Safety and efficacy of salvage surgery for unresectable hepatocellular carcinoma after conversion with triple therapy: a systematic review and meta-analysis of data from Chinese patients

Conversion therapy based on vascular intervention combined with targeted immunotherapy has gradually improved treatment outcomes for hepatocellular carcinoma (HCC). Salvage surgery after conversion therapy is worthy of attention. The aim of this study is to summarize the safety and efficacy of salvage surgery after triple therapy for patients with HCC. The PubMed, EMBASE, Cochrane Library, Web of Science, and Chinese databases were used to screen eligible studies evaluating the clinical efficacy and safety of triple therapy for patients with unresectable hepatocellular carcinoma (uHCC) up to April 2025. Survival outcomes, pathological characteristics, and perioperative features were extracted for further analysis. This meta-analysis included 15 studies of 742 uHCC patients who underwent surgery after triple therapy. The median overall survival (mOS) could not be performed in the present meta-analysis, as most trials did not reach mOS. The pooled one-year overall survival (OS) rate and two-year OS rate was 0.92 (95% confidence interval (CI) = 0.89–0.96) and 0.84 (95% CI = 0.75–0.92), respectively. In terms of pathological characteristics, the pooled incidence of microvascular invasion (MVI) was 0.20 (95% CI = 0.10–0.30), and the pooled pathologic complete response (pCR) rate was 0.40 (95% CI = 0.29–0.52). The pooled postoperative complication rate of posthepatectomy liver failure (PHLF) and Clavien–Dindo (CD) III–V were 0.23 (95% CI = 0.15–0.30) and 0.11 (95% CI = 0.06, 0.16), respectively. Salvage surgery after conversion with triple therapy might have promising clinical benefits, efficacy and safety for patients with unresectable hepatocellular carcinoma. Further prospective studies are needed to validate these findings and improve HCC management.