Rethinking Surgical Margins in Colorectal Liver Metastases: Vessel-Skeletonized Parenchymal-Sparing Hepatectomy (VESPAH) and Treatment Continuity
- 1Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Japan
- 2Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
- 3Department of Clinical Oncology, Kawasaki Medical School, Kurashiki 701-0192, Japan
Abstract
Complete (R0) resection remains the primary surgical objective for colorectal liver metastases (CRLM), but margin width cannot be interpreted independently of tumor anatomy, biology, and the amount of functional liver sacrificed to obtain it. This focused narrative review re-examines surgical margins from the perspective of parenchymal preservation and longitudinal multimodal treatment. We distinguish parenchymal R1 exposure (R1par), an undesirable transection-surface event consistently associated with local recurrence in retrospective series, from planned vascular R1 detachment (R1vasc), which has shown more favorable outcomes than R1par in selected retrospective series but remains dependent on careful anatomical selection. Vessel-skeletonized parenchymal-sparing hepatectomy (VESPAH) is presented as one operative model for achieving complete macroscopic clearance while preserving intrahepatic vascular architecture; the evidence for this model is confined to retrospective series and is therefore illustrative and hypothesis-generating rather than confirmatory. We further propose “treatment continuity”—preservation of the physiological and anatomical capacity to receive indicated systemic therapy and repeat local treatment—as a reportable surgical outcome. A four-axis framework integrating technical resectability, functional reserve, tumor biology, and future treatment options is outlined, together with a minimum set of reporting elements for margin phenotype and operational definitions for four candidate measures of treatment continuity. R0 resection should remain the goal, but the quality of hepatectomy for CRLM may be more comprehensively assessed by considering both the margin achieved at the index operation and the treatments that remain feasible thereafter.
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BibTeX
@article{umeda2026rethinking,
title = {{Rethinking Surgical Margins in Colorectal Liver Metastases: Vessel-Skeletonized Parenchymal-Sparing Hepatectomy (VESPAH) and Treatment Continuity}},
author = {Yuzo Umeda and Tomokazu Fuji and Kosei Takagi and Kunitoshi Shigeyasu and Mikiya Shine and Kei Tamura and Munenori Takaoka and Takeshi Nagasaka},
journal = {Cancers},
year = {2026},
month = oct,
doi = {10.3390/cancers18213492},
url = {https://www.mdpi.com/2072-6694/18/21/3492},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Rethinking Surgical Margins in Colorectal Liver Metastases: Vessel-Skeletonized Parenchymal-Sparing Hepatectomy (VESPAH) and Treatment Continuity
AU - Yuzo Umeda
AU - Tomokazu Fuji
AU - Kosei Takagi
AU - Kunitoshi Shigeyasu
AU - Mikiya Shine
AU - Kei Tamura
AU - Munenori Takaoka
AU - Takeshi Nagasaka
PY - 2026
DA - 2026/10/29
JO - Cancers
DO - 10.3390/cancers18213492
UR - https://www.mdpi.com/2072-6694/18/21/3492
AB - Complete (R0) resection remains the primary surgical objective for colorectal liver metastases (CRLM), but margin width cannot be interpreted independently of tumor anatomy, biology, and the amount of functional liver sacrificed to obtain it. This focused narrative review re-examines surgical margins from the perspective of parenchymal preservation and longitudinal multimodal treatment. We distinguish parenchymal R1 exposure (R1par), an undesirable transection-surface event consistently associated with local recurrence in retrospective series, from planned vascular R1 detachment (R1vasc), which has shown more favorable outcomes than R1par in selected retrospective series but remains dependent on careful anatomical selection. Vessel-skeletonized parenchymal-sparing hepatectomy (VESPAH) is presented as one operative model for achieving complete macroscopic clearance while preserving intrahepatic vascular architecture; the evidence for this model is confined to retrospective series and is therefore illustrative and hypothesis-generating rather than confirmatory. We further propose “treatment continuity”—preservation of the physiological and anatomical capacity to receive indicated systemic therapy and repeat local treatment—as a reportable surgical outcome. A four-axis framework integrating technical resectability, functional reserve, tumor biology, and future treatment options is outlined, together with a minimum set of reporting elements for margin phenotype and operational definitions for four candidate measures of treatment continuity. R0 resection should remain the goal, but the quality of hepatectomy for CRLM may be more comprehensively assessed by considering both the margin achieved at the index operation and the treatments that remain feasible thereafter.
SN - 2072-6694
ER -