Role of endoscopic ultrasound-guided portal pressure gradient measurement in assessing liver function before liver-directed therapies

Liver-directed therapies such as resection, ablation, and embolization offer potentially curative options for patients with primary and metastatic liver tumors as part of multidisciplinary oncology care. However, these treatments pose significant hepatic decompensation risks, particularly with underlying liver disease and chemotherapy-associated steatohepatitis. Accurate assessment of liver function and portal hypertension (PH) is critical for candidate selection. While Child-Pugh score and model for end-stage liver disease are commonly used, they have substantial limitations. Hepatic venous pressure gradient (HVPG) measurement remains the gold standard for assessing PH but is invasive and not widely available. Endoscopic ultrasound (EUS) guided portal pressure gradient (PPG) measurement has emerged as a promising minimally invasive alternative. EUS-PPG demonstrates excellent technical success rates, safety profile, and correlation with HVPG in early studies. By providing direct portal pressure measurement, EUS-PPG offers several advantages over existing methods for prognostication and risk stratification prior to liver-directed therapies, particularly in detecting presinusoidal hypertension. Furthermore, it has potential applications in assessing response to neoadjuvant treatments and guiding adjuvant therapies. However, research is needed to validate its predictive performance and cost-effectiveness in larger prospective cohorts and to establish its accuracy compared to non-invasive assessment of liver function.