Liver resection for hepatocellular carcinoma in patients with clinically significant portal hypertension
Daniel Azoulay,
Emilio Ramos,
Margarida Casellas-Robert,
Chady Salloum,
Laura Lladó,
Roy Nadler,
Juli Busquets,
Celia Caula-Freixa,
Kristel Mils,
Santiago Lopez-Ben,
Joan Figueras,
Chetana Lim
Affiliations
Daniel Azoulay
Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Paul Brousse Hospital, Villejuif, France; Department of Hepato-Biliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Tel Aviv, Israel; Corresponding author. Address: Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, Avenue Paul Vaillant Couturier, 94000 Villejuif, France.
Emilio Ramos
Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, CIBERehd, Barcelona, Catalonia, Spain
Margarida Casellas-Robert
Unit of Hepato-Biliary and Pancreatic Surgery, Department of General Surgery, Hospital Universitari Dr Josep Trueta, Girona, Catalonia, Spain
Chady Salloum
Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Paul Brousse Hospital, Villejuif, France
Laura Lladó
Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, CIBERehd, Barcelona, Catalonia, Spain
Roy Nadler
Department of Hepato-Biliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
Juli Busquets
Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, CIBERehd, Barcelona, Catalonia, Spain
Celia Caula-Freixa
Unit of Hepato-Biliary and Pancreatic Surgery, Department of General Surgery, Hospital Universitari Dr Josep Trueta, Girona, Catalonia, Spain
Kristel Mils
Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, CIBERehd, Barcelona, Catalonia, Spain
Santiago Lopez-Ben
Unit of Hepato-Biliary and Pancreatic Surgery, Department of General Surgery, Hospital Universitari Dr Josep Trueta, Girona, Catalonia, Spain
Joan Figueras
Hepato-Biliary and Pancreatic Surgery, Department of Surgery, “Sagrat Cor” Hospital University of Barcelona, Barcelona, Spain
Chetana Lim
Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
Background & Aims: Liver resection (LR) in patients with hepatocellular carcinoma (HCC) and clinically significant portal hypertension (CSPH) defined as a hepatic venous pressure gradient (HVPG) ≥10 mmHg is not encouraged. Here, we reappraised the outcomes of patients with cirrhosis and CSPH who underwent LR for HCC in highly specialised liver centres. Methods: This was a retrospective multicentre study from 1999 to 2019. Predictors for postoperative liver decompensation and textbook outcomes were identified. Results: In total, 79 patients with a median age of 65 years were included. The Child-Pugh grade was A in 99% of patients, and the median model for end-stage liver disease (MELD) score was 8. The median HVPG was 12 mmHg. Major hepatectomies and laparoscopies 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% of patients at 3 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). Of the patients, 34% achieved a textbook outcome, of which the laparoscopic approach was the sole predictor (p = 0.004). The 5-year overall survival and recurrence-free survival rates were 55% and 43%, respectively. Conclusions: Patients with cirrhosis, 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. Lay summary: Patients with cirrhosis, hepatocellular carcinoma, and clinically significant portal hypertension (defined as a hepatic venous pressure gradient ≥10 mmHg) can undergo resection with acceptable mortality, morbidity, liver decompensation rates, and a textbook outcome. These results can be achieved in selected patients with preserved liver function, good general status, and sufficient remnant liver volume.
