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R1 Resection for Colorectal Liver Metastases: a Survey Questioning Surgeons about Its Incidence, Clinical Impact, and Management

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Journal of Gastrointestinal Surgery

Abstract

Background

A ≥ 1-mm margin is standard for resection of colorectal liver metastases (CLM). However, R1 resection is not rare (10–30%), and chemotherapy could mitigate its impact. The possibility of detaching CLM from vessels (R1 vascular margin) has been described. A reappraisal of R1 resection is needed.

Methods

A 19-question survey regarding R1 resection for CLM was sent to hepatobiliary surgeons worldwide. Seven clinical cases were included.

Results

In total, 276 surgeons from 52 countries completed the survey. Ninety percent reported a negative impact of R1 resection (74% local recurrence, 31% hepatic recurrence, and 36% survival), but 50% considered it sometimes required for resectability. Ninety-one percent of responders suggested that the impact of R1 resection is modulated by the response to chemotherapy and/or CLM characteristics. Half considered the risk of R1 resection to be an indication for preoperative chemotherapy in patients who otherwise underwent upfront resection, and 40% modified the chemotherapy regimen when the tumor response did not guarantee R0 resection. Nevertheless, 80% scheduled R1 resection for multiple bilobar CLM that responded to chemotherapy. Forty-five percent considered the vascular margin equivalent to R0 resection. However, for lesions in contact with the right hepatic vein, right hepatectomy remained the standard. Detachment from the vein was rarely considered (10%), but 27% considered detachment in the presence of multiple bilobar CLM.

Conclusions

A negative margin is still standard for CLM, but R1 resection is no longer just a technical error. R1 resection should be part of the modern multidisciplinary, aggressive approach to CLM.

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Acknowledgements

The authors thank all the colleagues that completed the survey for their precious contribution to this study.

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Authors and Affiliations

  1. Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy

    Luca Viganò, Guido Costa, Matteo Maria Cimino, Fabio Procopio, Matteo Donadon, Daniele Del Fabbro & Guido Torzilli

  2. Department of Biomedical Sciences, Humanitas University, Rozzano, Italy

    Luca Viganò, Matteo Donadon & Guido Torzilli

  3. Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France

    Jacques Belghiti

  4. Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

    Norihiro Kokudo

  5. Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Japanese Red Cross Medical Center, Tokyo, Japan

    Masatoshi Makuuchi

  6. Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Jean-Nicolas Vauthey

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  1. Luca Viganò
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  2. Guido Costa
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  3. Matteo Maria Cimino
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  4. Fabio Procopio
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  7. Jacques Belghiti
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  8. Norihiro Kokudo
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  9. Masatoshi Makuuchi
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  11. Guido Torzilli
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Contributions

• Substantial contributions to the conception or design of the work: Viganò, Belghiti, Kokudo, Makuuchi, Vauthey, Torzilli

• Acquisition, analysis, or interpretation of data for the work: Costa, Cimino, Procopio, Donadon, Del Fabbro

• Drafting the work: Viganò, Costa, Cimino, Procopio, Donadon, Del Fabbro

• Revising it critically for important intellectual content: Viganò, Belghiti, Kokudo, Makuuchi, Vauthey, Torzilli

• Final approval of the version to be published: all the authors

• Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: all the authors

Corresponding author

Correspondence to Guido Torzilli.

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Viganò, L., Costa, G., Cimino, M.M. et al. R1 Resection for Colorectal Liver Metastases: a Survey Questioning Surgeons about Its Incidence, Clinical Impact, and Management. J Gastrointest Surg 22, 1752–1763 (2018). https://doi.org/10.1007/s11605-018-3820-z

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