Extreme Liver Surgery With Vascular Reconstruction: Feasible—but Patient Selection Is Everything: BJS Open | October 2026

What Did the Study Find?

This international study evaluated 532 patients undergoing liver resection with major vascular reconstruction across 21 expert centres, including IVC, hepatic vein, portal vein, and hepatic artery reconstruction.

• Major complications (Clavien–Dindo ≥IIIa) occurred in 40.8%.
• 90-day mortality was 9.8%, underscoring the substantial operative risk.
• Portal-vein reconstruction independently predicted post-hepatectomy liver failure, ascites, infection and major morbidity.
• IVC reconstruction showed a comparatively more favourable perioperative profile.
• Vascular graft-related complications occurred in 22.3%, without a clear relationship to graft type.
• Ante-situs and ex situ resections carried substantially greater morbidity than conventional in situ surgery.
• Long-term benefit varied markedly by tumor biology.
• Five-year OS reached 68.8% for sarcoma and 42.7% for HCC, whereas perihilar cholangiocarcinoma had a higher recurrence risk.

Why Does It Matter?

Vascular involvement does not automatically make an advanced hepatobiliary tumor unresectable. In selected patients, complex reconstruction can create a curative-intent surgical opportunity, but at considerable physiological cost.

GastroAGI Takeaway

The key question is no longer simply “Can we technically resect it?” but “Is the oncological benefit worth the operative risk?” In expert centres, vascular reconstruction can extend resectability, but ~41% major morbidity and ~10% 90-day mortality demand rigorous selection. The in situ approach had the most favorable perioperative profile, while tumor biology—not technical feasibility alone—should determine who is offered extreme liver surgery.