Accurate preoperative evaluation of PH with HVWP and reduction of PH by PSE were effective in controlling portal vein pressure in an older patient who needed major hepatic resection after achieving SVR. In recent years, SVR for chronic HCV infection and compensated liver cirrhosis has been achieved in many cases due to the widespread use of antiviral therapy using DAAs [5]. SVR with DAAs is expected to improve liver function and prevent the development of PH, with improvement in liver fibrosis and liver function [4, 6]. However, despite achieving SVR, liver function and PH do not improve and may even worsen in patients with pronounced PH [7, 8]. Chronic viral hepatitis has been reported as a risk factor for intrahepatic cholangiocarcinoma, for which surgical resection is the optimal curative treatment [9]. However, large hepatic resection or anticancer chemotherapy for patients with cirrhosis is associated with a high risk of liver failure [10].

Hepatic resection for patients with PH is not indicated in Europe and the United States, but the safety of partial resection has been reported in Japan [3]. In addition, appropriate management of PH, such as endoscopic treatment of esophageal and gastric varices, Hassab’s procedure, and preoperative treatment for splenomegaly by splenectomy, or PSE, allows safe liver resection [11,12,13]. Preoperative endoscopic treatments for varices and Hassab’s procedure could prevent the postoperative rupture of uncontrolled varices. Furthermore, splenectomy and PSE for PH before hepatectomy are effective for portal pressure control. Although splenectomy reduces PH, portal vein thrombosis caused by hypercoagulable status and overwhelming post-splenectomy infection (OPSI) are risks associated with splenectomy [14]. Compared with splenectomy, PSE reduces the risk of OPSI due to the partial preservation of splenic function and reduces the risk of intraoperative bleeding. However, for patients with PH, despite improvement of liver function after achieving SVR, the significance of splenectomy or PSE before hepatectomy for control of PH is unclear [15]. We found that if the functional hepatocyte volume is sufficient, the appropriate HVWP after hepatectomy should be < 15 mmHg, which seems to be a marker for complications associated with portal hypertension. A recent report on living donor liver transplantation revealed that PVP should be < 15 mmHg to prevent post-surgical massive ascites or hyperbilirubinemia [16]. In our case, we simulated the increase in PVP after left hepatectomy as 16 mmHg by left PVE and compensated down to 12 mmHg by PSE to prevent post-surgical portal hypertension.

Although the diagnosis of PH is mainly based on the imaging evaluation of collateral circulation, a discrepancy between liver function and PH grades has been found in some patients who achieved SVR after treatment with DAAs for liver cirrhosis caused by HCV infection. Therefore, an accurate assessment of liver function and portal pressure is important before hepatectomy in patients at a high risk of postoperative liver failure. In patients with cirrhosis, the HVWP is an accurate reflection of portal pressure. In this case, the FLR volume was relatively sufficient (49%), and the patient had a mildly decreased liver reserve, suggesting PH with dilation of the paraumbilical vein, splenomegaly, elevation of liver fibrosis markers, and a decrease in platelet count. We assessed the HVWP, which was mildly elevated, and the patient was diagnosed with PH. To ensure safety while performing major hepatectomy with PH in an older patient with impaired liver function, we performed PSE and PTPE. Conventionally, PTPE is performed in patients with an inadequate FLR volume after right lobectomy. However, in patients with cirrhosis, PTPE is thought to be effective in enlarging the remaining liver volume to avoid the risk of postoperative liver failure. Furthermore, laparoscopic hepatectomy in patients with PH is associated with a lower risk of liver failure and faster recovery than open hepatectomy [17]. Therefore, a laparoscopic hepatectomy was performed. We believe that laparoscopic hepatectomy may become a standard procedure for older patients with PH in the future.

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