Retrohepatic Vena Cava Encirclement, as Surrogate of Extensive Liver Manipulation During Caval Sparing Hepatectomy, Is a Risk Factor for Tumor Recurrence After Liver Transplantation for Hepatocellular Carcinoma.

INTRODUCTION: In liver transplantation (LT) with a caval sparing (CS) approach, the presence of complete encirclement of inferior vena cava (IVC-E) by hypertrophic segment 1 increases the technical complexity of hepatectomy. Thus, in LT for hepatocellular carcinoma (HCC), It may be suspected that the resulting greater liver manipulation and delayed vascular exclusion might increase the risk of intraoperative dissemination of tumor cells. METHODS: A multicenter, retrospective study was performed to assess the association between IVC-E and the risk of post-transplant tumor recurrence in a cohort of 537 HCC patients treated with CS-LT, between 2010 and 2021. IVC-E was defined on preoperative imaging. RESULTS: IVC-E (n = 150) and no-IVC-E (n = 387) groups were comparable in terms of severity of underlying liver disease, recipient characteristics, morphological and biological features of HCC. Recipient hepatectomy was significantly longer in IVC-E group (IVC-E vs. no-IVC-E, 144 min [110-180] versus 120 min [90-150], p < 0.001) and was associated with higher blood transfusion requirements (no transfusion cases, 15.3% vs. 25.8%, p = 0.034). The cumulative incidence of HCC recurrence at 1, 3, and 5-year, accounting for the competing risk of death unrelated to tumor recurrence, was significantly higher in IVC-E group (8.1%, 18.5%, and 20.1% vs. 3.9%, 8.4%, and 11.3%, p = 0.001, respectively). CONCLUSIONS: The technical complexity associated with IVC-E during CS hepatectomy not only increases intraoperative morbidity but may also trigger the risk of post-transplant tumor recurrence in LT for HCC.