Screening for thrombophilia does not identify patients at risk of portal or splenic vein thrombosis following 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.

Research on Portal Venous Hemodynamics and Influencing Factors of Portal Vein System Thrombosis for Wilson’s Disease after Splenectomy

Objective

Splenectomy is one crucial solution for hypersplenism with portal hypertension. However, portal vein system thrombosis (PVST) caused by hemodynamic changes affects the prognosis of patients. We analyze the changes in portal vein hemodynamics following splenectomy for Wilson’s disease combined with portal hypertension and the influencing factors that lead to PVST.

Methods

A retrospective cohort study was conducted, in which 237 Wilson’s disease patients with hypersplenism underwent splenectomy. The hemodynamic indices of the portal vein were monitored before surgery and on the 1st, 7th, and 14th days around surgery. The patients were divided into PVST and non-PVST groups. The clinical factors were identified by univariate and multivariate logistic regression. The Logit P was calculated according to the logistic regression prediction model, and the ROC curve for each independent factor was plotted.

Results

The portal vein velocity, flow, and inner diameter showed a downward trend around surgery, with statistically significant differences between each time point (P < 0.01). The PVST incidence rate was 55.7%. Univariate analysis revealed that the platelet (PLT) levels on the postoperative 3rd and 7th days (P = 0.001; P < 0.001), D-dimer (D-D) on the postoperative 7th and 14th days (P = 0.002; P < 0.001), preoperative portal vein velocity, flow, diameter (P < 0.001), and splenic vein diameter (P < 0.001) were all statistically and significantly different between the two groups. Multivariate logistic regression revealed a significant increase in PLT on the postoperative 7th day (OR = 1.043, 95% CI, 1.027–1.060, P < 0.001) and D-D on the postoperative 14th day (OR = 1.846, 95% CI, 1.400–2.435, P < 0.001). Preoperative portal and splenic vein diameters (OR = 1.565, 95% CI, 1.213–2.019, P = 0.001; OR = 1.671, 95% CI, 1.305–2.140, P < 0.001) were the risk factors for PVST. However, preoperative portal vein velocity and flow (OR = 0.578, 95% CI, 0.409–0.818, P = 0.002; OR = 0.987, 95% CI, 0.975–0.990, P = 0.046) were protective factors for PVST. Logit P was calculated using a logistic regression prediction model with a cut-off value of −0.32 and an area under receiver operating characteristic curve of 0.952 with 88.61% accuracy.

Conclusions

Splenectomy relieves portal hypertension by reducing the hemodynamics index. PVST is linked to multiple factors, including preoperative portal vein diameter, velocity, flow, and splenic vein diameter, especially PLT on the postoperative 7th day and D-D on the postoperative 14th day. The predictive model is accurate in predicting PVST.

Splenic volume and splenic vein diameter are independent pre-operative risk factors of portal vein thrombosis after splenectomy: a retrospective cohort study

BACKGROUND

Portal vein thrombosis (PVT) is a common complication following splenectomy. It affects between 5 and 55% of patients undergoing surgery with no clearly defined pre-operative risk factors. The aim of this study was to determine the pre-operative risk factors of PVT.

PATIENTS AND METHOD

Single centre, retrospective study of data compiled for every consecutive patient who underwent splenectomy at Toulouse University Hospital between January 2009 and January 2019. Patients with pre- and post-surgical CT scans have been included.

RESULTS

149 out of 261 patients were enrolled in the study (59% were males, mean age 52 years). The indications for splenectomy were splenic trauma (30.9%), malignant haemopathy (26.8%) and immune thrombocytopenia (8.0%). Twenty-nine cases of PVT (19.5%) were diagnosed based on a post-operative CT scan performed on post-operative day (POD) 5. Univariate analysis identifies three main risk factors associated with post-operative PVT: estimated splenic weight exceeding 500 g with an OR of 8.72 95% CI (3.3-22.9), splenic vein diameter over 10 mm with an OR of 4.92 95% CI (2.1-11.8) and lymphoma with an OR of 7.39 (2.7-20.1). The role of splenic vein diameter with an OR of 3.03 95% CI (1.1-8.6), and splenic weight with an OR of 5.22 (1.8-15.2), as independent risk factors is confirmed by multivariate analysis. A screening test based on a POD 5 CT scan with one or two of these items present could indicate sensitivity of 86.2% and specificity of 86.7%.

CONCLUSION

This study suggests that pre-operative CT scan findings could predict post-operative PVT. A CT scan should be performed on POD 5 if a risk factor has been identified prior to surgery.

Serum Lipoprotein (a) on Postoperative Day 3: A Strong Predictor of Portal and/or Splenic Vein Thrombosis in Cirrhotic Patients With Splenectomy

Elevated lipoprotein (a) [Lp(a)] is related to the incidence of lower limb deep vein thrombosis and pulmonary embolism. Its role in portal and/or splenic vein thrombosis (PSVT) is not established. A total of 77 consecutive patients who underwent splenectomy for cirrhotic portal hypertension were prospectively studied between 2014 and 2017. The impact of Lp(a) on preoperative day 1 and postoperative days (PODs) 1, 3, 5, 7, and 14 was analyzed. Color Doppler ultrasound examination was performed for the diagnosis of PSVT. The median interval between surgery and postoperative PSVT was 6 days (range: 2-13 days). The levels of Lp(a) were highly increased in patients with PSVT and significant intergroup differences (vs non-PSVT) were found until day 3 and day 5 after operation, respectively. On POD 3, at a threshold of 309.06 mg/L, Lp(a) was a better predictor of PSVT (area under the curve [AUC] = 0.872) compared to the levels on PODs 1, 5, and 7 (AUC = 0.775, 0.796, and 0.791, respectively). The median Lp(a) values peaked at 382.5 mg/L on POD 5 for patients without PSVT. After POD 5, the Lp(a) decreased with values at 347.4 mg/L on POD 7 and 150.7 mg/L on POD 14. For the first time, Lp(a) was shown to be abnormal in patients with PSVT following splenectomy. Monitoring of serum Lp(a) levels on POD 3 might represent a valuable tool to predict early PSVT after splenectomy in cirrhotic patients.

Splenectomy in childhood for non-malignant haematologic disorders - long-term follow-up shows minimal adverse effects

Splenectomy is considered therapeutic in various non-malignant haematologic diseases. Adverse events - specifically infections and thromboembolism - are not extensively documented in the paediatric population, maintaining the concern over risks-versus-benefits of the procedure. We studied a cohort of paediatric haematology patients undergoing splenectomy between 1977 and 2015 to determine short- and long-term complications. We summarised all the patients of the haematology clinic in our major Israeli tertiary centre undergoing splenectomy for therapeutic reasons, capturing infectious and thromboembolic events. The data of 103 patients, comprising 1657 follow-up years, were analysed. The cohort included 33 patients with transfusion-dependent thalassaemia, seven with non-transfusion-dependent thalassaemia, four with sickle-thalassaemia, 41 with hereditary spherocytosis, and 18 with immune thrombocytopenia. Standard presplenectomy vaccinations were noted in most. No typical cases of overwhelming postsplenectomy infection (OPSI) were identified, nor were typical OPSI bacteria isolated. Thalassaemics with central lines were most prone to infection and thrombosis. Beyond this subgroup, thrombotic events were anecdotal. This is the largest study to date to comprehensively analyse infectious and thrombotic complications of childhood splenectomy for the treatment of haematologic diseases. The use of splenectomy appears to be a relatively safe therapeutic option in paediatric patients with proper preoperative vaccination and follow-up care; use of central venous lines or catheters increase the risk in thalassaemic patients and should be avoided if possible.

Thrombocytosis and portal vein thrombosis after splenectomy for paediatric haemolytic disorders: How should they be managed?

Splenectomy is indicated in selected children with haemolytic anaemia. Postoperatively, thrombocytosis occurs in at least 80% and is one of the factors implicated in the development of acute portal venous thrombosis after splenectomy in adults. A literature review shows that children are also at risk of this complication, but the incidence is low. The risk is greatest in those with particularly large spleens. Laparoscopic splenectomy does not reduce the risk of this complication. Early detection and anticoagulation usually leads to successful resolution of the thrombosis and can mitigate the risk of developing cavernous transformation of the portal vein and chronic portal hypertension. Any child with severe or unexplained postoperative abdominal pain, fever and/or vomiting after splenectomy demands urgent abdominal imaging to exclude this complication. In asymptomatic individuals, a routine Doppler ultrasound scan 1 week postoperatively is advisable if they had a particularly large spleen, longer than usual duration of surgery and/or have a marked postoperative thrombocytosis. There is no evidence for routine administration of antiplatelet drugs and/or subcutaneous heparin prophylaxis in children after splenectomy, including those who develop postoperative thrombocytosis, but children with particularly large spleens may be a subset that benefit.

Thromboembolic Events Following Splenectomy: Risk Factors, Prevention, Management and Outcomes

BACKGROUND

Thromboembolic events following splenectomy are not uncommon. However, the role of thromboprophylaxis and risk factors for thrombosis, as well as the clinical course and outcomes, are not well characterized.

METHODS

A retrospective review of individuals who underwent splenectomy between January 2006 and December 2015 in two university hospitals.

RESULTS

Overall, 297 patients underwent splenectomy [open splenectomy (n = 199), laparoscopic splenectomy (n = 98)]. Mechanical (thigh-length pneumatic compression stockings) and pharmacologic thromboprophylaxis (40 mg enoxaparin daily, starting 12 h after surgery until discharge) was provided for all patients. One hundred and sixteen patients (39%) also received an extended thromboprophylaxis course of enoxaparin for 2-4 weeks after discharge. Twenty-three patients (7.7%) experienced thrombotic complications following splenectomy, including 16 cases (5.4%) of portal-splenic mesenteric venous thrombosis (PSMVT), 5 (1.7%) pulmonary embolism and 2 (0.7%) deep vein thrombosis. Longer operative time (mean operative time of 405 vs. 273 min, P = 0.03) was independently associated with PSMVT. Post-splenectomy thrombocytosis was not associated with thrombosis (P = 0.41). The overall thrombosis rate was significantly lower in patients who received an extended thromboprophylaxis course following splenectomy (3.4 vs. 10.5%, P = 0.02). Complete resolution of thrombosis was observed in most cases (n = 20, 87.0%), with no recurrent thrombosis during a mean follow-up of 38 ± 25 months.

CONCLUSIONS

Thromboembolic complications, mainly PSMVT, are common following splenectomy. Longer operative time was associated with thrombosis. Significantly lower rates of thrombosis were found in patients who received an extended thromboprophylaxis course.

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.

Recommendations regarding splenectomy in hereditary hemolytic anemias

Hereditary hemolytic anemias are a group of disorders with a variety of causes, including red cell membrane defects, red blood cell enzyme disorders, congenital dyserythropoietic anemias, thalassemia syndromes and hemoglobinopathies. As damaged red blood cells passing through the red pulp of the spleen are removed by splenic macrophages, splenectomy is one possible therapeutic approach to the management of severely affected patients. However, except for hereditary spherocytosis for which the effectiveness of splenectomy has been well documented, the efficacy of splenectomy in other anemias within this group has yet to be determined and there are concerns regarding short- and long-term infectious and thrombotic complications. In light of the priorities identified by the European Hematology Association Roadmap we generated specific recommendations for each disorder, except thalassemia syndromes for which there are other, recent guidelines. Our recommendations are intended to enable clinicians to achieve better informed decisions on disease management by splenectomy, on the type of splenectomy and the possible consequences. As no randomized clinical trials, case control or cohort studies regarding splenectomy in these disorders were found in the literature, recommendations for each disease were based on expert opinion and were subsequently critically revised and modified by the Splenectomy in Rare Anemias Study Group, which includes hematologists caring for both adults and children.