Predictors of morbidity and oncological benefit after liver resection with vascular reconstruction: international collaborative study from expert centres

Abstract

BACKGROUND: Liver resection with vascular reconstruction is a highly complex procedure for advanced hepatobiliary tumours. This study evaluated the postoperative and oncological outcomes of this patient cohort. METHODS: This retrospective multicentre study included patients undergoing liver resection with vascular reconstruction between 1990 and 2024 across 21 expert centres. Reconstructions involved the inferior vena cava, hepatic veins, portal vein, or hepatic artery. Primary endpoints were postoperative morbidity and 90-day mortality. Secondary endpoints included overall survival (OS), disease-free survival (DFS), and predictors of complications. Multivariable logistic regression, Kaplan-Meier, and Fine-Gray analyses were performed. RESULTS: In all, 532 patients were included and classified according to surgical approach as in situ (455, 85.3%), ante situm (48, 9.2%), or ex situ (29, 5.5%). The most frequent indications were colorectal liver metastases (162, 30.4%), intrahepatic cholangiocarcinoma (139, 26.1%), and perihilar cholangiocarcinoma (106, 19.9%). The median operative time was 390 minutes. Clavien-Dindo ? IIIa occurred in 217 patients (40.8%), and the 90-day mortality rate was 9.8% (52). Portal vein reconstruction independently predicted post-hepatectomy liver failure, ascites, infectious complications, and major morbidity, whereas inferior vena cava reconstruction showed a more favourable perioperative profile. Hepatic vein reconstruction was associated with greater transfusion requirements and longer operative time. Vascular graft-related complications occurred in 22.3% (58) of reconstructions and were not associated with graft type. After excluding patients with perihilar cholangiocarcinoma (426), ante situm and ex situ procedures were associated with higher rates of Clavien-Dindo ? IIIa than in situ procedures (67.3% (33) and 64.3% (18) versus 35.5% (124), respectively; P < 0.001), longer intensive care unit stay (6.5 and 5 versus 3 days, respectively; P < 0.001), and higher mortality (16.3% (8) and 17.9% (5) versus 8.3% (29), respectively; P = 0.060). DFS was superior for hepatocellular carcinoma (P = 0.011), whereas perihilar cholangiocarcinoma showed a higher risk of recurrence (P = 0.022). Five-year OS was highest for sarcoma (68.8%) and hepatocellular carcinoma (42.7%). CONCLUSION: Liver resection with vascular reconstruction is feasible in specialized centres but remains associated with substantial morbidity and mortality. The in situ approach showed the most favourable perioperative outcomes, although oncological benefit varied according to tumour biology, highlighting the importance of careful patient selection.