title: Selecting patients for a second hepatectomy for colorectal metastases: an systemic review and meta-analysis.
abstract: BACKGROUND
  Opinions on the suitability of repeat hepatectomy for patients with recurrent colorectal liver metastases (CRLMs) vary among studies. We conducted a meta-analysis to establish the criteria for selecting the best candidates for a second hepatectomy.
  
  
  METHODS
  Database and manual searches were performed to identify comparative or prognostic studies published up to October 2013. Outcomes of interest included disease characteristics, perioperative outcomes, and long-term survival after initial and second hepatectomies for patients with CRLM. Study quality was appraised using the Newcastle-Ottawa scale and a modified Hayden's score.
  
  
  RESULTS
  A total of 7226 patients from 27 studies were included. Recurrent CRLMs after initial hepatectomy were more likely to be solitary (RR = 0.86, P = 0.045), unilobar (RR = 0.60, P < 0.001), and smaller (WMD = -0.66, P < 0.001). Postoperative morbidity and mortality were comparable between initial and second hepatectomies (RR = 1.10, P = 0.191; RR = 0.78, P = 0.678, respectively). In high-quality studies, patients showed better survival after a second hepatectomy than those after a single hepatectomy (HR = 0.68, P = 0.022). Patients meeting the following six predictors survived longer after second hepatectomy: disease-free survival after initial hepatectomy >1 y (P = 0.034); solitary CRLM at second hepatectomy (P < 0.001); unilobar CRLM at second hepatectomy (P = 0.009); maximal size of CRLM at second hepatectomy ≤ 5 cm (P = 0.035); lack of extrahepatic metastases at second hepatectomy (P < 0.001); and R0 resection at second hepatectomy (P < 0.001).
  
  
  CONCLUSIONS
  Second hepatectomy is a safe and feasible procedure for patients with recurrent CRLM. In fact, in well-selected patients it improves overall survival. The established criteria can help clinicians to select the best candidates for second hepatectomy and to achieve better long-term outcomes after resection.
authors.affiliation: Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China. Electronic address: luolixi1987@gmail.com.
authors.forename: L X
authors.initials: LX
authors.lastname: Luo
authors.affiliation: Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China.
authors.forename: Z Y
authors.initials: ZY
authors.lastname: Yu
authors.affiliation: Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China.
authors.forename: J W
authors.initials: JW
authors.lastname: Huang
authors.affiliation: Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China.
authors.forename: H
authors.initials: H
authors.lastname: Wu
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002277:Carcinoma / Q000556:secondary / Q000601:surgery*; D015179:Colorectal Neoplasms / Q000473:pathology*; D018572:Disease-Free Survival; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery*; D008297:Male; D059146:Metastasectomy / Q000379:methods*; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000556:secondary / Q000601:surgery*; D018579:Patient Selection; D012086:Reoperation / Q000379:methods
keywords: Colorectal cancer; Liver metastasis; Repeat hepatectomy