Published online Feb 21, 2021. doi: 10.3748/wjg.v27.i7.654
Peer-review started: November 25, 2020
First decision: December 8, 2020
Revised: December 20, 2020
Accepted: January 13, 2021
Article in press: January 13, 2021
Published online: February 21, 2021
The most effective treatment for advanced cirrhosis and portal hypertension is liver transplantation (LT). However, splenomegaly and hypersplenism can persist even after LT in patients with massive splenomegaly. Persistent hypersplenism-related pancytopenia may interfere with the management of immunosuppressive therapy. Splenomegaly may further result in excessive portal pressure or splenic artery steal syndrome. The resulting decrease in hepatic arterial inflow can then affect liver graft function.
The most common therapies for splenomegaly and hypersplenism are total splenectomy during LT and selective splenic artery embolization after LT, but they have considerable limitations. Cirrhosis with severe splenomegaly and hypersplenism is common, yet satisfactory treatment is lacking. To realize this need, we first proposed and designed the procedure of partial splenectomy during LT (PSLT), which is an all-in-one treatment for post-LT complications.
To examine the feasibility of performing partial splenectomy during LT in patients with advanced cirrhosis combined with severe splenomegaly and hypersplenism.
Between October 2015 and February 2019, 762 cases of classic orthotopic LT were performed at our institution. Among these, there were 84 cases of advanced cirrhosis combined with severe splenomegaly and hypersplenism. Forty-one cases received PSLT (PSLT group), and 43 cases received only LT with no intervention (LT group). Patient characteristics, intraoperative parameters, and postoperative outcomes were compared between the LT and PSLT groups and retrospectively analyzed.
The incidence of postoperative hypersplenism and recurrent ascites in the PSLT group was significantly lower than that in the LT group. Seventeen patients in the LT group required two-stage splenic embolization, and further splenectomy was required in 6 of them. The operation time and intraoperative blood loss in the PSLT group were relatively increased compared with the LT group. The incidence of postoperative bleeding, pulmonary infection, thrombosis and splenic arterial steal syndrome in the PSLT group was similar to that in the LT group, respectively.
PSLT can reduce the incidence of postoperative hypersplenism and recurrent ascites, and reduce the risk of secondary splenic embolization and splenectomy, but the operation time and intraoperative blood loss were increased.
According to our experience, patients with preoperative severe splenomegaly and hypersplenism are more likely to have intractable hypersplenism after LT, and PSLT is recommended.