@ SURGERYTODAY

The Japanese Journal of Surgery (1992) 22:260-264

© Springer-Verlag 1992

Aggressive Repeat Liver Resection for Hepatic Metastases of Colorectal Carcinoma SATOSHI NAKAMURA,1 SHUKICHI SAKAGUCHI,1 RAISUKE NISHIYAMA,1 SHOHACHI SUZUKI, 1 YOSHIHIRO YOKOI, SHOZO BABA,1 and HIROYUKI MARO2 ~Second Department of Surgery, 2Second Department of Pathology, Hamamatsu University School of Medicine, Hamamatsu, Japan

Abstract: Although hepatectomy for liver metastases from coiorectal carcinoma is an effective treatment, recurrence in the liver is still the most common site after hepatectomy. Thirty patients underwent hepatectomy for hepatic metastases and 17 of them had recurrence in the remnant liver during the following 12-year period. Six of the 17 patients underwent a removal of isolated hepatic recurrences. Two of the six patients underwent a third hepatectomy, and three patients underwent partial lung resection on a total of five occasions. There were no operative deaths while complications after a third hepatectomy contributed to a high morbidity rate of 40 per cent. The mean length of survival of the six patients was 28.5 months from the second hepatectomy. The prognosis of the six patients who underwent a repeat hepatectomy was significantly better than that of patients with unresectable recurrence after an initial hepatectomy (p < 0.01). The overall 5-year survival of 29 patients excluding one inhospital death was 44.7 per cent. Our results reveal that aggressive removal of isolated and resectable recurrent disease has the potential to improve the prognosis of selected patients with metastatic cancer.

resection range from 20 to 45 per cent 2"3 and are far superior to those of patients with unresected hepatic metastases. 4 However, recurrences limited to the liver are seen in up to 30-40 per cent of patients after the initial hepatectomy. 4'5 At present, there is still little information available to help surgeons decide on the correct treatment of patients who have further hepatic recurrences after an initial hepatectomy, since only a few reports have been published on repeat hepatectomy in such patients. 6-10 We have performed aggressive surgery for colorectal metastases in the liver over a 12-year period. This paper reports on our experience with repeat hepatectomy for the recurrence of hepatic metastases of colorectal cancer after an initial hepatic resection.

Patients and methods

Patients Key Words: Colorectal carcinoma, hepatic metastases,

hepatectomy

Introduction

The majority of patients with recurrence of colorectal cancer after curative surgery have liver metastases, l and hepatic resection has been performed for liver metastases with everincreasing frequency. There is no longer any controversy concerning whether patients undergoing resection are better off than those who do not since the 5-year survival rates after hepatic Reprint requests to: Satoshi Nakamura, MD, Second Department of Surgery, Hamamatsu University School of Medicine, 3600 Handa-cho, Hamamatsu-shi 431-31, Japan (Received for publication on Dec. 28, 1990)

During the 12-year period from 1978 to 1990, 30 patients underwent hepatic resection for liver metastases of colorectal cancer at the Second Department of Surgery of Hamamatsu University School of Medicine. There was one hospital death (3.3 per cent) at the time of the first hepatectomy. Seventeen of the remaining 29 patients had recurrence of carcinoma. Six of them underwent repeat hepatectomy on a total of eight occasions and three of the six underwent a partial lung resection on five occasions. Eleven patients did not undergo a resection of recurrent disease because of the presence of multiple nonresectable tumors. Concerning repeat hepatectomies, they were only performed on patients with the following requirements: When the tumor in the liver was single and resectable without simultaneous metastases to the abdominal cavity. When liver function, including prothrombin activity of more than 70 per cent, and

S. Nakamura et al.: Liver Resection for Hepatic Metastases of Colorectal Carcinoma a 15 minute-retention rate of less than 30 per cent of Indocyanin Green as well as a total bilirubin level of less than 2.0mg/dl was sufficiently kept. Lung metastases of less than five nodules in a single lobe were indicated in principle for resection. The follow-up period for the 30 patients who underwent hepatectomy ranged between 2 and 108 months. The sites of recurrence in the 17 patients after initial hepatectomy were the liver in 12 patients, the lung in four, the para-aortic lymph nodes in one, the brain in one, and the primary lesion in one. Two of them also had extrahepatic metastases. One had metastatic involvement of the lymph nodes lying behind the head of the pancreas while the other had a giant metastasis in the right adrenal gland that also invaded the inferior vena cava.

Surgical Procedures The terminology of hepatic resection used was that of Healey and Schroy's nomenclature. 11 At the time of surgery, intraoperative ultrasonic echography was performed to determine the size, location, and nature of the tumor. Thirteen operations were performed for the six patients with recurrence comprising seven hepatic resections in six patients, five partial lung resections in three patients, and one hepatic subsegmentectomy combined with right adrenatectomy (Table 1). This last procedure included resection of 5cm of the inferior vena cava and an implantation with an expanded polytetrafluoroethylene graft. Repeat hepatic resection procedures comprised one subsegmentectomy in two patients, a partial resection in five, and a left lateral segmentectomy in one. The weight of the resected specimens ranged 16 g to 330 g,

261

with an average of 153g. Patient No. 1 underwent a partial lung resection after the third hepatectomy. Patient No. 2 underwent a partial lung resection after the first and second hepatectomies, while patient No. 4 had a right-side partial lung resection after the third hepatectomy. Survival was tested for statistical significance using the generalized Wilcoxon test, ~2 with P < 0.05 being considered significant.

Results

The operative mortality was 0 per cent in the 13 operations for these six patients, the average hospital stay was 24.6 days after liver and lung resection, and there was a total of six (40 per cent) complications. Patient No. 1 had persistent bleeding from the liver stump during and after the third liver resection. Administration of 3 g/day of Tranexamic acid was effective in achieving hemostasis on the first postoperative day. The two patients who underwent the third hepatectomy developed hemothorax after partial lung resection. Both patients showed hypofibrinogenemia (

Aggressive repeat liver resection for hepatic metastases of colorectal carcinoma.

Although hepatectomy for liver metastases from colorectal carcinoma is an effective treatment, recurrence in the liver is still the most common site a...
403KB Sizes 0 Downloads 0 Views