Will partial splenic embolization followed by splenectomy increase intraoperative bleeding?

BACKGROUND Partial splenic embolization(PSE)has been suggested as an alternative to splenectomy in the treatment of hypersplenism.However,some patients may experience recurrence of hypersplenism after PSE and require splenectomy.Currently,there is a lack of evidence-based medical support regarding whether preoperative PSE followed by splenectomy can reduce the incidence of complications.AIM To investigate the safety and therapeutic efficacy of preoperative PSE followed by splenectomy in patients with cirrhosis and hypersplenism.METHODS Between January 2010 and December 2021,321 consecutive patients with cirrhosis and hypersplenism underwent splenectomy at our department.Based on whether PSE was performed prior to splenectomy,the patients were divided into two groups:PSE group(n=40)and non-PSE group(n=281).Patient characteristics,postoperative complications,and follow-up data were compared between groups.Propensity score matching(PSM)was conducted,and univariable and multivariable analyses were used to establish a nomogram predictive model for intraoperative bleeding(IB).The receiver operating characteristic curve,Hosmer-Lemeshow goodness-of-fit test,and decision curve analysis(DCA)were employed to evaluate the differentiation,calibration,and clinical performance of the model.RESULTS After PSM,the non-PSE group showed significant reductions in hospital stay,intraoperative blood loss,and operation time(all P=0.00).Multivariate analysis revealed that spleen length,portal vein diameter,splenic vein diameter,and history of PSE were independent predictive factors for IB.A nomogram predictive model of IB was constructed,and DCA demonstrated the clinical utility of this model.Both groups exhibited similar results in terms of overall survival during the follow-up period.CONCLUSION Preoperative PSE followed by splenectomy may increase the incidence of IB and a nomogram-based prediction model can predict the occurrence of IB.

Evaluation of the effect of partial splenic embolization on platelet values for liver cirrhosis patients with thrombocytopenia

AIM： TO investigate the effect of partial splenic embolization （PSE） on platelet values in liver cirrhosis patients with thrombocytopenia and to determine the effective embolization area for platelet values improvement.METHODS： Blood parameters and liver function indicators were measured on 10 liver cirrhosis patients （6 in Child-Pugh grade A and 4 in grade B） with thrombocytopenia （platelet values 〈 80 × 10^3/μL） before embolization. Computed tomography scan was also needed in advance to acquire the splenic baseline. After 2 to 3 d, angiography and splenic embolization were performed. A second computed tomography scan was made to confirm the embolization area after 2 to 3 wk of embolization. The blood parameters of patients were also examined biweekly during the 1 year follow-up period. RESULTS： According to the computed tomography images after partial splenic embolization, we divided all paUents into two groups： low （〈 30%）, and high （≥ 30%） embolization area groups. The platelet values were increased by 3 times compared to baseline levels after 2 wk of embolization in high embolization area group. In addition, there were significant differences in platelet values between low and high embolization area groups. GPT values decreased significantly in all patients after 2 wk of embolization. The improvement in platelet and GPT values still persisted until 1 year after PSE. In addition, 3 of 4 （75%） Child-Pugh grade B patients progressed to grade A after 2 mo of PSE. The complication rate in 〈 30% and ≥30% embolization area groups was 50% and 100%, respectively. CONCLUSION： Partial splenic embolization is an effective method to improve platelet values and GPT values in liver cirrhosis patients with thrombocytopenia and the ≥ 30% embolization area is meaningful for platelet values improvement. The relationship between the complication rate and embolization area needs further studies.

Combined treatment of hepatocellular carcinoma with partial splenic embolization and transcatheter hepatic arterial chemoembolization

AIM: To prospectively evaluate the effi cacy and safety of partial splenic embolization (PSE) combined with transcatheter hepatic arterial chemoembolization (TACE) in treatment of hepatocellular carcinoma (HCC). METHODS: Fifty patients suffering from primary HCC associated with hypersplenism caused by cirrhosis were randomly assigned to 2 groups: group A receiving PSE combined with TACE (n = 26) and group B receiving TACE alone (n = 24). Follow-up examinations included calculation of peripheral blood cells (leukcytes, platelets and red blood cells) and treatment-associated complications. RESULTS: Prior to treatment, there was no signifi cant difference in sex, age, Child-Pugh grade, tumor diameter, mass pathology type and peripheral blood cell counts between the 2 groups. After treatment, leukocyte and platelet counts were significantly higher in group A during the 3-mo follow-up period (P < 0.05), but lower in group B (P < 0.05). Severe complications occurred in 3 patients (11.5%) of group A and in 19 patients (79.2%) of group B (P < 0.05), and there was no significant difference in symptoms of post-embolization syndrome, including abdominal pain, fever, mild nausea and vomiting between the 2 groups (P > 0.05). CONCLUSION: PSE combined with TACE is more effective and safe than TACE alone for patients with HCC associated with hypersplenism caused by cirrhosis.

Outcomes of partial splenic embolization in patients with massive splenomegaly due to idiopathic portal hypertension

AIM To determine the outcomes of partial splenic em-bolization(PSE) for massive splenomegaly due to idiopathic portal hypertension(IPH).METHODS In this prospective study, we evaluated the charac-teristics and prognosis of consecutive patients with IPH who underwent PSE for all indications at a single medical center between June 2009 and January 2015. The inclusion criteria were: presence of hypersplenism, massive splenomegaly, and resultant pancytopenia. The exclusion criteria were: presence of other diseases causing portal hypertension. During the post-PSE period, the patients were hospitalized. All patients underwent abdominal computed tomography imaging 4 wk post-PSE to determine total splenic and non-infarcted splenic volumes.RESULTS A total of 11 patients, with median age of 33.27 ± 4.8 years, were included in the study. Mean spleen size was 22.9 cm(21-28 cm), and severe hypersplenismwas diagnosed in all patients before PSE. Post-PSE, leukocyte and platelet counts increased significantly, reaching peak levels in the second week with gradual decreases thereafter. Liver function tests did not exhibit significant changes during post-intervention follow-up. All patients developed post-embolization syndrome, and one patient experienced serious complications; all complications were successfully treated with conservative therapy and no death occurred. CONCLUSION Our findings showed that PSE has a lower complication rate than previously-reported surgical complication rates, which supports this intervention as a viable alternative for high-risk operable patients with severe hypersplenism.

Transhepatic catheter-directed thrombolysis for portal vein thrombosis after partial splenic embolization in combination with balloon-occluded retrograde transvenous obliteration of splenorenal shunt

A 66-year-old woman underwent partial splenic embolization （PSE） for hypersplenisrn with idiopathic portal hypertension （IPH）. One week later, contrast-enhanced CT revealed extensive portal vein thrombosis （PVT） and dilated portosystemic shunts. The PVT was not dissolved by the intravenous administration of urokinase. The right portal vein was canulated via the percutaneous transhepatic route under ultrasonic guidance and a 4 Fr. straight catheter was advanced into the portal vein through the thrombus. Transhepatic catheter-directed thrombolysis was performed to dissolve the PVT and a splenorenal shunt was concurrently occluded to increase portal blood flow, using balloon-occluded retrograde transvenous obliteration （BRTO） technique. Subsequent contrast-enhanced CT showed good patency of the portal vein and thrombosed splenorenal shunt. Transhepatic catheter-directed thrombolysis combined with BRTO is feasible and effective for PVT with portosystemic shunts.

Treatment of gastric varices with partial splenic embolization in a patient with portal vein thrombosis and a myeloproliferative disorder

Therapeutic options for gastric variceal bleeding in the presence of extensive portal vein thrombosis associated with a myeloproliferative disorder are limited.We report a case of a young woman who presented with gastric variceal bleeding secondary to extensive splanchnic venous thrombosis due to a Janus kinase 2 mutation associated myeloproliferative disorder that was managed effectively with partial splenic embolization.

Management of thrombocytopenia due to liver cirrhosis:A review

Thrombocytopenia is a common complication in liver disease and can adversely affect the treatment of liver cirrhosis,limiting the ability to administer therapy and delaying planned surgical/diagnostic procedures because of an increased risk of bleeding.Multiple factors,including splenic sequestration,reduced activity of the hematopoietic growth factor thrombopoietin,bone marrow suppression by chronic hepatitis C virus infection and anti-cancer agents,and antiviral treatment with interferon-based therapy,can contribute to the development of thrombocytopenia in cirrhotic patients.Of these factors,the major mechanisms for thrombocytopenia in liver cirrhosis are(1)platelet sequestration in the spleen;and(2)decreased production of thrombopoietin in the liver.Several treatment options,including platelet transfusion,interventional partial splenic embolization,and surgical splenectomy,are now available for severe thrombocytopenia in cirrhotic patients.Although thrombopoietin agonists and targeted agents are alternative tools for noninvasively treating thrombocytopenia due to liver cirrhosis,their ability to improve thrombocytopenia in cirrhotic patients is under investigation in clinical trials.In this review,we propose a treatment approach to thrombocytopenia according to our novel concept of splenic volume,and we describe the current management of thrombocytopenia due to liver cirrhosis.

Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices

Rupture of gastric varices(GVs)can be fatal.Balloon-occluded retrograde transvenous obliteration(BRTO),as known as retrograde sclerotherapy,has been widely adopted for treatment of GVs because of its effectiveness,ability to cure,and utility in emergency and prophylactic treatment.Simplifying the route of blood flow from GVs to the gastrorenal shunt is important for the successful BRTO.This review outlines BRTO indications and contraindications,describes basic BRTO procedures and modifications,compares BRTO with other GVs treatments,and discusses various combination therapies.Combined BRTO and partial splenic embolization may prevent exacerbation of esophageal varices and shows promise as a treatment option.

Effect of spleen operation on antiviral treatment in hepatitis Cvirus-related cirrhotic patients

AIM: To investigate the impact of spleen operation (SO) on interferon-&#x003b1; (IFN-&#x003b1;)-based antiviral treatment in patients with hepatitis C virus (HCV)-related cirrhosis.

Expectations for partial splenic arterial embolization simultaneous transcatheter arterial chemoembolization for hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is frequently complicated by cirrhosis,and it is not unusual for treatment options to be limited as a result of pancytopenia due to hypersplenism.Partial splenic embolization(PSE)has been performed for thrombocytopenia resulting from hypersplenism.However,the safety and effi cacy of concurrent transcatheter arterial chemoembolization(TACE)with PSE for HCC remain unclear.Thrombocytopenia has been improved,and treatment continued using concurrent PSE.In addition,the hepatic functional reserve could be maintained even after treatment for HCC.Concurrent TACE and PSE for HCC with thrombocytopenia can be expected to help maintain a hepatic reserve,and it may contribute to improving the prognosis of HCC.Hence,PSE could lead to an asplenic state.The appearance of Howell-Jolly bodies on a peripheral blood smear is reported useful for assessing splenic function.The appearance of Howell-Jolly bodies is associated with an increased risk for post-splenectomy sepsis/overwhelming post-splenectomy infection in patients with reduced splenic function.These bodies are frequently observed in peripheral erythrocytes after PSE,and when they are present,it is appropriate to administer the pneumococcal vaccine to prevent severe infection.The expectations for PSE combined with TACE for the treatment of HCC associated with cirrhosis are reviewed.