Seoul National university bundang hospital Short-term Outcomes of Simultaneous Major Liver Resection For Colorectal Liver Metastases Good afternoon………………….., My name is Paramin , fellowship from seoul national university bundang hospital. Today I would like to present our data. The topic is ……………….. Seoul National university bundang hospital Paramin Muangkaew, Jai Young Cho, Ho-Seong Han, Yoo-Seok Yoon, YoungRok Choi, Jae Yool Jang, Han Lim Choi, Jae Seong Jang

Introduction There were multiple approaches for treatment Colorectal cancer with synchronous liver metastases. 1 According from NCCN we have multiple approaching for treatment resectable syn. Liver metastases. However , surgical resection still the best treatment to achieve long survival. But type of resection , timing of resection & chemotherapy were still debate. 2 3

Introduction There are 11published articles for comparison staged and simultaneous liver resection in CRLM General liver resection Nowadays we ve had some evidences for comparison stage and simultaneous but they said for general liver resection, didn’t focus in major liver resection. Robert Martin, JACS 2003

Introduction Only one published article to compare simultaneous major liver resection N=31 patients Simultaneous major hepatectomy had lower complication Mostly in simultaneous group underwent right colectomy There was only one paper ,talking about simultaneous liver resection. And they reported simultaneous major liver resection had lower complication when compare to staged, but they has 31 cases in this study, more mostly patient underwent Rt hemicolectomy Lorenzo Capussotti, Annals of Surgical Oncology 2006

For comparison short-term outcomes Simultaneous and Liver only Purpose For comparison short-term outcomes Simultaneous and Liver only major liver resection in CRLM Subgroup analysis for simultaneous major liver resection in rectal cancer So, our study want to study short term outcome after perform simultaneous major liver resection , moreover we will analyse patient who underwent simultaneous major liver resection in rectal cancer. Liver Complication Colon Complication Morbidity Mortality

Methods From March 2004 to January 2015 Retrospective analysis patients who underwent simultaneously major liver resection compare with patients who underwent major liver resection alone for CRLM 103 patients 55 for simultaneous group 48 for liver-only resection group

Methods For stage IV colorectal cancer with synchronous CRLM, we perform simultaneous resection without neoadjuvant chemotherapy as the first choice if resectable. The simultaneous resection didn’t perform 1.Obstructed/perforated primary tumor 2.Unresectable extrahepatic metastases 3.Insufficient remnant liver volume 4.ASA ≥ 4

Flow chart Simultaneous resection n = 55 Liver only resection n = 48 *Extensive metastases Insufficient remnant liver vol. **Obstruction, perforation 1º tumor Synchronous CRLM (n=70) Recurrent CRLM after primary resection (n=34) Resectable (n=51) Unresectable* (n=18) Improper** simultaneous (n=1) Primary resection We had 70 synchronous CRLM, 51 was resectable but one case received neoadjuvant because of on going trial. Patient who unresectable revieved chemotherapy and 4 cases underwent simultaneous , 14 cases underwent staged. 3 cases underwent PVE. Some patients got recurrence metastases after primary resection , most of these group received chemo before underwent liver resection. Chemo Primary resection (n=14) Chemo Chemo Neoadj. Chemo 50 1 4 11 1 29 5 3 PVE Simultaneous resection n = 55 Liver only resection n = 48

RESULTS

Data Patient demographics data Simultaneous n=55 Liver only n=48 p value   Female (n,%) Male (n,%) 32(58.2%) 23(41.8%) 33(68.8%) 15(31.2%) .267 Age (yr) mean 60(38-86) 58(33-81) .160 ASA score (n,%) 1 2 3 29(52.7%) 25(45.5%) 1(1.8%) 25(52.1%) 22(45.8%) 1(2.1%) .994 BMI 23(17-35) 24(15-29) .902 Tumor location (n,%) Colon Rectum 32(66.7%) 16(33.3%) .376 Preop. chemo. (n,%) 5(9.1%) 43(89.6%) <0.001 We have 55 patients in simultaneous and 48 patient in liver-only. Most of patient didn’t receive neoadjuvant chemo

Data Tumor characteristic Simultaneous n=55 Liver only n=48 p value   T staging (n,%) T1 T2 T3 T4 41(74.5%) 14(25.5%) 5(11.4%) 30(68.2%) 9(20.5%) .036 N staging (n,%) N0 N1 N2 5(9.1%) 16(29.1%) 34(61.8%) 10(20.8%) 26(54.2%) 12(25.0%) .001 Liver metas. Number (mean) 2.9(1-10) 2.7(1-8) .604 Liver metas. Max. size (mm) 34.6(10-90) 36(8-104) .668 margin (mm) 17.9(0-78) 16(0-114) .645 There is lessor T2 staging in simultaneous but more N2. However liver metastases number , size and margin were no difference.

Data Operative detail Simultaneous n=55 Liver only n=48 p value   Liver operation (n,%) Lt hepatectomy Rt hepatectomy Central hepatectomy Rt trisectionectomy Lt trisectionectomy 14(25.5%) 31(56.4%) 3 (5.5%) 3(5.5%) 4(7.3%) 11(22.9%) 32(66.7%) 2(4.2%) 3(6.2%) .390 Colorectal operation (n,%) AR LAR ULAR Rt hemicolectomy Lt hemicolectomy Subtotal colectomy Total colectomy Hartman’s 17(30.9%) 5(9.1%) 8(14.5%) 1(1.8%) 16(33.3%) 14(29.2%) 10(20.8%) 1(2.8%) .669 Order first Colorectal Liver 41(74.54%) 14(25.45%) Ileostomy (n,%) 9(16.4%) 7(14.6%) .803 EBL (mL) 742(100-4000) 708(30-4100) .815 Blood trans. (n,%) 16(29.1%) .477 Operative time (minute) 415(120-720) 348(130-1020) .019 Data Operative detail Liver resection and colorectal resection were no difference. Most of patient underwent colorectal first. The rate od ileostomy, EBL, blood transfusion were same. Operative time in simultaneous was longer.

Reoperation (Bleeding from round ligament) Data Postoperative detail Simultaneous n=55 Liver only n=48 p value   Overall Complication(n,%) 42(76.4%) 30(62.5%) .126 Complication grading(n,%) Grade I Grade II Grade III Grade IV Grade V Grade VI 12(28.6%) 14(33.3%) 2(4.8%) 8(26.7%) 10(33.3%) 12(40.0%) .644 Major complication (Grade III-VI) (n,%) 16(29%) 12(25%) .513 Soft diet start (D) 6.0(3-10) 3.4(2-9) <0.001 Hospital stay (day) mean 14.9(7-68) 13.3(5-41) .345 PHLF grade B The overall complication was 76 %, major complication was 29% and no difference when compare to liver-only group. We had 2 cases for grade IV complication, one is liver failure gradeB, other one is bleeding from round ligament. Patients was more delay starting the diet in simultaneous, but length of hospital stay Reoperation (Bleeding from round ligament)

Data Rectal subgroup analysis No statistically significant of difference in operative detail Simultaneous n=23 Liver only n=16 p value   Overall Complication 20(87.0%) 9(56.2%) .031 Complication grading Grade I Grade II Grade III Grade IV Grade V Grade VI 7(35.0%) 5(25.0%) 1(5.0) 4(44.4%) 1(11.1%) .724 Major complication (Grade III-VI) 8(34.7%) 4(25%) .822 For rectal subgroup analysis, we have 23 patients for simultaneous and 16 patients for liver only. The overall complication was 87% higher than liver-only group. But major complication was similar 34.7% vs 25%.

SUMMARY No mortality in 103 patients No anastomotic leakage Operative time was shorter in liver-only group Overall complication, major complication were similar. (Except in rectal subgroup : more overall complication in simultaneous) EBL, blood transfusion, hospital stay were similar, too.

CONCLUSION Simultaneous major liver resection in CRLM can be safely performed and no difference in major complication when compare with liver- only resection, even in rectal cancer.

Thank you

Definition Major liver resection is resect at least three Couinaud ‘s segment. Complication grading was classified by Accordion classification Major complication was grade III – VI according to Accordion classification If there are multiple complications in one patient , we will use highest grading complication. Postoperative complication were reviewed for at least 30 days. Postoperative mortality was defined as death within 90 days after surgery

Data Liver specific complication Complication Treatment Simultaneous Liver only n=48 Treatment - Liver failure 1 Supportive treatment - Bile duct stricture ERBD - Biloma 2 PCD - Fluid collection 5 - Bleeding from round ligament Re-operation -Hepatic vein thrombosis Medical treatment

Data Non-liver specific complication Complication Treatment Simultaneous n=55 Liver only n=48 Treatment -Wound complication 15 10 Wound repair - Pleural effusion 8 1 PCD, supportive treatment - Anemia 5 2 Blood transfusion - Ascitis 3 Diuretic - Atelectasis Breathing exercise -Urinary retention Re-insert foley catheter - Leg edema -Ileus Supportive treatment -Pneumonia Antibiotic -DVT Medical treatment -AF -PTE Non-liver specific complication

Accordion severity grading system We use Accordion system to classified complication , that reported by Prof Strasberg. Its quite similar to Clavian Dindo system Steven M Strasberg , Ann Surg 2009