Dr. Suzana Buac
Dr. Roberto Hernandez-Alejandro
London Health Sciences Centre
London, ON, Canada
Project title:
How do you approach the use of ALPPS in synchronous colorectal metastasis resection?
Hypothesis:
ALPPS combined with simultaneous colorectal primary tumour resection is a safe approach for synchronous
colorectal metastases.
Study design:
A retrospective analysis of all patients registered in the ALPPS registry for colorectal liver metastases.
Study questions:
With respect to patient outcomes including complete resection with R0 margins, in-hospital mortality, 90 day
mortality, length of hospital stay, postoperative liver failure, postoperative bile leak, comprehensive
complication index, failure to reach the second operation, and progression of primary or metastatic tumours,
how do the following three approaches to combining ALPPS with primary tumour resection compare with one
another?
1. The “classical approach” consisting of two separate operations (primary tumour resection first, followed by
liver resection second)?
2. The “reverse approach” consisting of two separate operations (liver resection first for metastatic tumours,
followed by primary tumour resection second)?
3. The combined approach involving simultaneous colorectal liver metastasis resection as well as primary
tumour resection.
Possible confounders/co-variables to be included
1. Age
2. Sex
3. Location of primary tumour
4. Size of primary tumour
5. Primary tumour lymph nodes
6. Type of colorectal surgery performed
7. Number of liver metastases
8. Location and size of metastases
9. Specific type of ALPPS (number of segments in FLR, what side)
10. Patient medical history and comorbidities
11. Neoadjuvant/adjuvant therapy
12. Preoperative CEA level
13. Hepatic macrosteatosis
Background:
Synchronous colorectal liver metastases occur in as many as 1 in 5 patients diagnosed with colorectal cancer
on initial presentation. Currently there is clinical equipoise with respect to management options for those
patients not presenting with extrahepatic metastatic disease, obstruction or perforation. Treatment consists of a
combination of neoadjuvant systemic chemotherapy and surgical resection of the primary tumour as well as
liver metastases. However, the surgical approach for synchronous liver metastases varies between three
possible pathways. 1. The “classic approach” consists of intial colorectal resection, interval chemotherapy,
followed by liver resection last. 2. The “reverse” or “liver first approach” takes place before or after systemic
thermotherapy with resection of the primary tumour last. 3. The “simultaneous” approach consists of resection
of the colorectal primary tumour and liver metastases at the same time in combination with neoadjuvant or
adjuvant chemotherapy. ALPPS has been used as a part of the simultaneous approach for colorectal liver
metastases that would not otherwise be resectable, but the outcomes of this procedure have not yet been
studied.