Safe major hepatectomy in HCC patients with remnant-to-standard liver volume below 40% and preserved ICG clearance.

BACKGROUND

A future liver remnant (FLR) ≥40% is commonly recommended for major hepatectomy in patients with chronic liver disease; however, volumetry alone may not adequately reflect functional reserve. We evaluated whether FLR <40% increases posthepatectomy liver failure (PHLF) in hepatocellular carcinoma (HCC).

METHODS

This retrospective study included 269 consecutive patients who underwent major hepatectomy for HCC between October 2016 and December 2024. Patients were stratified into FLR <40% (n = 84) and FLR ≥40% (n = 185). Clinically relevant PHLF was defined as ISGLS grade B-C, and liver failure was also assessed using the 50-50 criteria. Propensity score matching (1:2) and inverse probability of treatment weighting (IPTW) were performed.

RESULTS

ISGLS grade B-C PHLF occurred more frequently in the FLR <40% group in unadjusted (13.1% vs 3.8%), matched (15.9% vs 1.7%), and IPTW analyses (16.4% vs 3.5%). In contrast, liver failure defined by the 50-50 criteria did not differ between groups. Postoperative mortality and length of hospital stay were comparable.

CONCLUSION

FLR <40% is associated with increased ISGLS-defined PHLF but not with PHLF defined by the 50-50 criteria, mortality, or prolonged hospitalization in patients with preserved functional reserve.