Impact of malnutrition on short- and long-term outcomes following laparoscopic liver resection for hepatocellular carcinoma

Aim: Laparoscopic liver resection (LLR) is increasingly used in the management of hepatocellular carcinoma (HCC), even among patients traditionally considered high risk due to advanced age or poor nutritional status. Malnutrition, assessed by the prognostic nutritional index (PNI), is known to negatively affect surgical outcomes; however, its impact in the context of LLR remains unclear. We aimed to clarify the effect of malnutrition, defined by the PNI, on short- and long-term outcomes following laparoscopic liver resection for HCC. Methods: We retrospectively analyzed 121 patients with HCC who underwent primary LLR between 2011 and 2019. Nutritional status was evaluated using the PNI, with a cutoff of < 40 indicating malnutrition. Short-term outcomes were assessed using the textbook outcome (TO), defined as meeting five criteria: no 30-day mortality, R0 resection, no major complications (Clavien–Dindo ≥ III), no unplanned readmission, and no prolonged hospitalization. Long-term outcomes included overall survival (OS) and recurrence-free survival (RFS). Results: Seventeen patients (14%) were classified as malnourished. TO achievement rates were similar between the malnutrition and normal-nutrition groups (70.6% vs. 74.0%, P = 0.771). No significant differences were observed in individual TO criteria. However, OS was significantly worse in the malnutrition group (median 40 vs. 107 months, P < 0.001), while RFS showed a non-significant trend (P = 0.085). In multivariate analysis, PNI-defined malnutrition was the only independent predictor of poorer OS. Conclusion: LLR yields acceptable short-term outcomes even in malnourished patients with HCC, as defined by the PNI. However, malnutrition remains a strong independent risk factor for decreased long-term survival. These findings underscore the importance of preoperative nutritional assessment and optimization in surgical candidates with HCC.