Quelles sont les indicarions reelles des hepatectomies pour metastases d'origine colorectale ?

Aim. - To ascertain the real impact of classical contraindications (relative or absolute according to various authors) represented by : a high number of liver metastases (LM), the presence of associated extra-hepatic localizations (EHL), and a surgical margin less than 10 mm. Methods. - A prospective study was conducted in 269 consecutive hepatectomized patients. Inclusion criteria were only the resection of all tumoral tissue, and lack of major operative risk. Fifty-nine patients had at least 4 LM, 62 had an associated EHL, and 187 had a surgical margin < 10 mm. Altogether, 83 % of the patients did not match the classical selection criteria. Sixty-two parameters were registered. A uni- and multivariate study of prognostic factors was performed. Results. - Although 18 % of the resections were palliative (R1 or R2 according to the UICC classification), and the hospital mortality was 3.3 % (2.2 % during the first postoperative month), global and disease-free 5-year survival rates were 34.3 % and 23.3 % respectively. The number of LM had no prognostic implication. A surgical margin > 9 mm improved significantly the prognosis. Between 0 and 9 mm, it had no important prognostic impact if the surface was histologically disease-free. A margin < 10 mm was greatly associated with a high number of LM, a bilateral localization of LM, and extended hepatectomy. Among the EHL, only those discovered during laparotomy had a significant adverse impact on prognosis. Conclusion. - Fundamental principles of the indications of hepatectomy for colorectal LM are to resect all the lesions and to avoid major operative risk. In complex cases, the most frequent these principles can only be completely followed in a specialized center.