Wicherts Dennis A, Miller Rafael, de Haas Robbert J, Bitsakou Georgia, Vibert Eric, Veilhan Luc-Antoine, Azoulay Daniel, Bismuth Henri, Castaing Denis, Adam René
Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, Villejuif, France.
Ann Surg. 2008 Dec;248(6):994-1005. doi: 10.1097/SLA.0b013e3181907fd9.
To assess feasibility, risks, and long-term outcome of 2-stage hepatectomy as a means to improve resectability of colorectal liver metastases (CLM).
Two-stage hepatectomy uses compensatory liver regeneration after a first noncurative hepatectomy to enable a second curative resection.
Between October 1992 and January 2007, among 262 patients with initially irresectable CLM, 59 patients (23%) were planned for 2-stage hepatectomy. Patients were eligible when single resection could not achieve complete treatment, even in combination with chemotherapy, portal embolization, or radiofrequency, but tumors could be totally removed by 2 sequential resections. Feasibility and outcomes were prospectively evaluated.
Two-stage hepatectomy was feasible in 41 of 59 patients (69%). Eighteen patients failed to complete the second hepatectomy because of disease progression (n = 17) or bad performance status (n = 1). The 41 successfully treated patients had a mean number of 9.1 metastases (mean diameter, 48.5 mm at diagnosis). Chemotherapy was delivered before (95%), in between (78%), and after (78%) the 2 hepatectomies. Mean delay between the 2 liver resections was 4.2 months. Postoperative mortality was 0% and 7% (3/41) after the first and second hepatectomy, respectively. Morbidity rates were also higher after the second procedure (59% vs. 20%) (P < 0.001). Five-year survival was 31% on an intention to treat basis, and all but 2 patients who did not complete the 2-stage strategy died within 19 months. After a median follow-up of 24.4 months (range, 3.7-130.3), overall 3- and 5-year survivals for patients that completed both hepatectomies were 60% and 42%, respectively, after the first hepatectomy (median survival, 42 months from first hepatectomy and 57 months from metastases diagnosis). Disease-free survivals were 26% and 13% at 3 and 5 years, respectively.
Two-stage hepatectomy provides a 5-year survival of 42% and a hope of long-term survival for selected patients with extensive bilobar CLM, irresectable by any other means.
评估两阶段肝切除术作为提高结直肠癌肝转移（CLM）可切除性方法的可行性、风险及长期疗效。
两阶段肝切除术利用首次非根治性肝切除术后的肝脏代偿性再生，以实现第二次根治性切除。
1992年10月至2007年1月期间，在262例初始不可切除的CLM患者中，59例（23%）计划接受两阶段肝切除术。当单次切除即使联合化疗、门静脉栓塞或射频消融也无法实现完全治疗，但肿瘤可通过连续两次切除完全切除时，患者符合条件。对可行性和疗效进行前瞻性评估。
59例患者中有41例（69%）可行两阶段肝切除术。18例患者因疾病进展（n = 17）或身体状况差（n = 1）未能完成第二次肝切除术。41例成功治疗的患者平均有9.1个转移灶（诊断时平均直径48.5 mm）。在两次肝切除术之前（95%）、期间（78%）和之后（78%）均进行了化疗。两次肝切除之间的平均间隔时间为4.2个月。第一次和第二次肝切除术后的死亡率分别为0%和7%（3/41）。第二次手术后的并发症发生率也更高（59%对20%）（P < 0.001）。意向性治疗基础上的5年生存率为31%，除2例未完成两阶段治疗策略的患者外，所有患者均在19个月内死亡。中位随访24.4个月（范围3.7 - 130.3个月）后，完成两次肝切除术的患者的总体3年和5年生存率分别为60%和42%，第一次肝切除术后（中位生存期，从第一次肝切除起42个月，从转移灶诊断起57个月）。无病生存率在3年和5年时分别为26%和13%。
两阶段肝切除术为部分广泛双侧CLM且无法通过其他任何方法切除的患者提供了42%的5年生存率及长期生存的希望。
