Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
Colorectal Dis. 2018 Jun;20(6):486-495. doi: 10.1111/codi.14019.
There is uncertainty regarding the optimal sequence of surgery for patients with colorectal cancer (CRC) and synchronous liver metastases. This study was designed to describe temporal trends and inter-hospital variation in surgical strategy, and to compare long-term survival in a propensity score-matched analysis.
The National Bowel Cancer Audit dataset was used to identify patients diagnosed with primary CRC between 1 January 2010 and 31 December 2015 who underwent CRC resection in the English National Health Service. Hospital Episode Statistics data were used to identify those with synchronous liver-limited metastases who underwent liver resection. Survival outcomes of propensity score-matched groups were compared.
Of 1830 patients, 270 (14.8%) underwent a liver-first approach, 259 (14.2%) a simultaneous approach and 1301 (71.1%) a bowel-first approach. The proportion of patients undergoing either a liver-first or simultaneous approach increased over the study period from 26.8% in 2010 to 35.6% in 2015 (P < 0.001). There was wide variation in surgical approach according to hospital trust of diagnosis. There was no evidence of a difference in 4-year survival between the propensity score-matched cohorts according to surgical strategy: bowel first vs simultaneous [hazard ratio (HR) 0.92 (95% CI: 0.80-1.06)] or bowel first vs liver first [HR 0.99 (95% CI: 0.82-1.19)].
There is evidence of wide variation in surgical strategy in dealing with CRC and synchronous liver metastases. In selected patients, the simultaneous and liver-first strategies have comparable long-term survival to the bowel-first approach.
对于同时患有结直肠癌（CRC）和肝转移的患者，手术的最佳顺序存在不确定性。本研究旨在描述手术策略的时间趋势和医院间差异，并在倾向评分匹配分析中比较长期生存情况。
使用国家肠道癌症审计数据集（National Bowel Cancer Audit dataset），确定 2010 年 1 月 1 日至 2015 年 12 月 31 日期间在英国国民保健系统（National Health Service）接受 CRC 切除术的原发性 CRC 患者，并使用医院住院统计数据（Hospital Episode Statistics data）确定接受肝切除术的同时伴有肝局限性转移的患者。比较倾向评分匹配组的生存结果。
在 1830 名患者中，有 270 名（14.8%）接受了肝优先方法，259 名（14.2%）接受了同步方法，1301 名（71.1%）接受了肠优先方法。在研究期间，接受肝优先或同步方法的患者比例从 2010 年的 26.8%增加到 2015 年的 35.6%（P<0.001）。根据诊断医院信托的不同，手术方法存在很大差异。根据手术策略，在倾向评分匹配的队列中，没有证据表明 4 年生存率存在差异：肠优先与同步[风险比（HR）0.92（95%CI：0.80-1.06）]或肠优先与肝优先[HR 0.99（95%CI：0.82-1.19）]。
在处理 CRC 和同步肝转移方面，有证据表明手术策略存在广泛差异。在选定的患者中，同步和肝优先策略与肠优先方法具有相当的长期生存效果。
