Impact of clinically significant portal hypertension on posthepatectomy liver failure: A systematic review and meta-analysis

Abstract

BACKGROUND

The health challenges of partial hepatectomy in patients with clinically significant portal hypertension (CSPH) have been a subject of study for decades. No meta-analysis has systematically evaluated the relationship between CSPH and posthepatectomy liver failure (PHLF), despite its potential role as a critical factor in surgical decision-making. This systematic review and meta-analysis investigated the incidence of PHLF in patients with and without CSPH.

AIM

To include more recent studies and focus on short-term postoperative outcomes, particularly the association between CSPH and PHLF. Additionally, stratified analyses were also performed according to CSPH and PHLF assessment methods, study design, study period, surgical technique, and underlying liver diseases.

METHODS

A comprehensive literature search was conducted in EMBASE, PubMed, MEDLINE, ScienceDirect, Elsevier, and Cochrane databases using combinations of the following terms: (“portal hypertension” OR “hypertension, portal” OR “portal hypertensions”) AND (“hepatectomy” OR “hepatectomies” OR “liver resection”) AND (“liver failure” OR “hepatic failure” OR “liver decompensation”). Studies published from January 1996 to April 2025, 21 published studies were finally included in the systematic review and meta-analysis. The quality assessment was performed independently by using the Newcastle-Ottawa Scale. Odds ratios (OR) and 95% confidence intervals (CI) were calculated and compared using a random-effects model. Heterogeneity was assessed with the χ² test, and the degree of inconsistency was measured using I². A P value < 0.05 or I² > 50% indicated substantial heterogeneity. Sensitivity analysis was conducted to test the robustness of the findings and to identify potential sources of bias.

RESULTS

A total of 6981 patients (1453 patients with CSPH and 5529 patients without CSPH) were finally included in this study. Compared with patients without CSPH, the incidences of PHLF increased in patients with CSPH (OR = 3.14; 95%CI: 2.45-4.02; P < 0.001). Subsequent subgroup analysis suggested that the diagnostic methods for CSPH is a potential interfering factor in PHLF, the OR was maximal in hepatic venous pressure gradient measurement groups (OR = 15.61; 95%CI: 2.11-115.35; P = 0.007).

CONCLUSION

The presence of CSPH should be considered as a significant risk factor, it still should be taken into account seriously prior to surgery and needs strict perioperative management. Meanwhile, different methods of diagnosing CSPH could influence PHLF.

Key Words: Clinically significant portal hypertension; Posthepatectomy liver failure; Partial hepatectomy; Systematic review; Meta-analysis

Core Tip: The health challenges of partial hepatectomy in patients with clinically significant portal hypertension (CSPH) have been a subject of study for decades. There was no meta-analysis has systematically examined the relationship between CSPH and posthepatectomy liver failure (PHLF), despite its potential role as a critical factor in surgical decision-making. This systematic review and meta-analysis assessed PHLF in patients with and without CSPH and showed the presence of CSPH should be considered as a significant risk factor and should be taken into account seriously prior to surgery and needs strict perioperative management. Meanwhile, different methods of diagnosing CSPH could influence PHLF.

INTRODUCTION

Recent advancements in liver surgery techniques[1-3] and the introduction of novel medications[4] have significantly improved the prognosis for patients with liver diseases, such as cirrhosis and liver tumors, including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Partial hepatectomy remains the primary curative treatment for patients with liver masses[5,6], yet a substantial proportion of patients present with clinically significant portal hypertension (CSPH).

In 1996, Bruix et al[7] reported that elevated portal pressure increases the risk of posthepatectomy liver failure (PHLF) following HCC resection, suggesting that surgery should be restricted to patients without CSPH. This viewpoint has sparked ongoing debate about the feasibility of partial hepatectomy in patients with CSPH, persisting for over three decades. According to the latest Barcelona Clinic Liver Cancer staging system, while a history of CSPH may not strongly predict prognosis in liver cancer patients, it remains an important factor in treatment planning[8]. For these patients, liver transplantation is recommended as a curative option; however, donor shortages significantly limit its availability[9,10]. Despite these concerns, many surgeons have reported favorable outcomes from liver resections performed in CSPH patients, often attributing success to minimally invasive techniques[11] and improved perioperative management strategies[12-15]. Consequently, the optimal strategy for managing liver resection in CSPH patients remains unclear.

In clinical practice, a small yet significant number of patients experience irreversible liver failure after hepatic resection, which remains a major contributor to perioperative mortality. Although some meta-analyses have investigated the impact of CSPH on partial hepatectomy outcomes, these studies were limited in scope and outdated[16,17]. Furthermore, no meta-analysis has systematically examined the relationship between CSPH and PHLF, despite its potential role as a critical factor in surgical decision-making. Therefore, this meta-analysis aims to include more recent studies and focus on short-term outcomes, particularly the association between CSPH and PHLF. Additionally, we conducted stratified analyses based on CSPH and PHLF assessment methods, study design, study period, surgical techniques, and underlying liver diseases.

MATERIALS AND METHODS

Search strategy

A systematic search in EMBASE, PubMed, MEDLINE, ScienceDirect, Elsevier, and Cochrane databases was performed with different combinations of the following keywords: (“portal hypertension” OR “hypertension, portal” OR “portal hypertensions”) AND (“hepatectomy” OR “Hepatectomies” OR “liver resection”) AND (“liver failure” OR “hepatic failure” OR “liver decompensation”) for studies that were published from January 1996 to April 2025. In addition, in-press or pre-reviewed studies, as well as the references of all included studies, were searched individually. The titles and abstracts of these studies were evaluated independently by two investigators for the initial screening of our study. The articles were then reviewed to eliminate repeated data. Two independent investigators then subsequently reviewed full-text articles and quality assessment, and a third investigator was available to adjudicate the case of disagreement arising between the two investigators. Figure 1 summarizes the process of study identification, inclusion, and exclusion according to PRISMA guidelines.

Figure 1 PRISMA flowchart showing study identification and selection process.

Study selection

Both prospective and retrospective studies were included in our research only if they were fully published in order to ensure the quality of our meta-analysis. Qualitative analysis would perform only if the studies met all the following criteria: (1) They were published in English language with full text accessible; (2) Involving patients who underwent partial hepatectomy; (3) The absence or presence of CSPH in patients was clearly stated; and (4) They reported PHLF classified by the presence or absence of CSPH. Studies that did not meet the above-mentioned criteria were excluded including case reports and reviews.

Data extraction

The following data were extracted from the included studies: (1) Study characteristics, including authors, year of publication, study period, geographical region where the study was conducted, and the study population; (2) Patient characteristics, including Child-Pugh class distribution, disease types, types of surgical procedures, number of patients undergoing major liver resection, number of patients with or without CSPH, and number of patients with or without PHLF (primary outcomes); (3) Definitions and methods, including criteria used to define CSPH and PHLF, independent predictors of PHLF reported by the studies, and potential sources of heterogeneity; and (4) Study design and quality, including whether the study was retrospective or prospective, and details of quality assessment.

Quality assessment

The quality assessment was performed independently by using the Newcastle-Ottawa Scale, two study investigators[16] evaluated the validity and quality across three domains: Selection of population (adequate definition of cases, representativeness of cases, selection of controls and representativeness of controls), intra-group comparability (control for important factor) and outcome (assessment of outcome, sufficiency of length of follow-up and controls and no response rate). The studies were graded as 0 or 1 point in the column of selection and outcome, while the column of comparability was graded by 0, 1, or two points. The final score for each study was calculated, and studies with a score greater than 7 were considered high quality.

Outcomes

This study focuses on the short-term prognosis following surgery, particularly PHLF. Stratified meta-analyses were performed based on various factors, including different diagnostic methods for CSPH, definitions of PHLF, geographical regions, study designs, patient diseases, study periods, and types of surgery.

Statistical analysis

The data from the 21 included studies were statistically analyzed using StataSE 15 (64-bit). Odds ratios (OR) and 95% confidence intervals (CI) were calculated and compared using a random-effects model. Heterogeneity was assessed with the χ² test, and the degree of inconsistency was measured using I². A P value < 0.05 or I² > 50% indicated substantial heterogeneity. Additionally, sensitivity analysis was performed to assess the robustness of the primary results and explore potential sources of bias in the included studies.

RESULTS

Literature search

Figure 1 shows the complete process of the selection of studies. Following the removal of duplicates, 2443 records were identified through preliminary searches of the mentioned databases and other sources. After initial review of the study abstracts, 2388 articles were excluded. The full texts of the remaining 55 articles were downloaded and re-evaluated. Of these, 34 were excluded because of the irrelevant aim as our systematic review. Further, of the remaining, 21 were further excluded because of the different focus on surgical outcomes, or because the surgical methods were not what was expected (n = 7, such as splenectomy, chemoembolization, or radiofrequency ablation), or because they used special medicines which could interfere with the prognosis (n = 2), the rest were reviews (n = 3) and a surgical case report (n = 1). The remaining 21 studies were eventually included in the analysis consisting of total 6981 patients.

Characteristics of included studies

Of the 21 studies, four of them were prospective[7,18-20] and the remaining[12,13,15,21-34] were retrospective. The included studies’ geographical distribution covered China (n = 8), Italy (n = 3), Japan (n = 3), France (n = 2), Korea (n = 2), and the same number of Spain, Egypt and Taiwan (n = 1). Overall, 6981 patients (1452 with CSPH and 5529 without CSPH) were included in the PHLF analysis. Among those with CSPH, 276 (19.0%) had undergone PHLF while those without CSPH, 481 (8.7%) had undergone PHLF.

The diagnostic and evaluation approaches of CSPH in these studies were different. CSPH was evaluated by the gold-standard method [hepatic venous pressure gradient (HVPG) measurement, HVPG ≥ 10 mmHg] in 2 studies[7,19]; by direct measurement of portal venous pressure (PVP, PVP ≥ 20 cmH₂O) in 2 studies[20,25]; and by standard surrogate criteria (oesophageal varices detected by endoscopy or a platelet count < 100 × 10⁹/L with spleen diameter > 12 cm) in all the remaining 14 studies[12,13,15,18,21,23,24,26-30,32,34]. Concerning the definition of PHLF, 10 studies used International Study Group of Liver Surgery definition[12,18-20,23,26,28,31-33] while 3 studies used the 50-50 criteria[27,29,34], two studies defined PHLF as the presence of at least one sign of hepatic decompensation (jaundice, ascites, or encephalopathy) within three months after surgery[7,22], and there was no specific definition written in the remaining studies (Table 1). The characteristics of the rate of liver resection, PHLF, and the duration of the postoperative hospital stay (days) in the included studies was summarized in Table 2.

Table 1 Main characteristics of studies included in this systematic review.

Ref.	Included population	Proportion of Child A (%)	Study design	Geographical area	Period of inclusion	Assessment of CSPH1	Definition of liver failure2
[31]	1461	NR	Retrospective	Asia (China)	November 2009-November 2014	NR	ISGLS
[33]	1025	90.6	Retrospective	Asia (Japan)	October 2002-July 2014	Standard surrogate criteria	ISGLS
[21]	217	82.0	Retrospective	Europe (Italy)	January 1985-December 2003	Standard surrogate criteria	NR
[24]	100	100.0	Retrospective	Asia (Korea)	January 1996-August 2006	Standard surrogate criteria	NR
[32]	185	95.1	Retrospective	Asia (China)	April 2015-June 2016	Standard surrogate criteria	ISGLS
[26]	209	97.6	Retrospective	Asia (China)	January 2003-December 2008	Standard surrogate criteria	ISGLS
[25]	177	94.6	Retrospective	Asia (Japan)	January 1997-December 2009	PVP	Other 1
[28]	152	92.1	Retrospective	Asia (Korea)	January 2001-December 2010	Standard surrogate criteria	ISGLS
[23]	241	94.6	Retrospective	Europe (Italy)	January 1997-March 2007	Standard surrogate criteria	ISGLS
[29]	672	100.0	Retrospective	Asia (China)	January 2009-December 2013	Standard surrogate criteria	50-50 criteria
[12]	355	93.8	Retrospective	Asia (China)	2010-2014	Standard surrogate criteria	ISGLS
[27]	125	96.8	Retrospective	Asia (China)	May 2001-December 2008	Standard surrogate criteria	50-50 criteria
[34]	352	91.2	Retrospective	Asia (China)	September 2005-December 2015	Standard surrogate criteria	50-50 criteria
[30]	892	82.3	Retrospective	Asia (Japan)	2001-2015	Standard surrogate criteria	NR
[7]	29	100.0	Prospective	Europe (Spain)	May 1991-June 1994	HVPG	Other 2
[22]	40	77.5	Retrospective	Asia (Taiwan)	January 1995-June 2003	NR	Other 3
[15]	96	98.0	Retrospective	Europe (France, Spain)	April 1, 2011-March 31, 2018	Standard surrogate criteria	NR
[13]	170	NR	Retrospective	Africa (Egypt)	January 2011-July 2015	Standard surrogate criteria	NR
[18]	223	100.0	Prospective	Europe (France, Italy)	February 1997-May 2012	Standard surrogate criteria	ISGLS
[19]	70	100.0	Prospective	Europe (Italy)	October 2009-November 2014	HVPG	ISGLS
[20]	190	100.0	Prospective	Asia (China)	April 2009-May 2011	PVP	ISGLS

¹Hepatic venous pressure gradient ≥ 10 mmHg; portal venous pressure ≥ 20 cmH₂O; standard surrogate criteria: Presence of gastroesophageal varices or platelet count < 100000/mL and spleen diameter > 12 cm.

²International Study Group of Liver Surgery: An increased international normalized ratio of prothrombin time and concomitant hyperbilirubinemia on or after postoperative day 5; 50-50 criteria: Prothrombin time less than 50% and serum total bilirubin > 50 μmol/L on postoperative day 5; other 1: Liver failure was defined by hyperbilirubinaemia, severe ascites, lower prothrombin time and raised sustained levels in liver function tests after hepatectomy; other 2: Liver failure was defined by the presence of at least one sign of hepatic decompensation (jaundice, ascites, or encephalopathy) 3 months after surgery; other 3: Posthepatectomy hepatic failure was defined as when a patient died of unresolved hepatic decompensation within 3 months, without tumour recurrence.

NR: Not reported; PVP: Portal venous pressure; HVPG: Hepatic venous pressure gradient; ISGLS: International Study Group of Liver Surgery.

Table 2 Characteristics of surgical intervention, operative, and perioperative outcomes in the included studies.

Ref.	Number	PHLF, %		Hospital stay, day		Type of resection (> 2 segments, %)
		CSPH	Without CSPH	CSPH	Without CSPH	CSPH	Without CSPH
[31]	1461	40.00	15.10	NR	NR	NR	NR
[33]	1025	8.70	2.40	NR	NR	NR	NR
[21]	217	14.10	7.60	NR	NR	16.70	33.90
[24]	100	8.50	1.90	NR	NR	NR	NR
[32]	185	35.30	10.10	NR	NR	NR	NR
[26]	209	37.30	17.80	12.9 ± 3.9	12.1 ± 5.3	NR	NR
[25]	177	14.60	1.60	NR	NR	NR	NR
[28]	152	43.20	35.20	NR	NR	NR	NR
[23]	241	11.20	3.90	NR	NR	2.20	6.60
[29]	672	19.00	7.50	NR	NR	NR	NR
[12]	355	14.80	4.10	14 (10-19)	11 (9-14)	9.80	22.40
[27]	125	15.50	9.00	NR	NR	NR	NR
[34]	352	7.50	4.90	NR	NR	NR	NR
[30]	892	0.50	0.40	13 (7-190)	12 (4-93)	4.60	14.20
[7]	29	73.30	0.00	NR	NR	NR	NR
[22]	40	62.50	9.40	NR	NR	NR	NR
[15]	96	9.40	0.00	6 (4-8)	4 (3-5)	3.20	6.20
[13]	170	28.60	15.20	12 ± 10	9 ± 5	40.70	38.00
[18]	223	28.60	13.80	NR	NR	17.50	31.30
[19]	70	50.00	11.10	9 (5-23)	8 (5-55)	20.60	50.00
[20]	190	59.00	24.00	NR	NR	52.50	29.50

NR: Not reported; PHLF: Posthepatectomy liver failure; CSPH: Clinically significant portal hypertension.

Quality of the included studies

From the Newcastle-Ottawa Scale evaluation, the overall quality assessment results of included studies present as obtained (Supplementary Table 1). Seventeen studies were recognized of having high quality[7,12,13,15,18,19,21-26,28,29,32-34].

Outcomes

Based on the 21 studies we included, ten of them showed that PHLF and poor prognosis following hepatectomy was significantly associated with the presence of CSPH[7,19,20,22,24,25,29,32-34]. However, six studies pointed out that there is no impact on the postoperative prognosis of the presence of CSPH[18,21,23,26,28,30], and should not be regarded as a contraindication for hepatectomy. Three studies revealed that patients with CSPH would significantly increase PHLF, postoperative complications with a decreasing long-term survival, but surgery could be carefully selected due to the improvement in surgical technique and perioperative management[12,13,15]. The remaining two studies did not indicate the relations among these aspects clearly[27,31].

Impact on PHLF

The meta-analysis of 21 studies revealed that the presence of CSPH increased the risk of PHLF after hepatectomy (OR = 3.14, 95%CI: 2.45-4.02; P < 0.001; Figure 2A). The PHLF rate was 19.0% (276/1453) in patients with CSPH and 8.7% (481/5529) in patients without CSPH. In this analysis, there was also nonsignificant heterogeneity (P = 0.151; I² = 24.4%). Funnel plots and sensitivity analysis showed little effect from each individual study (Supplementary Figure 1).

Figure 2 Impact of clinically significant portal hypertension on postoperative outcomes of patients in the included studies. A: Posthepatectomy liver failure (PHLF); B: PHLF in Child-Pugh A stage patients; C: Stratified meta-analysis of PHLF (the diagnostic methods used for clinically significant portal hypertension). CSPH: Clinically significant portal hypertension; CI: Confidence interval.

When the objects were only restricted to Child A patients, the meta-analysis of 6 studies[7,18-20,24,29] revealed the same result as documented above (OR= 4.06, 95%CI: 2.45-6.72; P < 0.001; Figure 2B) with nonsignificant heterogeneity (P = 0.210; I² = 30.1%). Little effect from each individual study was also showed by funnel plots and sensitivity analysis on the total effect (Supplementary Figure 2). Moreover, the time of perioperative hospital stay was longer in patients with CSPH compared with patients without CSPH (OR = 0.45, 95%CI: 0.34-0.56; P < 0.001; I² = 97.4%; Supplementary Figure 3)[12,13,15,19,26,30].

Impact on PHLF stratified by the different diagnostic criteria of CSPH

The subsequent stratified meta-analysis of 18 studies[7,12,13,15,18-21,23-30,32,34] specifically on the diagnostic method of CSPH showed that heterogeneity was largely influenced by the methods (P = 0.019; Figure 2C). When only using standard surrogate criteria (oesophageal varices detected by endoscopy or a platelet count < 100 × 10⁹/L with spleen diameter > 12 cm) for CSPH in 14 studies[12,13,15,18,21,23,24,26-30,32,34] were analyzed CSPH can still increase the risk of PHLF after surgery (OR = 2.44, 95%CI: 1.90-3.12; P < 0.001; Figure 2C). Notably, a lower postoperative risk which may associated with preoperative CSPH were estimated in these studies, as compared to the invasive measurement of CSPH. The OR was maximal in HVPG measurement groups (OR = 15.61, 95%CI: 2.11-115.35; P = 0.007)[7,19], followed by PVP measurement groups (OR = 5.14, 95%CI: 2.81-9.40; P < 0.001)[20,25]. The moderate, nonsignificant heterogeneity was observed in the studies’ subgroups (P = 0.173; I² = 23.8%). Similarly, the meta-regression of these studies also demonstrated a statistically significant influence of CSHP diagnosis on PHLF (P = 0.017, Supplementary Figure 4).

Impact on PHLF stratified by other factors

Further stratified meta-analysis according to the time period when the studies were conducted (9 earlier studies[7,21-28] and 12 recent studies[12,13,15,18-20,29-34]) showed stable results (OR = 3.14; 95%CI: 2.45-4.02; P < 0.001; I² = 24.4%) and no heterogeneity among groups (P = 0.842; Supplementary Figure 5). A subsequent stratified meta-analysis based on the proportion of patients from different geographical areas (Asia, Europe, and Africa; P = 0.583; Supplementary Figure 6) was also done. Stratified meta-analysis based on the different definitions of PHLF (International Study Group of Liver Surgery or 50-50 criteria; P = 0.168; Supplementary Figure 7) and operation types (open hepatectomy and laparoscopic hepatectomy; P = 0.357; Supplementary Figure 8) also revealed stable results with no heterogeneity among subgroups included in the studies. Finally, stable results were observed among groups of patients with diseases (HCC, ICC and other diseases; P = 0.323; Supplementary Figure 9) and study design (retrospective or prospective; P = 0.186; Supplementary Figure 10) with no statistically significant differences.

DISCUSSION

Our systematic review and meta-analysis of 21 studies indicate that patients with CSPH have a poorer prognosis following partial hepatectomy. Comparison of patients with and without CSPH revealed that CSPH significantly increases the incidence of PHLF, with the presence of CSPH associated with approximately three times higher odds of developing PHLF. This negative impact was also observed in patients with Child-Pugh A stage, further supporting these findings.

A subgroup meta-analysis indicated that the diagnostic methods used to identify CSPH could influence PHLF outcomes. Currently, three primary diagnostic techniques are employed: HVPG measurement, PVP measurement, and non-invasive surrogate criteria. HVPG is widely considered the gold standard, while PVP serves as an alternative[35]. However, both methods are limited in clinical application due to their high cost, invasive nature and certain possible complications like bleeding, soft tissue hematoma, nerve injury, or arrhythmia[36]. Non-invasive surrogate criteria, introduced in 1999[37], include the presence of esophageal varices detected by endoscopy or a platelet count < 100 × 10⁹/L combined with a spleen diameter > 12 cm. These criteria are commonly used due to their feasibility and cost-effectiveness.

Stratified meta-analysis based on diagnostic method revealed that patients diagnosed with CSPH using HVPG had the highest odds of developing PHLF, approximately 16 times greater than those without CSPH. In contrast, the odds were about five times higher for patients diagnosed with PVP measurement and roughly 2.5 times higher for those diagnosed using non-invasive surrogate criteria. However, the extremely wide CI in Bruix’s study suggests that a larger sample size in the HVPG group is needed to ensure statistical stability. Previous studies have also shown that HVPG-diagnosed CSPH predicts poorer survival compared to diagnoses based on surrogate criteria[17]. While HVPG offers superior diagnostic precision, patients diagnosed with CSPH via surrogate criteria may still be suitable candidates for surgery, as reflected in the relatively lower PHLF risk observed in this group. These findings highlight the need for improved non-invasive diagnostic methods to guide clinical decision-making. Few studies have explored such approaches[38,39], but a novel digital prediction model for portal hypertension risk assessment, proposed by Golse et al[40], offers promising potential for future research.

Further stratified analysis based on liver failure assessment criteria, different study designs or patient disease types showed no statistically significant differences between subgroups. The consistency observed across studies of varying quality and design supports the robustness of our findings. Notably, for patients with ICC, CSPH may not significantly influence PHLF risk. Given the limited number of studies in ICC, this observation warrants validation in larger, more rigorously designed cohorts.

Some studies suggest that intentionally regulating PVP via splenectomy may benefit CSPH patients undergoing major hepatectomy[41-43]. Pharmacological interventions also show promise[44,45], and radiofrequency ablation has been proposed as a first-line treatment for solitary HCC (≤ 3 cm in diameter)[46]. Additionally, a novel portal vein banding device designed to control portal venous flow has shown potential for preventing postoperative liver failure[47]. Despite these advances, our stratified meta-analysis based on study periods indicated minimal changes in PHLF outcomes over time, suggesting that further clinical advancements are still needed.

Our subgroup analysis revealed a trend towards improved outcomes and reduced risk in CSPH patients undergoing laparoscopic hepatectomy. However, this subgroup analysis was limited to only three studies. However, an increasing body of evidence supports the potential advantages of laparoscopic approaches in this population[48-51]. Regarding postoperative outcomes, we found that patients with CSPH had longer hospital stays, likely due to poorer baseline status and complications such as PHLF. Meanwhile, the substantial heterogeneity suggests instability of the results suggests that international differences may influence these findings in discharge policies, perioperative management strategies, or healthcare system practices.

Despite these insights, our systematic review and meta-analysis has limitations. As most of the included studies were retrospective observational research, controlling for confounding variables was challenging. Significant heterogeneity was observed in some meta-analysis groups, which may be attributed to geographic differences, variations in surgical techniques, or differing diagnostic methods. Furthermore, comorbidities such as chronic obstructive pulmonary disease and diabetes, which may influence PHLF, were not consistently reported across the studies. The prevalence of postoperative complications is also closely linked to factors like liver remnant volume[52], underscoring the importance of rigorous patient selection and meticulous postoperative management to optimize clinical outcomes.

CONCLUSION

In conclusion, our systematic review and meta-analysis demonstrates that CSPH patients are at a higher risk of PHLF following partial hepatectomy. For individuals requiring surgical intervention, HVPG measurement, despite its invasiveness, remains the most reliable assessment and is strongly associated with PHLF risk and poor prognosis. CSPH should be considered as a significant risk factor and carefully evaluated before surgery, with stringent perioperative management essential to improving patient outcomes.