Intentional Modulation of Portal Venous Pressure by Splenectomy Saves the Patient with Liver Failure and Portal Hypertension After Major Hepatectomy: Is Delayed Splenectomy an Acceptable Therapeutic Option for Secondary Portal Hypertension?

Abstract

Patient: Female, 56Final Diagnosis: Secondary portal hypertensionSymptoms: Intractable ascitesMedication: —Clinical Procedure: SplenectomySpecialty: Gastroenterology and HepatologyObjective:Unusual clinical courseBackground:Major or aggressively-extended hepatectomy (MAEH) may cause secondary portal hypertension (PH), and postoperative liver failure (POLF) and is often fatal. Challenges to prevent secondary PH and subsequent POLF, such as shunt creation and splenic arterial ligation, have been reported. However, these procedures have been performed simultaneously only during the initial MAEH.Case Report:A 58-year-old female with chronic hepatitis C developed a solitary hepatic cellular carcinoma with portal tumor thrombosis. Blood examination and imaging revealed a decreased platelet count and splenomegaly. Her liver viability was preserved, and collaterals did not develop, and her tumor thrombosis forced us to perform a right hepatectomy from an oncological standpoint. The estimated volume of her liver remnant was 51.8%. A large volume of ascites and pleural effusion were observed on post-operative day (POD) 3, and ascetic infection occurred on POD 14. Hepatic encephalopathy was observed on POD 16. According to the post-operative development of collaterals due to secondary PH, submucosal bleeding in the stomach occurred on POD 37. Though it is unclear whether delayed portal venous pressure (PVP) modulation after MAEH is effective, a therapeutic strategy for recovery from POLF may involve PVP modulation to resolve intractable PH. We performed a splenectomy on POD 41 to reduce PVP. The initial PVP value was 32 mm Hg, and splenectomy decreased PVP to 23 mm Hg. Thereafter, she had a complete recovery from POLF.Conclusions:Our thought-provoking case is the first successfully-treated case of secondary PH and POLF after MAEH, achieved by delayed splenectomy for PVP modulation.

Safety of Simultaneous Hepatectomy and Splenectomy in the Treatment of Hepatocellular Carcinoma Complicated with Hypersplenism: A Meta-analysis

“…Major or aggressively extended hepatectomy for liver cancer may give rise to secondary portal hypertension (PH), which would arouse massive ascites, edema, and refractory hemorrhage [38]. Kamanaka et al [36] found significantly lower blood flow of portal vein and congestion index in cirrhotic patients undergoing splenectomy, which was associated with lower ET-1 and increased NO and contributed to amelioration of complications related to secondary PH such as ascites and upper gastrointestinal bleeding.…”

Associated liver partition and portal vein ligation for staged hepatectomy: a review

“…It is also reported to improve function (increase in prothrombin time, platelet and albumin levels) in patients with HCC and concomitant hypersplenism (102). However, the role of splenectomy post-hepatectomy is unclear, but may have a therapeutic potential to treat PHLF (103). Splenic artery ligation (SAL) is an alternative to splenectomy intraoperatively to reduce PVP in PHLF or SFSS.…”

Long-term outcomes of synchronous splenectomy and hepatectomy or radiofrequency ablation for hepatocellular carcinoma and esophagogastric variceal bleeding

“…The rebleeding rate was 13.04%, much higher than that reported in previous studies. The complication PVT should not be the main cause of rebleeding because only one of six patients who rebled had PVT and a much longer follow-up time (12-129 months vs 4-75 months), hepatectomy might cause secondary portal hypertension 35 , and tumor in ltration might aggravate portal hypertension 36 .…”