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Simultaneous Resection for Synchronous Colorectal Liver Metastasis: The New Standard of Care?
Jonathan S. Abelson*1, Fabrizio Michelassi1, Jeffrey Milsom1, Benjamin Samstein1, Art Sedrakyan2, Heather L. Yeo1
1Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New york, NY; 2Healthcare Policy and Research, Weill Cornell Medicine, New York, NY

Objective: There are 3 operative strategies for patients with colorectal cancer and synchronous liver metastases: liver resection first, colorectal resection first or simultaneous resection. Despite a large body of literature evaluating each strategy, optimal surgical management of these patients is still controversial with few real-world studies. We sought to characterize the NY State surgical experience with each approach as well as analyze operative morbidity and mortality.
Methods: The longitudinal NY Department of Health SPARCS database was used to follow patients undergoing surgery for colorectal cancer with liver metastases from 2005-2013. Using ICD-9 codes, we identified 3 groups: Group 1(liver resection first, followed by colorectal resection within 6 mos); Group 2(colon resection first, followed by liver resection within 6 mos); Group 3(simultaneous colon/liver resection). We analyzed trends in volume and outcomes.
Results: 1,193 patients were included: 28(2.4%) in Group 1, 173(14.8%) in Group 2, and 968(82.8%) in Group 3. Four high volume centers account for 53% of all cases. Due to small sample size, Group 1 was removed from further analysis. The number of simultaneous surgeries (Group 3) per year increased from 93 in 2005 to 131 in 2013(p=0.005), while the number of patients undergoing colon resection first then liver resection (Group 2) over the same time period increased from 9 to 16(p=0.04). Patients in Group 3 were older(59.5 vs. 56.8yrs, p = 0.02) and more likely to have Medicare(33.8% vs. 28.9%, p<0.01) and commercial insurance(54.9% vs. 49.7%, p<0.01). There was a trend towards more patients with >2 comorbidities in Group 3(28.2% vs. 22.0%, p=0.11). A lower percent of procedures in Group 3 were performed using MIS compared to Group 2(6.4% vs. 15.6%, p<0.01). There was a higher proportion of right hemicolectomies (34.2% vs. 27.2%, p<0.01) and rectal resections(35.1% vs. 32.4%, p<0.01) in Group 3. There was no difference in the percent of patients with complications between groups. The median LOS(8 days IQR=7-12 vs. 13 days IQR=10-18; p<0.01) and hospital charges(,380 IQR=,622-,116 vs. ,376 IQR=,944-,395; p<0.01) were less for Group 3. A sensitivity analysis was performed to evaluate major liver combined with rectal resection, but did not identify a statistical difference between simultaneous vs. staged procedures.
Conclusions: The overwhelming majority of patients in New York state undergoing surgery for synchronous colorectal liver metastasis are having simultaneous liver and colon resections. There was no difference in complications between groups, however, LOS and hospital charges were less for patients undergoing simultaneous resections. This supports previously published high volume center experiences and demonstrates that simultaneous resections may be associated with patient benefit.

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