title: Morbidity of staged proctectomy after hepatectomy for colorectal cancer: a matched case-control analysis.
abstract: BACKGROUND
  Proctectomy after hepatectomy, or the reverse approach, is an alternative to traditional sequencing for advanced liver metastases with asymptomatic colorectal primary tumors. We sought to evaluate the surgical morbidity of proctectomy for colorectal cancer after previous liver surgery.
  
  
  METHODS
  A single-institution colorectal database was queried for patients treated with proctectomy after previous hepatectomy from 2003 to 2011. Reverse-approach patients (n = 31) were matched 1:2 with a cohort of standard proctectomy patients (n = 62) using operation, age, gender, and surgeon. Perioperative factors were analyzed by univariate/multivariate models for associations with complications graded by Dindo-Clavien criteria.
  
  
  RESULTS
  Thirty-one patients with adenocarcinoma ≤ 20 cm from the anal verge underwent proctectomy after hepatectomy. Median time from hepatectomy to proctectomy was 5.1 months. Median tumor distance was 8.5 cm. Before proctectomy, patients underwent 28 (90 %) major hepatectomies and 7 (22 %) portal vein embolizations. There were no perioperative deaths. Reverse-approach patients did not differ from control patients in operation, demographics, body mass index (BMI), comorbidities, tumor distance, operative time, estimated blood loss, length of stay, or complication rates (p > 0.05). Grade 2 or higher complications developed in 42 % of reverse-approach and 27 % of standard proctectomies (p = 0.17). Grade 3 or higher complications developed in 10 % and 8 %, respectively (p = 1.00). Independent predictors of complications of grade 2 or higher were BMI ≥30 kg/m(2) (p = 0.007), operative time ≥300 min (p = 0.012), intraoperative transfusion (p = 0.044), concurrent procedures (p = 0.024), and age ≥50 years (p = 0.030).
  
  
  CONCLUSIONS
  Risk factors for morbidity of staged proctectomy are similar to those for standard proctectomy. In selected patients, the reverse-approach proctectomy is safe with acceptable morbidity.
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. cdtzeng@mdanderson.org
authors.forename: Ching-Wei D
authors.initials: CW
authors.lastname: Tzeng
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Aloia
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
authors.forename: George J
authors.initials: GJ
authors.lastname: Chang
authors.forename: Lee M
authors.initials: LM
authors.lastname: Ellis
authors.forename: Barry W
authors.initials: BW
authors.lastname: Feig
authors.forename: Steven A
authors.initials: SA
authors.lastname: Curley
authors.forename: John M
authors.initials: JM
authors.lastname: Skibber
authors.forename: Eddie K
authors.initials: EK
authors.lastname: Abdalla
authors.forename: Y Nancy
authors.initials: YN
authors.lastname: You
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Rodriguez-Bigas
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D003082:Colectomy; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D009367:Neoplasm Staging; D011183:Postoperative Complications; D011379:Prognosis; D015996:Survival Rate; D055815:Young Adult