부산대학교 도서관

The objective of this paper is to review the evidence for the “liver first” or “reverse strategy” for treating synchronous rectal metastasis. A literature search including abstracts of English and foreign language publications was performed, using Ovid MEDLINE (1946 to Jan 2014), Ovid EMBASE (1947 to Jan 2014), Scopus, and Web of Science. Five studies (one prospective and three retrospective observational studies, and one retrospective cohort study) describing the results of the liver-first approach were identified. No randomised controlled trials were identified. Most studies combined outcomes of colon and rectal primaries. The percentages of rectal primaries in the five studies were 43 %, 100 %, 68.2 %, 86.4 %, and 67.5 %. The outcomes specific to rectal versus colon primaries were not reported separately. A total of 111 (70.2 %) completed the procedure with resection of the primary as planned. Morbidity after liver resection was 25.8 %. There was one fatality (0.6 %) after liver resection. Among patients who underwent colorectal resection, the complication rate was 15.3 %. Mortality was 1.8 %. The overall mortality among patients offered the “liver-first approach” was four (2.5 %). One fatality occurred during initial induction chemotherapy, one was within 90 days of primary liver resection, and two were within 90 days of rectal surgery. Only five patients (3.1 %) developed obstruction from the primary and required diversion colostomies. Overall recurrence among patients who completed the procedure was 55 % over a median follow-up of 18 months, with a period ranging from 1–159 months. The median survival ranged from 19 months to 50 months. One-year survival varied from 66 % to 100 %, and three-year survival 30 % to 79 %. Five-year survival was 31–39 %. We conclude that the liver-first approach to treating synchronous rectal metastases is feasible. Published data suggest low procedure-related mortality, but a wide range of survival data suggests major differences to treatment procedures. The outcomes at five years are comparable with historical outcomes of the primary-first approach. The efficacy of the liver-first approach for rectal primaries needs to be proved by randomised controlled trials, with careful stratification of the primary extent and metastatic disease burden.