Ann Hepatobiliary Pancreat Surg.  2016 Nov;20(4):159-166. 10.14701/ahbps.2016.20.4.159.

Impact of clinically significant portal hypertension on surgical outcomes for hepatocellular carcinoma in patients with compensated liver cirrhosis: a propensity score matching analysis

• Jang CW
• Kwon HJ
• Kong H
• Ha H
• Han YS
• Chun JM
• Kim SG
• Hwang YJ

• KMID: 2362465
• DOI: http://doi.org/10.14701/ahbps.2016.20.4.159

Abstract

BACKGROUNDS/AIMS
The roles of portal hypertension (PHT) on the postoperative course after hepatectomy are still debated. The aim of this study was to evaluate surgical outcomes of hepatectomy in patients with PHT.
METHODS
Data from 152 cirrhotic patients who underwent hepatectomy for hepatocellular carcinoma (HCC) were collected retrospectively. Patients were divided into two groups according to the preoperative presence of PHT as follows: 44 patients with PHT and 108 without PHT. Propensity score matching (PSM) analysis was used to overcome selection biases.
RESULTS
There were no significant differences in morbidity (56.8% vs. 51.9%, p=0.578) and 90-days mortality (4.5% vs. 4.6%, p=0.982) between the two groups. Post-hepatectomy liver failure (PHLF) was not significantly different between the two groups (43.2% vs. 35.2%, p=0.356). Patients without PHT had a better 5-year disease-free survival than those with PHT, although the difference did not reach statistical significance (30.9% vs. 17.2%, p=0.081). Five-year overall survivals were not significantly different between the two groups (46.6% vs. 54.9%, p=0.724). Repeat analyses after PSM showed similar rates of morbidity (p=0.819), mortality (p=0.305), PHLF (p=0.648), disease-free survival (p=0.241), and overall survival (p=0.619). The presence of PHT was not associated with either short-term or long-term poor surgical outcomes.
CONCLUSIONS
Child-Pugh A and B patients with PHT have surgical outcomes similar to those without PHT. Hepatectomy can be safely performed and can also be considered as a potentially curative treatment in HCC patients with PHT.

Keyword

Portal hypertension; Hepatocellular carcinoma; Hepatectomy; Complication; Prognosis

MeSH Terms

Carcinoma, Hepatocellular*
Disease-Free Survival
Hepatectomy
Humans
Hypertension, Portal*
Liver Cirrhosis*
Liver Failure
Liver*
Mortality
Prognosis
Propensity Score*
Retrospective Studies
Selection Bias

Figure

• 

  Fig. 1 Propensity score matching (PSM) process. (A) Parallel line plot of the standardized difference in means before and after PSM in hepatocellular carcinoma patients with and without portal hypertension (PHT). As the standardized difference in means was reduced, the covariate balance was improved in the matched samples. (B) Dot plot of the propensity scores of patients in the PHT and the non-PHT groups showing individual units in the dataset and whether they were matched or discarded.

• 

  Fig. 2 Kaplan-Meier survival curves of the population undergoing hepatectomy for hepatocellular carcinoma with and without portal hypertension (PHT). (A) and (B) show disease-free survival before and after propensity score matching, respectively. (C) and (D) show overall survival before and after propensity score matching, respectively (blue line, without PHT; and green line, with PHT).

Reference

1. Hidaka M, Takatsuki M, Soyama A, Tanaka T, Muraoka I, Hara T, et al. Intraoperative portal venous pressure and long-term outcome after curative resection for hepatocellular carcinoma. Br J Surg. 2012; 99:1284–1289. PMID: 22864890.

2. Bruix J, Castells A, Bosch J, Feu F, Fuster J, Garcia-Pagan JC, et al. Surgical resection of hepatocellular carcinoma in cirrhotic patients: prognostic value of preoperative portal pressure. Gastroenterology. 1996; 111:1018–1022. PMID: 8831597.

3. Lisotti A, Azzaroli F, Buonfiglioli F, Montagnani M, Cecinato P, Turco L, et al. Indocyanine green retention test as a noninvasive marker of portal hypertension and esophageal varices in compensated liver cirrhosis. Hepatology. 2014; 59:643–650. PMID: 24038116.

4. Boleslawski E, Petrovai G, Truant S, Dharancy S, Duhamel A, Salleron J, et al. Hepatic venous pressure gradient in the assessment of portal hypertension before liver resection in patients with cirrhosis. Br J Surg. 2012; 99:855–863. PMID: 22508371.

5. Llovet JM, Brú C, Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis. 1999; 19:329–338. PMID: 10518312.

6. Rahbari NN, Garden OJ, Padbury R, Brooke-Smith M, Crawford M, Adam R, et al. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery. 2011; 149:713–724. PMID: 21236455.

7. D'Agostino RB Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998; 17:2265–2281. PMID: 9802183.

8. Grazi GL, Ercolani G, Pierangeli F, Del Gaudio M, Cescon M, Cavallari A, et al. Improved results of liver resection for hepatocellular carcinoma on cirrhosis give the procedure added value. Ann Surg. 2001; 234:71–78. PMID: 11420485.

9. Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, Yeung C, et al. Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths. Ann Surg. 1999; 229:322–330. PMID: 10077043.

10. Poon RT, Fan ST, Lo CM, Ng IO, Liu CL, Lam CM, et al. Improving survival results after resection of hepatocellular carcinoma: a prospective study of 377 patients over 10 years. Ann Surg. 2001; 234:63–70. PMID: 11420484.

11. Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg. 2002; 236:397–406. discussion 406-407. PMID: 12368667.

12. Ikai I, Arii S, Okazaki M, Okita K, Omata M, Kojiro M, et al. Report of the 17th nationwide follow-up survey of primary liver cancer in Japan. Hepatol Res. 2007; 37:676–691. PMID: 17617112.

13. Llovet JM, Fuster J, Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation. Hepatology. 1999; 30:1434–1440. PMID: 10573522.

14. Bruix J, Sherman M. Management of hepatocellular carcinoma. Hepatology. 2005; 42:1208–1236. PMID: 16250051.

15. Bruix J, Sherman M, Llovet JM, Beaugrand M, Lencioni R, Burroughs AK, et al. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol. 2001; 35:421–430. PMID: 11592607.

16. Imamura H, Seyama Y, Kokudo N, Maema A, Sugawara Y, Sano K, et al. One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg. 2003; 138:1198–1206. PMID: 14609867.

17. Capussotti L, Ferrero A, Viganò L, Muratore A, Polastri R, Bouzari H. Portal hypertension: contraindication to liver surgery? World J Surg. 2006; 30:992–999. PMID: 16736327.

18. Cucchetti A, Ercolani G, Vivarelli M, Cescon M, Ravaioli M, Ramacciato G, et al. Is portal hypertension a contraindication to hepatic resection? Ann Surg. 2009; 250:922–928. PMID: 19855258.

19. Kawano T, Sasaki A, Kai S, Endo Y, Iwaki K, Uchida H, et al. Short- and long-term outcomes after hepatic resection for hepatocellular carcinoma with concomitant esophageal varices in patients with cirrhosis. Ann Surg Oncol. 2008; 15:1670–1676. PMID: 18368453.