Trends and Outcomes of the Liver-First Surgical Approach for Patients with Colorectal Cancer and Isolated Liver Metastases.

[BACKGROUND] The optimal sequencing for resection of primary and liver metastases in stage IV colorectal cancer (CRC) remains debated. This study evaluated utilization trends and outcomes of liver resection before colon/rectal resections.

[METHODS] A retrospective analysis was performed using the National Cancer Database (2010-2020) for patients with stage IV CRC and isolated liver metastases who underwent resection of primary CRC and liver metastases. The study identified two cohort groups: a group that underwent liver resection before colon/rectal resection (LRCR) and a group that underwent colon/rectal resection synchronous with or before liver resection (CRLR). Overall survival (OR) was evaluated using Cox proportional hazard models, whereas logistic regression was used for binary outcomes.

[RESULTS] Among 10,959 patients, 1178 underwent LRCR and 9781 underwent CRLR. Utilization of LRCR increased from 5.37% in 2010 to 15.43% in 2020. Predictors of LRCR utilization included rectal primary sites (OR, 5.88; 95% confidence interval [CI], 4.55-7.60) and academic treatment facilities (OR, 2.74; 95% CI, 1.25-6.00). Predictors of lower LRCR included lymphovascular invasion (OR, 0.69; 95% CI, 0.54-0.87) and moderate (OR, 0.61; 95% CI, 0.39-0.95) to poorly differentiated (OR, 0.47; 95% CI, 0.27-0.81) pathology. Patients undergoing the LRCR approach were associated with better overall survival than those undergoing CRLR (hazard ratio, 0.87; 95% CI, 0.77-0.99). The 90-day mortality (1.11% vs 4.47%; p < 0.01) and 30-day readmissions (3.69% vs 5.81%; p<0.01) after primary tumor resection were lower in the LRCR group.

[CONCLUSION] The LRCR approach has been increasingly used over time. Compared with CRLR, the LRCR approach was associated with better overall survival, lower postoperative mortality and fewer readmissions after colon/rectal resection.