1. 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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. RESULTS

10. 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

11. 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.

12. 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( )
708( )
.815
Blood trans. (n,%)
16(29.1%)
.477
Operative time (minute)
415( )
348( )
.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.

13. 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)

14. 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%.

15. 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.

16. 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.

17. Thank you

18. 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

19. 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

20. 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

21. 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