Unexpected postoperative liver failure in patients with splenomegaly induced by induction chemotherapy for colorectal liver metastases

Abstract Purpose: With advances in chemotherapy, conversion surgery is often performed for initially unresectable colorectal cancer liver metastasis (CLM). However, unexpected postoperative liver failure (POLF) is sometimes associated with chemotherapy-related hepatotoxicity following long-term chemotherapy. We aimed to identify predictive factors for POLF after conversion surgery for initially unresectable CLM. Methods: We retrospectively identified 774 consecutive patients who underwent initial liver resections for histologically confirmed CLMs between 2010 and 2019 at our institute. We enrolled 107 patients with initially unresectable CLMs. Clinicopathological characteristics were evaluated to determine their association with POLF. Logistic regression analysis was performed to analyze the predictors of POLF. Results: Among the 107 patients, POLF occurred in 15. Significant risk factors for POLF include splenomegaly during preoperative chemotherapy (>135%), two-stage hepatectomy, and increased operative times and blood loss. Multivariate analysis revealed that splenomegaly was an independent risk factor for POLF (P=0.002). In the analysis limited to the splenomegaly group, lower platelet counts, increased blood loss and operative times, and large liver resection areas (>100 cm²) were significant risk factors for POLF. Among them, a liver resection area >100cm² can be calculated preoperatively and correlate with a complex hepatectomy. Conclusion: These findings could help predict POLF after conversion surgery and induction chemotherapy for initially unresectable CLMs. Careful decisions, including detailed procedures and timing of hepatectomy, should be made before conversion hepatectomy in patients who develop splenomegaly after induction chemotherapy and require complex hepatectomies with a large liver resection area.