title: Synchronous colorectal liver metastasis: a network meta-analysis review comparing classical, combined, and liver-first surgical strategies.
abstract: BACKGROUND
  In recent years, the management of synchronous colorectal liver metastasis has changed significantly. Alternative surgical strategies to the classical colorectal-first approach have been proposed. These include the liver-first and combined resections approaches. The objectives of this review were to compare the short- and long-term outcomes for all three approaches.
  
  
  METHODS
  A systematic review of comparative studies was performed. Evaluated endpoints included surgical outcomes (5-year overall survival, 30-day mortality, and post-operative complications). Pair-wise and network meta-analysis (NMA) were performed to compare survival outcomes.
  
  
  RESULTS
  Eighteen studies were included in this review, reporting on 3,605 patients. NMA and pair-wise meta-analysis of the 5-year overall survival did not show significant difference between the three surgical approaches: combined versus colorectal-first, mean odds ratio (OR) 1.02 (95% CI 0.8-1.28, P = 0.93); liver-first versus colorectal-first, mean OR 0.81 (95% CI 0.53-1.26, P = 0.37); liver-first versus combined, mean OR 0.80 (95% CI 0.52-1.24, P = 0.41). In addition NMA of the 30-day mortality among the three approaches also did not observe statistical difference. Analysis of variance showed that mean post-operative complications of all approaches were comparable (P = 0.51).
  
  
  CONCLUSIONS
  There are considerable differences in the peri-operative management of synchronous CLM patients. This meta-analysis demonstrated no clear statistical surgical outcome or survival advantage towards any of the three approaches.
authors.affiliation: Department of Surgery, St Vincent's University Hospital, Dublin, Ireland.
authors.forename: M E
authors.initials: ME
authors.lastname: Kelly
authors.forename: G
authors.initials: G
authors.lastname: Spolverato
authors.forename: G N
authors.initials: GN
authors.lastname: Lê
authors.forename: M N
authors.initials: MN
authors.lastname: Mavros
authors.forename: F
authors.initials: F
authors.lastname: Doyle
authors.forename: T M
authors.initials: TM
authors.lastname: Pawlik
authors.forename: D C
authors.initials: DC
authors.lastname: Winter
mesh_terms: D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006498:Hepatectomy / Q000401:mortality*; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D009367:Neoplasm Staging; D009378:Neoplasms, Multiple Primary / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D011379:Prognosis; D015996:Survival Rate
keywords: colorectal resection; hepato-biliary resections; long-term survival; surgical oncology; surgical outcomes; surgical strategies; synchronous colorectal liver metastases