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Background: The presence of clinically significant portal hypertension (CSPH) remains a relative contraindication to liver resection for patients with resectable hepatocellular carcinoma (HCC). The goal of this study was to explore whether a laparoscopic approach could extend the indications for hepatectomy to patients with PH. Method: Patients who underwent laparoscopic liver resection (LLR) from February 2016 to September 2019 performed by a single medical team were included in this study. We analyzed the surgical and oncological outcomes between groups with and without CSPH before and after propensity score matching (PSM). Result: We enrolled 156 patients divided into two groups according to the presence (CSPH, n= 26) or absence (non-CSPH, n= 130) of CSPH. CSPH group was associated with more clinical signs of liver dysfunction (p< 0.05). After PSM (n= 48 patients), the CSPH group tended to have a longer postoperative hospital stay (p= 0.054); however, there was no difference in operation time (p= 0.329), blood loss volume (p= 0.392), transfusion rates (p= 0.701), rate of conversion to open surgery (p= 0.666), surgical margin (p = 0.306), surgical mortality (n= 0), or comprehensive complication index (p= 0.844) between the two groups. The median follow-up time for the entire cohort was 19.6 months (range 0.2–40.6 months). The 3-year overall survival rate was 62.9% in the CSPH group and 84.3% in the non-CSPH group (p= 0.1090), and results were similar after PSM (p= 0.5734). Conclusions: LLR is safe and feasible for HCC with PH. The introduction of minimally invasive surgery, represented by LLR, can appropriately expand the indications for hepatectomy.

Enhanced recovery after surgery (ERAS), with several evidence-based elements, has been shown to shorten length of hospital stay and reduce perioperative hospital costs in many operations. This randomized clinical trial was performed to compare complications and hospital stay of laparoscopic liver resection between ERAS and traditional care. A randomized controlled trial was performed for laparoscopic liver resection from August 2015 to August 2016. Patients were randomly divided into ERAS group and traditional care group. The primary outcome was length of hospital stay (LOS) after surgery. Second outcomes included postoperative complications, hospital cost, and 30-day readmissions. Elements used in ERAS group included more perioperative education, nurse navigators, nutrition support for liver diseases, respiratory therapy, oral carbohydrate 2 h before operation, early mobilization and oral intake, goal-directed fluid therapy, less drainages, postoperative nausea and vomiting (PONV) prophylaxis and multimodal analgesia. The study included 58 (two conversion to laparotomy) patients in ERAS group and 61 (three conversion to laparotomy) patients in the traditional care group. Postoperative LOS was significantly shorter in the ERAS group than traditional care group (5 vs. 8 days; p< 0.001). ERAS program significantly reduced the hospital costs (CNY 45413.1 vs. 55794.1; p= 0.006) and complications (36.2 vs. 55.7%; p= 0.033). Duration till first flatus and PONV were significantly reduced in ERAS group. Pain control was better in ERAS (Visual analogue scale (VAS) POD1 (≥ 4) 19.0 vs. 39.3%, p= 0.017; VAS POD1 2.5 vs. 3.1, p= 0.010). There was no difference in the rate of 30-day readmissions (6.9 vs. 8.2%; p= 1.000). ERAS protocol is feasible and safe for laparoscopic liver resection. Patients in ERAS group have less pain and complications.