Failure to Achieve a 2-Stage Hepatectomy for Colorectal Liver Metastases How to Prevent It?

Objectives:The aim of the study was to identify predictive factors of failure of 2-stage hepatectomy (TSH) forthe selection of patients with extensive bilobar colorectal liver metastases (CRLM), who are candidates for TSH.Background:The main weakness of TSH is the risk of failure to complete both the sequential procedures.Methods:Between 2000 and 2012, from a total cohort of 845 patients resected for CRLM, 125 patients (14.8%) with extensive CRLM were planned for TSH. All factors related to the failure of TSH were analyzed, and a predictive model was built utilizing the independent predictive factors of failure.Results:Forty-four patients (35.2%) could not proceed to the second stage, and their overall survival (OS) was significantly worse than that of those who completed the TSH (5-year OS: 0% vs 44.2%; P<0.0001). Multivariate analysis revealed that carcinoembryonic antigen >30ng/mL [relative risk (RR) 2.73, P=0.03], tumor size >40mm (RR 2.89, P=0.04), chemotherapy cycles >12 (RR 3.46, P=0.01), and tumor progression during first-line chemotherapy (RR 6.56, P=0.01) were independent predictive factors of failure. For patients not presenting any factors, the probability of failure was 10.5%, with a 5-year OS rate of 41.9%. The addition of each subsequent factor increased the risk to 43.5%, 72.7%, 88.5%, and 95.5%, and decreased the 5-year OS to 38.8%, 29.2%, 0%, and 0%, respectively, for 1, 2, 3, and 4 factors.Conclusions:TSH should not be recommended in patients with more than 2 risk factors. Avoidance of these factors significantly reduces the risk of failure and is crucial for long-term survival.