Jarnagin W R, Conlon K, Bodniewicz J, Dougherty E, DeMatteo R P, Blumgart L H, Fong Y
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Cancer. 2001 Mar 15;91(6):1121-8. doi: 10.1002/1097-0142(20010315)91:6<1121::aid-cncr1108>3.0.co;2-2.
Laparoscopy may identify occult metastatic disease and prevent unnecessary laparotomy in some patients with potentially resectable colorectal liver metastases but is unnecessary in the majority of individuals who undergo resection. The objectives of the current study were to assess the impact of laparoscopy after extensive preoperative imaging and to determine whether a preoperative clinical risk score can identify those patients most likely to benefit from the procedure.
Between December 1997 and July 1999, 103 consecutive patients with potentially resectable colorectal liver metastases underwent laparoscopy prior to planned laparotomy and partial hepatectomy. Surgical findings, length of hospital stay, and hospital charges were analyzed. Patients were assigned a clinical risk score (CRS) based on five factors related to the primary tumor and the hepatic disease. The likelihood of finding occult unresectable disease and the yield of laparoscopy were analyzed with respect to the CRS.
Seventy-seven patients (75%) underwent resection. Laparoscopy identified 14 of 26 patients with unresectable disease, 10 of whom were spared an unnecessary laparotomy. In patients who underwent biopsy only, the laparoscopic identification of unresectable disease shortened the hospital stay (1.2 +/- 0.6 days vs. 5.8 +/- 2.3 days; p = 0.0001) and reduced the total hospital charges by 55% (P = 0.0001). The CRS predicted the likelihood of occult unresectable disease, which was 12% in those with a score < or = 2 but increased to 42% in those with a score > 2 (P = 0.001). If laparoscopy were used only in high risk patients (CRS > 2), 57 laparoscopies would have been avoided and the net savings doubled.
With extensive preoperative imaging, the vast majority of patients with potentially resectable hepatic colorectal metastases do not benefit from laparoscopy. However, in the minority of patients with occult unresectable disease, laparoscopy prevents unnecessary laparotomy and reduces hospital stay and the total hospital charges. The CRS, previously shown to predict survival after hepatic resection, identifies those high risk patients most likely to benefit from laparoscopy and may improve resource utilization.
腹腔镜检查可能会发现隐匿性转移性疾病，并可避免一些有可能切除的结直肠癌肝转移患者进行不必要的剖腹手术，但对于大多数接受切除术的患者而言并无必要。本研究的目的是评估在进行广泛的术前影像学检查后腹腔镜检查的影响，并确定术前临床风险评分是否能够识别出最有可能从该手术中获益的患者。
在1997年12月至1999年7月期间，103例连续的有可能切除的结直肠癌肝转移患者在计划进行剖腹手术和部分肝切除术之前接受了腹腔镜检查。分析手术结果、住院时间和住院费用。根据与原发性肿瘤和肝脏疾病相关的五个因素为患者分配临床风险评分（CRS）。针对CRS分析发现隐匿性不可切除疾病的可能性和腹腔镜检查的收益。
77例患者（75%）接受了切除术。腹腔镜检查在26例不可切除疾病患者中发现了14例，其中10例避免了不必要的剖腹手术。在仅接受活检的患者中，腹腔镜检查发现不可切除疾病可缩短住院时间（1.2±0.6天对5.8±2.3天；p = 0.0001），并使总住院费用降低55%（P = 0.0001）。CRS预测了隐匿性不可切除疾病的可能性，评分≤2的患者中为12%，但评分>2的患者中增加到42%（P = 0.001）。如果仅对高危患者（CRS>2）使用腹腔镜检查，可避免57次腹腔镜检查，净节省费用翻倍。
通过广泛的术前影像学检查，绝大多数有可能切除的肝结直肠癌转移患者无法从腹腔镜检查中获益。然而，在少数隐匿性不可切除疾病患者中，腹腔镜检查可避免不必要的剖腹手术，并缩短住院时间和降低总住院费用。先前已证明CRS可预测肝切除术后的生存率，它能识别出最有可能从腹腔镜检查中获益的高危患者，并可能改善资源利用。
