Preoperative <scp>FIB</scp> ‐4 Index as a Potential Factor Associated With Severe Postoperative Complications and Endogenous Organ Failure After Hepatectomy for Hepatocellular Carcinoma

ABSTRACT Background Liver fibrosis influences tolerance to surgical stress, dictating postoperative complication risks after hepatectomy for hepatocellular carcinoma (HCC). While conventional systems assess hepatic function, they may not fully capture structural fibrosis. This study evaluated the whether preoperative Fibrosis‐4 (FIB‐4) index is associated with severe complications and “endogenous organ failure” (EOF: systemic decompensation unaccompanied by localized surgical‐site complications). Methods This retrospective study analyzed 1778 HCC patients undergoing hepatectomy between 2001 and 2020. A restricted cubic spline (RCS) model identified the optimal preoperative FIB‐4 cutoff for predicting major complications (Clavien‐Dindo [C‐D] Grade ≥ IIIa). Following stratification by this cutoff, intergroup comparisons and multivariable logistic regression analyses were performed to identify independent predictors of major and severe (C‐D Grade ≥ IIIb) complications. Results RCS analysis suggested a FIB‐4 threshold of 5.0 for an increased trend in complication risk. The High FIB‐4 index group (≥ 5.0, n = 385) showed a higher frequency of severe complications (7.0% vs. 3.4%) and EOF (3.1% vs. 0.4%) compared to the Low FIB‐4 index group (&lt; 5.0, n = 1393). Among patients developing life‐threatening complications (C‐D Grade ≥ IV), 92.3% of the High FIB‐4 index group presented with EOF. In multivariable analyses, FIB‐4 ≥ 5.0 was consistently and independently associated with both major and severe complications. Conclusion A preoperative FIB‐4 ≥ 5.0 was associated with an increased incidence of severe complications, particularly EOF, after hepatectomy. This simple index could serve as a clinical indicator of systemic vulnerability, enhancing surgical risk stratification beyond traditional functional markers.