Refining Surgical Strategies: Addressing Portal Hypertension in Hepatocellular Carcinoma

Portal hypertension remains an underrecognized driver of postoperative decompensation and posthepatectomy liver failure in hepatocellular carcinoma resections, challenging hepatobiliary surgeons to refine risk assessment and surgical strategies.

A multicenter series demonstrated that clinically significant portal hypertension (CSPH) increases the risk of postoperative liver decompensation and posthepatectomy liver failure, underscoring the urgency of precise preoperative planning and multidisciplinary coordination, as detailed in the Impact and outcomes of liver resection for hepatocellular carcinoma in patients with CSPH. This evidence has shifted clinical practice toward more nuanced assessment of portal pressures alongside traditional metrics of liver function.

Building on these insights, minimally invasive approaches have emerged as promising techniques supported by recent studies to mitigate risks in high-pressure portal systems.

Data from The Impact of Portal Hypertension Assessment Method on the Outcomes of Hepatocellular Carcinoma Resection reveal that laparoscopic and robotic techniques can reduce intraoperative blood loss and postoperative complications compared to open surgery, especially in patients with HVPG measurements of 10–12mmHg.

Drawing on insights from Recent Advances in the Pathogenesis and Clinical Evaluation of Portal Hypertension, clinicians now correlate HVPG thresholds and Child-Pugh classification to predict hemodynamic reserve and postoperative hepatic function—as recommended in EASL and AASLD guidelines—guiding decisions on resection extent and timing.

At one high-volume center, a 58-year-old woman with HCC and an HVPG of 12mmHg underwent a laparoscopic left lobectomy after tailored preoperative modulation through nonselective β-blockade and transjugular intrahepatic portosystemic shunt (TIPS), with endoscopic variceal ligation performed for bleeding prophylaxis.

These advances underscore a paradigm in which detailed patient stratification and refined surgical strategy converge to improve hepatic resection outcomes. Through this approach, surgeons are improving surgical outcomes for hepatocellular carcinoma by addressing portal hypertension proactively. As hepatobiliary centers integrate portal pressure assessment into routine preoperative evaluation, ongoing research is exploring noninvasive surrogates for HVPG and the role of perioperative portal modulation in further reducing postoperative morbidity.

Key Takeaways:

• Patients with CSPH have a threefold higher risk of postoperative complications (odds ratio 3.5; 95% CI 1.8–6.8) compared to those without elevated portal pressure, underscoring the need for precise planning.
• Minimally invasive surgical techniques show promise in reducing risks associated with portal hypertension.
• Effective patient stratification using HVPG and liver function scores is critical for optimized surgical outcomes.