Liver resection for hepatocellular carcinoma in patients with clinically significant portal hypertension

Abstract Background & Aims Liver resection (LR) in patients with hepatocellular carcinoma (HCC) and clinically significant portal hypertension (CSPHT) defined as hepatic venous pressure gradient (HVPG) ≥ 10 mmHg is not encouraged. We aimed to reappraise the outcomes of cirrhotic patients with CSPHT who underwent LR for HCC in highly specialized liver centers. Methods This was a retrospective multicenter study from 1999 to 2019. Predictors for postoperative liver decompensation and textbook outcomes were identified. Results Seventy-nine patients with a median age of 65 years were included. The Child-Pugh grade was A in 99% of patients, and the median MELD score was 8. The median HVPG was 12 mmHg. Major hepatectomy and laparoscopy were performed in 28% and 34% of patients, respectively. Ninety-day mortality and severe morbidity rates were 6% and 27%, respectively. Postoperative and persistent liver decompensation occurred in 35% and 10% at three months. Predictors of liver decompensation included increased preoperative HVPG (p = 0.004), increased serum total bilirubin (p = 0.02), and open approach (p = 0.03). Thirty-four percent of patients achieved a textbook outcome, and the laparoscopic approach was the sole predictor of this outcome (p = 0.004). The 5-year overall survival and recurrence-free survival rates were 55% and 43%, respectively. Conclusions Cirrhotic patients with HCC and HVPG ≥ 10 mmHg can undergo LR with acceptable mortality, morbidity, and liver decompensation rates. The laparoscopic approach was the sole predictor of a textbook outcome.