Association between unplanned conversion and patient survival after laparoscopic liver resection for hepatocellular carcinoma: A propensity score matched analysis

Abstract

Background: Unplanned conversion (UPC) to open surgery is considered to be a predictor of poor postoperative outcomes. However, the effects of UPC on the survival of patients with hepatocellular carcinoma (HCC) remain controversial. Therefore, in this study, we compared the surgical and oncological outcomes between patients who underwent LLR and those who underwent UPC during LLR for hepatocellular carcinoma (HCC) located in posterosuperior (PS) segments. Patients were matched by propensity score matching (PSM). Methods: Among 1,029 patients with HCC who underwent hepatectomy between 2004 and 2021, 251 were eligible for the study. UPC was defined as resection attempted by LLR, which required conversion to unscheduled open surgery owing to bleeding. Results: Of 251 patients who underwent liver resection for HCC in PS segments, 29 (26.0%) required UPC and 222 underwent LLR. After 1 : 5 PSM, 25 patients were selected for the UPC group and 120 for the LLR group. Blood loss, intraoperative transfusion rate, hospital stay, and postoperative complication rates were greater in the UPC group. Regarding oncologic outcomes, although the 5-year overall survival rate was similar in both groups (p = 0.544), the recurrence-free survival rate was lower in the UPC group (p < 0.001). Multivariable analysis showed that only hypoalbuminemia was significantly associated with increased likelihood of UPC (hazard ratio 4.873; 95% confidence interval 1.904-12.474; p = 0.001). Conclusions: UPC was associated with poor short-term outcomes as well as inferior long-term outcomes compared with LLR for HCC in PS segments. Therefore, surgeons must carefully select patients and consider early conversion if unexpected bleeding occurs to maintain safety and oncologic outcomes.