• anticoagulants
• hemorrhage
• liver cirrhosis
• liver diseases
• treatment outcome

• Takeda Pharmaceutical Company Limited

• Hepatectomy
• Hypersplenism
• Portal vein thrombosis
• Splenectomy

• Humans
• Splenectomy/adverse effects
• Splenectomy/methods
• Retrospective Studies
• Female
• Male
• Portal Vein
• Hepatectomy/adverse effects
• Hepatectomy/methods
• Venous Thrombosis/etiology
• Venous Thrombosis/diagnostic imaging
• Venous Thrombosis/epidemiology
• Middle Aged
• Risk Factors
• Postoperative Complications/etiology
• Postoperative Complications/epidemiology
• Aged
• Liver Cirrhosis/complications
• Adult
• Incidence

• extrahepatic portal vein obstruction
• extramedullary hematopoiesis
• myeloproliferative neoplasm
• splenectomy
• thrombocytosis

• Anticoagulant
• Antithrombin
• Bispecific antibody
• Hemophilia A
• Thrombin generation

• Antibodies, Bispecific/pharmacology
• Antibodies, Bispecific/therapeutic use
• Humans
• Antibodies, Monoclonal, Humanized/therapeutic use
• Antibodies, Monoclonal, Humanized/pharmacology
• Blood Coagulation/drug effects
• Anticoagulants/pharmacology
• Anticoagulants/therapeutic use
• Antithrombins/pharmacology
• Antithrombins/therapeutic use

• antithrombin
• cirrhosis
• hypercoagulability
• prothrombin
• thrombin
• thrombosis

• Humans
• Prothrombin
• Thrombin/metabolism
• Male
• Female
• Middle Aged
• Case-Control Studies
• Blood Coagulation
• Liver Cirrhosis/blood
• Liver Cirrhosis/diagnosis
• Aged
• Thrombomodulin/blood
• Adult
• Antithrombins/blood
• Blood Coagulation Tests
• Phenotype
• Thromboplastin/metabolism

• antithrombin III
• cirrhosis
• liver failure
• portal vein thrombosis
• prognosis

• 20K08280-00 Japan Society for the Promotion of Science

For patients with portal hypertension (PH), portal vein thrombosis (PVT) is a fatal complication after splenectomy. Postoperative platelet elevation is considered the foremost reason for PVT. However, the value of postoperative platelet elevation rate (PPER) in predicting PVT has never been studied.

To investigate the predictive value of PPER for PVT and establish PPER-based prediction models to early identify individuals at high risk of PVT after splenectomy.

We retrospectively reviewed 483 patients with PH related to hepatitis B virus who underwent splenectomy between July 2011 and September 2018, and they were randomized into either a training (n = 338) or a validation (n = 145) cohort. The generalized linear (GL) method, least absolute shrinkage and selection operator (LASSO), and random forest (RF) were used to construct models. The receiver operating characteristic curves (ROC), calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were used to evaluate the robustness and clinical practicability of the GL model (GLM), LASSO model (LSM), and RF model (RFM).

Multivariate analysis exhibited that the first and third days for PPER (PPER1, PPER3) were strongly associated with PVT [odds ratio (OR): 1.78, 95% confidence interval (CI): 1.24-2.62, P = 0.002; OR: 1.43, 95%CI: 1.16-1.77, P < 0.001, respectively]. The areas under the ROC curves of the GLM, LSM, and RFM in the training cohort were 0.83 (95%CI: 0.79-0.88), 0.84 (95%CI: 0.79-0.88), and 0.84 (95%CI: 0.79-0.88), respectively; and were 0.77 (95%CI: 0.69-0.85), 0.83 (95%CI: 0.76-0.90), and 0.78 (95%CI: 0.70-0.85) in the validation cohort, respectively. The calibration curves showed satisfactory agreement between prediction by models and actual observation. DCA and CIC indicated that all models conferred high clinical net benefits.

PPER1 and PPER3 are effective indicators for postoperative prediction of PVT. We have successfully developed PPER-based practical models to accurately predict PVT, which would conveniently help clinicians rapidly differentiate individuals at high risk of PVT, and thus guide the adoption of timely interventions.

• Portal hypertension
• Splenectomy
• Portal vein thrombosis
• Postoperative platelet elevation rate
• Practical model
• Machine learning

• Humans
• Hypertension, Portal/diagnosis
• Hypertension, Portal/etiology
• Hypertension, Portal/surgery
• Liver Cirrhosis/pathology
• Machine Learning
• Portal Vein/diagnostic imaging
• Portal Vein/pathology
• Portal Vein/surgery
• Retrospective Studies
• Risk Factors
• Splenectomy/adverse effects
• Splenectomy/methods
• Venous Thrombosis/complications
• Venous Thrombosis/etiology

• Bleeding
• Cardiac surgery
• Direct oral anticoagulant
• Liver failure
• Prothrombin complex concentrate
• Thromboembolism
• Trauma-induced coagulopathy

We aimed to determine the association between the preoperative antithrombin III (ATIII) level and postoperative acute kidney injury (AKI) after LT (post-LT AKI). We retrospectively evaluated 2395 LT recipients between 2010 and 2018 whose data of perioperative ATIII levels were available. Patients were divided into two groups based on the preoperative level of ATIII (ATIII < 50% vs. ATIII ≥ 50%). Multivariable regression analysis was performed to assess the risk factors for post-LT AKI. The mean preoperative ATIII levels were 30.2 ± 11.8% in the ATIII < 50% group and 67.2 ± 13.2% in the ATIII ≥ 50% group. The incidence of post-LT AKI was significantly lower in the ATIII ≥ 50% group compared to that in the ATIII < 50% group (54.7% vs. 75.5%, p < 0.001); odds ratio (OR, per 10% increase in ATIII level) 0.86, 95% confidence interval (CI) 0.81–0.92; p < 0.001. After a backward stepwise regression model, female sex, high body mass index, low albumin, deceased donor LT, longer duration of surgery, and high red blood cell transfusion remained significantly associated with post-LT AKI. A low preoperative ATIII level is associated with post-LT AKI, suggesting that preoperative ATIII might be a prognostic factor for predicting post-LT AKI.

• acute kidney injury
• antithrombin
• liver transplantation

• Inflammation biomarker
• Portal vein
• Splenectomy
• Thrombosis

Whether hepatocellular carcinoma (HCC) patients with hypersplenism can benefit from splenectomy is unclear. This study aimed at exploring the efficacy and safety of concurrent splenectomy for HCC patients with hypersplenism.

PubMed, EMBASE and Web of Science databases were systematically searched to compare data on the combination of hepatectomy or transhepatic arterial infusion (TAI) with splenectomy (the splenectomy group) with data on hepatectomy or TAI alone (the non-splenectomy group) for the treatment of HCC with hypersplenism. Prospective clinical trials or retrospective cohort studies from inception to May 10, 2020 were considered eligible for this analysis. The relevant outcomes, including patients’ demographics, clinicopathologic characteristics, perioperative indices and long-term outcomes, were independently extracted by two investigators. Publication bias for overall survival (OS) and disease-free survival (DFS) was qualitatively assessed by funnel plots and quantitatively evaluated by Begg’s and Egger’s tests.

Nine retrospective studies including 1,650 patients were analyzed. Short-term outcomes suggested that the incidence rate of postoperative complications, including portal or splenic vein thrombosis [odds ratio (OR) =26.28, P<0.001] and pancreatic injury (OR =14.89, P=0.001), was significantly higher in the splenectomy group, whereas the perioperative mortality rate was similar between the splenectomy and non-splenectomy groups (P=0.541). Long-term outcomes indicated that the occurrence of variceal re-hemorrhage (OR =0.31, P<0.001) and tumor progress or recurrence (OR =0.62, P=0.001) was markedly reduced for patients who underwent splenectomy, while the long-term mortality rates were not statistically different between the two groups (P=0.087). The prognostic evaluation revealed that the OS and DFS were comparable between the splenectomy and non-splenectomy groups [for OS: hazard ratio (HR) =0.77, 95% confidence interval (CI): 0.53–1.13; for DFS: HR =0.87, 95% CI: 0.63–1.19]. Funnel plots suggested an HRs symmetric distribution for OS and DFS. Begg’s and Egger’s tests confirmed that there was no significant HR publication bias for OS and DFS.

Due to the significant progress in surgical techniques and perioperative care, concomitant splenectomy should be considered as an optional treatment for some HCC patients with hypersplenism.

• Hepatocellular carcinoma (HCC)
• hepatectomy
• hypersplenism
• prognosis
• splenectomy

• AT-III
• Hepatectomy
• PVT

Cirrhosis-associated portal vein thrombosis (CA-PVT) has been reportedly observed in 5–30% of cirrhotic patients. Moreover, the acute exacerbation of CA-PVT is likely to occur after certain situations, such as a status after abdominal surgery. Safety and efficacy of the direct-acting oral anticoagulant (DOAC) used for cirrhotic patients have been being confirmed. However, use of the DOAC as an initial treatment for CA-PVT appears still challenging especially in the early postoperative period after major surgery in terms of unestablished efficacy and safety in such occasion.

We herein report a case of the acute exacerbation of CA-PVT in the early postoperative period after abdominal surgery, which was successfully treated with DOAC, edoxaban used as an initial treatment. The patient was a 79-year-old Japanese male with alcoholic cirrhosis. The patient suffered choledocholithiasis and had a mural chronic CA-PVT extending from the superior mesenteric vein to the portal trunk. He underwent open cholecystectomy and choledochotomy. Early postoperative clinical course was uneventful except for abdominal distension due to ascites diagnosed on postoperative day (POD)7 when hospital discharge was planned. Contrast enhancement computed tomography (CE-CT) taken on POD 7 revealed the exacerbation of the CA-PVT. Despite recommendation for extension of hospital admission with low molecular weight heparin treatment, the patient strongly hoped to be discharged. Unwillingly, we selected DOAC, edoxaban, as an initial treatment, which was commenced the day after discharge (POD8). As a result, the remarkable improvement of the exacerbated CA-PVT was confirmed by the CE-CT taken on POD21. Any bleeding complications were not observed. Although a slight residue of the CA-PVT remains, the patient is currently doing well 4 years after surgery and is still receiving edoxaban. Any adverse effects of edoxaban have not been observed for 4 years.

A case of successful treatment of the acute exacerbation of CA-PVT with edoxaban was reported. Moreover, edoxaban has been safely administered in a cirrhotic patient for 4 years. The findings obtained from the present case suggest that DOAC can be used as an initial treatment for CA-PVT even in early postoperative period after major abdominal surgery.

• Direct-acting oral anticoagulant
• Early postoperative period after major abdominal surgery
• Edoxaban
• Liver cirrhosis
• Portal vein thrombosis

• Living donor liver transplantation
• Small-for-size graft syndrome
• Splenectomy

• Colorectal cancer
• Ectopic varices
• Hybrid surgery
• Sinusoidal obstruction

• Child–Pugh
• FIB-4
• anticoagulation
• cirrhosis
• platelet
• portal vein thrombosis
• recurrence
• reduction
• treatment efficiency
• volume

Liver cirrhosis occurs in approximately 80–90% of patients with hepatocellular carcinoma (HCC), and hepatic resection may be dangerous because of well-documented liver cirrhosis, which may be accompanied by portal hypertension (PH). Here we report a patient with advanced HCC with gastric varices and PH who experienced a good clinical course after undergoing balloon-occluded retrograde transvenous obliteration (BRTO), percutaneous transhepatic portal vein embolization (PTPE), hand-assisted laparoscopic (HALS) splenectomy, and right lobectomy of the liver.

A 72-year-old man had two HCCs with gastric varices. CT revealed one tumor (4.5 cm) located in segment 7, involving the right hepatic vein, adjacent to the middle hepatic vein. Another tumor (2.7 cm) was located in segment 6. He first underwent BRTO for gastric varices and PTPE for planned right lobectomy of the liver. To reduce PH, HALS splenectomy was performed, and uncomplicated right lobectomy of the liver was performed 10 weeks after the first visit. He has remained free of recurrence for at least 1 year.

Our patient underwent uncomplicated BRTO, PTPE, HALS splenectomy, and right lobectomy of the liver for advanced HCC with PH. Controlling portal pressure is important when hepatic resection is required to treat HCC with PH.

• Balloon-occluded retrograde transvenous obliteration
• Hepatic resection
• Hepatocellular carcinoma
• Portal hypertension
• Portal vein embolization

• Portal hypertension
• Schistosomiasis cirrhosis
• Splenectomy
• Variceal bleeding

• Aged
• Case-Control Studies
• Esophageal and Gastric Varices/complications
• Esophageal and Gastric Varices/mortality
• Esophageal and Gastric Varices/surgery
• Female
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/mortality
• Gastrointestinal Hemorrhage/prevention & control
• Gastrointestinal Hemorrhage/surgery
• Humans
• Liver Diseases, Parasitic/complications
• Liver Diseases, Parasitic/parasitology
• Liver Function Tests
• Male
• Middle Aged
• Neoplasm Recurrence, Local/etiology
• Prognosis
• Retrospective Studies
• Schistosomiasis/complications
• Schistosomiasis/mortality
• Schistosomiasis/surgery
• Secondary Prevention
• Splenectomy/adverse effects
• Splenectomy/methods
• Survival Rate
• Venous Thrombosis/etiology

• antithrombin III
• dosage
• liver transplantation
• population pharmacokinetics

• Colorectal surgery
• Inflammatory bowel disease
• Postoperative complications

• Laparoscopic splenectomy
• prophylactic antibiotics
• surgical-site infection

Small-for-size graft (SFSG) syndrome after living donor liver transplantation (LDLT) is the dysfunction of a small graft, characterized by coagulopathy, cholestasis, ascites, and encephalopathy. It is a serious complication of LDLT and usually triggered by excessive portal flow transmitted to the allograft in the postperfusion setting, resulting in sinusoidal congestion and hemorrhage. Portal overflow injures the liver directly through nutrient excess, endothelial activation, and sinusoidal shear stress, and indirectly through arterial vasoconstriction. These conditions may be attenuated with portal flow modulation. Attempts have been made to control excessive portal flow to the SFSG, including simultaneous splenectomy, splenic artery ligation, hemi-portocaval shunt, and pharmacological manipulation, with positive outcomes. Currently, a donor liver is considered a SFSG when the graft-to-recipient weight ratio is less than 0.8 or the ratio of the graft volume to the standard liver volume is less than 40%. A strategy for transplanting SFSG safely into recipients and avoiding extensive surgery in the living donor could effectively address the donor shortage. We review the literature and assess our current knowledge of and strategies for portal flow modulation in LDLT.

• Living donor liver transplantation
• Modulation
• Portal flow

• Abdominal Cavity/surgery
• Adult
• Aged
• Appendectomy/adverse effects
• Appendectomy/methods
• Cause of Death
• Cohort Studies
• Female
• France
• Gastrectomy/adverse effects
• Gastrectomy/methods
• Humans
• Hypertension, Portal/complications
• Hypertension, Portal/diagnosis
• Hypertension, Portal/surgery
• Liver Cirrhosis
• Male
• Middle Aged
• Prognosis
• Retrospective Studies
• Risk Assessment
• Severity of Illness Index
• Splenectomy/adverse effects
• Splenectomy/methods
• Survival Analysis

• PN-IIIP1-PD-2016-0689 UEFISCDI, Ministry of Education of Romania

• Laparoscopic sleeve gastrectomy
• liver cirrhosis
• portomesenteric vein thrombosis

• cirrhosis
• portal vein thrombosis
• risk factors

• coagulopathy
• direct oral anticoagulants (DOACs)
• hemostasis & thrombosis
• point-of-care testing
• thromboembolism
• transfusion algorithm

• glycoprotein VI
• hepatobiliary-pancreatic surgery
• portal vein thrombosis

• Adult
• Aged
• Female
• Hepatectomy/adverse effects
• Humans
• Liver Cirrhosis/complications
• Liver Cirrhosis/surgery
• Male
• Middle Aged
• Platelet Activation
• Platelet Count
• Platelet Membrane Glycoproteins/analysis
• Portal Vein/pathology
• Splenectomy/adverse effects
• Venous Thrombosis/diagnosis
• Venous Thrombosis/etiology
• Venous Thrombosis/surgery

• diagnostic imaging
• liver cirrhosis
• medication
• portal hypertension
• portal vein thrombosis

• anticoagulation therapy
• bleeding diathesis
• portal vein thrombosis

Portal vein thrombosis (PVT) is a serious complication in liver cirrhosis with portal hypertension. We examined the treatment, recurrence and prognosis of PVT in cirrhotic patients.

The study subjects were all 90 cirrhotic patients with PVT treated with danaparoid sodium (DS) at our department between July 2007 and September 2016. The mean age was 68 years and mean Child-Pugh score was 7. All patients received 2500 U/day of DS for 2 weeks, and repeated in those who developed PVT recurrence after the initial therapy.

Complete response was noted in 49% (n = 44), partial response (shrinkage ≥70%) in 33% (n = 30), and no change (shrinkage <70%) in 18% (n = 16) of the patients after the initial course of treatment. DS treatment neither caused adverse events, particularly bleeding or thrombocytopenia, nor induced significant changes in serum albumin, total bilirubin, prothrombin time, and residual liver function. Re-treatment was required in 44 patients who showed PVT recurrence and 61% of these responded to the treatment. The cumulative recurrence rates at 1 and 2 posttreatment years were 26 and 30%, respectively. The recurrence rates were significantly lower in patients with acute type, compared to the chronic type (p = 0.0141). The cumulative survival rates at 1 and 3 years after treatment (including maintenance therapy with warfarin) were 83 and 60%, respectively, and were significantly higher in patients with acute type than chronic type (p = 0.0053).

We can expect prognostic improvement of liver cirrhosis by warfarin following two-week DS therapy for the treatment of PVT in patients with liver cirrhosis safety and effectiveness. An early diagnosis of PVT along with the evaluation of the volume of PVT on CT and an early intervention would contribute to the higher efficacy of the treatment.

• Danaparoid sodium
• Liver cirrhosis
• Portal vein thrombosis

• Esophageal varices
• Gastric varices
• Hand-assisted laparoscopic surgery
• Hassab’s procedure
• Laparoscopic devascularization
• Portal hypertension

• Balloon-occluded retrograde transvenous obliteration
• Gastric devascularization
• Gastric varices
• Liver cirrhosis
• Portal hypertension
• Splenectomy

To determine the best anticoagulation strategy for the patients who underwent splenectomy with cirrhosis through network meta-analysis.

We conducted a systematic review of the literature in PubMed, Embase, and the Cochrane Library database. We extracted data on incidence of Portal vein system thrombosis (PVST) from studies that compared various anticoagulation strategies for use with patients who underwent splenectomy with cirrhosis. Network meta-analysis was conducted in ADDIS by evaluating the different incidence of PVST. Consistency and inconsistency models were developed to identify differences among the therapeutic strategies. Cumulative probability was utilized to rank the strategies under examination. Results. A total of 11 studies containing 1153 patients were included in the network meta-analysis. The results revealed that the application of Antithrombin III was the best anticoagulation option for patients who underwent splenectomy with cirrhosis (P = 0.59). The data of consistency and inconsistency models exhibited basically consistent and showed good convergence.

Application of Antithrombin III seemed to be the best anticoagulation strategy for cirrhotic patients who underwent splenectomy and should be considered a first-choice clinical reference.

• Congenital hepatic fibrosis
• Gastroesophageal varices
• Hassab’s operation
• Joubert syndrome
• Joubert syndrome and related disorders
• Portal hypertension

• anticoagulation
• cirrhosis
• pharmacologic prophylaxis
• portal hypertension
• portal venous system thrombosis
• splenectomy and devascularization

• chronic schistosomiasis
• coagulation and fibrinolysis system
• pathogenesis
• structural equation model

• Adult
• Antithrombins/metabolism
• Blood Coagulation Factors/metabolism
• Case-Control Studies
• Chronic Disease
• Female
• Fibrinolysis/physiology
• Humans
• Liver Function Tests
• Male
• Middle Aged
• Schistosomiasis/blood
• Schistosomiasis/physiopathology
• Schistosomiasis japonica
• Tissue Plasminogen Activator/metabolism
• Urokinase-Type Plasminogen Activator/metabolism
• Urokinase-Type Plasminogen Activator/physiology

• anticoagulation
• meta-analysis
• portal vein system thrombosis
• splenectomy

• liver cirrhosis
• portal vein
• venous thrombosis

• Adult
• Aged
• Aged, 80 and over
• Cohort Studies
• Female
• Hospital Mortality
• Humans
• Liver Cirrhosis/complications
• Liver Cirrhosis/diagnostic imaging
• Liver Cirrhosis/pathology
• Male
• Middle Aged
• Portal Vein/pathology
• Prevalence
• Retrospective Studies
• Risk Factors
• Splenectomy/adverse effects
• Venous Thrombosis/diagnostic imaging
• Venous Thrombosis/etiology
• Venous Thrombosis/pathology