What are the true indications of hepatectomy for colorectal metastases?

Aim. - To ascertain the real impact of classical contraindications (relativ e or absolute according to various authors) represented by: a high number o f liver metastases (LM), the presence of associated extra-hepatic localizat ions (EHL), and a surgical margin less than 10 mm. Methods. - A prospective study was conducted in 269 consecutive hepatectomi zed patients. Inclusion criteria were only the resection of all tumoral tis sue, and lack of major operative risk. Fifty-nine patients had at least 4 L M, 62 had an associated EHL, and 187 had a surgical margin < 10 mm. Altoget her 83 % of the patients did nor match the classical selection criteria. Si xty-two parameters were registered. A uni- and multivariate study of progno stic factors was performed. Results. - Although 18 % of the resections were palliative (R1 or R2 accord ing to the UICC classification), and the hospital mortality was 3.3 % (2.2 % during the first postoperative month), global and disease-free 5-year sur vival rates were 34.4 % and 23.3 %, respectively. The number of LM had no p rognostic implication. A surgical margin > 9 mm improved significantly the prognosis. Between 0 and 9 mm, it had no important prognostic impact if the cut surface was histologically disease-free. A margin < 10 mm was greatly associated with a high number of LM, a bilateral localization of LM, and ex tended 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 ri sk. In complex cases, the most frequent, these principles can only be compl etely followed in a specialized center.