Biliary and respiratory complications after right hepatectomy for hepatocellular carcinoma following selective internal radiation therapy (SIRT): a retrospective case-control study

Background: Selective internal radiation therapy (SIRT) has emerged as a promising and recent treatment for downstaging hepatocellular carcinoma (HCC) before surgical intervention. However, the potential occurrence of postoperative biliary and respiratory complications following major hepatectomy subsequent to SIRT remains unclear. We hypothesized that SIRT can increase the rate of biliary leakage and cause diaphragmatic dysfunction, especially for huge HCC in contact with the diaphragm. Methods: We conducted a retrospective study including consecutive HCC patients from January 2015 to December 2022 undergoing right hepatectomy after SIRT in the Montpellier University Hospital. Patients were compared in a 1:1 ratio with non-SIRT-treated patients based on the following criteria: same diagnosis, same surgery, same American Society of Anesthesiologists (ASA) score, Child-Turcotte-Pugh (CTP) class, and similar tumor burden. Analysis was done using either a linear or logistic regression. Outcomes were the rate of biliary leakage and of 3 diaphragm-related complications: oxygen flow on day 1, need for intensive oxygen therapy, and pleural effusion. Results: Twenty patients with comparable preoperative characteristics were included in each group. Eight patients (40%) in the SIRT group experienced a postoperative bile leak versus only 2 (10%) in the other, with a significantly increased risk [odds ratio (OR) =6; 95% confidence interval (CI): 1.1-33.3; P<0.05]. Similarly, the risk of large postoperative pleural effusion was increased after SIRT, with 6 patients (30%) against 0, respectively (OR =10.5; 95% CI: 1.8-61.4; P<0.05). Conclusions: SIRT may increase the risk of postoperative biliary leakage and respiratory complications after right hepatectomy.