Selection criteria for combined resection of synchronous colorectal cancer hepatic metastases: A cautionary note

Purpose: Combined resection of primary colorectal cancer and synchronous hepatic metastases has been shown to be safe and associated with acceptable oncologic outcomes in selected patients. The purpose of this study was to determine if selection criteria for combined resection could be identified using major morbidity or mortality as an avoidable outcome. Methods: We queried the American College of Surgeons National Surgery Quality Improvement Program dataset from 2005 to 2010 for combined liver and colorectal resections for colorectal cancer using procedure and diagnosis codes. These patients were compared to colorectal cancer patients receiving colectomy alone and patients receiving liver-directed surgery for secondary liver cancer. Results: During the study period, 1,641 (53.1%) of patients underwent colectomy alone, 1,113 (36%) underwent liver-directed surgery alone, and 334 (10.9%) underwent combined colectomy and liver-directed surgery for colorectal cancer. The combined patient population had statistically significant increases in American Society of Anesthesiologists class, preoperative ascites, preoperative systemic inflammatory response syndrome/sepsis, weight loss, functional dependence, and decreased serum albumin compared to the other cohorts. While major hepatectomy was less frequent in the combined cohort, the rate of rectal resection was similar to the colectomy-alone cohort. These selection disparities resulted in a subsequent increase in composite major morbidity, return to operating room, infectious complications, and length of stay in combined patients. Conclusions: While combined resection in patients with synchronous colorectal cancer hepatic metastases may be feasible, it is associated with considerable increase in morbidity without application of stringent selection criteria. We recommend only patients without known risk factors for perioperative morbidity and infectious complications be considered for this approach.