mobilization of the liver, are more complex and difficult to resect and are generally excluded from laparoscopic surgery. ¹³ A tumor located in the posterior and superior segment is close or connected to major vessels such as inferior vena cava and major or accessory hepatic veins. In the present study, metastatic tumor located in the caudate lobe was excluded from laparoscopic liver surgery, and the case in which the tumor was located in the posterior and superior segments was converted to open surgery because of bleeding from hepatic vein.

The present study had several limitations, including small sample size and no comparative study. The study does demonstrate that simultaneous laparoscopic resection of primary colorectal cancer and metastatic liver tumor can be performed safely and is technically feasible in selective patients. Future large-scale studies and long-term follow-up studies are needed to establish whether it could be a therapeutic option for selected patients with colorectal cancer and liver metastasis.