Two-stage Hepatectomy Versus Liver Transplantation for Patients with Marginally Resectable Extensive Bilobar Colorectal Liver Metastases.

To compare outcomes following two-stage hepatectomy (TSH) or liver transplantation (LT) in patients with extensive bilobar colorectal liver metastases (CRLM). Given the high rate of intrahepatic recurrence after TSH in patients with resectable but extensive bilobar CRLM, LT may be an alternative option. However, studies comparing TSH for potentially resectable patients to LT for unresectable ones are lacking. We compared oncological outcomes of consecutive patients who underwent TSH for extensive bilobar CRLM (resection group, n=32) without extrahepatic disease with those of all patients who underwent LT for unresectable liver-only CRLM (LT group, n=19) at a single center within the 2016-2023 period. Results were analysed both in intention to treat (ITT) and in per protocol (PP). Propensity score matching (PSM) was used to refine the comparability of both groups. The baseline and biological tumor characteristic of both groups were comparable except for unresectability and higher number of lesions in the LT group. Overall survival (OS), recurrence-free survival (RFS), and time to surgical failure (TSF) in the LT group were all significantly better than those in the TSH group (5-year OS: 84% vs. 32%, P=0.003, 5-year RFS: 24% vs. 0%, P=0.0001, 5-year TSF: 61% vs. 7.7%, P<0.0001). Multivariable analysis revealed that left primary sidedness (hazard ratio [HR] 0.38, P=0.049) and LT (HR 0.20, P=0.01) were independent prognostic factors of favorable OS. These results were confirmed after PSM. Our results suggest that LT might achieve better outcomes than TSH in patients with extensive bilobar but resectable liver-only CRLM.