Rescue liver transplantation after post-hepatectomy acute liver failure: A systematic review and pooled analysis

background: post-hepatectomy liver failure is a severe complication after major liver resection and is associated with a high mortality rate. nevertheless, there is no effective treatment for severe liver failure. In such a setting, rescue liver transplantation (LT) is used only in extraordinary cases with unclear results. this systematic review aims to define indication of LT in post-hepatectomy liver failure and post-LT outcomes, in terms of patient and disease-free survivals, to assess the procedure's feasibility and effectiveness. methods: a systematic review of all english language full-text articles published until september 2022 was conducted. Inclusion criteria were articles describing patients undergoing LT for post-hepatectomy liver failure after liver resection, which specified at least one outcome of interest regarding patient/graft survival, postoperative complications, tumour recurrence and cause of death. a pseudo-individual participant data meta-analysis was performed to analyse data. study quality was assessed with MINORS system. PROSPERO CRD42022349358.results: postoperative complication rate was 53.6%. all patients transplanted for benign indications survived. for malignant tumours, 1-, 3-and 5-year overall survival was 94.7%, 82.1% and 74.6%, respectively. the causes of death were tumour recurrence in 83.3% of cases and infection-related in 16.7% of LT recipients. at cox regression, being transplanted for unconventional malignant indications (colorectal liver metastasis, cholangiocarcinoma) was a risk factor for death HR = 8.93 (95%CI = 1.04-76.63; P-value = 0.046). disease-free survival differs according to different malignant tumours (P-value = 0.045).conclusions: post-hepatectomy liver failure is an emergent indication for rescue LT, but it is not universally accepted. In selected patients, LT can be a life-saving procedure with low short-term risks. however, special attention must be given to long-term oncological prognosis before proceeding with rescue LT in an urgent setting, considering the severity of liver malignancy, organ scarcity, the country's organ allocation policies and the resource of living-related donation.