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Anterior Approach vs Conventional Hepatectomy for Resection of Colorectal Liver MetastasisA Randomized Clinical Trial

Educational Objective
To identify whether an anterior approach hepatectomy vs a conventional hepatectomy for resection of colorectal liver metastasis results in a difference in tumor cell dissemination.
1 Credit CME
Key Points

Question  Does anterior approach hepatectomy reduce tumor cell dissemination during resection of colorectal liver metastasis compared with conventional hepatectomy?

Findings  In this randomized clinical trial including 80 participants, no statistically significant difference in tumor cell dissemination (5 of 21 [24%] vs 6 of 22 [27%]) and overall (median, 73 vs 55 months) and disease-free (median, 48 vs 40 months) survival was found between conventional hepatectomy and the anterior approach.

Meaning  These findings suggest that both techniques offer safe and comparable postoperative and survival outcomes in patients undergoing right-sided hepatectomy for colorectal cancer.

Abstract

Importance  Tumor relapse after partial hepatectomy for colorectal liver metastasis (CRLM) remains an unsolved issue. Intraoperative manipulation of the liver during conventional hepatectomy might enhance hematogenous tumor cell spread. The anterior approach is an alternative approach that may reduce intraoperative tumor cell dissemination.

Objective  To determine the efficacy and safety of the anterior approach compared with conventional hepatectomy in patients undergoing resection for CRLM.

Design, Setting, and Participants  This randomized clinical study evaluated the efficacy and safety of the anterior approach compared with conventional hepatectomy in adult patients with CRLM who were scheduled for hepatectomy from February 1, 2003, to March 31, 2012, at a tertiary-care hospital. A total of 80 patients with CRLM were randomized to the anterior approach and conventional hepatectomy groups in a 1:1 ratio. Bone marrow and blood samples were analyzed for disseminated tumor cells and circulating tumor cells (CTC) using cytokeratin 20 reverse transcriptase–polymerase chain reaction analysis. Data were analyzed from April 1 to December 1, 2018, using intention to treat.

Interventions  Anterior approach vs conventional hepatectomy.

Main Outcomes and Measures  The primary end point was intraoperative CTC detection in central blood samples after liver resection. Secondary end points included postoperative morbidity, mortality, and long-term survival.

Results  Among the 80 patients included in the analysis (48 men [60%]; mean [SD] age, 61 [10] years), baseline characteristics, including preoperative CTC detection, were comparable between both groups. There was no statistically significant difference in intraoperative CTC detection between patients in the conventional hepatectomy (5 of 21 [24%]) and anterior approach (6 of 22 [27%]) groups (P > .99). Except for a longer operating time in the anterior approach group (mean [SD], 171 [53] vs 221 [53] minutes; P < .001), there were no significant differences in intraoperative and postoperative outcomes between both study groups. Although detection of CTC was associated with poor overall (median, 46 [95% CI, 40-52] vs 81 [95% CI, 54-107] months; P = .03) and disease-free (median, 40 [95% CI, 34-46] vs 60 [95% CI, 46-74] months; P = .04) survival, there was no significant difference in overall (median, 73 [95% CI, 42-104] vs 55 [95% CI, 35-75] months; P = .43) and disease-free (median, 48 [95% CI, 40-56] vs 40 [95% CI, 28-52] months; P = .88) survival between the conventional hepatectomy and anterior approach groups. Also, there was no significant difference in patterns of recurrence between both groups.

Conclusions and Relevance  This randomized clinical trial found that the anterior approach was not superior to conventional hepatectomy in reducing intraoperative tumor cell dissemination in patients undergoing resection of CRLM.

Trial Registration  isrctn.org Identifier: ISRCTN45066244

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: July 30, 2020.

Published Online: November 4, 2020. doi:10.1001/jamasurg.2020.5050

Correction: This article was corrected on May 26, 2021, to fix the P value for the detection of preoperative and intraoperative tumor cells in the Abstract, main text, and Table 3, and to fix an error in the numbers at risk in Figure 2A.

Corresponding Author: Jürgen Weitz, MD, Department of Gastrointestinal, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany (juergen.weitz@uniklinikum-dresden.de).

Author Contributions: Drs Rahbari and Birgin contributed equally to this study. Drs Rahbari and Birgin had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Weitz.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Rahbari, Birgin.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Rahbari, Birgin.

Administrative, technical, or material support: Bork, Mehrabi, Weitz.

Supervision: Rahbari, Bork, Reißfelder.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the Department of Surgery, University of Heidelberg.

Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; interpretation of the data; and preparation, review, or approval of the manuscript. The sponsor was involved in the collection, management, and analysis of the data and granted approval to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

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