Combined and staged resection of rectal liver metastases had similar outcomes nationally

Design

Target trial emulation, French national discharge database, IPTW

Population

1,872 adults with rectal cancer and synchronous liver metastases

Primary outcome

30-day severe complications and overall survival

Effect

Severe complications adjusted OR 0.82 (95% CI 0.58-1.16); survival HR 0.88 (0.65-1.19)

The best order of surgery for rectal cancer with synchronous liver metastases is unsettled. This study emulated a target trial in the French national discharge database from 2014 to 2023, comparing combined resection with a staged approach (rectum first or liver first within 14 weeks).

Of 1,872 eligible patients, 73% had combined resection. Severe complications (Clavien-Dindo III or higher) occurred in 39.7% vs 45.3% (adjusted OR 0.82, 95% CI 0.58-1.16). Thirty-day mortality was 1.8% vs 1.5%. Median survival was 52.4 vs 57.3 months, with no significant difference after weighting (HR 0.88, 0.65-1.19). Major hepatectomy was independently associated with more severe complications (OR 1.81, 1.06-3.08).

This is observational data from an administrative database, weighted to resemble a trial. It cannot remove confounding by the surgeon's choice of strategy.

The practical reading: combined resection is a reasonable option, and the extent of the liver resection matters more to morbidity than the sequencing itself.

• Combined and staged resection were associated with similar severe-complication rates and survival.
• Major hepatectomy was the factor linked to more severe complications.
• Consider combined resection when the liver component is a minor resection.
• Make the sequencing decision in a multidisciplinary meeting, case by case.
• Administrative data cannot capture tumour burden fully, so confounding remains.

Why it matters

It gives rectal-specific evidence for a decision that has mostly been extrapolated from colon cancer.

Don't overread it

An emulated trial from discharge data is still observational and cannot prove the two strategies are equivalent.

The statistics, in plain English

Both intervals cross 1, so neither strategy was shown to be better or worse. The weighting balances measured factors only; unmeasured ones, such as how extensive the disease looked to the surgeon, can still bias the comparison.

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