The role of salvage transplantation in patients initially treated with open vs minimally invasive liver surgery: an intention-to-treat analysis.

BACKGROUND: Recently, minimally invasive liver surgery (MILS) has gained wide consensus in the management of hepatocellular carcinoma (HCC). However, its role in the setting of a salvage liver transplantation (SLT) has been poorly investigated. We analyzed the intention-to-treat survival of HCC patients treated with MILS vs. the open approach and eventually waitlisted for SLT. The secondary end-point was identification of risk factors for post-transplant death and tumor recurrence. MATERIALS AND METHODS: A multicenter, retrospective analysis was carried out in six Italian centers. A total of 211 HCC patients resected with open surgery (n=167) vs. MILS (n=44) and waitlisted for SLT during the period January 2007 - December 2017 was enrolled. RESULTS: MILS was the most important protective factor for the composite risk of de-listing, post-transplant patient death and HCC recurrence (OR=0.26, 95%CI=0.11-0.63; p=0.003). MILS was also the only independent protective factor for the risk of post-SLT patient death (OR=0.29, 95%CI=0.09-0.93; P=0.04). After propensity score matching, MILS was the only independent protective factor against the risk of de-listing, post-transplant death and HCC recurrence (OR=0.22, 95%CI=0.07-0.75; p=0.02). CONCLUSIONS: Based on current analysis, MILS seems protective over open surgery for the risk of de-listing, post-transplant patient death and tumor recurrence. Larger prospective studies balancing liver function and tumor stage are strongly favored to better clarify the beneficial effect of MILS for HCC patients eventually referred to SLT.