Portal hypertension should not be a contraindication of hepatic resection to treat hepatocellular carcinoma with compensated cirrhosis

Abstract

P < 0.001), 1 thus reflecting a more advanced liver dysfunction at the time of surgery, the competing role of which, with regard to CSPH, cannot be assessed with the present meta-analysis. In the present study CSPH remains a determinant of surgical outcome because the investigators selected results that intrinsically bring a significant difference, regarding covariates, between the two groups. In individual series, this imbalance was handled using different statistical approaches, in particular, regression analyses, which cannot be fully captured with the present meta-analytic approach. The investigators indicated the observed (medium) heterogeneity as the consequence of the different methods used for diagnosing CSPH, 1 but a considerable source of heterogeneity may be caused by different covariate distributions among patients (clinical heterogeneity) with or without CSPH in each of the included studies. 3 In 2009, we outlined the role of such selection bias and how it could be reduced by applying a propensity-score match between patients with cirrhosis with or without CSPH. 2 Before match, CSPH patients had significantly worse preoperative liver function and survival rates in comparison to patients without CSPH. After one-toone propensity score matching, patients with and without CSPH (78 patients in each group) had the same preoperative characteristics (d-values: <|0.1|), experiencing the same intra-and postoperative courses. Thus, if this aspect was not taken into account in the individual series included in the meta-analysis, results would be inevitability affected by pooling togheter the selection bias. At this point, it is worth noting that survival rates extracted from our study, and reported in Table 3 of the article, are neither those of the whole study population nor those from the matched sample, but they were derived from the analysis of outliers after match (best compensated patients without CSPH vs. CSPH patients with worst liver function), thus not representative of our findings. 2 For these reasons, we are uncertain that findings from Berzigotti et al. can really help in clarifying the role of CSPH in the selection process of surgical candidates. The present results reinforce the need for well-conducted studies on this topic.

Hepatic venous pressure gradient for preoperative assessment of patients with resectable hepatocellular carcinoma: A comment for moving forward

“…In their study, length of hospitalization was similar between patients with HVPG P10 mmHg or <10 mmHg, and major hepatectomy was significantly less common among patients with HVPG P10 mmHg. These findings are consistent with several studies showing that patients with earlystage HCC or patients undergoing minor hepatectomy had similar short-and long-term prognoses in the presence or absence of PHT [2,3,5]. Thus, the findings of Cucchetti and coworkers [1] coincide with those of numerous previous studies suggesting that PHT should not be considered a contraindication of resection.…”

Surgical Treatment of Hepatocellular Carcinoma

“…Only patients with CEPH undergoing major LR have had a decreased OS (1-year 88% vs 95%, 3-year 59% vs 73%, and 5-year 30% vs 50%). 9 Zhong et al 86 argued that the impact of portal hypertension on the outcome of LR for HCC is lower than the potential benefit of LR on OS as compared to other therapeutic strategies. 86 A recent multinational collaborative study evaluated the application of current guidelines among 20 centers from 3 continents: CEPH (defined by platelet count <100 000/µL and imaging findings; splenomegaly, varices, or ascites) had little impact on the centers’ decision to offer LR to patients with HCC.…”

Measurement of Portal Pressure and its Application in the Clinical Setting

“…47 Similarly, several other reports argue that HVPG > 10 mm Hg should not be considered an absolute contraindication to resection. 42,[48][49][50][51] Response to Therapy for Portal Hypertension…”