Figure 1
Study inclusion criteria and patient flow. Study subjects were identified from a prospectively maintained database of 572 patients who underwent liver resections for colorectal liver metastases (CLM) from January 2000 to December 2016 at the Department of Abdominal and General Surgery, University Medical Center Maribor.
TABLE 1
Preoperative clinical characteristics of patients, primary colorectal tumor and synchronous colorectal liver metastases
| Variable | Simultaneous Open | Simultaneous Laparoscopy | P |
|---|---|---|---|
| (n = 10) | (n = 10) | ||
| Patients | |||
| Gender (male/female) | 6/4 | 6/4 | 1.00 |
| Age [mean ± SD (years)] | 65.4 ± 8.1 | 62.2 ± 7.9 | 0.39 |
| BMI [median (IQR) (kg/m2)] | 24.0 (23.1–25.5) | 26.9 (23.6–32.1) | 0.34 |
| ASA (I /II/III) | 4/3/3 | 5/3/2 | 0.86 |
| Preoperative chemotherapy (y/n) | 3/7 | 7/3 | 0.18 |
| Preoperative radiotherapy (y/n) | 3/7 | 4/6 | 1.00 |
| CEA at diagnosis [mean ± SD (ng/mL)] | 15.2 ± 12.5 | 7.7 ± 7.7 | 0.12 |
| Colorectal tumor | |||
| Right colon/ left colon/ rectum | 3/3/4 | 2/2/6 | 0.67 |
| Colorectal liver metastases | |||
| Number of lesions [median (IQR)] | 1 (1–2) | 1 (1–2) | 0.68 |
| Larger diameter [mean ± SD (cm)] | 2.9 ± 1.5 | 2.0 ± 1.2 | 0.17 |
| Laterality (unilateral /bilateral) | 9/1 | 9/1 | 1.00 |
| Proximity of major vessel [(hilar or hepatic confluence) (y/n)] | 0/10 | 0/10 | 1.00 |
| Location (anterolateral / posterosuperior) | 8/2 | 9/1 | 1.00 |
[i] ASA = American Society of Anesthesiologist physical status score; BMI = body mass index; CEA = carcinoembryonic antigen; SD = standard deviation
TABLE 2
Intraoperative - simultaneous liver and colorectal surgery related variables
| Variable | Simultaneous Open | Simultaneous Laparoscopy | P |
|---|---|---|---|
| (n = 10) | (n = 10) | ||
| Totally pure laparoscopic | – | 10 | – |
| Conversion to laparotomy | – | 0 | – |
| Liver surgery | |||
| Minor/major resection | 10/0 | 10/0 | 1.00 |
| Atypical/ segmentectomy/LLS | 6/2/2 | 5/3/2 | 0.87 |
| Pringle’s maneuver (y/n) | 2/8 | 3/7 | 1.00 |
| Colorectal surgery | |||
| Colon/rectal resection | 6/4 | 5/5 | 1.00 |
| Temporary stoma covering low anastomosis (y/n) | 2*/8 | 3*/7 | 1.00 |
| Terminal colostomy (Hartman or APE) | 2/8 | 2/8 | 1.00 |
| Operative time [mean ± SD (min)] | 257 ± 66.8 | 261 ± 92.8 | 0.91 |
| Blood loss | |||
| Estimated [median (IQR) (mL)] | 170 (70-230) | 105 (30-180) | 0.23 |
| Hemoglobin drop** [median (IQR) (g/L)] | 22.5 (9–28) | 15.5 (9–17) | 0.38 |
| Transfusion required (y/n) | 3/7 | 3/7 | 1.00 |
APE = abdominoperineal excision; LLS = left lateral sectionectomy;
TABLE 3
Postoperative oncological results after patohistology and clinical risk score
| Variable | Simultaneous Open (n = 10) | Simultaneous Laparoscopy (n = 10) | P |
|---|---|---|---|
| Colorectal tumor | |||
| T (T1/T2/T3/T4) | 0/1/8/1 | 0/1/9/0 | 1.00 |
| N (N0/N+) | 2/8 | 2/8 | 1.00 |
| Number of harvested lymph nodes (mean ± SD) | 9.5 ± 6.2 | 13.7 ± 6.9 | 0.17 |
| Well/moderately/poorly differentiated | 4/5/1 | 4/6/0 | 1.00 |
| Negative surgical margin | |||
| Liver (y/n) | 10/0 | 10/0 | 1.00 |
| Colorectal (y/n) | 10/0 | 10/0 | 1.00 |
| Liver resection margin [median (IQR) (mm)] | 2.5 (2–5) | 5.0 (1.8–8) | 0.38 |
| CRS (1/2/3/4) | 2/5/2/1 | 2/4/3/1 | 0.96 |
[i] CRS = clinical risk score (no patients with CRS 0 or 5 in any of the group)
TABLE 4
Postoperative outcome: patient’s recovery, morbidity and mortality. No postoperative mortality occurred in either group. Adjuvant chemotherapy and incisional hernias
| Variable | Simultaneous Open | Simultaneous Laparoscopy | P |
|---|---|---|---|
| (n = 10) | (n = 10) | ||
| ICU stay | 0 | 0 | – |
| HDU stay [median (IQR) (days)] | 4 (2–6) | 3 (2–5) | 0.59 |
| Solid food oral intake [median (IQR) (days)] | 5.5 (4–6) | 3 (3–4) | 0.006 |
| Stool passing [median (IQR) (days)] | 4.5 (4–5) | 4 (3–5) | 0.46 |
| Intravenous narcotics requirement [median (IQR) (days)] | 6.5 (6–7) | 4.5 (3–7) | 0.08 |
| Hospital stay [median (IQR) (days)] | 11.5 (10–33) | 8 (8–12) | 0.044 |
| Morbidity | |||
| Overall (y/n) | 5/5 | 3/7 | 0.65 |
| Liver specific* (y/n) | 2/8 | 0/10 | 0.47 |
| CD < III (y/n) | 2/8 | 2/8 | 1.00 |
| CD IIIab (y/n) | 3/7 | 1/9 | 0.58 |
| CD > III (y/n) | 0/10 | 0/10 | 1.00 |
| Mortality (y/n) | 0/10 | 0/10 | 1.00 |
| Postoperative chemotherapy (y/n) | 5/5 | 2/8 | 0.35 |
| Incisional hernias (y/n) | 3/7 | 0/10 | 0.21 |
HDU = high dependency unit; ICU = intensive care unit
TABLE 5
Morbidity details, hospital stay, patterns and time of recurrence, redo procedures and long-term outcome.
| Patients | Morbidity | Hospital stay (days) | Recurrence location (years after first surgery) | Redo | Survival (years) | Survival status (March 2017) |
|---|---|---|---|---|---|---|
| OPEN | ||||||
| 1 | Wound infection (CD II) | 12 | 1) Liver (2Y) 2) Liver (3Y) | 1) Liver 2) / | 3 | DOD |
| 2 | Bile collection (CD IIIa) | 36 | Liver (1Y) | Liver | 7 | NED |
| 1) Liver (1Y) | 1) Liver | |||||
| 3 | nil | 9 | 2) Colon (3Y) | 2) Colon | 4 | DOD |
| 3) Peritoneal carcinosis (4Y) | 3) / | |||||
| 4 | Anastomotic leak (CD IIIb) | 54 | Liver (1Y) | Liver | 5 | NED |
| 5 | nil | 10 | no | / | 11 | NED |
| 6 | Pneumonia (CD II) | 12 | no | / | 10 | D - other |
| 7 | nil | 11 | no | / | 8 | NED |
| 8 | nil | 9 | no | / | 8 | NED |
| 9 | Bile collection (CD IIIa) | 33 | no | / | 7 | NED |
| 10 | nil | 10 | no | / | 5 | NED |
| LAP | ||||||
| 1 | nil | 8 | no | / | 5 | NED |
| 2 | Anastomotic leak (CD IIIb) | 42 | Liver and peritoneal carcinosis (1Y) | / | 2 | DOD |
| 3 | nil | 7 | no | / | 4 | NED |
| 4 | nil | 7 | Liver and peritoneal carcinosis (3Y) | / | 4 | AWD |
| 5 | nil | 8 | no | / | 2 | NED |
| 6 | nil | 12 | no | / | 2 | NED |
| 7 | nil | 8 | no | / | 1 | NED |
| 8 | Pulmonary embolism (CD II) | 9 | no | / | 1 | NED |
| 9 | nil | 8 | no | / | <1 | NED |
| 10 | Ictus cerebri (CD II) | 21 | no | / | <1 | NED |
[i] AWD = alive with disease; CD = Clavien Dindo classification of complication severity; D - other = death without recurrence of disease; DOD = dead of disease; LAP = simultaneous laparoscopic surgery; OPEN = simultaneous open surgery; NED = no evidence of disease; Y = years
Figure 2
Kaplan-Meier estimates of overall survival between the simultaneous laparoscopy (blue line) and open surgery groups (red line).
Figure 3
Kaplan-Meier estimates of disease-free survival between the simultaneous laparoscopy (blue line) and open surgery groups (red line).