Management of colorectal liver metastases
Sir
We were interested to read Professor Taylor's review of the management of colorectal liver metastases (Ur J Surg 72: 51 1-16), and were interested to note in particular his comments on the place of resection for colorectai liver metastases. The world experience of resection for metastatic liver disease is now substantial, and this approach is becoming widely accepted as the treatment of choice for those patients with tumour localized to a resectable area of liver who are fit to undergo such a procedure.
The several series quoted are almost entirely restricted to reports from the USA, and we felt it might be of interest to add to these results a voice of agreement from the UK, since published reports from this country are rare. Our early results quoted by Professor Taylor (Blumgart et al. 1979) contained only nine patients (from a group of 37 liver resections) in whom the operation was performed for secondary malignancies. We have not since that time published our results for resection in such patients, since we felt that our period of follow-up was not yet sufficiently long to make a meaningful comment. However, we have now reviewed our results in cases treated in the Hepatobiliary Surgery Unit at Hammersmith Hospital over a five year period since 1979. Of 55 patients undergoing elective hepatic resection for malignant disease during this period, 20 were performed for secondaries from carcinoma of the colon. This is approximately one half of a group of 39 patients referred during that time for consideration of resection of such tumours, although this clearly represents a high degree of selection in our referral practice. There was no operative mortality. During a followup period of 3 4 2 months, actuarial survivals at 12,24, and 36 months were 88,65 and 65 per cent respectively, with an overall median survival of 38 months. These results are comparable with those recorded in the rest of the world literature.
We would add one caveat in relation to assessment of resectability. While it is true that the majority of patients with liver secondaries will be irresectable, it is important that this judgement be based not simply on an assessment of tumour size by means of scanning techniques, but by careful examination of hepatic anatomy, with use of vascular imaging when appropriate, since some large tumours extending beyond the confines of the right or left liver may still be resectable. Of the resections referred to above, four required extended right hepatic lobectomy with tumour clearance in all cases. While we would not suggest that this approach is applicable to a majority of patients, in view of the excellent results now obtainable, it is important to consider this possibility, particularly in young patients with large solitary liver metastases.