Surgeon’s awareness of the synchronous liver metastases during colorectal cancer resection may affect outcome Z.Z.R. Hamady, H.Z. Malik, N. Alwan, J.I. Wyatt, R.K. Prasad, G.T. Toogood, J.P.A. Lodge * HPB and Transplant Unit, St. James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK Accepted 19 September 2007 Available online 5 November 2007 Abstract Aim: There is conflicting evidence about the importance of synchronous metastases upon tumor outcome. The aim of this study is to identify the effect of finding synchronous colorectal liver metastases on the performance of the surgeon whilst operating on primary colorectal cancer. Methods: Patients with completed colorectal cancer data who underwent liver resection for colorectal metastases between 1993 and 2001 were included. Two hundred seventy patients were categorised according to the site of the primary tumour (colon or rectum) and knowledge of the presence of liver metastases by the colorectal surgeon (SA ¼ surgeon aware, n ¼ 112, SNA ¼ surgeon not aware, n ¼ 158). The num- ber of retrieved lymph nodes and colorectal resection margin involvement were used as surgical performance indicators. Survival and local recurrence rate were monitored. Results: The SA group had a higher rate of colorectal circumferential resection margin involvement, the local and intra-abdominal recur- rence rate was also significantly higher in this group ( p < 0.001). Conclusions: Awareness of the presence of liver metastases by the operating surgeon is an independent predictor of intra abdominal extra hepatic recurrence of colorectal cancer following potentially curative hepatic resection. This is related to an increased rate of primary colorectal resection margin involvement. Ó 2007 Elsevier Ltd. All rights reserved. Keywords: Colorectal cancer; Liver metastases; Synchronous Introduction Colorectal cancer remains the second most common cause of cancer death in the Western World. Haematogenous spread to the liver occurs in 40e60% of colorectal cancer patients. Synchronous lesions are detected in 15e25% 1 and metachro- nous metastases are detected in a similar percentage within three years of potentially curative colorectal resection. 2 Liver resection remains the ‘‘gold standard’’ potentially curative treatment for colorectal liver metastases (CRLM) with re- ported median survival times of 35e69 months from resec- tion of CRLM. There is conflicting evidence about the importance of synchronous metastases upon tumour outco- me. 3e7 Advances in liver resection procedures and adjuvant therapies mean that fewer patients with CRLM should be considered unresectable. Earlier referral and rapid assess- ment are required to improve outcomes. We hypothesised that the higher tumor recurrence rate associated with synchronous than metachronous liver me- tastases from colorectal cancer is due to inadequate tumour clearance at time of the primary colorectal cancer resection. This may be due to a negative impact (conscious or uncon- scious) of finding synchronous CRLM on the operating sur- geon. We undertook this study to explore for the first time the influence of finding a synchronous liver metastasis on the performance of the surgeon who is resecting the pri- mary colorectal cancer. Materials and methods Between 1993 and 2001 patients undergoing primary liver resection for CRLM and colorectal cancer data avail- able were included in this study. Pre-operative investiga- tions included CT of thorax and abdomen as well as * Corresponding author. Tel.: þ44 (0) 113 206 4890; fax: þ44 (0) 113 244 8182. E-mail address: peter.lodge@leedsth.nhs.uk (J.P.A. Lodge). 0748-7983/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2007.09.013 Available online at www.sciencedirect.com EJSO 34 (2008) 180e184 www.ejso.com