title: Hepatic resection for hepatocellular carcinoma in patients with Child-Pugh's A cirrhosis: is clinical evidence of portal hypertension a contraindication?
abstract: BACKGROUND
  According to international guidelines [European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD)], portal hypertension (PHTN) is considered a contraindication for liver resection for hepatocellular carcinoma (HCC), and patients should be referred for other treatments. However, this statement remains controversial. The aim of this study was to elucidate surgical outcomes of minor hepatectomies in patients with PHTN (defined by the presence of esophageal varices or a platelet count of <100,000 in association with splenomegaly) and well-compensated liver disease.
  
  
  METHODS
  Between 1997 and 2012, a total of 223 cirrhotic patients [stage A according to the Barcelona Clinic Liver Cancer (BCLC) classification] were eligible for this analysis and were divided into two groups according to the presence (n = 63) or absence (n = 160) of PHTN. The demographic data were comparable in the two patient groups.
  
  
  RESULTS
  Operative mortality was not different (only one patient died in the PHTN group). However, patients with PHTN had higher liver-related morbidity (29% versus 14%; P = 0.009), without differences in hospital stay (8.8 versus 9.8 days, respectively). The PHTN group showed a worse survival rate only if biochemical signs of liver decompensation existed. Multivariate analysis identified albumin levels as an independent predictive factor for survival.
  
  
  CONCLUSIONS
  PHTN should not be considered an absolute contraindication to a hepatectomy in cirrhotic patients. Patients with PHTN have short- and long-term results similar to patients with normal portal pressure. A limited hepatic resection for early-stage tumours is an option for Child-Pugh class A5 patients with PHTN.
authors.affiliation: Chirurgia, Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, Italy. rsantambrogio@mclink.it
authors.forename: Roberto
authors.initials: R
authors.lastname: Santambrogio
authors.forename: Michael D
authors.initials: MD
authors.lastname: Kluger
authors.forename: Mara
authors.initials: M
authors.lastname: Costa
authors.forename: Andrea
authors.initials: A
authors.lastname: Belli
authors.forename: Matteo
authors.initials: M
authors.lastname: Barabino
authors.forename: Alexis
authors.initials: A
authors.lastname: Laurent
authors.forename: Enrico
authors.initials: E
authors.lastname: Opocher
authors.forename: Daniel
authors.initials: D
authors.lastname: Azoulay
authors.forename: Daniel
authors.initials: D
authors.lastname: Cherqui
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000209:etiology / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000075202:Contraindications; D005260:Female; D006498:Hepatectomy / Q000401:mortality; D006801:Humans; D006975:Hypertension, Portal / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D007558:Italy; D053208:Kaplan-Meier Estimate; D008103:Liver Cirrhosis / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D008113:Liver Neoplasms / Q000209:etiology / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D010297:Paris; D018579:Patient Selection; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome