Drop-out between the two liver resections of two-stage hepatectomy. Patient selection or loss of chance?
BACKGROUND
Two-stage hepatectomy (TSH) is the present standard for multiple bilobar colorectal liver metastases (CLM), but 25-35% of patients fail to complete the scheduled procedure (drop-out). To elucidate if drop-out of TSH is a patient selection (as usually considered) or a loss of chance.


METHODS
All the consecutive patients scheduled for a TSH at the Paul Brousse Hospital between 2000 and 2012 were considered. TSH patients were matched 1:1 with patients receiving a one-stage ultrasound-guided hepatectomy (OSH) at the Humanitas Research Hospital in the same period. Matching criteria were: primary tumor N status; timing of CLM diagnosis; CLM number and distribution into the liver.


RESULTS
Sixty-three pairs of patients were analyzed. Demographic and tumor characteristics were similar (median 7 CLM), except for more chemotherapy lines and adjuvant chemotherapy in TSH. Drop-out rate of TSH was 38.1% (0% of OSH). The two groups had similar R0 resection rate (19.0% OSH vs. 15.9% TSH). OSH and completed TSH had similar five-year survival (from CLM diagnosis 49.8% vs. 49.7%, from liver resection 36.1% vs. 44.3%), superior to drop-out (10% three-year survival, p < 0.001). OSH and completed TSH had similar recurrence-free survival (at three years 21.7% vs. 20.5%) and recurrence sites. The completion of resection (drop-out vs. OSH/completed TSH) was the only independent prognostic factor (p = 0.003).


CONCLUSIONS
Drop-out of TSH could be a loss of chance rather than a criteria for patient selection. "Unselected" OSH patients had the same outcomes of selected patients who completed TSH. A complete resection is the main determinant of prognosis.
Department of Surgery, Division of Hepatobiliary & General Surgery, Humanitas Research Hospital, Humanitas University, Rozzano, Milano, Italy.
L
L
Viganò
Department of Surgery, Division of Hepatobiliary & General Surgery, Humanitas Research Hospital, Humanitas University, Rozzano, Milano, Italy. Electronic address: guido.torzilli@hunimed.eu.
G
G
Torzilli
Department of Surgery, Division of Hepatobiliary & General Surgery, Humanitas Research Hospital, Humanitas University, Rozzano, Milano, Italy.
M
M
Cimino
AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Villejuif, France.
K
K
Imai
AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Villejuif, France.
E
E
Vibert
Department of Surgery, Division of Hepatobiliary & General Surgery, Humanitas Research Hospital, Humanitas University, Rozzano, Milano, Italy.
M
M
Donadon
AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Villejuif, France.
D
D
Castaing
AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Villejuif, France.
R
R
Adam
D000368:Aged; D017024:Chemotherapy, Adjuvant / Q000706:statistics & numerical data*; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology*; D018572:Disease-Free Survival; D005260:Female; D005602:France; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D018579:Patient Selection; D011379:Prognosis; D012189:Retrospective Studies
Colorectal liver metastases; Drop-out; One-stage hepatectomy; Overall survival and recurrence-free survival; Surgical margin; Two-stage hepatectomy