g. bleeding, obstruction, perforation) or cases where the

hepatic metastases may be rendered resectable. In the latter two groups, the following treatment strategies have been employed: (I) resection of the primary followed by systemic chemotherapy followed by liver resection ± additional systemic chemotherapy (Staged approach), (II) systemic chemotherapy followed by simultaneous resection of the primary and hepatic metastases (Synchronous approach) and (III) systemic chemotherapy followed by resection of hepatic metastases followed by resection of the primary (so-called “Reverse Strategy”) Inhibitors,research,lifescience,medical (5). The potential risks and benefits of synchronous compared to staged resections are summarized in Table 1. Advocates of a staged approach endorse this clinical trial strategy due to concerns about increased morbidity and mortality associated with simultaneous resection of the colorectal primary and hepatic metastases. Concerns about the potential safety and technical feasibility of rectal

resections and major hepatic resections have been raised as concerns Inhibitors,research,lifescience,medical regarding simultaneous resections (6). In addition, some surgeons and oncologists have pointed to complications associated Inhibitors,research,lifescience,medical with the unresected primary tumor as another reason for not adopting synchronous resections (7,8). In contrast, proponents of synchronous resections point to the morbidity associated with multiple procedures as a major advantage of a simultaneous resection approach. From an oncologic standpoint, synchronous resection following neoadjuvant chemotherapy provides insight into the patient’s tumor biology and prevents a delay in administering systemic therapy which may occur due to complications

following resection of Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical the colorectal primary. Table 1 Potential risks and benefits of synchronous versus staged resection. The current discussion will review the existing literature on staged versus synchronous resection of colorectal cancer and isolated hepatic metastases. Two key issues will be considered: the safety of each resection strategy and oncologic outcomes followed a synchronous versus staged resection. Lastly, we will examine the emerging data available regarding a minimally invasive approach to synchronous colorectal disease with hepatic metastases. Safety of simultaneous versus staged resections The first question to be addressed when considering from a synchronous versus staged resection for colorectal tumors with hepatic metastases is the safety of each approach. A study by Vogt et al. was among the first to examine the safety of synchronous resection for colorectal cancer (9). The authors compared operative mortality between 19 patients who underwent a synchronous resection to 17 patients who had a staged resection (median 2 months between resections). There were no perioperative deaths in either group.