Propensity matched comparison between one-stage and two-stage hepatectomy after portal vein embolization for bilateral colorectal liver metastases

BACKGROUND: Bilobar colorectal liver metastases present significant surgical challenges. Portal vein embolization followed by one-stage hepatectomy (PVE-OSH), omitting prior future liver remnant clearance, has been proposed as an alternative to two-stage hepatectomy with PVE (TSH-PVE). This study used propensity matching to address selection bias. METHODS: Propensity scores were estimated using a probit model including demographic, clinical, and disease-related variables. Nearest-neighbour matching (up to 3 controls per treated patient) was performed. The primary outcome was successful resection, defined as completion without 90-day mortality. RESULTS: Following matching, 52 TSH-PVE and 75 PVE-OSH patients were analysed with well-balanced characteristics (SMD 0.1). Successful resection rates were comparable (76% TSH-PVE vs 82% PVE-OSH, p = 0.683). The chemotherapy-to-major-surgery interval was longer for TSH-PVE. Logistic regression demonstrated that metastasis size and number, rather than resection strategy, predominantly influenced successful resection. Rescue-ALPPS requirement was significantly higher for TSH-PVE (24% vs 7%, p = 0.006), and time to completion was shorter for PVE-OSH. Overall survival showed no significant differences between groups. CONCLUSION: PVE-OSH is comparable to TSH-PVE regarding complications, completion rates, and survival while reducing the chemotherapy-free interval. Metastasis size and number, rather than resection strategy, determine resection success and overall survival, demonstrating PVE-OSH as a feasible alternative to TSH-PVE.