Avoidance Of Remnant Liver Ischaemia ‘Essential’ During Colorectal Cancer Metastases Resection

The long-term survival of patients undergoing resection of colorectal cancer that has metastasised to the liver is predicted by the severity of postoperative remnant liver ischaemia

medwireNews: The extent of remnant liver ischaemia (RLI) after removal of colorectal cancer metastases in the liver is a significant predictor of both recurrence-free survival (RFS) and cancer-specific survival (CSS), researchers report in JAMA Surgery.

“High-quality anatomic surgery to minimize RLI after resection is essential”, Claudius Conrad and co-authors, from The University of Texas MD Anderson Cancer Center in Houston, USA, therefore advise.

Noting that ischaemic reperfusion injury during hepatic resection has previously been demonstrated to accelerate liver cancer progression, the team reviewed the outcome of 202 patients who underwent surgery to remove colorectal cancer metastases that had spread to the liver between 2008 and 2014 at their center.

All the patients had enhanced computed tomographic imaging performed within 30 days of their procedure to look for postoperative RLI, defined as reduced or absent contrast enhancement during the portal phase.

In all, 105 patients were classified as grade 0, free from postoperative RLI, and 47 patients were classified as grade 1, denoting marginal RLI after surgery. A further 45 patients had grade 2, partial RLI, and five patients grade 3, segmental RLI. There were no cases of grade 4, necrotic RLI.

Patients with grade 2 or more severe RLI had significantly poorer RFS than those with grade 0–1 RLI, with 3-year rates of 6.4% versus 39.2%. This was also true for the proportion of patients achieving CSS at 5 years, at 20.7% versus 63.7%.

Multivariable analysis revealed that grade 2 or more severe RLI was significantly associated with resection of a metastasis of at least 3 cm in size (odds ratio [OR]=2.74), removal of more than one colorectal cancer metastasis (OR=2.51) and receipt of nonanatomic resection (OR=3.29).

And multivariable analysis indicated that poor CSS was significantly predicted by a metastasis of at least 3 cm in size, detection of a RAS mutation in the primary tumour or metastatic disease, and grade 2 or higher RLI, with hazard ratios of 1.70, 2.15 and 2.90, respectively.

“In the era of modern chemotherapy and increased knowledge regarding the influence of mutation status on patient outcome, meticulous surgery based on detailed anatomic knowledge of each patient and precise intraoperative ultrasonography to avoid RLI remains of critical importance”, the authors conclude.

They add: “On an optimistic note, RLI may be the only prognostic factor today that can be positively influenced by liver surgeons caring for patients with [colorectal liver metastases].”


Yamashita S, Venkatesan AM, Mizuno T, et al. Remnant liver ischemia as a prognostic factor for cancer-specific survival after resection of colorectal liver metastases. JAMA Surg; Advance online publication 30 August 2017. doi:10.1001/jamasurg.2017.2986

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