Hepatocellular carcinoma in a patient with alcohol-related chronic liver disease with major portosystemic shunt successfully treated with shunt ligation and hepatic resection.

A 72-year-old male with a history of heavy alcohol consumption was referred for evaluation and treatment of hepatic lesions. Imaging examinations revealed two masses in liver segments III and VIII, consistent with hepatocellular carcinoma (HCC). Despite normal liver enzyme and tumor marker levels, fasting serum bile acid was markedly elevated (89.7 µmol/L). Contrast-enhanced computed tomography (CT) identified a major portosystemic shunt (PSS) between the left gastric and renal veins. Although the indocyanine green (ICG) retention rate at 15 min was elevated at 51.4%, we attributed the abnormal ICG result to the large PSS rather than cirrhosis. Therefore, partial hepatectomy with shunt ligation was planned. Intraoperative portal pressure remained below 20 cmH₂O both before and after shunt clamping. The patient underwent successful resection and shunt ligation. Postoperatively, liver function normalized, bile acid levels decreased, and ICG retention improved to 12.1%. The patient recovered uneventfully, and follow-up CT at four months showed no recurrence and disappearance of the shunt. This case highlights the importance of intraoperative portal pressure monitoring and functional assessment in patients with major PSS. Shunt ligation can improve hepatic functional reserve and prevent complications such as hepatic encephalopathy. The decision-making process for such cases should integrate preoperative functional assessments with intraoperative hemodynamic findings.