(1) The document discusses a retrospective study evaluating outcomes of complete extirpative surgeries including multivisceral en-bloc resection and metastasectomy for locally advanced and advanced colorectal cancers. (2) It found that these extensive surgeries were safe, with no in-hospital mortality, though morbidity was 60% and complications requiring intervention occurred in 31.2% of cases. (3) The study achieved a 2-year survival rate of 80% using these aggressive surgical approaches when other options were not feasible.

1. Multivisceral en-bloc resection and
metastasectomy for colorectal malignancy
Happykumar Kagathara, Shailendra Lalwani, Vivek Mangla, Naimish Mehta,
Amitabh Yadav, Samiran Nundy
Department of Surgical Gastroenterology and Liver Transplantation
Sir Ganga Ram Hospital, New Delhi

2. Background
• Long term survival in primary and recurrent
colorectal tumors
– Complete resection of all macroscopic disease
• The decision to embark on an extensive operation
– Multivisceral en-bloc organ resection and metastasectomy
– Weigh the risks against the potential benefits of such
procedures

3. Aim
• Evaluation of outcomes from complete extirpative
operations in selected patients with locally advanced
and advanced colorectal cancers
• Outcome measures
– Survival
– Surgery related complications

4. Patients and Methods
• Retrospective study from prospectively maintained
database
Colorectal carcinoma
(n= 675 patients)
Conventional curative resection
n= 604 patients
Extended resection
n= 35 patients
Multivisceral en-bloc resection
n= 19 patients
Metastasectomy
n= 8 patients
MVR + Metastasectomy
n= 8 patients
Study cohort
August, 1996 to December, 2012

5. • Common symptoms
– Abdominal pain, weight loss, bleeding P/R,
constipation, anorexia, diarrhoea
• Rare presentation
– P/V discharge, lump, fever, anaemia, vomitting
• Preoperative evaluation of tumor
– CEA level, Colonoscopy, CT scan
– PET-CT scan in selected group of patients presented with
recurrence or metastasis

6. • Clinicopathological analysis, operative findings
– Hospital records
• Follow up information
– Out patient visit
– Telephonic survey
• Kaplan-Meier analysis for survival

7. Results
• Age : 53 ± 13.6 yrs
• M:F: 1 : 1.1
• BMI: 23.2 ± 5
• Recurrent tumor – 6 pts (17.6%)
– Surgery – 6 pts
– Chemotherapy – 4 pts
– Radiotherapy – 1 pts
• Length of stay: 10 ± 5.5 days
• Follow up: 53%
– 15 ± 9.4 months (7 – 48 months)

8. Disease Pattern
15
10
5
3
1
0
2
4
6
8
10
12
14
16
1 2 3 4 5
Number of involved organs
5
4
3
9
13
Ascending
colon
Transverse
colon
Descending
colon
Sigmoid
Rectum
Tumor location

9. Organ Involvement
Organ involvement
by local invasion
Pancreas 7 (27%)
Uterus 6 (23%)
Urinary bladder 5 (19%)
Small bowel 5 (19%)
Spleen 3 (11%)
Ureter 3 (11%)
Duodenum 3 (11%)
Vagina 3 (11%)
Ovary 3 (11%)
Liver 2 (7.6%)
Stomach 1 (3.8%)
Kidney 1 (3.8%)
Omentum 1 (3.8%)
Organ involvement
by distant
metastasis
Liver 10 (67%)
Peritoneum 5 (33%)
Omentum 3 (20%)
Small bowel 2 (13%)
Stomach 1 (6.6%)
Diaphragm 1 (6.6%)

10. Histology
• Adenocarcinoma – 68%
• Microscopic tumor infiltration (pT4) – 44%
– Stage I and II: 50%
– Stage III: 17%
– Stage IV: 32%
• Positive lymph nodes
– Mean – 2
– Median – 0 (0-29)
• Lymphovascular permeation – 9 (26%)

11. Postoperative Outcome
• Morbidity
– Overall incidence – 60%
– Complications treated with intervention – 31.2%
(n=13)
• Anastomotic leaks – 14.2% (n=3)
• In hospital mortality: 0%
• Recurrence rate: 25.7%

12. Survival
• Overall 2-year survival rate: 80%

13. Literature Review
• Actual pathological infiltration - 50-85%
Sokmen S, Terzi C et al. Int J Colorectal Dis 1999;14:282-5
• Complications after a multivisceral resection and
metastasectomy
– 11% to 44%
Nakafusa Y, Tanaka T et al. Rectum 2004;47:2055– 63
• Mortality – 0-7.5%
Lehnert T, Methner M et al. Ann Surg 2002;235:217–25
Kruschewski M, Pohlen U et al. Zentralbl Chir 2006;131:217–22
• Overall 5-year survival rate – 51-53%
Gebhardt C, Meyer W et al Langenbecks Arch Surg 384(2): 194-199, 1999

14. Conclusion
• Multivisceral en-bloc resection and metastasectomy
in advanced colorectal carcinoma
– Safe procedure
– May achieve 2-year survival rate up to 80%