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ALPPS for Synchronous CRLM - Liver first vs. Standard Approach

Suzanna Buac, Roberto Hernandez-Alejandro
Department / Institution: 
London Health Sciences Centre, London, Ontario, Canada
Date Project Approved: 
Thursday, 10 July, 2014
Project Status: 
Application / Abstract: 
Synchronous colorectal liver metastases occur in as many as 1 in 5 patients diagnosed with colorectal cancer on initial presentation. Currently there is clinical equipoise with respect to management options for those patients not presenting with extrahepatic metastatic disease, obstruction or perforation. Treatment consists of a combination of neoadjuvant systemic chemotherapy and surgical resection of the primary tumour as well as liver metastases. However, the surgical approach for synchronous liver metastases varies between three possible pathways. 1. The “classic approach” consists of intial colorectal resection, interval chemotherapy, followed by liver resection last. 2. The “reverse” or “liver first approach” takes place before or after systemic thermotherapy with resection of the primary tumour last. 3. The “simultaneous” approach consists of resection of the colorectal primary tumour and liver metastases at the same time in combination with neoadjuvant or adjuvant chemotherapy. ALPPS has been used as a part of the simultaneous approach for colorectal liver metastases that would not otherwise be resectable, but the outcomes of this procedure have not yet been studied.
ALPPS combined with simultaneous colorectal primary tumour resection is a safe approach for synchronous colorectal metastases.
Hypothesis: ALPPS combined with simultaneous colorectal primary tumour resection is a safe approach for synchronous colorectal metastases. Study design: A retrospective analysis of all patients registered in the ALPPS registry for colorectal liver metastases. Study questions: With respect to patient outcomes including complete resection with R0 margins, in-hospital mortality, 90 day mortality, length of hospital stay, postoperative liver failure, postoperative bile leak, comprehensive complication index, failure to reach the second operation, and progression of primary or metastatic tumours, how do the following three approaches to combining ALPPS with primary tumour resection compare with one another? 1. The “classical approach” consisting of two separate operations (primary tumour resection first, followed by liver resection second)? 2. The “reverse approach” consisting of two separate operations (liver resection first for metastatic tumours, followed by primary tumour resection second)? 3. The combined approach involving simultaneous colorectal liver metastasis resection as well as primary tumour resection. Possible confounders/co-variables to be included 1. Age. 2. Sex. 3. Location of primary tumour. 4. Size of primary tumour. 5. Primary tumour lymph nodes. 6. Type of colorectal surgery performed. 7. Number of liver metastases. 8. Location and size of metastases. 9. Specific type of ALPPS (number of segments in FLR, what side). 10. Patient medical history and comorbidities. 11. Neoadjuvant/adjuvant therapy. 12. Preoperative CEA level. 13. Hepatic macrosteatosis.


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