Journal of Gastrointestinal Surgery

, Volume 16, Issue 11, pp 2074–2085 | Cite as

Is There a Role for Simultaneous Hepatic and Colorectal Resections? A Contemporary View from NSQIP

  • Mathias Worni
  • Christopher R. Mantyh
  • Igor Akushevich
  • Ricardo Pietrobon
  • Bryan M. Clary
Original Article



The optimal timing of primary and metastatic tumor management in patients with synchronous hepatic colorectal metastases remains controversial. We aimed to compare perioperative outcomes of simultaneous colorectal/liver resection (SCLR) with isolated resections utilizing a national clinical database.


NSQIP data from 2005 to 2009 were examined to construct risk-adjusted generalized linear models and to calculate group-specific predicted estimates. These were used to compare 30-day perioperative outcomes among patients undergoing SCLR with colorectal (CR) and liver resections (LR) only in patients with metastatic colorectal cancer.


A total of 3,983 patients were identified, who underwent SCLR (192), LR (1,857), or CR (1,934). Rectal resection was performed in 45 (23.4 %) SCLR patients and 269 (13.9 %) CR patients (p < 0.001). Major hepatectomy was performed in 69 (35.9 %) SCLR patients and 774 (41.7 %) LR patients (p = 0.12). Median adjusted operation time (SCLR: 273 min, 95 % CI: 253–295; CR: 172, CI: 168–177; LR: 222, CI: 217–228; p < 0.001) and median adjusted length of hospital stay (SCLR: 9.5 days, CI: 8.8–10.4; CR: 8.1, CI: 7.9–8.3; LR: 6.4, CI: 6.3–6.6; p < 0.001) were longer for SCLR compared to CR and LR. Adjusted predicted risks for at least one postoperative complication were higher in SCLR (36.3 %) than in CR (26.6 %) and LR (19.8 %) (p < 0.003), mostly due to infectious/cardiopulmonary issues.


In SCLR patients, the risk of 30-day adverse outcomes is higher, and median operation time as well as length of hospital stay is longer compared to CR and LR patients. However, the expected combined morbidities of staged procedures though likely favor SCLR in carefully selected patients undergoing even complex hepatic and colorectal resections and should be considered.


Hepatic resection Liver resection Colorectal cancer Metastases 


  1. 1.
    Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62:10-29.PubMedCrossRefGoogle Scholar
  2. 2.
    Galandiuk S, Wieand HS, Moertel CG, Cha SS, Fitzgibbons RJ, Jr., Pemberton JH, Wolff BG. Patterns of recurrence after curative resection of carcinoma of the colon and rectum. Surg Gynecol Obstet 1992;174:27-32.PubMedGoogle Scholar
  3. 3.
    Weiss L, Grundmann E, Torhorst J, Hartveit F, Moberg I, Eder M, Fenoglio-Preiser CM, Napier J, Horne CH, Lopez MJ, et al. Haematogenous metastatic patterns in colonic carcinoma: an analysis of 1541 necropsies. J Pathol 1986;150:195-203.PubMedCrossRefGoogle Scholar
  4. 4.
    Poon MA, O'Connell MJ, Moertel CG, Wieand HS, Cullinan SA, Everson LK, Krook JE, Mailliard JA, Laurie JA, Tschetter LK, et al. Biochemical modulation of fluorouracil: evidence of significant improvement of survival and quality of life in patients with advanced colorectal carcinoma. J Clin Oncol 1989;7:1407-1418.PubMedGoogle Scholar
  5. 5.
    Schiesser M, Chen JW, Maddern GJ, Padbury RT. Perioperative morbidity affects long-term survival in patients following liver resection for colorectal metastases. J Gastrointest Surg 2008;12:1054-1060.PubMedCrossRefGoogle Scholar
  6. 6.
    Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg 1999;230:309-318; discussion 318-321.PubMedCrossRefGoogle Scholar
  7. 7.
    Choti MA, Sitzmann JV, Tiburi MF, Sumetchotimetha W, Rangsin R, Schulick RD, Lillemoe KD, Yeo CJ, Cameron JL. Trends in long-term survival following liver resection for hepatic colorectal metastases. Ann Surg 2002;235:759-766.PubMedCrossRefGoogle Scholar
  8. 8.
    Vigano L, Ferrero A, Lo Tesoriere R, Capussotti L. Liver surgery for colorectal metastases: results after 10 years of follow-up. Long-term survivors, late recurrences, and prognostic role of morbidity. Ann Surg Oncol 2008;15:2458-2464.PubMedCrossRefGoogle Scholar
  9. 9.
    Abdalla EK, Vauthey JN, Ellis LM, Ellis V, Pollock R, Broglio KR, Hess K, Curley SA. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Ann Surg 2004;239:818-825; discussion 825-817.PubMedCrossRefGoogle Scholar
  10. 10.
    Reddy SK, Pawlik TM, Zorzi D, Gleisner AL, Ribero D, Assumpcao L, Barbas AS, Abdalla EK, Choti MA, Vauthey JN, Ludwig KA, Mantyh CR, Morse MA, Clary BM. Simultaneous resections of colorectal cancer and synchronous liver metastases: a multi-institutional analysis. Ann Surg Oncol 2007;14:3481-3491.PubMedCrossRefGoogle Scholar
  11. 11.
    Benzoni E, Cojutti A, Lorenzin D, Adani GL, Baccarani U, Favero A, Zompicchiati A, Bresadola F, Uzzau A. Liver resective surgery: a multivariate analysis of postoperative outcome and complication. Langenbecks Arch Surg 2007;392:45-54.PubMedCrossRefGoogle Scholar
  12. 12.
    Imamura H, Seyama Y, Kokudo N, Maema A, Sugawara Y, Sano K, Takayama T, Makuuchi M. One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg 2003;138:1198-1206; discussion 1206.PubMedCrossRefGoogle Scholar
  13. 13.
    Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, Yeung C, Wong J. Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database. Ann Surg 2004;240:698-708; discussion 708-610.PubMedGoogle Scholar
  14. 14.
    Kohn GP, Nikfarjam M. The effect of surgical volume and the provision of residency and fellowship training on complications of major hepatic resection. J Gastrointest Surg 2010;14:1981-1989.PubMedCrossRefGoogle Scholar
  15. 15.
    Lyass S, Zamir G, Matot I, Goitein D, Eid A, Jurim O. Combined colon and hepatic resection for synchronous colorectal liver metastases. J Surg Oncol 2001;78:17-21.PubMedCrossRefGoogle Scholar
  16. 16.
    Weber JC, Bachellier P, Oussoultzoglou E, Jaeck D. Simultaneous resection of colorectal primary tumour and synchronous liver metastases. Br J Surg 2003;90:956-962.PubMedCrossRefGoogle Scholar
  17. 17.
    Tanaka K, Shimada H, Matsuo K, Nagano Y, Endo I, Sekido H, Togo S. Outcome after simultaneous colorectal and hepatic resection for colorectal cancer with synchronous metastases. Surgery 2004;136:650-659.PubMedCrossRefGoogle Scholar
  18. 18.
    Chua HK, Sondenaa K, Tsiotos GG, Larson DR, Wolff BG, Nagorney DM. Concurrent vs. staged colectomy and hepatectomy for primary colorectal cancer with synchronous hepatic metastases. Dis Colon Rectum 2004;47:1310-1316.PubMedCrossRefGoogle Scholar
  19. 19.
    Slupski M, Wlodarczyk Z, Jasinski M, Masztalerz M, Tujakowski J. Outcomes of simultaneous and delayed resections of synchronous colorectal liver metastases. Can J Surg 2009;52:E241-244.PubMedGoogle Scholar
  20. 20.
    Morris EJ, Forman D, Thomas JD, Quirke P, Taylor EF, Fairley L, Cottier B, Poston G. Surgical management and outcomes of colorectal cancer liver metastases. Br J Surg 2010;97:1110-1118.PubMedCrossRefGoogle Scholar
  21. 21.
    Rutten-van Molken MP, van Doorslaer EK, van Vliet RC. Statistical analysis of cost outcomes in a randomized controlled clinical trial. Health Econ 1994;3:333-345.PubMedCrossRefGoogle Scholar
  22. 22.
    Saltz LB, Clarke S, Diaz-Rubio E, Scheithauer W, Figer A, Wong R, Koski S, Lichinitser M, Yang TS, Rivera F, Couture F, Sirzen F, Cassidy J. Bevacizumab in combination with oxaliplatin-based chemotherapy as first-line therapy in metastatic colorectal cancer: a randomized phase III study. J Clin Oncol 2008;26:2013-2019.PubMedCrossRefGoogle Scholar
  23. 23.
    Peeters M, Price TJ, Cervantes A, Sobrero AF, Ducreux M, Hotko Y, Andre T, Chan E, Lordick F, Punt CJ, Strickland AH, Wilson G, Ciuleanu TE, Roman L, Van Cutsem E, Tzekova V, Collins S, Oliner KS, Rong A, Gansert J. Randomized phase III study of panitumumab with fluorouracil, leucovorin, and irinotecan (FOLFIRI) compared with FOLFIRI alone as second-line treatment in patients with metastatic colorectal cancer. J Clin Oncol 2010;28:4706-4713.PubMedCrossRefGoogle Scholar
  24. 24.
    Lehmann K, Rickenbacher A, Weber A, Pestalozzi BC, Clavien PA. Chemotherapy before liver resection of colorectal metastases: friend or foe? Ann Surg 2012;255:237-247.PubMedCrossRefGoogle Scholar
  25. 25. Last accessed 07/2012.
  26. 26.
    Mulcahy MF, Lewandowski RJ, Ibrahim SM, Sato KT, Ryu RK, Atassi B, Newman S, Talamonti M, Omary RA, Benson A, 3rd, Salem R. Radioembolization of colorectal hepatic metastases using yttrium-90 microspheres. Cancer 2009;115:1849-1858.PubMedCrossRefGoogle Scholar
  27. 27.
    Reddy SK, Zorzi D, Lum YW, Barbas AS, Pawlik TM, Ribero D, Abdalla EK, Choti MA, Kemp C, Vauthey JN, Morse MA, White RR, Clary BM. Timing of multimodality therapy for resectable synchronous colorectal liver metastases: a retrospective multi-institutional analysis. Ann Surg Oncol 2009;16:1809-1819.PubMedCrossRefGoogle Scholar
  28. 28.
    Martin R, Paty P, Fong Y, Grace A, Cohen A, DeMatteo R, Jarnagin W, Blumgart L. Simultaneous liver and colorectal resections are safe for synchronous colorectal liver metastasis. J Am Coll Surg 2003;197:233-241; discussion 241-232.PubMedCrossRefGoogle Scholar
  29. 29.
    Mentha G, Majno PE, Andres A, Rubbia-Brandt L, Morel P, Roth AD. Neoadjuvant chemotherapy and resection of advanced synchronous liver metastases before treatment of the colorectal primary. Br J Surg 2006;93:872-878.PubMedCrossRefGoogle Scholar
  30. 30.
    de Jong MC, van Dam RM, Maas M, Bemelmans MH, Olde Damink SW, Beets GL, Dejong CH. The liver-first approach for synchronous colorectal liver metastasis: a 5-year single-centre experience. HPB (Oxford) 2011;13:745-752.CrossRefGoogle Scholar
  31. 31.
    Folprecht G, Grothey A, Alberts S, Raab HR, Kohne CH. Neoadjuvant treatment of unresectable colorectal liver metastases: correlation between tumour response and resection rates. Ann Oncol 2005;16:1311-1319.PubMedCrossRefGoogle Scholar
  32. 32.
    de Santibanes E, Fernandez D, Vaccaro C, Quintana GO, Bonadeo F, Pekolj J, Bonofiglio C, Molmenti E. Short-term and long-term outcomes after simultaneous resection of colorectal malignancies and synchronous liver metastases. World J Surg 2010;34:2133-2140.PubMedCrossRefGoogle Scholar
  33. 33.
    Thelen A, Jonas S, Benckert C, Spinelli A, Lopez-Hanninen E, Rudolph B, Neumann U, Neuhaus P. Simultaneous versus staged liver resection of synchronous liver metastases from colorectal cancer. Int J Colorectal Dis 2007;22:1269-1276.PubMedCrossRefGoogle Scholar
  34. 34.
    Nakajima K, Takahashi S, Saito N, Kotaka M, Konishi M, Gotohda N, Kato Y, Kinoshita T. Predictive Factors for Anastomotic Leakage after Simultaneous Resection of Synchronous Colorectal Liver Metastasis. J Gastrointest Surg 2012 Apr;16(4):821-7.PubMedCrossRefGoogle Scholar
  35. 35.
    Chen J, Li Q, Wang C, Zhu H, Shi Y, Zhao G. Simultaneous vs. staged resection for synchronous colorectal liver metastases: a metaanalysis. Int J Colorectal Dis 2011;26:191-199.PubMedCrossRefGoogle Scholar
  36. 36.
    Capussotti L, Ferrero A, Vigano L, Ribero D, Lo Tesoriere R, Polastri R. Major liver resections synchronous with colorectal surgery. Ann Surg Oncol 2007;14:195-201.PubMedCrossRefGoogle Scholar
  37. 37.
    de Haas RJ, Adam R, Wicherts DA, Azoulay D, Bismuth H, Vibert E, Salloum C, Perdigao F, Benkabbou A, Castaing D. Comparison of simultaneous or delayed liver surgery for limited synchronous colorectal metastases. Br J Surg 2010;97:1279-1289.PubMedCrossRefGoogle Scholar
  38. 38.
    Cain KC, Harlow SD, Little RJ, Nan B, Yosef M, Taffe JR, Elliott MR. Bias due to left truncation and left censoring in longitudinal studies of developmental and disease processes. Am J Epidemiol 2011;173:1078-1084.PubMedCrossRefGoogle Scholar
  39. 39.
    Jaeck D, Bachellier P, Weber JC, Boudjema K, Mustun A, Paris F, Schaal JC, Wolf P. [Surgical strategy in the treatment of synchronous hepatic metastases of colorectal cancers. Analysis of a series of 59 operated on patients]. Chirurgie 1999;124:258-263.PubMedCrossRefGoogle Scholar
  40. 40.
    Bolton JS, Fuhrman GM. Survival after resection of multiple bilobar hepatic metastases from colorectal carcinoma. Ann Surg 2000;231:743-751.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2012

Authors and Affiliations

  • Mathias Worni
    • 1
  • Christopher R. Mantyh
    • 1
  • Igor Akushevich
    • 2
  • Ricardo Pietrobon
    • 1
  • Bryan M. Clary
    • 1
  1. 1.Department of SurgeryDuke University Medical CenterDurhamUSA
  2. 2.Center for Population Health and AgingDuke UniversityDurhamUSA

Personalised recommendations