Surgical resection of hepatocellular carcinoma in cirrhotic patients: Prognostic value of preoperative portal pressure

Background & Aims: Although resection of hepatocellular carcinoma complicating cirrhosis is restricted to patients with preserved liver function, postoperative hepatic decompensation develops in some patients. The aim of this study was to determine the value of increased portal pressure in the development of post-operative hepatic decompensation. Methods: Twenty-nine cirrhotic patients with Child-Pugh's class A disease and hepatocellular carcinoma (all except one <5 cm) scheduled to undergo resection were evaluated by conventional criteria and by a systemic and hepatic hemodynamic study. Predictors of decompensation were assessed among a series of 44 clinical, analytical, tumoral, and hemodynamic parameters. Results: Eleven patients had unresolved decompensation 3 months after surgery. Bilirubin and blood ureic nitrogen levels, platelet count, wedged hepatic venous pressure, hepatic venous pressure gradient, and indocyanine green intrinsic clearance were significantly associated with unresolved decompensation, but only hepatic venous pressure gradient was significant in the multi-variate analysis (P = 0.0001; odds ratio, 1.90; 95% confidence interval, 1.12-3.22). The preoperative gradient of patients with unresolved decompensation was higher than that of patients without it (13.9 +/- 2.4 and 7.4 +/- 3.5 mm Hg, respectively; P < 0.001). Conclusions: Cirrhotics with increased portal pressure are at high risk of hepatic decompensation after resection of hepatocellular carcinoma. Surgical resection should therefore be restricted to patients without portal hypertension.