Abstract
Abstract
Background:
The role of laparoscopy in two-stage hepatectomy for bilobar colorectal liver metastases (CRLMs) has not yet been extensively investigated.
Patients and Methods:
We reviewed a prospectively collected database of 302 consecutive patients undergoing laparoscopic liver resection at our institution between 2003 and 2011.
Results:
Eight patients undergoing laparoscopic first/second-stage hepatectomy for bilobar CRLMs (male/female 6:2; median age, 64 years) were analyzed. The first stage consisted of laparoscopic clearance of the left lobe in all patients with no postoperative morbidity and mortality. Seven patients underwent portal vein embolization or ligation. The median interval between first- and second-stage hepatic resections was 89 days (range, 36–123 days). Second-stage hepatectomy with right lobar clearance (open, n=5; laparoscopic, n=2; laparoscopic to open, n=1) was associated with no mortality and an operative morbidity rate of 50%. Adhesions were judged to be minimal or absent during the second-stage procedure. Complications included intra-abdominal collection (n=2), bleeding requiring re-operation (n=1), and bile leak (n=1). R0 resection was obtained in 7 of 8 cases after first-stage resection and in 8 of 8 cases after second-stage resection. Three patients (38%) died from disease recurrence. Of the remaining 5 patients, 4 are disease-free at a median follow-up of 24 months (range, 9–27 months).
Conclusions:
The well-recognized advantages of laparoscopy may play a favorable role in the management of patients with bilobar CRLMs candidate for a two-stage resection. The first-stage laparoscopic clearance of the left lobe could progressively become the “gold standard.” Laparoscopic second-stage hepatectomy should be limited to selected cases.
Introduction
One of the main barriers to resection in such patients is the future remnant liver volume (FRLV), which must be sufficient to prevent catastrophic postoperative liver failure. FRLV should be typically 20%–25% in patients with normal background liver parenchyma, 30% following chemotherapy or in case of steatosis and hepatitis, and 40% in the presence of chronic liver disease. 3
Adam et al. 4 introduced the concept of two-stage hepatectomy for patients with CRLMs and low FRLV that would historically have been unresectable. This concept consists of clearing the least diseased lobe (usually the left) during the first stage and proceeding with resection of the contralateral lobe after allowing time for ipsilateral lobe hypertrophy. Occlusion of the contralateral portal vein (PV) branches, by either surgical ligation or radiological embolization, has also been shown to stimulate hypertrophy of the future liver remnant. 4
The adoption of the laparoscopic approach in a two-stage hepatectomy has not yet been extensively discussed in the literature except for two case reports.5,6 This is understandable considering the novelty of the technique, the relatively low number of patients requiring two-stage clearance, and the substantial risk of postoperative morbidity and mortality. Here we have critically analyzed our preliminary data on feasibility, safety, and oncological efficiency of the laparoscopic approach in the management of patients with CRLMs undergoing two-stage hepatectomy.
Patients and Methods
We reviewed a prospectively collected database of 302 consecutive patients undergoing laparoscopic liver resection at our institution between August 2003 and December 2011, selecting patients who had first/second-stage laparoscopic hepatectomy for CRLMs. Prior to surgery, each case was individually evaluated at an open multidisciplinary team meeting with surgeons, pathologists, oncologists, gastroenterologists, and radiologists. Patients were considered eligible for two-stage resection if they had bilobar metastases that were not amenable to single-stage resection, as their FRLV would be typically less than 25% in patients with normal background liver parenchyma, 30% following chemotherapy, and 40% in the presence of chronic liver disease (based on estimates from computed tomography and magnetic resonance imaging). Patients were assessed for indication, feasibility, and the type of resection required, prior to a decision regarding the surgical approach.
Three hepatobiliary-pancreatic surgeons (M.A.H., N.W.P., and J.N.P.) were involved in this series. Laparoscopic resections were performed by either M.A.H. or N.W.P. Our group has previously described in detail the techniques for laparoscopic segmentectomies, left lateral sectionectomy, and right hemihepatectomy.7–9 Standard nomenclature was used to describe the resections performed. 10
Results are expressed as mean±standard deviation values or medians with ranges.
Results
Eight patients underwent two-stage hepatectomy at our institution for bilobar CRLMs in the study period (male/female, 6:2) (Table 1). The median age of the cohort was 64 years (range, 46–77 years). Six patients were American Society of Anesthesiologists grade 2, and 2 patients were American Society of Anesthesiologists grade 1. The primary tumors were colon (n=5) and rectum (n=3), and all patients had bilobar liver metastases with a median of four (range, two to six) separate deposits. Operations for the colorectal primary included right hemicolectomy (n=3), anterior resection (n=3), sigmoid colectomy (n=1), and Hartmann's procedure (n=1). Six patients had synchronous colorectal liver metastases. Of these, two procedures were performed prior to first-stage hepatectomy, one was undertaken at the same time as the first liver resection, and three were undertaken in the interval period. Six of the colorectal procedures were performed laparoscopically.
M, male; F, female; Lap, laparoscopic; LLS, left lateral sectionectomy (segments 2 and 3); RH, right hepatectomy (segments 5–8); PVE, portal vein embolization; PVL, portal vein ligation.
Neoadjuvant chemotherapy (oxaliplatin, capecitabine, or raltitrexed) was used prior to first-stage hepatectomy in 7 patients to reduce the tumor load or limit disease progression. One patient with rectal carcinoma who had left liver lobe clearance before resection of the primary tumor received chemotherapy–radiotherapy during the interval period between liver resections.
First-stage hepatectomy
The left lobe of the liver was the standard site of resection during first-stage hepatectomy, and the types of procedures performed are shown in Table 1. All resections were performed and completed laparoscopically. Mean intraoperative blood loss was 132±103 mL. Mean operative time was 139±45 minutes, and histopathology demonstrated a mean resection margin of 8.3±18.1 mm. R0 resection was obtained in 7 of 8 (88%) patients.
Interval period
The median interval between first- and second-stage hepatic resections was 89 days (range, 36–123 days). Right PV ligation was performed in 2 patients during first-stage hepatectomy. Right PV embolization was performed in 5 patients during the interval period. The median time between PV embolization and the second-stage hepatectomy was 45 days (range, 29–74 days). Computed tomography imaging confirmed growth of the future remnant liver with a mean FRLV of 420±28.3 mL. Causes of the comparatively long interval between resections in this series included (1) the need for colorectal resection (n=3), (2) poor recovery following the first-stage resection (n=1), and (3) patient preference over the timing of second-stage hepatectomy (n=1).
Second-stage hepatectomy
Right hepatectomy (n=7) and extended right hepatectomy (n=1) were performed as second-stage procedures to clear the remaining metastatic disease (Table 1). Adhesions were judged to be minimal or absent during the second-stage procedure. Three procedures (37.5%) were attempted laparoscopically. One of these was converted to the open approach because of difficult hilar dissection. None of the patients showed disease progression during the interval period to warrant abandoning second-stage resection. Mean intraoperative blood loss was 1225±468 mL. Mean operative time was 243±85 minutes, and histopathology demonstrated a mean resection margin of 5.3±7.5 mm. R0 resection was obtained in all patients.
Operative mortality and morbidity
There were no deaths within 30 days of either first- or second-stage hepatectomy. Complications for the first stage were nil. However, for the larger second-stage procedure, 4 patients (50%) had major liver-related postoperative complications, including intra-abdominal collection (n=2), bile leak (n=1), and intra-abdominal bleeding requiring re-operation (n=1). There were no cases of postoperative liver failure. No complications were associated with the resection of the primary tumor.
Following first-stage resection, patients spent a median of 0 days (range, 0–4 days) in the intensive care unit, 1 day (range, 0–2 days) in the high dependency unit, and 6 days (range, 4–10 days) in the hospital. For the second-stage procedure, median intensive care unit stay was 0 days (range, 0–8 days), median high dependency unit stay was 5.5 days (range, 2–10 days), and median hospital stay was 15.5 days (range, 6–43 days).
Survival and tumor recurrence
Follow-up after the second surgery was complete for a median of 23 months (range, 9–29 months). There were three late deaths in our series (38%), and all were attributable to disease recurrence. The first death occurred 17 months from diagnosis (12 months from second-stage surgery) and was due to widespread extrahepatic metastases. The second fatal case survived for 31 months from diagnosis (22 months from second-stage surgery) until death from intrahepatic recurrence. The last patient died 13 months from diagnosis (9 months from second-stage surgery), again because of intrahepatic recurrence. Of the remaining 5 patients, 4 are disease-free at a median follow-up of 24 months (range, 9–27 months); 1 patient developed intra- and extrahepatic recurrence but remains alive 29 months after the second-stage procedure.
Discussion
Our preliminary data support the feasibility, safety, and oncological efficiency of the laparoscopic approach for first-stage and selected second-stage liver resections.
The advantage of the first-stage laparoscopic hepatectomy in inducing fewer adhesions and rapid postoperative recovery may play a positive role in the management of patients with bilobar CRLMs who are candidates for a second-stage resection. Therefore, the first-stage laparoscopic clearance of the left lobe could progressively become the “gold standard.” On the other hand, feasibility of laparoscopic second-stage hepatectomy may be challenged by technically demanding hilar dissection as a consequence of PV embolization or ligation. Laparoscopic second-stage hepatectomy should be limited to selected cases and always performed by expert laparoscopic hepatobiliary surgeons.
One of the main concerns is that the wide adoption of the laparoscopic technique for extensive liver resections may jeopardize patient safety. We report no mortality and no complications after first-stage resection. Complication rates are reported to be 0%–50% for the first stage and up to 59% for the second stage.11–13 The higher complication rate after the second-stage surgery is a well-known occurrence and is likely to be related to prolonged chemotherapy and major liver resection. 14 These figures are comparable to our findings, suggesting that use of laparoscopic resection as part of a two-stage procedure is safe.
Some controversy exists regarding the risk of compromising oncological principles when the minimally invasive approach is adopted. In this series we gained R0 margins in 88% of patients, and our medium-term survival data are comparable with those of other open two-stage CRLMs resection series.11–15
Footnotes
Disclosure Statement
No competing financial interests exist.