Randomized controlled trial to investigate the impact of anticoagulation on the incidence of splenic or portal vein thrombosis after laparoscopic splenectomy

Porto-spleno-mesenteric venous thrombosis after elective splenectomy: a retrospective cohort study

Background

Elective splenectomy is the main treatment for a wide range of haematological diseases. Porto-spleno-mesenteric venous thrombosis represents one of the most severe complications of this procedure. The aim of this study was to evaluate risk factors associated with development of porto-spleno-mesenteric venous thrombosis after elective splenectomy.

Methods

All cases of elective splenectomy carried out from April 1st 2017 to January 31st 2023 were included in this single centre retrospective cohort study. Patients' demographics and perioperative data were analysed and correlated with the incidence of postoperative thrombosis. All patients underwent postoperative doppler ultrasound screening for thrombosis. Analysis was performed using SPSS 28, with p-value < 0.05 considered significant.

Results

Twenty-two patients (10 women, 12 men) underwent splenectomy during the study period. Indications were: immune thrombocytopenia (n: 6), myeloproliferative disorder (n: 6), hereditary spherocytosis (n: 4), thalassemia (n: 1), lymphoma (n: 1), leukaemia (n: 1), other malignancies (n: 3). Six patients developed porto-spleno-mesenteric venous thrombosis and only 2 of them were symptomatic. Patients were treated with anticoagulation therapy with complete resolution. Analysis identified three main factors associated with thrombosis: spleen diameter (p = 0.03), myeloproliferative disorder (p = 0.02), intraoperative platelet transfusion (p = 0.002) and intraoperative red blood cells transfusion (p = 0.009).

Conclusion

Standardized postoperative screening allows prompt diagnosis and treatment of porto-spleno-mesenteric venous thrombosis even in asymptomatic cases. Patient with splenomegaly and affected by myeloproliferative disorder have a greater risk to develop this complication.

Low-molecular weight heparin prevents portal vein system thrombosis after splenectomy: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to evaluate the safety and efficacy of low-molecular weight heparin (LMWH) in the prevention of portal vein system thrombosis (PVST) after splenectomy.

METHODS

A systematic search was performed using PubMed, EMBASE, Springer and Cochrane Library databases to screen out studies comparing the prognoses between post-splenectomy patients treated with and without LMWH. The incidences of PVST and bleeding complications were used as parameters to assess the effect of LMWH.

RESULTS

Six articles met the selection criteria and were included in this study. A total of 740 patients were involved in these six articles, including 336 patients treated with LMWH (LMWH group) and 385 patients not treated with LMWH (control group). The incidence of PVST in the LMWH group was significantly lower than that in the control group (relative risk 1.782 (1.449-2.192); P = 0.285; I2 = 19.7%), while the incidence of post-operative bleeding in the LMWH group was significantly higher (relative risk 0.592 (0.195-1.799); P = 0.817; I2 = 0.0%).

CONCLUSION

LMWH might decrease the incidence of PVST after splenectomy without a potential risk of bleeding.

Splenectomy and the incidence of venous thromboembolism and sepsis in patients with autoimmune hemolytic anemia

INTRODUCTION

The impact of splenectomy on venous thrombosis (VTE), abdominal thrombosis (abVTE) and sepsis in autoimmune hemolytic anemia (AIHA) is unclear.

METHODS

Using the California Discharge Dataset 1991-2014, 4756 AIHA patients were identified. Cumulative incidences (CI) of VTE, abVTE, and sepsis were determined in patients with and without splenectomy. Using propensity score matching adjusted for competing risk of death, the association between VTE, abVTE and sepsis with splenectomy was determined.

RESULTS

In those without splenectomy, the CIs of VTE, abVTE, and sepsis were 1.4%, 0.2%, and 4.3% respectively, compared to 4.4%, 3.0% and 6.7% with splenectomy. Splenectomy was associated with increased risk for VTE in immediate (HR 2.66, CI 1.36-5.23) and late (HR 3.29, CI 2.10-5.16) post-operative periods. AbVTE was increased in immediate post-operative period (HR 34.11, CI 4.93-236.11). Sepsis was only increased in late post-operative period (HR 2.20, CI 1.75-2.77). In multivariate models, older age, having >1 comorbidity and having VTE, abVTE, and sepsis were associated with increased mortality. Splenectomy was not associated with increased mortality.

DISCUSSION

Splenectomy in AIHA was associated with significant early thrombotic risk and long-term morbidity. Future research should evaluate the role of splenectomy in AIHA patients, and potential long-term thrombotic and antibiotic prophylaxis.

Effects of early antiplatelet therapy after splenectomy with gastro-oesophageal devascularization

BACKGROUND

This study aimed to explore the effects of early antiplatelet therapy (APT) for portal vein thrombosis (PVT) in patients with cirrhotic portal hypertension after splenectomy with gastro-oesophageal devascularization.

METHODS

We retrospectively analysed 139 patients who underwent splenectomy with gastro-oesophageal devascularization for portal hypertension due to cirrhosis between April 2010 and December 2016. Based on the post-operative platelet values, we used two different APT regimens: APT was started when platelet counts were increased to 200 × 10⁹ /L or above (group A, n = 64) or 300 × 10⁹ /L or above (group B, n = 75). We took note of the patients' clinical symptoms, operative factors and biochemical indicators.

RESULTS

Platelet count, mean platelet volume, D-dimer and pancreatic fistula were closely related to the development of PVT. Early APT was an independent protective factor for PVT. The incidence of post-operative PVT was 15.1% (21/139) overall, 4.7% (3/64) in group A and 24% (18/75) in group B; there was a significant difference between groups A and B (χ²  = 10.042, P = 0.002).

CONCLUSION

Platelet count, mean platelet volume, D-dimer and pancreatic fistula were independent risk factors for the development of PVT after splenectomy with gastro-oesophageal devascularization. Selection of the appropriate timing for early APT according to the post-operative platelet count was feasible. Moreover, the use of aspirin combined with dipyridamole was safe and effective for early prevention of PVT.

Incidence and predictors of portal and splenic vein thrombosis after pure laparoscopic splenectomy

BACKGROUND

Optimal modalities for diagnosis, treatment, and surveillance of portal or splenic vein thrombosis have not yet been defined. The present retrospective study aimed to investigate the role of computed tomography performed systematically before and after laparoscopic splenectomy to assess the incidence of portal or splenic vein thrombosis, predictors, and outcomes.

METHODS

Computed tomography scans were obtained from 170 patients undergoing elective laparoscopic splenectomy between 2005 and 2015. Pre- and postoperative splenic vein diameter was measured at the splenoportal junction and at a distance of 2, 4, 6 cm from it. Univariate and multivariate analyses were used to identify portal or splenic vein thrombosis risk factors and predictors of treatment outcome.

RESULTS

Overall, 68.2% of patients had benign hematologic diseases; 64.1% showed splenomegaly. Portal or splenic vein thrombosis occurred in 53.5% of patients (91/170), of whom 49.5% were asymptomatic. Preoperative splenic vein diameter measurements at 2, 4, and 6 cm from the splenoportal junction were significantly greater in portal or splenic vein thrombosis patients than in no-portal or splenic vein thrombosis patients. Patients with splenic vein diameter ≥8 mm at all measured sites had a greater risk of developing portal or splenic vein thrombosis (P = .009; odds ratio, 2.57; 95% confidence interval, 1.26-5.23). The majority of thromboses involved the distal splenic vein (45.1%, 41/91), and 41.7% of patients had thromboses located in multiple sites. Fully 71.4% showed complete resolution of portal or splenic vein thrombosis. Thrombus location at a single site predicted a favorable treatment outcome (P < .0001).

CONCLUSION

Portal or splenic vein thrombosis is a frequent complication of splenectomy that occurs asymptomatically in half of cases. Computed tomography could have an important role in identifying patients at risk of developing portal or splenic vein thrombosis as well as in predicting portal or splenic vein thrombosis resolution.

Laparoscopic Splenectomy for Benign Hematological Disorders in Adults: A Systematic Review

BACKGROUND

Since its introduction in the early 1990s, laparoscopic splenectomy (LS) has gained worldwide acceptance for spleen removal, especially in hematological patients.

AIM

The present review summarizes the current knowledge and results of LS for the treatment of benign hematological diseases in adults.

MATERIALS AND METHODS

A MEDLINE/PubMed database research was performed using the terms: "laparoscopic splenectomy" OR "laparoscopy" OR "splenectomy" AND "hematological disorders" OR "hematological disease" OR "hematology" AND "adults" as key words. We set our analysis starting date as January 1st 2010 and the end date as December 31st 2016. We identified 247 relative articles. All the references from the identified articles were searched for relevant information.

RESULTS

Twenty-seven articles were deemed appropriate for our analysis. LS was found to be feasible and safe in the majority of patients with benign hematological disorders, with a mortality rate ranging from 0% to less than 4% and the postoperative complications rate from 0% to 35.7%. The conversion rate was also very low (4%) and response (complete or partial) was achieved in more than 80% of patients. Lateral approach with four trocars was the most commonly used approach with concommitant cholecystectomy being correlated with increased operative time and morbidity.

CONCLUSION

Current literature holds that whenever splenectomy is required for the treatment of hematological disorders in adults, a laparoscopic approach should be offered as the gold standard. However, to strengthen the clinical evidence in favor of LS, more high-quality clinical trials on several issues of the procedure are necessary.

Hassab's operation for Joubert syndrome with congenital hepatic fibrosis: A case report

INTRODUCTION

Joubert syndrome is characterized by psychomotor developmental delay, hypotonia, oculomotor abnormalities, occasional retinal dystrophy and cystic kidneys, and frequent and often, striking breathing abnormalities, especially in the neonatal period, with panting tachypnea followed by apnea. We report a case of Joubert syndrome with hepatic fibrosis, portal hypertension, and pancytopenia treated by Hassab's operation.

PRESENTATION OF CASE

Our patient was a 27-year-old woman with a history of tachypnea, muscle hypotonia, and psychomotor retardation shortly after birth and a diagnosis of Joubert syndrome at 2 years of age. At 19 years of age, she was diagnosed with progressive pancytopenia. At 27 years of age, she visited her local doctor for sudden-onset hematemesis. Endoscopy revealed esophageal varices exhibiting the red color sign and no evidence of recent bleeding. Splenomegaly and development of portal collateral circulation were observed on computed tomography scans. The patient was referred to our hospital, where she was diagnosed with Joubert syndrome and hepatic fibrosis, portal hypertension, and hypersplenism. After performing Hassab's operation, the pancytopenia improved, but anticoagulant therapy was required for splenic vein thrombosis. The patient was discharged on postoperative day 25. Two years following surgery, the gastroesophageal varices were controlled, and no progression of the splenic vein thrombosis or hepatic failure was evident.

CONCLUSION

This is the first case report of Hassab's operation for congenital hepatic fibrosis in a patient with Joubert syndrome, a rare congenital condition. We achieved a favorable clinical outcome.

Effective Prevention for Portal Venous System Thrombosis After Splenectomy: A Meta-Analysis

PURPOSE

Portal venous system thrombosis (PVST) is a common and potentially life-threatening complication of splenectomy for portal hypertension due to cirrhosis.

METHODS

A meta-analysis was conducted to study the necessity of pharmacologic prophylaxis of PVST after splenectomy and how to select the feasible treatment method. Articles were searched through the PubMed, EMBASE, Cochrane Library databases, and CNKI.

RESULTS

Overall, 404 articles were initially identified, and 11 of them were eligible. Among these selected articles, 7 articles were associated with the necessity of anticoagulation for prevention of PVST, while 5 were about the drug selection. We first demonstrated that the incidence of PVST after splenectomy was significantly lower in patients who received the preventive measures than in those who did not (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.13-0.39, P < .00001). Then, we compared the new-style treatment with the conventional treatment and found that patients with new therapy method had lower incidence of PVST than those who received conventional treatment (OR: 0.37, 95% CI: 0.27-0.51, P < .00001). Also, some studies (n = 4) reported that early and combination use of anticoagulation drugs can lead to better outcome for patients with splenectomy and devascularization.

CONCLUSION

Preventative use of anticoagulant drugs might decrease the incidence of PVST after splenectomy in patients with portal hypertension, new anticoagulant drugs such as low-molecular-weight heparin should be used, and early or combination use of anticoagulation drugs might lead to lower PVST incidence for patients.

Early prophylactic anticoagulation for portal vein system thrombosis after splenectomy: A systematic review and meta-analysis

A systematic review and meta-analysis were conducted to evaluate the efficacy and safety of early prophylactic anticoagulation for the prevention of portal vein system thrombosis (PVST) after splenectomy. A systematic search of the PubMed, EMBASE, Springer and Cochrane Library databases was performed to identify studies comparing the outcomes in patients receiving or not receiving regular prophylactic anticoagulation after splenectomy. The quality of the included studies was assessed using the Jadad Score and the Newcastle-Ottawa Scale. Heterogeneity was evaluated using the χ² and I² tests. The parameters that were analyzed included the incidence of PVST and anticoagulation-associated complications. A total of seven studies qualified for the review, involving 383 and 283 patients receiving or not receiving regular prophylactic anticoagulation, respectively. The incidence of PVST was significantly reduced with an odds ratio (OR) of 0.31 [95% confidence interval (CI), 0.21-0.46; P<0.00001] in the regular prophylactic anticoagulation group compared with the control group. No difference in the incidence of anticoagulation-associated complications was identified between the two groups (OR=0.60, 95% CI, 0.23-1.56; P=0.30). Early prophylactic anticoagulation was associated with a reduced incidence of PVST, although it was not associated with the incidence of anticoagulation-associated complications. These results indicate that prophylactic anticoagulation could be safely administered after splenectomy, even to cirrhotic patients.

Resveratrol Reduces the Incidence of Portal Vein System Thrombosis after Splenectomy in a Rat Fibrosis Model

Purpose. To investigate the preventive effect of resveratrol (RES) on the formation of portal vein system thrombosis (PVST) in a rat fibrosis model. Methods. A total of 64 male SD rats, weighing 200–300 g, were divided into five groups: Sham operation, Splenectomy I, Splenectomy II, RES, and low molecular weight heparin (LMWH), with the former two groups as nonfibrosis controls. Blood samples were subjected to biochemical assays. Platelet apoptosis was measured by flow cytometry. All rats were euthanized for PVST detection one week after operation. Results. No PVST occurred in nonfibrosis controls. Compared to Splenectomy II, the incidences of PVST in RES and LMWH groups were significantly decreased (both p < 0.05). Two rats in LMWH group died before euthanasia due to intra-abdominal hemorrhage. In RES group, significant decreases in platelet aggregation, platelet radical oxygen species (ROS) production, and increase in platelet nitric oxide (NO) synthesis and platelet apoptosis were observed when compared with Splenectomy II (all p < 0.001), while in LMWH group only significant decrease in platelet aggregation was observed. Conclusion. Prophylactic application of RES could safely reduce the incidence of PVST after splenectomy in cirrhotic rat. Regulation of platelet function and induction of platelet apoptosis might be the underlying mechanisms.

A comparative study of two anti-coagulation plans on the prevention of PVST after laparoscopic splenectomy and esophagogastric devascularization

Cirrhosis and portal hypertension (PH) has a high incidence in China. Laparoscopic splenectomy and esophagogastric devascularization (LS + ED) was confirmed as an effective and safe surgical approach. But compared to open surgery (OS + ED), the rate of portal vein system thrombosis (PVST) was found to be higher after LS + ED. PVST is a common and potentially life-threatening complication after LS + ED in patients with cirrhosis and PH. Anti-coagulation therapy should be given early, but no standard plan for PSVT prophylaxis has been developed for all patients. In this study, the efficacy and safety of early use of low molecular weight heparin (LMWH) to prevent PVST were retrospectively evaluated compared with conventional anti-coagulant therapy. Of 219 patients with cirrhosis and PH undergoing LS + ED at our hospital from January 2008 to June 2013, 139 received early anti-coagulant therapy with LMWH, and 80 received conventional anti-coagulant therapy. The rates and types of PVST, perioperative coagulation function, intra-abdominal active bleeding, and esophagogastric variceal bleeding (EGVB) were compared in these two groups. Of the 139 patients in the early anti-coagulation group, 42 (30.2 %) experienced postoperative PVST, including two (1.4 %) with main trunk. Of the 80 patients in the conventional anti-coagulation group, 40 (50.0 %) experienced postoperative PVST, including 12 (15.0 %) with main trunk; three (3.8 %) experienced recurrent EGVB due to main trunk thrombosis, and one (1.3 %) underwent an immediate second laparotomy for uncontrollable active bleeding. The rates of postoperative PVST (P = 0.004), main trunk thrombosis (P = 0.000), and EGVB (P = 0.048) were significantly lower in the early than in the conventional anti-coagulant group, but all tested perioperative indices of coagulation function and rates of intraperitoneal active bleeding were similar. Early anti-coagulation with LMWH is safe and effective in patients with LS + ED for cirrhosis and PH.

Predictive model of portal venous system thrombosis in cirrhotic portal hypertensive patients after splenectomy

OBJECTIVE

This study is to investigate the risk factors of portal venous system thrombosis (PVT) in patients with cirrhotic portal hypertension after splenectomy and to establish a Logistic regression prediction model.

METHODS

A total of 119 patients with cirrhotic portal hypertension were enrolled. Their clinical data was retrospectively analyzed. They were divided into PVT group (n = 18) and non-PVT group (n = 101). One-way analysis and multivariate Logistic regression analysis were performed to analyze the independent risk factors of PVT. Logistic regression prediction model was established. The receiver operating characteristic curve was generated and correlation analysis was conducted.

RESULTS

Platelet count (PLT), mean platelet volume (MPV) and D-Dimer were independent risk factors affecting PVT. Anticoagulation therapy (UAT) and usage of reducing portal pressure therapy (URPT) were independent protective factors of PVT. Logistic regression prediction model was expressed as Logit P = -9.165 + 0.664 × PLT (× 10(11)/L) + 0.413 × MPV (fL) + 0.662 × D-Dimer (mg/L) -1.674 × UAT (Yes = 1, No = 0) -1.518 × URPT (Yes = 1, No = 0). And, the cut-off value of Logit P was -1.14. The area under the receiver operating characteristic curve and the accuracy were 0.865 and 84.03%. The cut-off value of PLT, MPV and D-Dimer were 4.42 × 10(11)/L, 13.30 fL and 2.55 mg/L, respectively. MPV and D-Dimer were positively correlated.

CONCLUSION

PLT, MPV and D-Dimer are independent risk factors while UAT and URPT are independent protective factors of PVT. Logistic regression prediction model can predict PVT with a high sensitivity, specificity and accuracy. It provides theoretical foundation and cut-off value for predicting PVT after splenectomy.

Early joint application of anticoagulant drugs to prevent portal vein thrombosis after splenectomy and devascularization

AIM: To assess the preventive effects of early joint application of anticoagulant drugs on portal vein thrombosis after splenectomy and devascularization and to explore the possible mechanism

METHODS: One hundred and twenty-eight patients with portal hypertension who underwent splenectomy and devascularization were included, including 28 patients with early application of low molecular heparin calcium (heparin group), 42 with joint application of low molecular heparin calcium and low molecular dextran (joint group), and 58 without the use of anticoagulant drugs (control group). The rate of postoperative thrombosis, postoperative platelet count, and prothrombin time (PT) were compared among the three groups. The indexes of portal vein blood flow were also recorded.

RESULTS: One month after surgery, portal vein thrombosis developed in 5 (8.57%) cases in the heparin group, in 1 (2.38%) case in the joint group, and in 14 (24.13%) cases in the control group. The rate of postoperative portal vein thrombosis was significantly higher in the control group than in the heparin group (P < 0.05), and in the heparin group than in the joint group (P < 0.05).

CONCLUSION: Early anticoagulation use can effectively prevent the formation of portal vein thrombosis after splenectomy, and combined use of low molecular heparin calcium and low molecular dextran has better effects.

Pharmacologic prophylaxis of portal venous system thrombosis after splenectomy: a meta-analysis

Portal venous system thrombosis (PVST) is a life-threatening complication of splenectomy. A meta-analysis was conducted to explore the role of pharmacologic prophylaxis of PVST after splenectomy. Overall, 359 papers were initially identified via the PubMed, EMBASE, and Cochrane Library databases. Eight of them were eligible. The incidence of PVST after splenectomy was significantly lower in patients who received the preventive measures than in those who did not (odds ratio [OR]: 0.33, 95% confidence interval [CI]: 0.22-0.47, P < 0.00001). Subgroup analyses demonstrated that the significant difference remained in studies including patients with portal hypertension (n = 6), but not in those including patients with hematological diseases (n = 2); the significant difference remained in studies using any type of prophylactic drugs (anticoagulants [n = 6], thrombolytics [n = 1], and prostaglandin E1 [n = 1]); the significant difference remained in nonrandomized studies (n = 5), but not in randomized studies (n = 3). The risk of bleeding was similar between the two groups (OR: 0.65, 95% CI: 0.10-4.04, P = 0.64). In conclusion, pharmacologic prophylaxis might decrease the incidence of PVST after splenectomy in patients with portal hypertension and did not increase the risk of bleeding. However, the effect of pharmacologic prophylaxis of PVST in patients with hematological diseases remained questioned.

Splenic vein thrombosis and pancreatic fistula after minimally invasive distal pancreatectomy

BACKGROUND

This study aimed to investigate the clinical relevance of splenic vein thrombosis (SVT) in the splenic vein remnant following minimally invasive distal pancreatosplenectomy (DPS).

METHODS

Medical records of patients who underwent laparoscopic or robotic distal pancreatectomy (DP) with or without splenectomy between January 2006 and August 2012 were reviewed. Rates of SVT and clinically relevant postoperative pancreatic fistula (POPF) were compared in a group of patients undergoing DPS and a group having spleen-preserving DP.

RESULTS

Seventy-nine patients had minimally invasive DP, of whom 38 (48 per cent) developed SVT in the splenic vein remnant. DPS was associated with POPF (P = 0.001) and SVT (P < 0.001). SVT length was closely related to the amount of peripancreatic fluid collection (P = 0.025) and POPF (P = 0.045). In a comparison of splenic vessel-sacrificing, spleen-preserving DP and DPS, postoperative platelet count was significantly higher in the DPS group (P < 0.001). In addition, grade of SVT (P = 0.092) and POPF (P = 0.065) tended to be associated with DPS, suggesting that SVT may be related to both splenectomy and POPF.

CONCLUSION

Minimally invasive DPS is associated with SVT and POPF. Preservation of the spleen should be considered when treating patients with benign and borderline malignant tumours of the distal pancreas.

Portal vein thrombosis after partial splenic embolization in liver cirrhosis: efficacy of anticoagulation and long-term follow-up

PURPOSE

To investigate the treatment and long-term outcome of portal vein thrombosis (PVT) after partial splenic embolization (PSE).

MATERIALS AND METHODS

From January 2006 to December 2011, 145 patients with hypersplenism caused by cirrhotic portal hypertension underwent PSE. In 11 cases, PVT was detected 13-42 days after PSE. Among the 11 patients, 5 underwent anticoagulant therapy because of clinical symptoms, and 6 did not receive anticoagulation because they were symptom-free (4 patients) or experienced variceal bleeding (2 patients). The long-term follow-up data from these 11 patients were analyzed retrospectively.

RESULTS

The 11 patients with PVT had a mean splenic infarction ratio of 71.5%. The mean duration of follow-up was 37.6 months. During the follow-up period, none of the 5 patients who underwent anticoagulation developed variceal hemorrhage despite presenting with large esophagogastric varices. Four of the five patients achieved complete resolution of thrombosis, and one did not develop thrombus progression. However, among the 6 patients who did not undergo anticoagulation, 2 developed esophagogastric variceal hemorrhage secondary to thrombus progression, 3 developed cavernous transformation of the portal vein and variceal progression, and 1 had partial calcification of the thrombus. Two patients who had variceal bleeding or rebleeding underwent a transjugular intrahepatic portosystemic shunt. Complete recanalization of the portal vein was achieved after the procedures.

CONCLUSIONS

PVT is a severe, potentially fatal complication of PSE. Early detection of PVT and prompt anticoagulation are effective to avoid serious consequences of PVT.

Postoperative outcomes after laparoscopic splenectomy compared with open splenectomy

OBJECTIVE

To evaluate 30-day postoperative outcomes in laparoscopic (LS) versus open splenectomy (OS).

SUMMARY BACKGROUND DATA

LS has generally been associated with lower rates of postoperative complications than OS. However, evidence mainly comes from small studies that failed to adjust for the confounding effects of the underlying indication or clinical condition that may have favored the use of one technique over the other.

METHODS

A retrospective cohort study of patients undergoing splenectomy in 2008 and 2009 using data from the American College of Surgeons National Surgical Quality Improvement Program database (n = 1781). Retrieved data included 30-day mortality and morbidity (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thromboembolism, and major bleeding outcomes), demographics, indication, and preoperative risk factors. We used multivariate logistic regression to assess the adjusted effect of the splenectomy technique on outcomes.

RESULTS

A total of 874 (49.1%) cases had LS and 907 (50.9%) had OS. After adjusting for all potential confounders including the indication and preoperative risk factors, LS was associated with decreased 30-day mortality [OR (odds ratio): 0.39, 95% CI: 0.18-0.84] and postoperative respiratory occurrences (OR: 0.46, 95% CI: 0.27-0.76), wound occurrences (OR: 0.37, 95% CI: 0.11-0.79), and sepsis (OR: 0.52, 95% CI: 0.26-0.89) when compared with OS. Patients who underwent LS also had a significantly shorter total length of hospital stay and were less likely to receive intraoperative transfusions compared with patients who underwent OS.

CONCLUSIONS

LS is associated with more favorable postoperative outcomes than OS, irrespective of the indication for splenectomy or the patient's clinical status.

Laparoscopic splenectomy: a single center experience. Unusual cases and expanded inclusion criteria for laparoscopic approach

Laparoscopic splenectomy (LS) is nowadays considered as the gold standard for most hematological diseases where splenectomy is necessary, but many questions still remain. The aim of this study was to analyze our 5-years experiences consisting of 48 consecutive LS cases in order to assess the optimal approach and the feasibility of the procedure also in malignant diseases and unusual cases such as a primary spleen lymphoma, a big splenic artery aneurism, or a spleen infarct due to a huge pancreatic pseudo-cyst. Forty-eight consecutive patients underwent LS from January 2006 to January 2011 with at least 1-year follow-up. Clinical data and immediate outcome were retrospectively recorded; age, diagnosis, operation time, perioperative transfusion requirement, conversion rate, accessory incision, hospital stay, and complications were analyzed. We had 14 cases of malignant splenic disease, the most frequent malignant diagnosis was non-Hodgkin's lymphoma (12/14, 85.7 %). Splenomegaly (interpole diameter (ID) >20 cm) was observed in 12 cases (25 %) and massive splenomegaly (ID >25 cm) in 3 cases (6.25 %). Conversion to laparotomy occurred in two patients (4.16 %), both associated to uncontrollable bleeding in patients with splenomegaly. Mean operative time was 138 ± 22 min. Mean hospital stay was 4.5 days. Postoperative morbidity rate was 8.8 % for the benign group and 35.7 % in the malignant group. Mortality occurred in 1/48 patients (2.08 %), as a result of overwhelming post-splenectomy infection (OPSI). LS can be performed safely for malignant splenic disease and splenomegaly without any statistically significant increase of morbidity and mortality rate. Conversion rate is increased for massive splenomegaly. LS should be considered as the preferential approach even in patients with malignant disease, splenomegaly, or unusual cases. Massive splenomegaly should be considered as relative contraindication to LS even at experienced centers.

Anticoagulation therapy prevents portal-splenic vein thrombosis after splenectomy with gastroesophageal devascularization

AIM: To compare the incidence of early portal or splenic vein thrombosis (PSVT) in patients treated with irregular and regular anticoagulantion after splenectomy with gastroesophageal devascularization.

METHODS: We retrospectively analyzed 301 patients who underwent splenectomy with gastroesophageal devascularization for portal hypertension due to cirrhosis between April 2004 and July 2010. Patients were categorized into group A with irregular anticoagulation and group B with regular anticoagulation, respectively. Group A (153 patients) received anticoagulant monotherapy for an undesignated time period or with aspirin or warfarin without low-molecular-weight heparin (LMWH) irregularly. Group B (148 patients) received subcutaneous injection of LMWH routinely within the first 5 d after surgery, followed by oral warfarin and aspirin for one month regularly. The target prothrombin time/international normalized ratio (PT/INR) was 1.25-1.50. Platelet and PT/INR were monitored. Color Doppler imaging was performed to monitor PSVT as well as the effectiveness of thrombolytic therapy.

RESULTS: The patients’ data were collected and analyzed retrospectively. Among the patients, 94 developed early postoperative mural PSVT, including 63 patients in group A (63/153, 41.17%) and 31 patients in group B (31/148, 20.94%). There were 50 (32.67%) patients in group A and 27 (18.24%) in group B with mural PSVT in the main trunk of portal vein. After the administration of thrombolytic, anticoagulant and anti-aggregation therapy, complete or partial thrombus dissolution achieved in 50 (79.37%) in group A and 26 (83.87%) in group B.

CONCLUSION: Regular anticoagulation therapy can reduce the incidence of PSVT in patients who undergo splenectomy with gastroesophageal devascularization, and regular anticoagulant therapy is safer and more effective than irregular anticoagulant therapy. Early and timely thrombolytic therapy is imperative and feasible for the prevention of PSVT.

Short- and long-term risks of splenectomy for benign haematological disorders: should we revisit the indications?

Splenectomy has represented a key treatment option in the treatment of many benign haematological diseases, including immune thrombocytopenia (ITP) and disorders associated with ongoing haemolysis (thalassaemia major and intermedia, sickle cell disease, and hereditary or acquired haemolytic anaemias). Improvements in surgical techniques have reduced perioperative complications and mortality. Preventive measures (new protein conjugate vaccines, antibiotic prophylaxis, and increased vigilance) are thought to greatly reduce the risk of overwhelming post-splenectomy infection (OPSI), although their implementation is inconsistent. Nevertheless, there is increasing documentation of the short- and long-term risks of splenectomy, which vary according to the underlying indication. Splenectomized patients are at increased risk of venous thromboembolism, particularly within the splenoportal system. The long-term thromboembolic risk is higher in haematological disorders associated with ongoing haemolysis, particularly in thalassaemia intermedia, which has led to a more conservative approach. In comparison, patients with ITP appear to be at lower risk of adverse effects of splenectomy, which maintains its place as the potentially most curative and safe second-line treatment. However, a splenectomy-sparing approach is also emerging for ITP, and recent guidelines recommend that this procedure is deferred until ≥ 12 months from ITP diagnosis, to allow sufficient time for possible remission.