Abstract
Background
The dilemma of current treatments for symptomatic patients with portal hypertension is how to resolve the problems of the varices and hypersplenism simultaneously and meanwhile preserve the splenic function. Partial splenectomy and pericardial devascularization is a potential alternative to currently used approaches, but it is incompletely defined. This study aimed to evaluate the efficacy and safety of partial splenectomy and pericardial devascularization.
Methods
This study followed 132 symptomatic patients with portal hypertension who underwent partial splenectomy and pericardial devascularization in the General Surgery Department of the Fifth Medical Center of PLA General Hospital from 2016 to 2023. Clinical, laboratory, endoscopic examination and imaging data were collected and compared between preoperative and postoperative levels at intervals using a mixed linear model.
Results
All 132 patients with portal hypertension successfully underwent partial splenectomy and pericardial devascularization without intraoperative uncontrolled massive bleeding or death. Leucocyte and platelet counts increased to normal levels at intervals from 1 year to ≥ 4 years postoperatively. Among the patients followed for six months postoperatively, 23 (52.27%) showed improvement in esophagogastric varices, 19 (43.18%) had no significant changes in their condition, and 2 (4.55%) experienced worsening of the varices. At subsequent follow-ups, the majority of patients either showed improvements or no change in their esophagogastric varices, with only a small fraction experiencing worsening of the condition. The splenic remnant survived in most patients, and regrowth was very limited postoperatively, while 13 (9.85%) patients splenic remnant necrosis during follow-up. Liver failure was observed in 5 (3.79%) patients postoperatively, and 3 (2.27%) of them died perioperatively. Portal vein thrombosis was found in 90 (75%) patients the 7th days after surgery. With the progression of follow-up time, the proportion of patients with postoperative portal vein system thrombosis decreased over time. 3 (2.27%) patients experienced postoperative abdominal bleeding, which improved after emergency surgery for hemostasis.
Conclusions
Partial Splenectomy and Pericardial Devascularization appears to be a safe and effective approach to treat symptomatic patients with Portal Hypertension, while preserving the potential function of the spleen.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12893-025-03091-5.
Keywords: Portal hypertension, Gastroesophageal varices, Hypersplenism, Partial splenectomy, Pericardial devascularization
Background
Portal hypertension is a common and complex clinical syndrome, especially in patients with cirrhosis [1]. Patients with gastroesophageal varices and severe hypersplenism secondary to portal hypertension confront life-threatening risks of variceal hemorrhage as well as potential harms, including abdominal compression symptoms from significant splenomegaly and contraindications to invasive treatments and chemotherapy due to obvious pancytopenia or thrombocytopenia or leukopenia [2, 3].
Currently, there is no satisfactory approach for addressing the issues of gastroesophageal varices and hypersplenism simultaneously, while preserving splenic function.
Endoscopic therapies used alone are effective in controlling active variceal hemorrhage and preventing rebleeding through regular monitoring and repeated treatment [4, 5]. However, they are ineffective for hypersplenism and carry risks for patients with severe hypersplenism due to the increased bleeding risk from significant platelet reduction.
Transjugular intrahepatic portosystemic shunt (TIPS) reduces the risk of gastroesophageal variceal bleeding by decreasing portal pressure via a stent placed between portal vein and hepatic vein. However, it increases the incidence of liver dysfunction and hepatic encephalopathy due to the reduced hepatic blood flow caused by the artificial shunt, and has no significant effect on hypersplenism [6, 7].
Splenic artery embolization and radiofrequency ablation can attenuate hypersplenism by reducing splenic size and improving pancytopenia. However, over a prolonged period of follow-up, blood cell counts tend to return to the initial range. Moreover, serious complications, such as splenic infarction and abscess after embolization [8, 9], as well as intraperitoneal bleeding post-ablation requiring emergency splenectomy [10], limited their usage.
Surgical treatments for portal hypertension include the creation of portosystemic shunts to decrease portal pressure, procedures to disrupt blood flow into the varices, and removal of the enlarged spleen to eliminate hypersplenism. Studies have shown that shunt surgery can reduce the risk of variceal bleeding, but it also increases the incidence of hepatic encephalopathy [11]. Total splenectomy and pericardial devascularization can effectively decrease the risk of variceal hemorrhage, although rebleeding rates may vary, with some studies reporting rates as high as 40% [5],while also eliminating hypersplenism simultaneously. However, removing the spleen, which is the largest secondary lymphoid organ in human body, can possibly decrease the patients'immune function and make them more susceptible to certain infectious diseases [12]. Another major problem associated with total splenectomy is the development of thrombosis in the splenic and portal vein postoperatively [13–15].
For most patients with gastroesophageal varices and hypersplenism secondary to portal hypertension, we seek a therapy that can not only resolve the problems of varices and hypersplenism, but also preserve the immune function of the spleen and reduce the formation of portal systemic thrombosis.
Partial splenectomy and pericardial devascularization appears to be one such treatment modality. Partial splenectomy, as a viable procedure, is usually used in treating benign splenic diseases [16, 17], with few reports on its use for hypersplenism secondary to portal hypertension due to the risk of perioperative hemorrhage from increased portal pressure. Nowadays, with the improvement of techniques and instruments, partial splenectomy for hypersplenism secondary to portal hypertension tends to be a technically feasible, safe and effective procedure.
In the West, gastroesophageal varices and hypersplenism related to portal hypertension are mostly treated at different times using different approaches, including endoscopic therapy, transjugular intrahepatic portosystemic shunt (TIPS), splenic artery embolization, radiofrequency ablation, etc. However, in China, we usually eliminate hypersplenism and relieve varices at the same time using surgical approach. Given the potential advantage of partial splenectomy over total splenectomy in preserving splenic function, we have been performing partial splenectomy and pericardial devascularization since 2016.
This study introduces partial splenectomy and pericardial devascularization as a treatment for portal hypertension combined with gastroesophageal varices and hypersplenism.
Methods
This study was approved by the Ethics Committee of the Fifth Medical Center of PLA General Hospital. Written informed consent was obtained from all participating patients.
Study design and population
It is a single-center retrospective study. From October 2016 to March 2023, a total of 132 symptomatic patients with hypersplenism and/or gastroesophageal varices secondary to portal hypertension, who underwent partial splenectomy and pericardial devascularization at the Department of General Surgery at the Fifth Medical Center of PLA General Hospital, were included. The patients’ characteristics are listed in Table 1. All the patients were diagnosed with portal hypertension, with or without esophageal and/or gastric varices, and hypersplenism, based on epidemiologic, clinical, laboratory, endoscopic examination, and imaging data.
Table 1.
Characteristics of 132 patients with symptomatic portal hypertension
| Characteristic | Data |
|---|---|
| Age, mean ± SD, years | 49.98 ± 12.00 |
| Sex, n (%) | |
| Male | 56 (42.4%) |
| Female | 76 (57.6%) |
| Primary liver disease, n (%) | |
| AIH | 2 (1.52%) |
| ALD + HBV | 1 (0.76%) |
| ALD | 7 (5.30%) |
| DILI | 2 (1.52%) |
| HBV | 82 (62.12%) |
| HCV | 7 (5.30%) |
| CC | 6 (4.55%) |
| IPH | 12 (9.09%) |
| NASH | 3 (2.27%) |
| PBC | 8 (6.06%) |
| PBC-AIH | 2 (1.52%) |
| History of upper gastrointestinal bleeding, n (%) | |
| NO | 21 (15.91%) |
| YES | 111 (84.09%) |
| Preoperative varicose veins, n (%) | |
| NO | 2 (1.65%) |
| Mild | 6 (4.96%) |
| Moderate | 38 (31.40%) |
| Severe | 75 (61.98%) |
| Laboratory tests before PSPD, mean ± SD | |
| Leucocyte count (*109/L) | 2.17 ± 0.99 |
| Platelet count (*109/L) | 58.61 ± 37.76 |
| Spleen diameter before PSPD, mean ± SD, mm | 138.48 ± 20.38 |
| CHILD–PUGH grade, n (%) | |
| A | 99 (75%) |
| B | 33 (25%) |
| Preoperative PVT, n (%) | |
| NO | 85 (64.39%) |
| Yes | 47 (35.61%) |
| Follow-up, n (%) | |
| 7days | 132 (100%) |
| 6months | 89 (67.42%) |
| 1 year | 63 (47.73%) |
| 2 years | 43 (32.58%) |
| 3 years | 26 (19.70%) |
| ≥ 4 years | 22 (16.67%) |
Data are expressed as mean ± SD or number (percent) of patients
AIH autoimmune hepatitis, ALD alcoholic liver disease, DILI drug-induced liver injury, HBV hepatitis B, HCV hepatitis C, CC cryptogenic cirrhosis, IPH idiopathic portal hypertension, NASH non-alcoholic steatohepatitis, PBC primary biliary cirrhosis, PSPD partial splenectomy and pericardial devascularization, PVT portal vein thrombosis
Diagnostic criteria include: a history (or lack thereof) of hematemesis or melena due to esophageal and/or gastric variceal rupture; esophageal and/or gastric varices confirmed by endoscopic examination; pancytopenia, thrombocytopenia, and/or leukopenia confirmed by hematological examination; cirrhotic or non-cirrhotic portal hypertension confirmed by CT scan, Ultrasound test, liver stiffness test, or liver biopsy.
Exclusion criteria: patients with gastroesophageal varices but no hypersplenism; patients with Child–Pugh C liver function; patients with no surgical indications or with surgical contraindications.
Indication for surgery: symptomatic patients with portal hypertension associated with hypersplenism and esophageal and/or gastric varices, with or without a history of gastrointestinal hemorrhage.
Contraindication for surgery: Child–Pugh C liver function; cardiopulmonary insufficiency; with any other factor that is not suitable for surgical operation.
Surgical procedure
After discussing the potential risks and benefits, the procedures of partial splenectomy and pericardial devascularization were performed.
The objective of each partial splenectomy and pericardial devascularization was to resect the majority of the enlarged spleen, preserve a small lobe at the lower pole of the spleen with its blood vessels, including branches from the splenic artery and vein, and disconnect the gastric coronary vein and its branches, the short gastric vein, retrogastric vein, left inferior phrenic vein and other venous branches related to esophageal and gastric varices.
All patients were prepared for conversion to total splenectomy in case of intraoperative uncontrollable bleeding or difficulty in preserving part of the spleen.
After exposure of the spleen via a left rectus incision with a small rostral extension toward the midline, the left gastroepiploic vessels and short gastric vessels are ligated on the greater curvature side of the stomach to expose the hilum of the spleen. The splenic artery is dissected out, suspended with a vascular tape, and intermittently clamped with an arterial clamp to facilitate splenic blood flow from the splenic vein to the portal vein, reduce the size of the spleen, and increase the space available for the surgery. The attachments and collateral circulation vessels around the spleen are ligated and disconnected to fully mobilize the spleen. The splenic pedicle is isolated and controlled with a hemostatic sling, allowing bleeding during surgery to be controlled by blocking the splenic pedicle at any time. The vessels of the reserved lobe from the lower pole of the spleen are isolated from the splenic pedicle and suspended with a vascular sling. The other splenic hilar vessels except for those of the reserved spleen, are disconnected by Endo-GIA, and the vascular ends are continuously sutured by Prolenes to prevent possible bleeding. The ischemic portion of the spleen is demarcated along the ischemic line that appears on the surface of the spleen. The vessels of the reserved spleen are intermittently clamped before dividing the splenic parenchyma to reduce intraoperative bleeding. The splenic parenchyma was transected along the demarcation line using an artery forceps, and the vessels at the splenic transection are ligated one by one with silk sutures before transection. After most of the spleen has been completely removed, the vascular clamp is released. Hemostasis is achieved by suturing, electrocoagulation, and other methods, depending on the bleeding condition of the splenic section. When there is no significant active bleeding from the splenic section, it was covered with absorbable hemostatic tissue to form a protective film to prevent further bleeding (Fig. 1). Gastric coronary vein and its branches along the gastric lesser curvature and the abdominal esophagus, short gastric vein, retrogastric vein, left inferior phrenic vein and other venous branches related to esophageal and gastric varices are ligated and disconnected. The abdominal esophagus is isolated to ligate and divide its surrounding varices, and its surrounding vagus nerves are preserved if possible. After ligating the varicose veins around the cardia, interrupted seromuscular layer sutures are performed at the sites where the short gastric veins and part of the left gastroepiploic vein are ligated along the greater curvature of the stomach using silk sutures. This technique causes part of the gastric wall along the greater curvature to invaginate toward the mucosal layer and protrude into the gastric lumen. This reduces the gastric cavity volume and minimizes the risk of postoperative gastric retention. A wedge liver biopsy is performed in all cases. Splenic blood bleeding during the operation is collected and proposed by CATS (Continuous Autotransfusion system, FRESENIU-KABI, Germany) and then transfused back into the patient. This is a particularly critical step to ensure the safety of the surgery, especially in patients at high risk of bleeding during the operation.
Fig. 1.
The surgical procedure of partial splenectomy and the comparison of preoperative and postoperative imaging of the spleen. A Markedly enlarged spleen in the abdominal cavity. B The indicated lower pole of the residual spleen. C Transection of the splenic parenchyma. D The preserved remaining spleen. E Preoperative spleen on abdominal CT (coronal plane). F Postoperative spleen on abdominal CT (corona plane). G Preoperative spleen on 3D reconstruction of the portal venous system. H postoperative spleen on 3D reconstruction of the portal venous system
All patients received standard postoperative care, and the average postoperative stay was 10.42 ± 4.22 days. Patients received antibiotic prophylaxis perioperatively and were kept under vigorous activity restriction for 4–6 weeks postoperatively to minimize the risk of intra-abdominal bleeding. Postoperatively, when the abdominal drainage fluid was no longer bloody, the patient began subcutaneous injections of low molecular weight heparin calcium,5000 units daily, continuing until one month after surgery. Then the patient switched to oral aspirin enteric-coated tablets (100mg/day) or clopidogrel tablets (75mg/day) for 3–6 months to prevent portal venous system thrombosis.
Evaluation
Clinical manifestations were used to analyze postoperative complications: abdominal bleeding, esophagogastric hemorrhagic recurrence, pancreatic fistula, gastric fistula, gastroparesis, encephalopathy, signs of hepatic failure, and death.
Laboratory evaluations in the preoperative and late postoperative periods included levels of hemoglobin, leukocytes, platelets, lymphocytes, albumin, bilirubin, cholinesterase, fibrinogen, and prothrombin activity.
Patients underwent upper digestive endoscopy during the preoperative and postoperative periods, and varices were assessed by location, diameter and risk factor and classified according to LDRf classification [18]. Six months after operation, some patients with the remaining severe esophageal and/or gastric varices underwent endoscopic therapy to eradicate varices and reduce the risk of rebleeding. Endoscopic treatment was repeated in cases of persistence of esophageal and/or gastric varices, appearance of new vessels, or rebleeding.
Splenic imaging
To evaluate the splenic regrowth and portal vein thrombosis after partial splenectomy and pericardial devascularization, we measured splenic size and detected portal vein thrombosis using enhanced abdominal CT scan (three-dimensional vascular reconstruction CT) preoperatively and at postoperatively intervals of 1 week, 6 months and 12 months, and then yearly thereafter.
The most accurate way to measure the size of the spleen is by determining its volume. However, since our imaging system cannot measure the volume of the spleen, we use an approximate method to assess its size. This method involves measuring the maximum diameter of the spleen in the sagittal, coronal, and transverse planes. We use the average of the maximum diameters in these three planes as an indicator to estimate the size of the spleen. Since the maximum diameter in the same plane is measured each time, the changes in the average maximum diameter can relatively accurately reflect the splenic size changes.
Effect on hypersplenism and esophageal and/or gastric varices
The effectiveness of surgery in treating hypersplenism and esophageal and/or gastric varices was mainly evaluated by serial measurements of blood cell counts, hemoglobin levels and gastroesophageal varices by endoscopy. Baseline levels were measured preoperatively. In most cases, laboratory values were measured during first postoperative week, at 6 months, 12 months postoperatively, and at yearly intervals thereafter. Endoscopic examinations were conducted 6 months postoperatively and at yearly intervals thereafter.
Statistical analysis
Mean values for the study groups were compared between preoperative and postoperative levels at intervals using a mixed linear model. A threshold of statistical significance was set at 0.05. Descriptive statistics, including frequency, percentage, and mean ± SD, were calculated separately for each period (preoperative and postoperative at different intervals).
Results
Surgical procedure
Partial splenectomy and pericardial devascularization were successfully performed in 132 patients. Three patients underwent reoperation for abdominal hemorrhage after surgery. Intraoperative and postoperative details are presented in Table 2.
Table 2.
Intraoperative details and postoperative complications
| Characteristic | Data |
|---|---|
| Operative time, minutes | 205.93 ± 52.62 |
| Blood loss, ml | 286.97 ± 327.45 |
| Intraoperative blood transfusion, ml | |
| Allogeneic red blood cell | 252.42 ± 330.79 |
| Allogeneic plasma | 246.97 ± 275.32 |
| Autologous blood reinfusion | 153.23 ± 256.45 |
| Postoperative hospital stay, days | 10.42 ± 4.22 |
| Complications, n (%) | 6 (4.5) |
| Motality | |
| Intra-operation | 0 (0) |
| post-operation | 3 (2.27) |
| Postoperative abdominal hemorrhage | 3 (2.27) |
| Reoperation | 3 (2.27) |
| Hepatic failure | 5 (3.79) |
| Gastric fistula | 0 (0) |
| Pancreatic fistula | 0 (0) |
| Gastroparensis | 0 (0) |
| Encephalopathy | 0 (0) |
| Residual spleen necrosis | 13 (9.85) |
Changes in hematological parameters
The average preoperative leukocyte count and platelet count were below the normal range, and they returned to normal by the 7th day postoperatively. In subsequent follow-ups (at 6 months,1 year,2 year, 3 years, ≥ 4 years), the average leukocyte count and platelet count in follow-up patients remained above normal levels, showing a significant increase compared to preoperative values(Fig. 2A and B; S1).
Fig. 2.
Changes in hematological parameters. A, B, C, D Changes in leukocyte, platelet, hemoglobin, and lymphocyte levels at preoperative and postoperative follow-up intervals
The average preoperative hemoglobin level of all patients was 92.63 ± 1.57 g/l. At 7 days postoperatively, the average hemoglobin level showed no significant difference compared to preoperative levels. However, at subsequent follow-up intervals, the average hemoglobin levels in patients showed a significant increase compared to preoperative levels (Fig. 2C; S1).
The average lymphocyte count at 7 days postoperatively decreased compared to preoperative levels, but at subsequent follow-up intervals, the average lymphocyte count in patients significantly increased compared to preoperative levels (Fig. 2D; S1).
Changes in liver function and coagulation function
The average albumin and cholinesterase levels at 7 days postoperatively decreased compared to preoperative levels, but at subsequent follow-up intervals, the average albumin and cholinesterase levels in patients increased compared to preoperative levels (Fig. 3A and B; S1).
Fig. 3.
Changes in liver function and coagulation function. A, B, D Changes in Albumin, cholinesterase, and total bilirubin levels at preoperative and postoperative follow-up intervals. C, E Changes in fibrinogen and prothrombin levels at preoperative and postoperative follow-up intervals
There were no significant changes in the average bilirubin levels in patients between preoperative and postoperative follow-up intervals (Fig. 3D; S1).
The average prothrombin time at 7 days postoperatively showed no significant difference compared to preoperative levels, but at subsequent follow-up intervals, the average prothrombin time in patients decreased compared to preoperative levels (Fig. 3E; S1).
The average fibrinogen level at 7 days postoperatively significantly increased compared to preoperative levels, and at subsequent follow-up intervals, the average fibrinogen level in patients increased compared to preoperative levels (Fig. 3C; S1).
Effects on esophagogastric varices
The status of esophagogastric varices at preoperative and postoperative follow-up intervals showed that, at each postoperative follow-up, the majority of patients had either no change or an improvement in the degree of varices, with only a small proportion experiencing worsening of the varices (Fig. 4; S2).
Fig. 4.
Distribution of varices during follow-up. The status of esophagogastric varices at preoperative and postoperative follow-up intervals
Regrowth of the splenic remnant
The change in the average maximum diameter of the spleen in patients, both preoperatively and postoperatively, is depicted in Fig. 5 (S3). At 7 days postoperatively, the average maximum diameter of the residual spleen was significantly reduced compared to preoperative measurements. At subsequent follow-up intervals, the average maximum diameter of the residual spleen gradually increased, but by a very limited percentage.
Fig. 5.
Regrowth of the splenic remnant. The average spleen diameter at preoperative and postoperative follow-up intervals
Effects on portal venous system thrombosis
The presence of portal venous system thrombosis preoperatively and postoperatively is illustrated in Fig. 6 (S4, S5). Among preoperative patients, 35.61% had thrombosis in the portal venous system. However, by the 7th day postoperatively, the incidence of portal venous system thrombosis had significantly increased to 75%. In subsequent follow-up intervals, the proportion of patients with portal venous thrombosis decreased.
Fig. 6.
Distribution of portal venous thrombosis at follow-up. The status of portal venous system thrombosis at preoperative and postoperative follow-up intervals is shown. The variable'n'represents the number of patients with thrombosis, and the value in parentheses indicates the number of patients followed up
Postoperative complications
Perioperative complications (morbidity) were minimal. Postoperatively, six patients developed severe complications. Among them, three patients experienced abdominal hemorrhage during the perioperative period. After undergoing a second surgery for hemostasis, two patients recovered and were discharged, while one patient developed liver failure postoperatively and died. The other three patients experienced liver failure during the perioperative period, resulting in two fatalities and one patient recovering and being discharged after treatment. All other patients recovered smoothly and were discharged without any cases of gastric fistula, gastroparesis, pancreatic fistula, or hepatic encephalopathy. Thirteen patients developed residual spleen necrosis postoperatively (Table 2), which was asymptomatic and detected during follow-up abdominal CT scans.
Discussion
To relieve gastroesophageal varices, eliminate hypersplenism, and preserve the splenic function simultaneously, we have performed Partial splenectomy and Pericardial devascularization (PSPD) for symptomatic patients with portal hypertension since 2016.
Few studies have been published on the use of partial splenectomy and pericardial devascularization for portal hypertension due to the high risk of bleeding caused by increased portal pressure and extensive collateral circulation during the perioperative period. However, with advancements in surgical techniques and equipment, this concept has evolved.
This study demonstrates that PSPD can be performed safely through the use of appropriate surgical procedures, advanced hemostatic instruments and agents.
The major concern with partial splenectomy and devascularization for the treatment of portal hypertension is the significant bleeding from the splenic transection surface during surgery, which makes hemostasis challenging and increases the risk of postoperative bleeding. However, our retrospective data shows that no patients experienced uncontrollable intraoperative bleeding. The average intraoperative blood loss was 286.97 ± 327.45ml (Table 2), which is considered acceptable. Postoperatively, three patients experienced abdominal bleeding, none of which was related to bleeding from the splenic transection surface. Two of these patients improved and were discharged after undergoing a second surgery for hemostasis, while one patient developed liver failure and died after the second surgery. The surgical procedure takes longer compared to total splenectomy and pericardial devascularization, but the average operative time was 205.93 ± 52.62 min (Table 2), which is also acceptable. Postoperatively, three patients developed liver failure, resulting in two deaths and one recovery after treatment. In terms of surgical safety, partial splenectomy and pericardial devascularization for the treatment of portal hypertension are considered acceptable.
The most critical step in reducing the risk of intraoperative bleeding from splenic vessels and transection is the application of a rational surgical hemostasis protocol. The first important procedure in controlling intraoperative bleeding is isolating the splenic artery before mobilizing the spleen. By intermittently blocking the splenic artery, we can promote splenic blood flow back to the portal vein via the splenic vein, which reduces the volume of the spleen, increases the surgical operating space, and decreases the possibility of bleeding from the collateral circulation formed along the surrounding attachments of the spleen during the mobilization process. The second key step is isolating and controlling the splenic pedicle with a hemostatic sling after the spleen has been mobilized. This will allow the surgeon to control bleeding from any location in the spleen by blocking the blood vessels in the splenic pedicle. The third critical procedure is using Endo-GIA to transect all of the splenic pedicle vessels except for those that supply the planned splenic remnant. This will cause ischemic lines to form on the surface of the spleen. The partial splenectomy can then be performed based on the location of the ischemic lines. The fourth key step is clamping the remaining splenic vessels with vascular clamps before transecting the spleen. The spleen is then transected along the demarcation line, and the vessels at the splenic transection are ligated one by one with silk sutures before being transected. After the spleen is completely transected, the vascular clamps are released. Hemostasis is achieved through suturing, electrocoagulation, and other methods according to the bleeding condition of the splenic transection surface. When there is no significant active bleeding from the splenic transection surface, it is covered with absorbable hemostatic tissue to form a protective barrier against further bleeding. Reliable intraoperative hemostasis is crucial in preventing postoperative intra-abdominal hemorrhage. By performing these key bleeding control processes effectively during surgery, the risk of surgical bleeding is greatly reduced, making the procedure both safe and feasible.
This study showed that more than 90% of all patients had their platelet count return to normal before discharge. Follow-up data suggested that very few patients experienced a recurrence of thrombocytopenia during follow-up in, with almost all cases being asymptomatic hypersplenism (S7). For the remaining follow-up patients, platelet levels remained within normal ranges up to the last follow-up. This indicates that partial splenectomy is highly effective in treating hypersplenism, with long-lasting therapeutic benefits. Compared to splenic artery embolization and splenic radiofrequency ablation, partial splenectomy demonstrates a significantly better outcome [10, 19].
The average maximum diameter of the spleen preoperatively was 138.48 ± 1.81cm. On the seventh day postoperatively, the average maximum diameter of the splenic remnant was 61.17 ± 1.63cm. The majority of patients had more than 90% of their spleen removed. At six months postoperatively, the average maximum diameter of the residual spleen in follow-up patients was 68.43 ± 1.95cm. At one year postoperatively, the average maximum diameter was 70.62 ± 2.33cm. At two years postoperatively, it was 77.11 ± 3.29cm. At three years postoperatively, it was 82.27 ± 3.89cm. For follow-up periods of four years or more, the average maximum diameter of the residual spleen at the last follow-up was 88.40 ± 3.32cm.The remaining spleen grew slowly over time, with very limited growth. Data from the follow-up of this study showed that the average spleen diameter increased by less than 5% per year(S3).
The study showed that about 52.27% of the follow-up patients experienced relief from gastroesophageal variceal, as confirmed by endoscopic examination, 6 months after surgery(S6). However, over time, gastroesophageal varices in a small proportion of follow-up patients progressed and worsened. Among all follow-up patients, 19 patients experienced rebleeding. 18 cases of these had esophagogastric variceal hemorrhage, and 1 case had gastric mucosal bleeding(S8). Similar studies have also showed that patients still carry a certain risk of variceal bleeding postoperatively and may need to undergo endoscopic treatment to eliminate the risk of rebleeding [20]. These results suggest that pericardial devascularization can relieve gastroesophageal varices and reduce the risk of variceal rupture and hemorrhage, but the effect is limited. For patients with severe gastroesophageal varices after surgery, endoscopic or other related treatments are still needed postoperatively to prevent rebleeding.
The greatest significance of partial splenectomy lies in addressing hypersplenism while preserving part of the spleen and its vessels. The remaining spleen retains its potential immune function in the circulartory system [21]. However, more research is needed to further clarify how to quantitatively measure the function of the remaining spleen. Thirteen patients developed necrosis of the remaining spleen postoperatively, all of whom were asymptomatic. A review of these patients’ CT results showed evidence of ischemia in the splenic remnant before discharge from the hospital. The necrosis of the spleen may be related to vascular injury of the remaining spleen during surgery.
One possible mechanism of the increased risk of portal venous system thrombosis after total splenectomy is the thrombosis in the splenic vein stump, with propagation or embolization into the portal vein [15]. However, after partial splenectomy, since part of the spleen and its blood vessels are preserved, the splenic vein does not form a stump, ensuring complete blood reflux from the splenic vein,. As a result, it is not easy to form thrombosis. Theoretically, the probability of portal vein thrombosis should be lower than that of total splenectomy. Our results showed that the incidence of portal venous system thrombosis (including splenic vein) 7 days after partial splenectomy was 75.0%, which was significantly higher than 35.6% observed before surgery (S4). The imaging results showed that, due to the complete blood reflux from the residual spleen into the portal vein via the splenic vein, only mural thrombosis was formed in the portal venous system of most patients, and splenic vein was completely blocked by thrombus is rare except for the patients with residual splenic necrosis. Over time, with postoperative anticoagulant therapy, our results indicated that portal vein thrombosis in many patients gradually decreased or disappeared in many patients. However, a minority of postoperative patients experienced progression of portal venous thrombosis. (S5).
The limitations of this study include its single-center, retrospective design, which may introduce biases due to patient selection and loss to follow-up at postoperative intervals. Future clinical research could focus on further optimizing the surgical procedure for partial splenectomy and pericardial devascularization. Randomized controlled trials could also be conducted to compare the advantages and disadvantages of PSPD with other treatment modalities.
Conclusion
Our study suggests that partial splenectomy and pericardial devascularization is a safe and effective procedure that can alleviate gastroesophageal varices in most of the patients and eliminate hypersplenism and preserve partial splenic function. For patients with severe hypersplenism due to portal hypertension who wish to alleviate hypersplenism while preserving splenic function, partial splenectomy and pericardial devascularization is a viable option.
Supplementary Information
Acknowledgements
Very grateful to Ruizhao Qi, Weihua Chang, Zhiwei Li, Xin Zhao, Wenlei Zhao, Xinlong Hu for their assistance during the implementation of the research.
Clinical trial number
Not applicable.
Abbreviations
- PSPD
Partial splenectomy and pericardial devascularization
- PVT
Portal vein thrombosis
- AIH
Autoimmune hepatitis
- ALD
Alcoholic liver disease
- DILI
Drug-induced liver injury
- HBV
Hepatitis B
- HCV
Hepatitis C
- CC
Cryptogenic cirrhosis
- IPH
Idiopathic portal hypertension
- NASH
Non-alcoholic steatohepatitis
- PBC
Primary biliary cirrhosis
Authors’ contributions
Ying Zhang participated in the clinical date collection, analysis, and manuscript writing; Jinxiang Bu collected clinical data; Jinghui Yang analyzed the patients’ data; Shenzhi Wang contributed to the study design; Feng Liang contributed to the design, implementation of the study, and manuscript revision. All authors read and approved the final manuscript.
Funding
Not applicable.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of the Fifth Medical Center of PLA General Hospital. Written informed consent was obtained from all participating patients.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Ying Zhang and Shenzhi Wang contributed equally to this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.