Resektion colorectaler Lebermetastasen Welche Prognosefaktoren bestimmen die Patientenselektion?

摘要

Aim of the study: Based on a consecutive series of patients undergoing liver resection for colorectal metastases, indicators of prognosis and selection criteria were evaluated. Patients and methods: From 1960 to 1998, a total of 654 patients underwent resection of colorectal liver metastases. In 516 patients (78.9 %) this was an R0 resection for initial metastatic disease. These patients form the basis for the investigation. Results: 30-day mortality in this group was 5.8 %, while the total procedure-related mortality was 8.3 %. Significant morbidity was observed in 16 % of patients. Follow-up information until 1 January, 2000 was achieved in 99.5 % of patients. Including operative mortality, the actuarial 5-, 10-, and 20-year survival is 38 ± 5 %, 27 ± 6 % und 24 ± 24 %, rising to 41 ± 5 %, 29 ± 6 % and 26 ± 26 % after excluding operative deaths. Tumor-free survival is 35 ± 5 % at 5 years. In the multivariate analysis the following factors are associated with decreased crude survival: extrahepatic tumor (P < 0.0001), intraoperative hypotension (P = 0.0001), non-anatomical procedures (P = 0.0002), a metastasis diameter ≥ 5 cm (P = 0.0002), unfavourable grading of the primary tumor (P = 0.0003), satellite metastases (P = 0.0069), mesenteric lymph node involvement (P = 0.0260), use of FFP (P = 0.0307) and synchronous diagnosis of metastases (P = 0.1240). With respect to disease-free survival metastasis diameter is first, followed by extrahepatic disease (P < 0.0001 each). Satellite metastases are removed, while the primary tumor site becomes important with inferior results for rectal cancer (P = 0.0188). The other factors remain stable and in the same order. The number of independent tumor nodules as well as the width of resection margin fail to be significant in both univariate and multivariate analysis. Conclusion: These results underline the paramount importance of an R0 resection, but diminish the relevance of most commonly used “contraindications”. For the actual decision on liver resection, beside the possibility of achieving an R0 situation, safety aspects regarding comorbidity and acceptable extent of parenchyma loss represent the prime limitation.