title: Two-stage hepatectomy: A planned strategy to treat irresectable liver tumors.
abstract: OBJECTIVE
  To assess feasibility, risks, and patient outcomes in the treatment of colorectal metastases with two-stage hepatectomy.
  
  
  BACKGROUND
  Some patients with multiple hepatic colorectal metastases are not candidates for a complete resection by a single hepatectomy, even when downstaged by chemotherapy, after portal embolization, or combined with a locally destructive technique. In two-stage hepatectomy, the highest possible number of tumors is resected in a first, noncurative intervention, and the remaining tumors are resected after a period of liver regeneration. In selected patients with irresectable multiple metastases not amenable to a single hepatectomy procedure, two-stage hepatectomy might offer a chance of long-term remission.
  
  
  METHODS
  Of consecutive patients with conventionally irresectable colorectal metastases treated by chemotherapy, 16 of 398 (4%) became eligible for curative two-stage hepatectomy combined with chemotherapy and adjuvant nonsurgical interventions as indicated.
  
  
  RESULTS
  Two-stage hepatectomy was feasible in 13 of 16 patients (81%). There were no surgical deaths. The postoperative death rate (2 months or less) was 0% for the first-stage procedure and 15% for the second-stage one. Postoperative complication rates were 31% and 45%, respectively, with only one complication leading to reoperation. The 3-year survival rate was 35%, with four patients (31%) disease-free at 7, 22, 36, and 54 months. Median survival was 31 months from the second hepatectomy and 44 months from the diagnosis of metastases.
  
  
  CONCLUSIONS
  Two-stage hepatectomy combined with chemotherapy may allow a long-term remission in selected patients with irresectable multiple metastases and increases the proportion of patients with resectable disease.
authors.affiliation: Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, and Université Paris-Sud, France. rene.adam@pbr.ap-hop-paris.fr
authors.forename: R
authors.initials: R
authors.lastname: Adam
authors.forename: A
authors.initials: A
authors.lastname: Laurent
authors.forename: D
authors.initials: D
authors.lastname: Azoulay
authors.forename: D
authors.initials: D
authors.lastname: Castaing
authors.forename: H
authors.initials: H
authors.lastname: Bismuth
mesh_terms: D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D015179:Colorectal Neoplasms / Q000473:pathology*; D003452:Cryosurgery; D018450:Disease Progression; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D008115:Liver Regeneration / Q000502:physiology; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome