A New Surgical Scheme for Determining Hepatectomy to Hepatocellular Carcinoma Patients with Clinically Significant Portal Hypertension

Objective: To establish a new surgical scheme defining risk classes of post-hepatectomy liver failure (PHLF) to facilitate the surgical decision-making and identify suitable candidates for individual hepatectomy among hepatocellular carcinoma (HCC) patients combined with clinically significant portal hypertension (CSPH). Backgrounds: Hepatectomy is the preferred treatment for HCC. Surgeons must maintain a balance between the expected oncological outcomes of HCC removal and short-term risks of severe PHLF and morbidity. CSPH aggravates liver decompensation and increases the risk of severe PHLF thus complicating hepatectomy for HCC. Methods Multivariate logistic regression and stochastic forest algorithm were performed, then the independent risk factors of severe PHLF were included in a nomogram to determine the risk of severe PHLF. Further, a conditional inference tree (CTREE) through recursive partitioning analysis validated supplement the misdiagnostic threshold of the nomogram. Results The analysis included 924 patients, of whom 721(78.0%) were without CSPH, 137(14.8%) with mild-CSPH, and 66(7.1%) with severe-CSPH. The nomogram incorporated preoperative prolonged prothrombin time (PT), total bilirubin (T-Bil), indocyanine green retention rate at 15 min (ICG-R15), CSPH grade, and standard future liver remnant (sFLR) volume, and achieved good prediction performance in the training (C index = 0.891, 95%CI: 0.855–0.920), internal validation (C index = 0.850, 95%CI: 0.786–0.901), and external validation (C index = 0.872, 95%CI: 0.835–0.904) cohorts, with well-fitted calibration curves. Calculations of total points of diagnostic errors with 95%CI were concentrated in 110.5(range 76.9-178.5). It showed a low risk of severe PHLF (2.3%), indicating hepatectomy is feasible when the points fall below 76.9, while the risk of severe PHLF is extremely high (93.8%) and hepatectomy should be rigorously restricted at scores over 178.5. Patients with points within the misdiagnosis threshold were further examined using CTREE according to a hierarchic order of factors represented by the presence of CSPH grade, ICG-R15, and sFLR. Conclusion This new surgical scheme is practical to stratify risk classes in severe PHLF, thereby facilitating surgical decision-making and identifying suitable candidates for individual hepatectomy.