title: A systematic review of two-stage hepatectomy in patients with initially unresectable colorectal liver metastases.
abstract: OBJECTIVE
  Selected patients with unresectable colorectal liver metastases (CLM) may be rendered resectable using the two-stage hepatectomy (TSH) approach. This review was conducted with the aim of collating and evaluating published evidence for TSH in patients with initially unresectable CLM.
  
  
  METHODS
  Searches of the MEDLINE and EMBASE databases were undertaken to identify studies of TSH in patients with initially unresectable CLM. Studies were required to focus on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes.
  
  
  RESULTS
  Ten observational studies were reviewed. A total of 459 patients with initially unresectable CLM were selected for the first stage of TSH. Preoperative chemotherapy was used in 88% of patients and achieved partial and stable response rates of 59% and 39%, respectively. Postoperative morbidity and mortality after the first stage of TSH were 17% and 0.5%, respectively. Portal vein embolization (PVE) was used in 76% of patients. Ultimately, 352 of the initial 459 (77%) patients underwent the second stage of TSH. Major liver resection was undertaken in 84% of patients; the negative margin (R0) resection rate was 75%. Postoperative morbidity and mortality after the second stage of TSH were 40% and 3%, respectively. Median overall survival was 37 months (range: 24-44 months) in patients who completed both stages of TSH. In patients who did not complete both stages of TSH, median survival was 16 months (range: 10-29 months). The 3-year disease-free survival rate was 20% (range: 6-27%).
  
  
  CONCLUSIONS
  Two-stage hepatectomy is safe and effective in selected patients with initially unresectable CLM. Further studies are required to better define patient selection criteria for TSH and the exact roles of PVE and preoperative and interval chemotherapy.
authors.affiliation: Department of Surgery, Westmead Hospital, Westmead, NSW, Australia. vincent.lam@sydney.edu.au
authors.forename: Vincent W T
authors.initials: VW
authors.lastname: Lam
authors.forename: Jerome M
authors.initials: JM
authors.lastname: Laurence
authors.forename: Emma
authors.initials: E
authors.lastname: Johnston
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Hollands
authors.forename: Henry C C
authors.initials: HC
authors.lastname: Pleass
authors.forename: Arthur J
authors.initials: AJ
authors.lastname: Richardson
mesh_terms: D017024:Chemotherapy, Adjuvant; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology*; D018572:Disease-Free Survival; D004621:Embolization, Therapeutic; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D008113:Liver Neoplasms / Q000098:blood supply / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D020360:Neoadjuvant Therapy; D018579:Patient Selection; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome