Splenectomy before hepatectomy for patients with hepatocellular carcinoma and hypersplenism: A retrospective study.

ABSTRACT: The spleen plays an important role in tumor progression and the curative effects of splenectomy before hepatectomy for hypersplenism and hepatocellular carcinoma (HCC) are not clear. We investigated whether splenectomy before hepatectomy increases survival rate among patients with HCC and hypersplenism compared with that of patients who underwent synchronous hepatectomy and splenectomy or hepatectomy alone.Between January 2011 and December 2016, 266 patients who underwent hepatectomy as a result of HCC and portal hypertension secondary to hepatitis were retrospectively analyzed. Their perioperative complications and survival outcome were evaluated.Patients underwent synchronous hepatectomy and splenectomy (H-S group) and underwent splenectomy before hepatectomy (H-preS group) exhibited significantly higher disease-free survival (DFS) rates than those of patients underwent hepatectomy alone (H-O group). The DFS rates for patients in the H-S group, H-preS group, and H-O group were 74.6%, 48.4%, 39.8%, and 80.1%, 54.2%, 40.1%, and 60.5%, 30.3%, 13.3%, at 1, 3, and 5 years after surgery, respectively. Tumor size, tumors number, and levels of alpha fetoprotein (AFP) were independent risk factors for DFS. Gender and tumor size were independent prognostic factor for overall survival (OS). The preoperative white blood cell (WBC) and platelet (PLT) counts were significantly higher in the H-preS group than in those of the H-S group and the H-O group. After operation, the WBC and PLT counts in the H-S group and H-preS groups were significantly higher compared to those of the H-O group.No matter splenectomy before hepatectomy or synchronous hepatectomy and splenectomy, hepatectomy with splenectomy may improve DFS rates in patients with HCC and hypersplenism, and splenectomy before hepatectomy alleviates hypersplenism without an increased surgical risk.

Splenectomy during whole liver transplantation: a morbid procedure which does not adversely impact long-term survival.

BACKGROUND: Indications for splenectomy (SP) during whole liver transplantation (LT) remain controversial and SP is often avoided because of common complications. We aimed to evaluate specific complications of these combined procedures. METHODS: Data were retrospectively analysed. Splenectomy was performed in patients with splenorenal shunt and/or splenic artery aneurysms or hypersplenism. Patients undergoing simultaneous transplantation and splenectomy (LTSP group) were matched to a non-splenectomy group (LT group). RESULTS: Between 1994 and 2013, we included 47 and 94 patients in LTSP and LT groups, respectively. The LTSP patients had a higher rate of pre-LT portal vein thrombosis (PVT). The LTSP group had a longer operative time and greater blood loss. Mean follow-up was 101 months and 5-year survivals were identical (LTSP 85% vs LT 88%, p = 0.831). Hospital morbidity and rejection incidence were comparable, whereas de novo PVT (34% vs 2%, p < 0.0001) and infection (47% vs 25%, p = 0.014) rates were higher after SP. CONCLUSION: Splenectomy during LT is technically demanding and exposes recipients to a higher thrombosis rate, therefore portal vein patency must be specifically assessed postoperatively. In selected recipients, SP can be performed without increased mortality but at the price of worsening outcome as evidenced by greater risk of infection and PVT.

Synchronous splenectomy and hepatectomy for patients with hepatocellular carcinoma and hypersplenism: A case-control study.

AIM: To investigate whether the use of synchronous hepatectomy and splenectomy (HS) is more effective than hepatectomy alone (HA) for patients with hepatocellular carcinoma (HCC) and hypersplenism. METHODS: From January 2007 to March 2013, 84 consecutive patients with HCC and hypersplenism who underwent synchronous hepatectomy and splenectomy in our center were compared with 84 well-matched patients from a pool of 268 patients who underwent hepatectomy alone. The short-term and long-term outcomes of the two groups were analyzed and compared. RESULTS: The mean time to recurrence was 21.11±12.04 mo in the HS group and 11.23±8.73 mo in the HA group, and these values were significantly different (P=0.001). The 1-, 3-, 5-, and 7-year disease-free survival rates for the patients in the HS group and the HA group were 86.7%, 70.9%, 52.7%, and 45.9% and 88.1%, 59.4%, 43.3%, and 39.5%, respectively (P=0.008). Platelet and white blood cell counts in the HS group were significantly increased compared with the HA group one day, one week, one month and one year postoperatively (P<0.001). Splenectomy and micro-vascular invasion were significant independent prognostic factors for disease-free survival. Gender, tumor number, and recurrence were independent prognostic factors for overall survival. CONCLUSION: Synchronous hepatectomy and hepatectomy potentially improves disease-free survival rates and alleviates hypersplenism without increasing the surgical risks for patients with HCC and hypersplenism.

Synchronous splenectomy and hepatectomy in patients with hepatocellular carcinoma, hypersplenism and liver cirrhosis.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) mainly arises from underlying liver disease. Complicated liver cirrhosis and secondary hypersplenism are the most risk factors preventing surgical treatment of patients with HCC. The present study aimed at investigating the safety and long term outcome of patients with HCC and liver cirrhosis undergoing synchronous hepatectomy and splenectomy. METHODOLOGY: The clinical data of 306 cases of patients with HCC and liver cirrhosis undergoing curative hepatectomy were reviewed. 18 cases underwent synchronous hepatectomy and splenectomy. The rest 288 cases of HCC with hepatectomy only were compared in aspects of clinicopathological and surgical variables and surgical outcomes. RESULTS: Preoperative hemoglobin and platelet count were significantly lower in splenectomy than non-splenectomy group (p<0.01, respectively). Patients undergoing combined splenectomy and hepatectomy needed longer surgery time and hospital stay time, and transfused much more blood intraoperatively (p=0.07, 0.03, and 0.02), and also experienced more portal vein thrombosis (p<0.01). The level of hemoglobin and platelet increased after splenectomy and finally to normal level one month postoperatively. There was no statistical difference of overall and disease-free survival of patients in splenectomy and non-splenectomy groups (p>0.05). CONCLUSIONS: With strict selection, patients with HCC and hypersplenism could undergo combined splenectomy and hepatectomy safely.

Coils versus gelatin particles with or without intraarterial antibiotics for partial splenic embolization: a comparative evaluation.

PURPOSE: To compare the efficacy, complications, and inflammatory levels in partial splenic embolization (PSE) with coils or gelatin sponge (GS) particles with or without intraarterial antibiotic agents. MATERIALS AND METHODS: Forty-four patients with hypersplenism treated by PSE were assessed. GS particles were used in 31 patients, and coils were used in 13 patients. In 17 of the 31 patients who received GS, GS suspended in antibiotic solution was injected via the splenic artery. In the other 14 patients, antibiotic agents were not used. In all 13 coil group patients, an antibiotic solution was intraarterially injected before embolization. Platelet counts were compared between the GS and coil groups. Complications and serum C-reactive protein (CRP) levels were compared among the three groups. RESULTS: There were no significant differences in platelet counts and platelet increased ratios at 6 months (10.0 × 10(4)/µL and 193% in the GS group vs 9.0 × 10(4)/µL and 221% in the coil group), and no significant differences in frequencies of complications. However, one splenic abscess occurred in a patient treated with GS without antibiotics, resulting in death. The mean serum CRP level in the GS with antibiotic group at 2 weeks was significantly lower than in the other two groups. CONCLUSIONS: The efficacy of PSE is similar with the use of coils versus GS particles. Prophylactic intraarterial antibiotic treatment could be useful in preventing inflammatory reactions after PSE.

Safety of synchronous hepatectomy and splenectomy for patients with hepatocellular carcinoma and hypersplenism.

BACKGROUND/AIMS: To assess the surgical safety of synchronous hepatic resection and splenectomy for patients with hepatocellular carcinoma (HCC) and hypersplenism. METHODOLOGY: Patients with HCC and hypersplenism who underwent surgical treatment were included in this study. According to the difference of operations, patients were divided into two groups (group A, patients who underwent hepatic resection; group B, patients who underwent synchronous hepatic resection and hypersplenism). Pre- and intra-operative parameters were statistically analyzed. Postoperative outcomes including white blood cell and platelet count changes, surgical complications and long-term survival rates were compared. RESULTS: The pre- and intra-operative parameters of two groups were comparable except for preoperative white blood cell and platelet counts. The incidences of postoperative surgical complication were 53.33% for group A and 35.48% for group B (p=0.161). The 1- and 3-year survival rates of the two groups were 83%, 42% and 82%, 54%, respectively (p=0.313). CONCLUSIONS: Synchronous hepatic resection and splenectomy could increase the postoperative WBC and platelet level for patients with hepatocellular carcinoma and hypersplenism without increasing surgical risks.

[Spleno-renal distal and proximal shunts for hypersplenism due to hepatic cirrhosis]. / Suntul spleno-renal distal si proximal pentru hipersplenismul datorat cirozei hepatice.

The secondary hypersplenism appears from 30-50% in liver cirrhosis with portal hypertension. The mechanism of the complication is the splenic congestion as the result of the progress of the portal hypertension. Between 1997-2005, 16 patients with hypersplenism due to liver cirrhosis were operated in the service. The aim of the operation was to decompress the portal hypertension, by spleno-renal shunt (Warren), in 6 patients, truncular shunts in 2 patients, and splenectomy with spleno-renal shunts in 8 patients. No postoperative death was noted on the series. The platelets number and the white blood cells, destroyed by the reticuloendothelial system of the spleen, were counted in the first month and the first year, as well as the spleen volume. In patients with non-splenectomy operations the improvement of the blood elements number was remarked in the first week, but the volume of the spleen remained increased during 1-6 month. In patients with splenectomy the platelets and the white cells dramatically increased, with the risk of coagulation disfunction. The survival rate at five years was 12 patients.

Long-term efficacy of partial splenic embolization in children.

PURPOSE: To elucidate the role of partial splenic embolization (PSE) procedures, long-term outcome was assessed in terms of the recurrence of thrombocytopenia. METHODS: A retrospective study was performed after 41 PSE procedures in 36 patients for hypersplenism owing to portal hypertension. The underlying disease was biliary atresia in 32 patients, extrahepatic portal obstruction in 3, and idiopathic cirrhosis in 1. RESULTS: The average volume embolized was 70.1%. The patients were followed up from 20 days to 182 months (average, 70.8 months). Five patients subsequently died, and 6 underwent liver transplantation. The causes of death or the reasons for liver transplantation were not related to hypersplenism. Eleven patients (30.6%) had recurrence of thrombocytopenia (<100,000/mm3). There was no significant difference in the volume embolized or platelet count before PSE between the patients with and without recurrence of thrombocytopenia. The peak value of platelet count after PSE was significantly lower in the patients with recurrence of thrombocytopenia (P =.0091). In 17 of 24 survivors without liver transplantation, platelet counts remained normal throughout the follow-up period. CONCLUSIONS: PSE is a safe and effective procedure. Hematologic indices improved in all 36 patients after PSE, and its long-term efficacy was shown in 70% of the survivors.

Prevention of variceal recurrence, bleeding, and death in cirrhosis patients with hypersplenism, especially those with severe thrombocytopenia.

BACKGROUND/AIMS: We investigated the impact of different treatments on the prognosis of cirrhosis patients with esophageal varices and thrombocytopenia. METHODOLOGY: This prospective study enrolled 52 cirrhosis patients with esophageal varices and hypersplenism (platelet count < 50,000/mm3). In 26 patients, endoscopic variceal ligation plus partial splenic embolization were performed, while endoscopic variceal ligation alone was done in 26 patients. Endoscopic variceal ligation was repeated until complete eradication of varices was achieved. Partial splenic embolization was performed using the Seldinger method and embolic material was injected until a 60% to 80% reduction of splenic blood flow was achieved. The primary endpoints during the follow-up period included recurrence of varices, variceal bleeding, and death. RESULTS: Comparison of endoscopic variceal ligation plus partial splenic embolization with endoscopic variceal ligation alone by multivariate analysis showed a relative risk ratio of 0.390 (95% CI [0.178-0.854]; p = 0.024) for new varices, 0.191 (95% CI [0.047-0.780]; p = 0.021) for variceal bleeding, and 0.193 (95% CI [0.053-0.699]; p = 0.012) for death. CONCLUSIONS: These results suggest that endoscopic variceal ligation plus partial splenic embolization can prevent variceal recurrence, bleeding, and death in cirrhosis patients with esophageal varices and thrombocytopenia.

Predictors and implications of severe hypersplenism in patients with cirrhosis.

BACKGROUND AND OBJECTIVES: Hypersplenism is frequently seen in patients with cirrhosis. However, it is unclear why some patients with cirrhosis develop marked hypersplenism and others do not. Additionally, the implications of severe hypersplenism are unknown. Therefore, we conducted a study to evaluate the predictors and implications of severe hypersplenism in patients with cirrhosis. SUBJECTS AND METHODS: All subjects with cirrhosis who were referred to Indiana University over a 53-month period for liver transplantation were studied. Severe hypersplenism was defined as platelet count < 75,000 per mm3 and/or white blood cell count < 2,000 per mm3 in the presence of splenomegaly. The outcomes of interest were development of spontaneous bacterial peritonitis (SBP), variceal bleeding, and death. Patients were observed until death, transplantation, or study closure. RESULTS: The study group comprised 329 subjects with cirrhosis and their median follow-up time was 450 days (0.25-42 months). The prevalence of severe hypersplenism was 33%. Decompensated liver disease [odds ratio (OR), 2.0; 95% confidence interval (CI), 1.1-3.7] and a history of alcohol consumption (OR 2.3; 95% CI, 1.4-3.8) were independent predictors of severe hypersplenism. The presence of severe hypersplenism independently predicted the development of variceal bleeding [hazard ratio (HR) 4.1; 95% CI, 1.7-10], SBP (HR 8.0; 95% CI, 3.1-20.5), and death (HR 2.0; 95% CI 1.2-3.4). CONCLUSIONS: This study suggests that severe hypersplenism is an independent risk factor for developing variceal bleeding, SBP, and death in patients with cirrhosis. If these observations are confirmed, severe hypersplenism can be considered as an indication for prophylactic measures against variceal bleeding and SBP.

Concomitant splenectomy for hypersplenic thrombocytopenia in hepatic resection for hepatocellular carcinoma.

BACKGROUND/AIMS: Resection of hepatocellular carcinoma (HCC) in patients with liver cirrhosis and hypersplenic thrombocytopenia (HSTC) is risky. Controversy exists concerning the role of concomitant splenectomy for HSTC in cirrhotic patients undergoing hepatectomy for HCC. METHODOLOGY: During the past 10 years, 294 patients have undergone hepatic resection for HCC in our department. Among them, 11 cirrhotic patients with severe HSTC (platelet count < or = 80000/mm3) underwent splenectomy simultaneously. The clinical outcomes were retrospectively reviewed. RESULTS: The resected spleen weighed 479 +/- 242 g. The post-operative mortality and morbidity were 9.1% and 27.3%, respectively. In all patients, the platelet count was elevated to above 100000/mm3, and serum total bilirubin was significantly lowered within 1 week of operation. The overall 5-year actuarial and disease-free survival rates were 66.7%. None of the patients developed severe infectious complications during the follow-up period. CONCLUSIONS: Concomitant splenectomy for severe HSTC in cirrhotic patients undergoing hepatectomy for HCC is justified as the benefits of concomitant splenectomy by far surpass the adverse effects.

[Results of partial splenic resection and transposition to the lateral abdominal wall in portal hypertension in childhood]. / Ergebnisse der Milzteilresektion und -transposition in die laterale Bauchwand bei portaler Hypertension im Kindesalter.

Between 1977 and 1995, 19 children with portal hypertension (nine extrahepatic, ten intrahepatic) were treated by transpositioning the spleen into the left abdominal wall. Among the patients with intrahepatic portal hypertension three died. Two patients underwent secondary diminuition of the transposed spleen due to relapsed hypersplenism. In one of our first patients the transposed spleen atrophied after tangential resection. All surviving patients except one preserved hepatic function. The serum colloid osmotic pressure was stable. Plasma ammonia levels were normal. Serum immunoglobulins (IgG, IgM, IgA and IgG subclasses) and complement components (C3c, C4) were analyzed. After transposition patients had normal or slightly elevated values of these proteins compared with controls.

Evaluation of early postsplenectomy complications.

This study was done to define the incidence of early postsplenectomy complications and is based upon 688 splenectomies--mainly in malignant and nonmalignant hematologic conditions--performed during the period 1952 to 1986. In 354 patients, early postoperative complications were observed, among whom wound and pulmonary infections were most common. A fatal outcome was noted in 32 patients for a mortality rate of 4.7 per cent. The incidence of early complications after splenectomy is higher than after most other surgical procedures within the abdominal cavity and depends upon the underlying diseases which lead to splenectomy. Deficient immunologic defense mechanisms may be a significant factor in the development of early complications in patients after splenectomy.

Role of splenectomy in homozygous sickle cell disease in childhood.

60 Jamaican children with homozygous sickle cell (SS) disease underwent splenectomy, 14 for prophylaxis against recurrent acute splenic sequestration and 46 for treatment of sustained hypersplenism. Age at operation varied from 9 months to 16 years. Patients were followed up for 1 month to 27 years (median 6 years), with a total of 369 years of patient-observation. None of the 3 patients who died, at ages 2 1/2, 6 1/2, and 21 years, had received prophylaxis against infection. Overwhelming sepsis was possible but not confirmed in the first two deaths which occurred 11 months and 2 1/2 years after operation; the third died from chronic renal failure 11 years after splenectomy. After operation, there were no confirmed cases of pneumococcal septicaemia or meningitis, and the commonest clinical event was the acute chest syndrome.

Acute splenic sequestration and hypersplenism in the first five years in homozygous sickle cell disease.

A cord blood screening programme initiated in June 1973 had screened 68 000 normal deliveries by February 1979 with the detection of 216 cases of homozygous sickle cell disease. Regular review of these children in the Medical Research Council paediatric clinic has identified acute splenic sequestration as a major cause of morbidity and mortality in the first 5 years of life. In addition to classical episodes characterised by peripheral circulatory failure, minor episodes of increasing anaemia associated with an enlarging spleen and an active marrow were also common. These minor episodes appeared to have predictive value in children who later developed severe life-threatening episodes of acute splenic sequestration. Sequestration. Sustained hypersplenism was also appreciably more common in children developing minor or major episodes of acute splenic sequestration compared with those without such a history. It is proposed that the classification of acute splenic sequestration be expanded to include these minor episodes, and that consideration be given to prevention of recurrences by splenectomy particularly in patients who also develop sustained hypersplenism.

Correction of hypersplenism following distal splenorenal shunt.

The effect of splenorenal shunt on hypersplenism was assessed in 47 patients with splenomegaly, 26 of whom had significant thrombocytopenia or leukopenia. Of 16 patients with thrombocytopenia, platelet count returned to normal in 15 (94%) following operation, an improvement which was statistically highly significant (P less than 0.001). Of 16 patients with leukopenia, leukocyte count returned to normal in 11 (69%), also a highly significant improvement (P less than 0.001). Dramatic relief of hypersplenism occurs in the majority of patients following splenorenal shunt. Thrombocytopenia is more consistently corrected than is leukopenia. The etiology of liver disease appeared not to be a factor, but leukopenia was corrected more consistently in alcoholic than in nonalcoholic patients, while there was no difference in the postoperative response of thrombocytopenia to the operation. Long-term follow-up in 26 patients demonstrated sustained improvement in 57% of patients with preoperative leukopenia and 78% of patients with thrombocytopenia. Since significant improvement in leukopenia and thrombocytopenia will occur following the distal splenorenal shunt, hypersplenism is not a contraindication to this procedure.

Subcutaneous transposition of the spleen: a method for treatment of complications in portal hypertension?

Eleven patients with portal hypertension were treated with subcutaneous transposition of a resected spleen. In eight of the patients the operation was performed after variceal bleeding. In this group there was one operative mortality--a 77-year-old woman. Another patient died after 28 months in upper gastrointestinal bleeding. Autopsy showed varices in the gastric fundus and a cancer in the cardia. The other six patients are alive and in good health after 41--60 months. The operation was performed in another three patients, who had not bled. The indication was hypersplenism and esophageal varices in two and severe thrombocytopenia in one. Two of these patients (both with advanced hepatic disease) died postoperatively. The operation is proposed as an alternative method in the treatment of portal hypertension--especially when the main problem is hypersplenism. The operation has no negative effects on liver function and does not cause encephalopathy. Hypersplenism is cured. The survival time and freedom from postoperative bleeding among those who bled preoperatively is in the present material very satisfactory. However, the operation cannot be recommended for the prophylactic treatment of patients with esophageal varices who have not bled--at least not in the patient with advanced hepatid dysfunction.