Value of hepatic venous pressure gradient measurement before liver resection for hepatocellular carcinoma

  • Author: S. Stremitzer, D. Tamandl, K. Kaczirek, J. Maresch, B. Abbasov, B. A. Payer, A. Ferlitsch, T. Gruenberger

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Sir

We read with great interest the report by Stremitzer and colleagues1 but disagree with them in their conclusion that hepatic venous pressure gradient (HVPG) predicts postoperative complications in patients with hepatocellular carcinoma (HCC), because not only the liver function, but also the extent of resection can affect the risk of postoperative liver dysfunction.
The morbidity and mortality have not improved significantly even after the introduction of preoperative HVPG measurement, and still remain rather high (59% and 3%, respectively).  Then, the authors did not clarify the number and background characteristics of the patients with HVPG values > 11mmHg, in whom liver resection was contraindicated. Our concern is that even such patients with high HVPG values may still have the chance to undergo curative surgical treatments for HCC depending on the tumour size and location.
The major limitation of HVPG as a preoperative liver function parameter is that it does not allow the acceptable range of liver resection to be estimated, in contrast to the indocyanine green retention rate at 15 minutes (ICGR15) 2. In our previous series3, the ICGR15 in 136 patients with clinical portal hypertension4 ranged widely from 5×0% to 48×0% (median, 20×0%), and anatomic resection was performed in 39% of them, which led to favourable overall survival after resection for HCC (56% at 5 years) even in the presence of portal hypertension. Preoperative HVPG measurement cannot be helpful for determining the surgical indication in a patient, unless it can predict the risk of postoperative liver dysfunction according to the extent of liver resection.
 Takeaki Ishizawa, MD, PhD; Kiyoshi Hasegawa, MD, PhD; Norihiro Kokudo, MD, PhD
Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo
Tish-tky@umin.ac.jp
References
1. Stremitzer S, Tamandl D, Kaczirek K, et al. Value of hepatic venous pressure gradient measurement before liver resection for hepatocellular carcinoma. Br J Surg 2011; 98: 1752-1758.
2. Makuuchi M, Kosuge T, Takayama T, et al. Surgery for small liver cancers. Semin Surg Oncol 1993;9:298-304.
3. Llovet JM, Brú C, Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis 1999;19:329-338.
4. Ishizawa T, Hasegawa K, Aoki T, et al. Neither multiple tumors nor portal hypertension are surgical contraindications for hepatocellular carcinoma. Gastroenterology 2008;134:1908-1916.

  • Commentor: Takeaki Ishizawa, Kiyoshi Hasegawa, and Norihiro Kokudo - Hepato-Biliary-Pancreatic Surgery Division, Department of Su
  • Date: Jan 12, 2012