Synchronous Rectal and Hepatic Resection of Rectal Metastatic Disease
Division of Gastroenterologic Surgery, Mayo Clinic, Rochester, MN 55905, USA. Journal of Gastrointestinal Surgery
(Impact Factor: 2.8).
09/2011; 15(9):1583-8. DOI: 10.1007/s11605-011-1604-9
The objectives were to determine the feasibility of combined rectal and hepatic resections and analyze the disease-free survival and overall survival.
Sixty patients who underwent resection for metastatic rectal disease from 1991 to 2005 at Mayo Clinic were reviewed. Inclusion criteria were: rectal cancer with metastatic liver disease and resectability of metastases. The exclusion criteria were: metachronous resection (n = 15). Kaplan-Meier Survival estimated overall survival (OS) and disease-free survival (DFS). Cox proportional hazard models examined the association between groups and survival.
The cohort comprised 22 men and 23 women, with median age of 63 years. Surgical management included: abdominoperineal resection, 13 patients (29%); low anterior resection, 29 (64%); local excision, one; total proctocolectomy, one; and pelvic exenteration, one. Major hepatic resection was performed in 22%. There was no mortality, but there were 26 postoperative complications. Disease-free survival from local recurrence at 1, 2, and 5 years was 92%, 86%, and 80%, respectively. Disease-free survival from distant recurrence at 1, 2, and 5 years was 62%, 43%, and 28%, respectively. Overall survival at 1, 2 and 5 years was 88%, 72%, and 32%, respectively.
Combined rectal and hepatic resection is safe. Morbidity and mortality do not preclude concurrent resection. The DFS and OS are comparable to that of patients undergoing a staged procedure.
Available from: Manousos-Georgios Pramateftakis
- "The importance of this is that rectal procedures are technically more challenging than colon procedures, with a higher risk of morbidity and mortality. Despite that, a study (possibly the only one identified in the literature) looking at synchronous rectal and hepatic resection of rectal metastatic disease from the Mayo Clinic showed that combined rectal and hepatic resection is safe . They reported overall survival at 1, 2, and 5 years of 88%, 72%, and 32%, respectively, as well as disease-free survival from local recurrence at 1, 2, and 5 years of 92%, 86%, and 80%, numbers that were comparable to those undergoing a staged procedure. "
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ABSTRACT: In the last few decades there have been significant changes in the approach to rectal cancer management. A multimodality approach and advanced surgical techniques have led to an expansion of the treatment of metastatic disease, with improved survival. Hepatic metastases are present at one point or another in about 50% of patients with colorectal cancer, with surgical resection being the only chance for cure. As the use of multimodality treatment has allowed the tackling of more complicated cases, one of the main questions that remain unanswered is the management of patients with synchronous rectal cancer and hepatic metastatic lesions. The question is one of priority, with all possible options being explored. Specifically, these include the simultaneous rectal cancer and hepatic metastases resection, the rectal cancer followed by chemotherapy and then by the liver resection, and finally the "liver-first" option. This paper will review the three treatment options and attempt to dissect the indications for each. In addition, the role of laparoscopy in the synchronous resection of rectal cancer and hepatic metastases will be reviewed in order to identify future trends.
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One in ten patients with rectal cancer presents with synchronous colorectal liver metastases. We present an up-to-date review of the different surgical strategies available for rectal cancer patients with synchronous colorectal liver metastases.
A literature review of MEDLINE, Cochrane and Google scholar was performed.
Twenty retrospective studies comparing staged versus simultaneous resections were found. Overall survival was similar for both approaches whilst the length of stay was decreased in simultaneous resections. Only two studies comparing the 'reverse' versus staged or simultaneous resections were found. The studies investigating resection versus non-resection for rectal primaries with unresectable liver metastases were limited.
Simultaneous resections are a reasonable alternative to staged resections for either advanced rectal cancers with limited liver disease or early rectal cancers with extensive liver disease. Currently, staged resections are favoured over simultaneous resections in patients with locally advanced rectal cancers with extensive liver disease. There are too few studies to determine the safety of reverse resections in the context of locally advanced rectal cancers. A resection of the primary tumour or a non-surgical intervention can be justified in the management of the rectal cancer primary in the presence of unresectable liver metastases.
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