Effect of operations for variceal hemorrhage on hypersplenism

doi:10.1016/0002-9610(82)90554-2

The American Journal of Surgery

Volume 144, Issue 6, December 1982, Pages 700-703

https://doi.org/10.1016/0002-9610(82)90554-2 Get rights and content

Abstract

Hypersplenism frequently accompanies cirrhosis with portal hypertension. In this series of 76 patients, 36 percent had thrombocytopenia, 41 percent had leukopenia, and 25 percent had both thrombocytopenia and leukopenia. However, hypersplenism was severe enough to necessitate splenectomy in only two patients (3 percent).

Nonalcoholic cirrhotic patients exhibit hypersplenism more frequently and to a greater magnitude than do alcoholic cirrhotic patients. Fourteen and 44 percent of alcoholic and nonalcoholic cirrhotics, respectively, had both thrombocytopenia and leukopenia. Distal splenorenal shunts and nonselective shunts are equally effective in relieving preoperative hypersplenism. Approximately two thirds of the patients were relieved of thrombocytopenia or leukopenia after either of these procedures. Splenectomy invariably corrects hypersplenism associated with cirrhosis and should be included as part of the operative procedure in patients requiring surgery for control of variceal hemorrhage.

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Cited by (48)

Laparoscopic Splenectomy with Technical Standardization and Selection Criteria for Standard or Hand-Assisted Approach in 390 Patients with Liver Cirrhosis and Portal Hypertension
2015, Journal of the American College of Surgeons
Laparoscopic splenectomy (LS) is still challenging in patients with liver cirrhosis and portal hypertension. This study was designed to establish safe and less invasive LS in patients with liver cirrhosis and portal hypertension.
We analyzed 390 patients with liver cirrhosis and portal hypertension, who underwent LS between 1993 and 2013. Patients were divided into 3 time periods; early (1993 to 2004, n = 106); middle (2005 to 2008, n = 159); and late (2008 to 2013, n = 125). During the middle time period, standardized technique for LS and selection criteria for hand-assisted LS were adopted. Patients with spleen volume ≥ 1,000 mL by CT volumetry, large perisplenic collateral vessels, and/or Child-Pugh score ≥ 9, underwent hand-assisted LS. During the late time period, the selection criteria were refined and patients with spleen volume ≥ 600 mL underwent hand-assisted LS.
Conversion to open splenectomy decreased (10.4% in the early time period, 1.9% in the middle time period, and 3.2% in the late time period, p = 0.004), median blood loss decreased (300g, 87g, and 98g, respectively, p < 0.001), and the success rate of pure LS tended to improve (87.2%, 89.5%, and 98.0%, respectively, p = 0.110). Mortality was 0% in each time period, Clavien-Dindo grade IIIb or more complications tended to decrease (5.7%, 2.5%, and 0.8%, respectively, p = 0.081), and technique-related complications decreased significantly (10.4%, 3.8%, and 2.4%, respectively, p = 0.014).
Laparoscopic splenectomy is now a safe and less invasive approach, even in patients with liver cirrhosis and portal hypertension, because of its technical standardization with the refined selection criteria for pure or hand-assisted LS.
Incidence, Prevalence, and Clinical Significance of Abnormal Hematologic Indices in Compensated Cirrhosis
2009, Clinical Gastroenterology and Hepatology
Citation Excerpt :
In contrast, leukopenia was present in 42% of patients at baseline and anemia in 37%. Previous studies have reported a wide range for abnormal HI in cirrhosis.1–8 This might partly be due to the cross-sectional nature of prior studies and the differing severities of cirrhosis.
Patients with cirrhosis develop abnormal hematologic indices (HI) from multiple factors, including hypersplenism. We aimed to analyze the sequence of events and determine whether abnormal HI has prognostic significance.
We analyzed a database of 213 subjects with compensated cirrhosis without esophageal varices. Subjects were followed for approximately 9 years until the development of varices or variceal bleeding or completion of the study; 84 subjects developed varices. Abnormal HI was defined as anemia at baseline (hemoglobin, ≤13.5 g/dL for men and 11.5 g/dL for women), leukopenia (white blood cell counts, ≤4000/mm³), or thrombocytopenia (platelet counts, ≤150,000/mm³). The primary end points were death or transplant surgery.
Most subjects had thrombocytopenia at baseline. Kaplan–Meier analysis showed that leukopenia occurred by 30 months (95% confidence interval, 18.5–53.6), and anemia occurred by 39.6 months (95% confidence interval, 24.1–49.9). Baseline thrombocytopenia (P = .0191) and leukopenia (P = .0383) were predictors of death or transplant, after adjusting for baseline hepatic venous pressure gradient (HVPG), and Child–Pugh scores. After a median of 5 years, a significant difference in death or transplant, mortality, and clinical decompensation was observed in patients who had leukopenia combined with thrombocytopenia at baseline compared with patients with normal HI (P < .0001). HVPG correlated with hemoglobin and white blood cell count (hemoglobin, r = −0.35, P < .0001; white blood cell count, r = −0.31, P < .0001).
Thrombocytopenia is the most common and first abnormal HI to occur in patients with cirrhosis, followed by leukopenia and anemia. A combination of leukopenia and thrombocytopenia at baseline predicted increased morbidity and mortality.
Laparoscopic splenectomy reverses thrombocytopenia in patients with hepatitis C cirrhosis and portal hypertension
2004, Journal of Gastrointestinal Surgery
Pegylated-interferon (IFN) plus ribavirin remains the most effective therapeutic regimen for patients with chronic hepatitis C infection. Thrombocytopenia is a common side effect of this treatment, often leading to discontinuation of a potentially curative therapy. We sought to determine the safety and efficacy of laparoscopic splenectomy in correcting thrombocytopenia, thus allowing completion of IFN therapy. Data were collected prospectively from September 2000 to May 2003 on all patients undergoing laparoscopic splenectomy for thrombocytopenia associated with IFN therapy and/or hepatitis C cirrhosis with portal hypertension. Demographic data, model of end-stage liver disease (MELD) score, platelet count, operative time, blood loss, spleen weight, complications, length of stay, and follow-up time were calculated. Eleven patients (7 men, 4 women) underwent laparoscopic splenectomy; their mean age was 45.4 years (range 27 to 55 years) and mean body mass index was 27 kg/m² (range 21 to 44 kg/m²). All patients were Child's class A, with a mean preoperative MELD score of 9.1 (range 6 to 11). Mean operative time was 189 minutes (range 70 to 245 minutes), and blood loss averaged 141 ml (range 10 to 600 ml). A hand-assisted laparoscopic technique was used in four cases. Six patients received empiric intraoperative platelet administration. None required transfusion with packed red cells. Splenic weight averaged 1043 g (range 245 to 1650 g). Average length of stay was 2.6 days (range 1 to 6 days). Four patients had the following minor postoperative complications: self-limited atrial fibrillation (n = 1), trocar site cellulitis (n = 1), and atelectasis (n = 2). There have been no major complications over an average follow-up of 11 months (range 1 to 18 months). Mean postoperative MELD score was 8.3 (range 6 to 10). Platelet counts improved from a preoperative mean of 55,000/ul (16,000 to 88,000/μl) to 439,000/μl (200,000 to 710,000/μl) postoperatively and have remained above 100,000/μl (104,000 to 397,000/μl) during subsequent pegylated-IFN therapy. Three patients have completed a full course of IFN therapy and have obtained a sustained virologic response. Treatment is ongoing in the remaining patients. Laparoscopic splenectomy is safe in the setting of portal hypertension and thrombocytopenia associated with chronic hepatitis C infection. It can be performed with little blood loss, no need for red cell transfusion, and minimal perioperative morbidity. Laparoscopic splenectomy appears to effectively reverse thrombocytopenia and may allow these patients to safely complete IFN therapy.
Splenectomy in patients with hepatocellular carcinoma and hypersplenism
2000, Journal of the American College of Surgeons
Background: Hypersplenism secondary to portal hypertension is common in hepatocellular carcinoma (HCC), but surgeons still face the unresolved problem of how to manage HCC patients with hypersplenism.
Study Design: The records of 48 patients with HCC and hypersplenism were retrospectively examined and postoperative changes in platelet counts, serum total bilirubin levels, and clinical staging scores were analyzed to evaluate the clinical value of combined splenectomy and liver resection. Hepatectomy and splenectomy were performed as a two-stage operation in 13 patients and synchronously in 35.
Results: Postoperative platelet counts were significantly increased, and serum total bilirubin levels were significantly decreased. Clinical staging scores were also reduced after splenectomy in patients who underwent splenectomy before hepatectomy.
Conclusions: Synchronous or metachronous splenectomy can increase the safety of hepatectomy in selected patients with HCC by reducing both the likelihood of bleeding complications and bilirubin overload.
Course of platelet counts in cirrhotic patients after implantation of a transjugular intrahepatic portosystemic shunt - A prospective, controlled study
1999, Journal of Hepatology
Background/Aims: The pathogenesis of thrombocytopenia associated with advanced liver disease is still controversial. To study the impact of portal decompression on this hematologic complication, we conducted a prospective, controlled study to compare the course of platelet counts in patients after implantation of a transjugular intrahepatic portosystemic shunt (TIPS) with matched controls without shunts.
Methods: Fifty-five TIPS patients and 110 controls matched for age, sex, Child-Pugh class, etiology of liver disease and baseline platelet count were included, and followed for 1 year. Follow-up visits were scheduled after 1 month, after 3 months, and at 3-month intervals thereafter.
Results: Nonparametric Mann-Whitney U-tests revealed significantly higher platelet counts for TIPS patients as compared to controls from the 1st through the 12th month (p<0.01). During the study period, the median platelet count of TIPS patients increased by 19.7%, from 104.0/nl (IR: 68.0) to 124.5/nl (IR: 41.0). In contrast, during the same period the median platelet count of controls decreased by 17.1%, from 102.5/nl (IR: 66.0) to 85.0/nl (IR: 67.5). In the group of cases with baseline platelet counts ≤100/nl, platelet counts had increased by at least 25% at month 12 in 65% of TIPS patients, but in only 5% of controls (p<0.001). However, normalization of platelet counts, i.e. ≥150/nl, was not achieved in any case. Neither the portosystemic pressure gradient after TIPS implantation, nor the percentage of portosystemic pressure gradient reduction during the procedure was predictive of platelet response.
Conclusions: TIPS implantation increases platelet counts significantly. However, portal hypertension is clearly not the only mechanism contributing to thrombocytopenia in advanced liver disease.
50 years of abdominal surgery at the Southwestern Surgical Congress: Common problems and uncommon surgeons
1998, American Journal of Surgery

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^☆: Presented at the 34th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 26–29, 1982.

¹: From the Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.

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Scientific paperEffect of operations for variceal hemorrhage on hypersplenism☆

Abstract

Am J Surg

Am J Med

Lancet

Lancet

Gastoenterology

Effect of portacaval anastomosis on hypersplenism

Dig Dis Sci

Correction of hypersplenism following DSRS

Surgery

Scientific paper
Effect of operations for variceal hemorrhage on hypersplenism☆