Background: The aim of this study was to compare the outcome of patients with hepatocellular carcinoma (HCC), Barcelona Clinic Liver Cancer (BCLC) stages 0 and A, and portal hypertension (PHT) who underwent liver resection (LR) or radiofrequency ablation (RFA). Methods: The study population consisted of 121 patients with PHT and HCC of BCLC stage 0 and A who underwent LR (n = 81) or RFA (n = 40). To reduce bias in patient selection, the different covariate distributions in two groups were adjusted using inverse probability treatment weighting (IPTW). The prognostic outcomes of LR- and RFA-treated patients were then analyzed. Results: Before IPTW adjustment, the 5-year overall survival (OS) of LR and RFA patients was comparable. Five-year recurrence-free survival (RFS) was significantly better in the LR group than in the RFA group (P < 0.0001). Multivariate analysis showed that RFA was an independent predictor of worse RFS (P = 0.0004). The local recurrence rate was higher in the RFA than in the LR group, with recurrences in each group tending to be treated with the same modality as initially. After IPTW adjustment, the OS of patients in the LR and RFA groups did not significantly differ, whereas the RFS of the LR group remained significantly better than that of the RFA group (P = 0.00014). However, the RFA group had fewer postoperative complication rates and a shortened length of hospital stay. Conclusions: By reducing postoperative complications, LR may be a treatment option for patients with BCLC stage 0 or A HCC and PHT.
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