Reframing Post‐Hepatectomy Liver Failure as a Determinant of Post‐Recurrence Survival in HCC

BACKGROUND: Post-hepatectomy liver failure (PHLF) is traditionally considered a transient perioperative complication with limited long-term consequences, yet its long-term oncologic implications in hepatocellular carcinoma (HCC) remain unclear. METHODS: Patients undergoing primary hepatectomy for HCC between 2007 and 2018 were analyzed. To ensure reliable assessment of recurrence and post-recurrence survival, follow-up was continued through 2023. Associations between PHLF and overall survival (OS), time to recurrence (TTR), and survival after recurrence (SAR) were assessed. Propensity score matching (PSM) analysis controlled for baseline differences. RESULTS: PHLF ≥ grade B occurred in 59 patients (14.6%). It was significantly associated with worse OS (45.6 vs. 109.7 months, p < 0.001) and SAR (21.5 vs. 55.9 months, p < 0.001), but not TTR. After PSM, these associations persisted. At recurrence, patients with PHLF had worse ALBI scores (-1.92 vs. -2.57, p < 0.001) and lower rates of re-resection for recurrent disease (6.9% vs. 29.3%, p = 0.026), even after PSM. CONCLUSIONS: PHLF ≥ grade B compromised hepatic reserve at recurrence and limiting curative salvage therapy, leading to impaired SAR and OS. Prevention of PHLF should be prioritized not only to reduce perioperative risk but also to optimize long-term oncologic outcomes in HCC.