Hepatic vulnerability is associated with post-hepatectomy liver failure and major morbidity after curative-intent resection of perihilar cholangiocarcinoma

Background Post-hepatectomy liver failure (PHLF) remains a major determinant of morbidity after resection for perihilar cholangiocarcinoma (pCCA). We evaluated whether a composite HVS is associated with PHLF and major morbidity after resection for pCCA. Methods Consecutive patients undergoing curative-intent resection for pCCA between 2010 and 2024 were retrospectively analyzed. The HVS combined preoperative hyperbilirubinemia, histological fibrosis and steatosis, with one point assigned to each component. The primary endpoint was PHLF according to ISGLS criteria; the secondary endpoint was major postoperative morbidity, defined as Clavien-Dindo grade ≥ III. Results Among 203 patients, PHLF occurred in 59 (29.1%) and major complications in 105 patients (51.7%). PHLF increased stepwise with higher HVS category (21.0% vs. 33.8% vs. 42.4%, p = 0.033), with a significant trend across groups ( p = 0.010). Major morbidity increased with higher score levels (44.0% vs. 57.7% vs. 63.6%, p = 0.071; trend p = 0.025). In multivariable analysis, HVS was independently associated with PHLF (OR 1.77, 95% CI 1.15–2.71, p = 0.009) and major morbidity (OR 1.51, 95% CI 0.99–2.27, p = 0.050). HVS showed a numerically higher AUC than its individual components in ROC analysis. Conclusions A simple composite HVS combining biochemical and histological liver parameters is significantly associated with PHLF and major complications after pCCA resection. Further prospective and external validation is required to determine its potential clinical utility for risk stratification and patient selection in complex hepatobiliary surgery.