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

doi:10.1016/j.jhepr.2020.100190

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

JHEP Rep. 2020 Oct 8;3(1):100190. doi: 10.1016/j.jhepr.2020.100190. eCollection 2021 Feb.

Authors

Affiliations

¹ Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Paul Brousse Hospital, Villejuif, France.
² Department of Hepato-Biliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Tel Aviv, Israel.
³ Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, CIBERehd, Barcelona, Catalonia, Spain.
⁴ Unit of Hepato-Biliary and Pancreatic Surgery, Department of General Surgery, Hospital Universitari Dr Josep Trueta, Girona, Catalonia, Spain.
⁵ Hepato-Biliary and Pancreatic Surgery, Department of Surgery, "Sagrat Cor" Hospital University of Barcelona, Barcelona, Spain.
⁶ Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France.

Abstract

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.

Keywords: AFP, alpha-fetoprotein; ASA, American Society of Anesthesiologists; BCLC, Barcelona-Clinic Liver Cancer; CCI, Comprehensive Complication Index; CSPH, clinically significant portal hypertension; CT, computed tomography; Clinically significant portal hypertension; EASL, European Association for the Study of the Liver; HVPG, hepatic venous pressure gradient; Hepatectomy; Hepatic venous pressure gradient; LLR, laparoscopic liver resection; LR, liver resection; MELD, model for end-stage liver disease; PHT, portal hypertension; PVE, portal vein embolisation; Postoperative liver decompensation; TACE, transarterial chemoembolisation; Textbook outcome.