Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.
Impact of textbook outcome after hepatectomy for colorectal metastases on salvage curative-intent treatment at recurrence
Long Chen, Hua-Chuan Song, Fan-Zheng Meng, Shen-Yu Zhang, Ze-Yang An, Xin-Yu Ling, Can Zhang, Xing-Chun Zhu, Ji-Zhou Wang, Rui-Peng Song, Lian-Xin Liu
Long Chen, Hua-Chuan Song, Fan-Zheng Meng, Shen-Yu Zhang, Ze-Yang An, Xin-Yu Ling, Can Zhang, Xing-Chun Zhu, Ji-Zhou Wang, Rui-Peng Song, Lian-Xin Liu, Department of Hepatobiliary Surgery, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
Long Chen, Hua-Chuan Song, Fan-Zheng Meng, Shen-Yu Zhang, Ze-Yang An, Xin-Yu Ling, Can Zhang, Xing-Chun Zhu, Ji-Zhou Wang, Rui-Peng Song, Lian-Xin Liu, Anhui Provincial Key Laboratory of Hepatopancreatobiliary Surgery, Hefei 230001, Anhui Province, China
Long Chen, Hua-Chuan Song, Fan-Zheng Meng, Shen-Yu Zhang, Ze-Yang An, Xin-Yu Ling, Can Zhang, Xing-Chun Zhu, Ji-Zhou Wang, Rui-Peng Song, Lian-Xin Liu, Anhui Provincial Clinical Research Center for Hepatobiliary Diseases, Hefei 230001, Anhui Province, China
Co-first authors: Long Chen and Hua-Chuan Song.
Co-corresponding authors: Rui-Peng Song and Lian-Xin Liu.
Author contributions: Chen L, Song HC, and Meng FZ designed the research study; Zhang SY, An ZY, Ling XY, Zhang C, and Zhu XC performed the research and collected the data; Chen L and Song HC analyzed and interpreted data, and they contributed equally to this manuscript as co-first authors; Chen L wrote the manuscript; Song RP and Liu LX contributed equally to this manuscript as co-corresponding authors; Wang JZ, Song RP, and Liu LX revised and proofed the manuscript. All authors have read and approved the final manuscript.
Supported by Scientific Research Project of Anhui Provincial Department of Education, No. 2024AH030058; Joint Fund Project of USTC, No. YD9110002083; and Joint Fund for Medical Artificial Intelligence, No. MAI2023Q034.
Institutional review board statement: The study was reviewed and approved by the First Affiliated Hospital of University of Science and Technology of China Institutional Review Board (approval No. 2025-RE-429).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: All data and materials are available from the corresponding author.
Corresponding author: Lian-Xin Liu, PhD, Dean, FACS, FRCS, Department of Hepatobiliary Surgery, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17 Lujiang Road, Hefei 230001, Anhui Province, China.
liulx@ustc.edu.cn
Received: March 9, 2026
Revised: March 31, 2026
Accepted: April 24, 2026
Published online: July 15, 2026
Processing time: 123 Days and 7.5 Hours
BACKGROUND
Colorectal cancer is a leading cause of cancer-related mortality worldwide, with the liver being the most common site of distant metastasis. Hepatectomy is the gold standard for colorectal liver metastases (CRLM). However, up to 70% of patients experience recurrence within 5 years, for whom salvage curative-intent treatment (SCT) provides a second chance for cure. Textbook outcome (TO) is a composite metric that captures the ideal perioperative course and is associated with improved long-term survival. However, whether achieving TO influences eligibility for SCT upon recurrence remains unexplored.
AIM
To investigate whether achieving TO following initial hepatectomy for CRLM is an independent predictor of a patient’s eligibility for SCT upon intrahepatic recurrence.
METHODS
This multicenter, retrospective cohort study was conducted at two tertiary referral centers in China. We enrolled patients with CRLM who underwent hepatectomy from February 2017 to March 2025 and subsequently developed intrahepatic recurrence. The primary exposure was TO, defined as a composite metric comprising R0 resection, absence of major complications, no prolonged postoperative length of stay, no readmission within 90 days, and no mortality within 90 days. Univariable and multivariable logistic regression analyses evaluated the impact of TO on receiving SCT. Furthermore, to rigorously account for immortal time bias, subsequent survival outcomes were assessed utilizing a 12-month landmark analysis and time-dependent Cox proportional hazards models. A directed acyclic graph was constructed to identify potential confounders and guide variable selection for multivariable models.
RESULTS
TO was achieved in 69.1% (141/204) of patients. The TO group had a higher rate of SCT upon recurrence than the non-TO group (47.5% vs 14.3%, P < 0.001). TO was identified as an independent predictor of receiving SCT (odds ratio: 3.54, 95% confidence interval: 1.52-8.25, P = 0.003). Median overall survival (OS) was significantly longer in the TO group (not reached at a median follow-up of 39.3 months) compared with the non-TO group (35.2 months; P < 0.001). To adjust for immortal time bias, a 12-month landmark analysis confirmed the survival advantage of SCT (median residual OS: Not reached vs 32.8 months; P < 0.001). Furthermore, multivariable time-dependent Cox analysis verified SCT as an independent prognostic factor for improved OS (hazard ratio: 0.50, 95% confidence interval: 0.26-0.94, P = 0.031).
CONCLUSION
Achieving TO is a robust independent predictor of eligibility for SCT upon recurrence.
Core Tip: Following hepatectomy for colorectal liver metastases, the quality of the index surgery determines more than just short-term recovery. This study suggests that achieving a textbook outcome is the strongest independent predictor of eligibility for salvage curative-intent treatment upon intrahepatic recurrence. By preserving physiological reserve, textbook outcome helps maintain the critical therapeutic window for life-prolonging repeat interventions.
