Simultaneous curative resection of double colorectal carcinoma with synchronous bilobar liver metastases

Abstract

Synchronous colorectal carcinoma (SCRC) indicates more than one primary colorectal carcinoma (CRC) discovered at the time of initial presentation, accounts for 3.1%-3.9% of CRC, and may occur either in the same or in different colorectal segments. The accurate preoperative diagnosis of SCRC is difficult and diagnostic failures may lead to inappropriate treatment and poorer prognosis. SCRC requires colorectal resections tailored to individual patients, based on the number, location, and stage of the tumours, from conventional or extended hemicolectomies to total colectomy or proctocolectomy, when established predisposing conditions exist. The overall perioperative risks of surgery for SCRC seem to be higher than for solitary CRC. Simultaneous colorectal and liver resection represents an appealing surgical strategy in selected patients with CRC and synchronous liver metastases (CRLM), even though the cumulative risks of the two procedures need to be adequately evaluated. Simultaneous resections have the noticeable advantage of avoiding a second laparotomy, give the opportunity of an earlier initiation of adjuvant therapy, and may significantly reduce the hospital costs. Because an increasing number of recent studies have shown good results, with morbidity, perioperative hospitalization, and mortality rates comparable to staged resections, simultaneous procedures can be selectively proposed even in case of complex colorectal resections, including those for SCRC and rectal cancer. However, in patients with multiple bilobar CRLM, major hepatectomies performed simultaneously with colorectal resection have been associated with significant perioperative risks. Conservative or parenchymal-sparing hepatectomies reduce the extent of hepatectomy while preserving oncological radicality, and may represent the best option for selected patients with multiple CRLM involving both liver lobes. Parenchymal-sparing liver resection, instead of major or two-stage hepatectomy for bilobar disease, seemingly reduces the overall operative risk of candidates to simultaneous colorectal and liver resection, and may represent the most appropriate surgical strategy whenever possible, also for patients with advanced SCRC and multiple bilobar liver metastases.

Keywords: Colorectal surgery, Synchronous colorectal liver metastases, Major hepatectomy, Parenchymal-sparing hepatectomy, Intraoperative ultrasonography, Simultaneous colorectal and liver surgery, Synchronous colorectal carcinoma, Ablative therapies

Core tip: Simultaneous colorectal and liver resection represents an appealing surgical strategy in selected patients with colorectal cancer and resectable synchronous liver metastases (CRLM). Synchronous colorectal carcinoma may represent an adequate indication to simultaneous resections, even though it may require more complex colorectal resections. In patients with multiple bilobar synchronous CRLM, major hepatectomies performed simultaneously with colorectal surgery have been associated with increased perioperative risks compared to major hepatectomies alone. Conservative or parenchymal-sparing hepatectomies reduce the extent of hepatectomy while preserving oncological radicality, and may represent the best option to reduce the perioperative risks of simultaneous colorectal and liver resection.