Severity Matters: The Differential Impact of Mild versus Severe Portal Hypertension on Post-Hepatectomy Liver Failure — A Systematic Review and Meta-Analysis

Background: Post-hepatectomy liver failure (PHLF) remains the principal cause of mortality following liver resection for malignancies, particularly in the context of hepatocellular carcinoma (HCC) and cirrhosis. While portal hypertension (PH) has traditionally been viewed as a monolithic contraindication to surgery, emerging evidence suggests that the risk it confers is heterogeneous. This study investigates the hypothesis that the risk of PHLF is strictly severity-dependent. Methods: A systematic review and meta-analysis were conducted on observational studies involving patients undergoing hepatectomy for liver malignancies. Search strategies targeted studies stratifying outcomes by PH severity (mild vs. severe). Primary outcomes were the incidence of PHLF defined by ISGLS criteria. Data were synthesized using random-effects models to calculate pooled odds ratios (OR). Results: Ten studies comprising 4,978 patients were included. The overall presence of PH significantly increased PHLF risk (Pooled OR 3.12; 95% CI: 2.15–4.53; p