Multivisceral en-bloc resection and metastasectomy for colorectal malignancy

Happykumar Kagathara, Shailendra Lalwani, Vivek Mangla, Naimish Mehta,

Amitabh Yadav, Samiran Nundy

Department of Surgical Gastroenterology and Liver Transplantation

Sir Ganga Ram Hospital, New Delhi

Background

• Long term survival in primary and recurrent colorectal tumors– Complete resection of all macroscopic disease

• The decision to embark on an extensive operation– Multivisceral en-bloc organ resection and metastasectomy

– Weigh the risks against the potential benefits of such procedures

Aim

• Evaluation of outcomes from complete extirpative operations in selected patients with locally advanced and advanced colorectal cancers

• Outcome measures– Survival

– Surgery related complications

Patients and Methods

• Retrospective study from prospectively maintained database

Colorectal carcinoma(n= 675 patients)

Conventional curative resectionn= 604 patients

Extended resectionn= 35 patients

Multivisceral en-bloc resectionn= 19 patients

Metastasectomyn= 8 patients

MVR + Metastasectomyn= 8 patients

Study cohort

August, 1996 to December, 2012

• Common symptoms– Abdominal pain, weight loss, bleeding P/R,

constipation, anorexia, diarrhoea

• Rare presentation– P/V discharge, lump, fever, anaemia, vomitting

• Preoperative evaluation of tumor– CEA level, Colonoscopy, CT scan

– PET-CT scan in selected group of patients presented with recurrence or metastasis

• Clinicopathological analysis, operative findings– Hospital records

• Follow up information– Out patient visit

– Telephonic survey

• Kaplan-Meier analysis for survival

Results

• Age : 53 ± 13.6 yrs

• M:F: 1 : 1.1

• BMI: 23.2 ± 5

• Recurrent tumor – 6 pts (17.6%)– Surgery – 6 pts

– Chemotherapy – 4 pts

– Radiotherapy – 1 pts

• Length of stay: 10 ± 5.5 days

• Follow up: 53%– 15 ± 9.4 months (7 – 48 months)

Disease Pattern

15

10

5

3

1

0

2

4

6

8

10

12

14

16

1 2 3 4 5

Number of involved organs

5

4

3

9

13

Ascending colon

Transverse colon

Descending colon

Sigmoid

Rectum

Tumor location

Organ Involvement

Organ involvement by local invasion

Pancreas 7 (27%)

Uterus 6 (23%)

Urinary bladder 5 (19%)

Small bowel 5 (19%)

Spleen 3 (11%)

Ureter 3 (11%)

Duodenum 3 (11%)

Vagina 3 (11%)

Ovary 3 (11%)

Liver 2 (7.6%)

Stomach 1 (3.8%)

Kidney 1 (3.8%)

Omentum 1 (3.8%)

Organ involvement by distant metastasis

Liver 10 (67%)

Peritoneum 5 (33%)

Omentum 3 (20%)

Small bowel 2 (13%)

Stomach 1 (6.6%)

Diaphragm 1 (6.6%)

Histology

• Adenocarcinoma – 68%

• Microscopic tumor infiltration (pT4) – 44%– Stage I and II: 50%

– Stage III: 17%

– Stage IV: 32%

• Positive lymph nodes – Mean – 2

– Median – 0 (0-29)

• Lymphovascular permeation – 9 (26%)

Postoperative Outcome

• Morbidity– Overall incidence – 60%

– Complications treated with intervention – 31.2% (n=13)• Anastomotic leaks – 14.2% (n=3)

• In hospital mortality: 0%

• Recurrence rate: 25.7%

Survival

• Overall 2-year survival rate: 80%

Literature Review

• Actual pathological infiltration - 50-85%Sokmen S, Terzi C et al. Int J Colorectal Dis 1999;14:282-5

• Complications after a multivisceral resection and metastasectomy

– 11% to 44%Nakafusa Y, Tanaka T et al. Rectum 2004;47:2055– 63

• Mortality – 0-7.5%Lehnert T, Methner M et al. Ann Surg 2002;235:217–25

Kruschewski M, Pohlen U et al. Zentralbl Chir 2006;131:217–22

• Overall 5-year survival rate – 51-53%Gebhardt C, Meyer W et al Langenbecks Arch Surg 384(2): 194-199, 1999

Conclusion

• Multivisceral en-bloc resection and metastasectomy in advanced colorectal carcinoma– Safe procedure

– May achieve 2-year survival rate up to 80%