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Background:
The optimal timing of primary and metastatic tumor management in patients with synchronous hepatic colorectal metastases remains controversial. Although simultaneous colorectal/liver resection (SCLR) is an attractive option, the safety of this strategy has not been explored outside of small single institutional experiences. The goal of this investigation was to compare perioperative outcomes of SCLR with isolated resections utilizing a more inclusive national clinical database.

Methods:
National Surgical Quality Improvement Program (NSQIP) data from 2005 to 2009 was examined to construct descriptive statistics and risk-adjusted generalized linear models. These were used to compare 30-day postoperative outcomes among patients undergoing SCLR with colorectal resections (CR) and liver resections (LR) only in patients with metastatic colorectal cancer.

Results:
3,983 patients with metastatic colorectal cancer were identified who underwent SCLR (192), LR (1,857) or CR (1,934). Minor differences in patient demographics were noted. Patients undergoing SCLR were younger compared to CR and LR with mean ages of 40.4 years (SD: 10.8), 45.5 (13.5), and 41.7 (11.7), respectively (p<0.001). Mean number of comorbidities in the SCLR group was 0.63 (SD: 0.89), in the CR group 0.87 (1.01), and 0.74 (0.89) in the LR group (p<0.001). Rectal resection was performed in 45 (23.4%) SCLR-patients and 269 (13.9%) CR-patients (p<0.001). Major hepatectomy (≥three segments) was performed in 69 (35.9%) SCLR-patients and 774 (41.7%) of LR-patients (p=0.12). Median operation time was significantly longer for SCLR 273 minutes (95%CI: 253-295), in comparison to CR (172 minutes, 95% CI: 167-176) and LR (223 minutes, 95% CI:217-229). Median length of hospital stay was significantly longer for SCLR (9.5 days, 95%CI: 8.7-10.4) than CR (8.1 days, 95%CI: 7.8-8.3) and LR (6.5 days, 95%CI: 6.3-6.6). Patients in the SCLR group were more likely to experience postoperative complications (risk-adjusted mean number of complications: 0.69, 95%CI: 0.47-0.90) compared to CR (0.44, 95%CI: 0.39-0.49) and LR (0.34, 95%CI: 0.30-38) (p<0.001 for CR and LR versus SCLR). Excess complications were dominated by infectious and cardiopulmonary issues (table below). Mortality in patients undergoing SCLR was not increased compared to patients undergoing LR.

Discussion:
Among hospitals reporting outcomes to NSQIP the risk of 30-day adverse outcomes for SCLR is significantly higher than for CR and LR. In addition, the median operation time and hospital stay is longer for SCLR than for CR and LR only. However, higher short-term adverse outcomes in patients undergoing SCLR might be acceptable since anesthetic risk is decreased and adjuvant consolidating chemotherapy regimens can be conducted earlier. Additional population-based investigations are necessary to prove that SCLR is widely beneficial.

	CR (n=1,934, 48.6%)*	LR (n=1,857, 46.6%)*	SCLR (n=192, 4.8%)*	Risk-adjusted OR (95% CI) #	p-value
Superficial surgical site infection	168 (8.7)	79 (4.3)	14 (7.3)	1.20 (0.62-2.32) 0.53 (0.27-1.04)	0.59 0.07
Incisional surgical site infection	48 (2.5)	13 (0.7)	13 (6.8)	0.42 (0.18-0.98) 0.14 (0.05-0.35)	0.05 <0.001
Organ space site infection	100 (5.2)	95 (5.1)	24 (12.5)	0.41 (0.24-0.69) 0.33 (0.19-0.56)	0.001 <0.001
Any surgical site infection	291 (15.1)	181 (9.8)	45 (23.4)	0.64 (0.42-0.97) 0.35 (0.23-0.53)	0.04 <0.001
Cardiopulmonary complication	120 (6.2)	108 (5.8)	19 (9.9)	0.37 (0.21-0.66) 0.43 (0.25-0.77)	0.001 0.004
Renal/urinary complication	129 (6.7)	85 (4.6)	15 (7.8)	0.59 (0.31-1.10) 0.54 (0.28-1.02)	0.09 0.06
DVT/pulmonary embolism	59 (3.1)	45 (2.4)	7 (3.7)	N/A	0.38ç
Septic complication	173 (9.0)	133 (7.2)	26 (13.5)	0.43 (0.26-0.71) 0.39 (0.24-0.64)	0.001 <0.001
Mortality	89 (4.6)	23 (1.2)	2 (1.0)	N/A	<0.001ç
Intraoperative use of red blood cell products	305 (15.8)	452 (24.3)	53 (27.6)	0.41 (0.27-0.62) 1.12 (0.75-1.67)	<0.001 0.58

*Numbers are given as counts and %. # Reference category SCLR, first estimate CR vs SCLR, second estimate LR vs SCLR. Adjustment for: sex, race, age, BMI, comorbidity, dyspnea, ASA score, preoperative weight loss, preoperative radio-/chemotherapy, wound classification, hypoalbuminemia, hypercreatininemia, anemia, and hyponatremia. ç Chi-square test.