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Long-Term Results of Two-Stage Hepatectomy for Irresectable Colorectal Cancer Liver Metastases

Wicherts, Dennis A. MD*†; Miller, Rafael MD*‡; de Haas, Robbert J. MD*†; Bitsakou, Georgia MD*; Vibert, Eric MD*; Veilhan, Luc-Antoine MD*; Azoulay, Daniel MD, PhD*; Bismuth, Henri MD, FACS(Hon)*; Castaing, Denis MD*§¶; Adam, René MD, PhD*§¶

doi: 10.1097/SLA.0b013e3181907fd9
Original Articles

Objective: To assess feasibility, risks, and long-term outcome of 2-stage hepatectomy as a means to improve resectability of colorectal liver metastases (CLM).

Summary Background Data: Two-stage hepatectomy uses compensatory liver regeneration after a first noncurative hepatectomy to enable a second curative resection.

Methods: Between October 1992 and January 2007, among 262 patients with initially irresectable CLM, 59 patients (23%) were planned for 2-stage hepatectomy. Patients were eligible when single resection could not achieve complete treatment, even in combination with chemotherapy, portal embolization, or radiofrequency, but tumors could be totally removed by 2 sequential resections. Feasibility and outcomes were prospectively evaluated.

Results: Two-stage hepatectomy was feasible in 41 of 59 patients (69%). Eighteen patients failed to complete the second hepatectomy because of disease progression (n = 17) or bad performance status (n = 1). The 41 successfully treated patients had a mean number of 9.1 metastases (mean diameter, 48.5 mm at diagnosis). Chemotherapy was delivered before (95%), in between (78%), and after (78%) the 2 hepatectomies. Mean delay between the 2 liver resections was 4.2 months. Postoperative mortality was 0% and 7% (3/41) after the first and second hepatectomy, respectively. Morbidity rates were also higher after the second procedure (59% vs. 20%) (P < 0.001). Five-year survival was 31% on an intention to treat basis, and all but 2 patients who did not complete the 2-stage strategy died within 19 months. After a median follow-up of 24.4 months (range, 3.7–130.3), overall 3- and 5-year survivals for patients that completed both hepatectomies were 60% and 42%, respectively, after the first hepatectomy (median survival, 42 months from first hepatectomy and 57 months from metastases diagnosis). Disease-free survivals were 26% and 13% at 3 and 5 years, respectively.

Conclusions: Two-stage hepatectomy provides a 5-year survival of 42% and a hope of long-term survival for selected patients with extensive bilobar CLM, irresectable by any other means.

The long-term benefit of 2-stage hepatectomy as a strategy to increase the resectability of multiple bilobar colorectal liver metastases remains unclear. Treatment outcomes and survival were analyzed in 59 patients selected for this procedure. A 2-stage strategy is able to provide a 5-year survival of 42% in up to 70% of selected patients with otherwise irresectable multinodular bilobar metastases.

From the *Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, Villejuif, France; †Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; ‡Department of Surgery, Kaplan Medical Center, Rehovot and Hebrew University, Jerusalem, Israel; §Inserm; and ¶Université Paris-Sud, Villejuif, France.

Reprints: René Adam, MD, PhD, AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France. E-mail: rene.adam@pbr.aphp.fr.

© 2008 Lippincott Williams & Wilkins, Inc.