Repeat Hepatectomy Versus Thermal Ablation for Intrahepatic Recurrence After Resection of Colorectal Liver Metastases: A Propensity-adjusted Analysis With Multiple Imputation

Background/Aim: While thermal ablation has emerged as a less invasive alternative for colorectal liver metastases (CRLM), evidence directly comparing repeat hepatectomy and ablation after prior resection remains limited. This study aimed to compare survival and short-term outcomes between the two strategies using propensity-adjusted analyses with multiple imputation. Patients and Methods: A total of 150 patients with recurrent CRLM after initial resection who underwent repeat hepatectomy (n=94) or ablation (n=56) were retrospectively enrolled. Outcomes included overall survival (OS), local tumor progression-free survival (LTPFS), distant progression-free survival (DPFS), and perioperative outcomes. Propensity score matching (PSM) was applied, and Inverse probability of treatment weighting (IPTW) was additionally used as a sensitivity analysis. Estimates were pooled across imputed datasets. Results: In pooled PSM analyses, ablation showed comparable OS to repeat hepatectomy [hazard ratio (HR)=1.330, p=0.370] and comparable DPFS (HR=1.310, p=0.299). However, ablation was associated with significantly worse LTPFS (HR=4.540, p=0.004). For short-term outcomes, ablation resulted in shorter hospital stay (4.6 versus 15.5 days, p<0.001) and lower incidence of Clavien–Dindo grade ≥IIIa complications (0% versus 19.5%, p=0.033). These findings were consistent in IPTW analyses. Conclusion: Repeat hepatectomy and ablation for intrahepatic recurrence after resection of colorectal metastases showed comparable OS, with a trade-off between superior local control and reduced perioperative burden. When both options are feasible, ablation may represent a reasonable alternative to repeat hepatectomy for patients prioritizing lower treatment burden.