title: Two-stage strategy for patients with extensive bilateral colorectal liver metastases.
abstract: BACKGROUND
  Two-stage hepatectomy has been proposed for patients with bilateral colorectal liver metastases. The present study assesses the feasibility and outcome of two-stage hepatectomy for the treatment of colorectal liver metastases.
  
  
  METHODS
  From January 1994 to December 2008, 720 patients underwent liver resections at two institutions for colorectal liver metastases. The feasibility and outcomes of two-staged hepatectomies were evaluated.
  
  
  RESULTS
  Forty-five patients were eligible for the two-stage approach and both stages were completed in 35 patients (78%). Reasons for failure included disease progression (n= 7), poor performance status (n= 1) and death after the first stage (n= 2). Patients who completed both stages had significantly fewer lesions than patients who failed to complete the second stage (5 vs. 8; P= 0.02). No differences between the two groups were observed with regard to lesion size, receipt of radiofrequency ablation (RFA) or presence of extrahepatic disease. Post-operative morbidity (24% vs. 26%; P= 0.9) and mortality (4% vs. 5%; P= 0.8) was similar between the first and second stages. Median overall survival was 16 months. Three-year survival was significantly worse for patients failing to complete both stages (18%) compared with patients completing both stages (58%) (P < 0.001). Similar survival rates were observed between patients who completed two-stage vs. patients treated with a planned single-stage hepatectomy (58% vs. 53%; P= 0.34).
  
  
  CONCLUSIONS
  The two-stage strategy for colorectal liver metastases can be performed with acceptable morbidity and mortality. The second stage will not be feasible in 20-25% of patients. Patients who are able to complete the two-stage approach, however, may have long-term survival comparable to patients treated with a planned single-stage hepatectomy.
authors.affiliation: Department of Surgery, Division of Surgical Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
authors.forename: Susan
authors.initials: S
authors.lastname: Tsai
authors.forename: Hugo P
authors.initials: HP
authors.lastname: Marques
authors.forename: Mechteld C
authors.initials: MC
authors.lastname: de Jong
authors.forename: Paulo
authors.initials: P
authors.lastname: Mira
authors.forename: Vasco
authors.initials: V
authors.lastname: Ribeiro
authors.forename: Michael A
authors.initials: MA
authors.lastname: Choti
authors.forename: Richard D
authors.initials: RD
authors.lastname: Schulick
authors.forename: Eduardo
authors.initials: E
authors.lastname: Barroso
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000328:Adult; D000368:Aged; D015142:Baltimore; D016009:Chi-Square Distribution; D015179:Colorectal Neoplasms / Q000473:pathology*; D018572:Disease-Free Survival; D005240:Feasibility Studies; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011174:Portugal; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome