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SAGES/AHPBA guidelines for the use of minimally invasive surgery for the surgical treatment of colorectal liver metastases (CRLM)

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Abstract

Background

Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM.

Methods

Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research.

Results

The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence.

Conclusions

These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM.

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Acknowledgements

We would like to thank Sarah Colon, the SAGES senior program coordinator, Holly Burt, the SAGES librarian, and the SAGES guideline committee members for their help with the creation of this guideline.

Disclaimer

Clinical practice guidelines are intended to indicate the best available approach to medical conditions as established by a systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the healthcare environment. These guidelines are intended to be flexible, as the surgeon must always choose the approach best suited to the patient and to the variables at the moment of decision. These guidelines are applicable to all physicians who are appropriately credentialed regardless of specialty and address the clinical situation in question. These guidelines are developed under the auspices of SAGES and AHPBA, the guidelines committee, and approved by the Board of Governors of both societies. The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline are reviewed, and guidelines are periodically updated.

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Author notes

  1. Timothy J. Vreeland and Amelia T. Collings have contributed equally to this work.

Authors and Affiliations

  1. Department of Surgery, Brooke Army Medical Center, San Antonio, TX, USA

    Timothy J. Vreeland & Alexandra M. Adams

  2. Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA

    Amelia T. Collings, Rebecca Dirks, Jake Whiteside & Eugene Ceppa

  3. Faculty of Medicine, King George’s Medical University, Lucknow, Uttar Pradesh, India

    Ahmad Ozair

  4. Washington University School of Medicine, St. Louis, MO, USA

    Bradley S. Kushner

  5. Digestive Health Institute, AdventHealth Tampa, FL, USA

    Iswanto Sucandy

  6. Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA

    David Morrell

  7. School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada

    Mohammed T. Ansari

  8. Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA

    Jordan Cloyd

  9. Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA

    Sean P. Cleary

  10. Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada

    Ahmed M. Abou-Setta

  11. Department of Surgery, University of California San Francisco, San Francisco, CA, USA

    Adnan Alseidi

  12. Department of Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA

    Ziad Awad

  13. Alpert Medical School of Brown University, Providence, RI, USA

    Subhashini Ayloo

  14. Division of Surgery, Mission Healthcare System, HCA Healthcare, Asheville, NC, USA

    Joseph Buell

  15. Department of Surgery, University of Massachusetts Chan Medical School-Baystate, Worcester, USA

    Georgios Orthopoulos

  16. Section of General Surgery, Oschner Clinic, New Orleans, LA, USA

    William Richardson

  17. Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA

    Samer Sbayi & Aurora D. Pryor

  18. Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Department of Surgery, Ageo Central General Hospital, Ageo City, Japan

    Go Wakabayashi

  19. Baptist Health Miami Cancer Institute, Miami, FL, USA

    Horacio Asbun

  20. Department of Surgery, University of Chicago Medicine, Chicago, USA

    Bethany J. Slater

  21. TCU/UNTHSC School of Medicine, Fort Worth, USA

    D. Rohan Jeyarajah

Authors
  1. Timothy J. Vreeland
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  2. Amelia T. Collings
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  3. Ahmad Ozair
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  4. Alexandra M. Adams
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  5. Rebecca Dirks
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  6. Bradley S. Kushner
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  7. Iswanto Sucandy
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  8. David Morrell
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  9. Jake Whiteside
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  10. Mohammed T. Ansari
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  11. Jordan Cloyd
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  12. Sean P. Cleary
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  13. Eugene Ceppa
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  14. Ahmed M. Abou-Setta
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  15. Adnan Alseidi
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  16. Ziad Awad
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  17. Subhashini Ayloo
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  18. Joseph Buell
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  19. Georgios Orthopoulos
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  20. William Richardson
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  21. Samer Sbayi
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  22. Go Wakabayashi
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  23. Horacio Asbun
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  24. Bethany J. Slater
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  25. Aurora D. Pryor
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  26. D. Rohan Jeyarajah
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Corresponding author

Correspondence to D. Rohan Jeyarajah.

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Disclosures

Dr. Vreeland receives financial support for travel expenses and registration fees for meetings from the Metis Foundation and consulting fees from Bantam Pharmaceuticals for clinical trial design. Dr. Collings was employed by SAGES as the guideline’s fellow. Dr. Adams receives financial support for travel expenses and registration fees for annual meetings for SAGES and AHPBA from the Metis Foundation. Dr. Dirks has privately purchased stock in Johnson & Johnson. Dr. Ansari is a consultant guideline methodologist and remunerated by SAGES for contribution to this work. Dr. Cleary receives consulting fees from Ethicon, Erbe, and Olympus. Dr. Buell receives speaker and consulting fees from Ethicon and Covidien. Dr. Slater receives consulting fees from Bolder Surgical and Cook Medical. Dr. Pryor receives speaker fees from Gore, Ethicon, and Stryker. Dr. Jeyarajah is a consultant for Ethicon, Angiodynamics, and Sirtex. Drs. Ozair, Kushner, Sucandy, Morrell, Cloyd, Ceppa, Abou-Setta, Alseidi, Awad, Ayloo, Orthopoulos, Richardson, Sbayi, Wakabayashi, and Mr. Whiteside have no conflicts of interest.

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Vreeland, T.J., Collings, A.T., Ozair, A. et al. SAGES/AHPBA guidelines for the use of minimally invasive surgery for the surgical treatment of colorectal liver metastases (CRLM). Surg Endosc 37, 2508–2516 (2023). https://doi.org/10.1007/s00464-023-09895-x

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