Why is splenectomy necessary for splenomegaly in extrahepatic portal vein obstruction (EHPVO)?

From the Guidelines

Splenectomy is not routinely necessary for splenomegaly in extrahepatic portal vein obstruction (EHPVO) and should only be considered in specific situations where the benefits outweigh the risks, such as severe hypersplenism or significant symptomatic splenomegaly. The decision to perform a splenectomy should be based on a thorough evaluation of the patient's condition, taking into account the potential risks and benefits of the procedure. According to the study by Su et al 1, splenectomy can be effective in reducing portal venous pressures and preventing variceal bleeding, but it should be performed in centers with substantial experience in operating on patients with pressurized varices.

The study by Cheng et al 1 also reported successful outcomes with laparoscopic splenectomy with esophagogastric devascularization in patients with portal hypertension and variceal bleeding. However, the study by Feng et al 1 suggested that combined surgical procedures, including splenectomy, may be effective in managing portal hypertension and variceal bleeding.

In patients with non-cirrhotic portal hypertension, including those with EHPVO, the management of bleeding gastric varices should be based on a multidisciplinary approach, taking into account the underlying vascular anatomy and the presence of comorbid portal hypertensive complications, as recommended by the AGA clinical practice update 1. The use of cross-sectional imaging with portal venous phase of contrast is necessary in planning definitive therapy for gastric varices, and splenectomy may be considered in patients with splenic vein thrombosis and gastric variceal bleeding, as suggested by the study 1.

The EASL clinical practice guidelines 1 recommend managing portal hypertension in patients with EHPVO according to the guidelines elaborated for cirrhosis, and considering surgical portosystemic shunting or TIPS in selected patients. However, the guidelines also emphasize the importance of preserving the spleen whenever possible, due to its important immune functions, particularly in children.

In summary, splenectomy should be reserved for severe symptomatic cases of EHPVO that do not respond to other interventions, and should be performed in centers with substantial experience in operating on patients with pressurized varices, as supported by the study by Su et al 1. The decision to perform a splenectomy should be based on a thorough evaluation of the patient's condition, taking into account the potential risks and benefits of the procedure, and should be made in consultation with a multidisciplinary team of experts.

Some key points to consider when evaluating the need for splenectomy in patients with EHPVO include:

• The presence of severe hypersplenism, significant symptomatic splenomegaly, or gastric variceal bleeding
• The underlying vascular anatomy and the presence of comorbid portal hypertensive complications
• The potential risks and benefits of the procedure, including the risk of intraoperative hemorrhage and the potential impact on immune function
• The availability of alternative treatments, such as endoscopic therapy or TIPS, and the potential benefits and risks of these alternatives.

Overall, the decision to perform a splenectomy in patients with EHPVO should be made on a case-by-case basis, taking into account the individual patient's condition and the potential risks and benefits of the procedure, as supported by the study by Cheng et al 1.

From the Research

Indications for Splenectomy in Extra Hepatic Portal Vein Obstruction

• Splenectomy is necessary for splenomegaly in extra hepatic portal vein obstruction (EHPVO) to relieve hypersplenism, which is commonly seen in patients with non-cirrhotic portal hypertension (NCPH) 2.
• The procedure can be performed alone or in combination with shunt operations, such as a proximal splenorenal shunt, to address the underlying portal hypertension and prevent complications like variceal bleeding 2, 3.
• Splenectomy can also be combined with partial resection of the spleen, as seen in the Warren shunt procedure, to effectively relieve hypersplenism and improve quality of life in pediatric patients with EHPVO 3.

Hemodynamic Basis and Treatment Implications

• There is no clear hemodynamic link between portal pressure and splenic enlargement, and splenectomy or splenic embolization alone may not be effective in managing cirrhotic patients with variceal bleeding 4.
• However, splenectomy can still be beneficial in patients with portal hypertension, particularly those with massive splenomegaly and severe hypersplenism, as it can improve platelet count and reduce the risk of variceal bleeding 2, 5.

Surgical Approaches and Outcomes

• Laparoscopic splenectomy is a viable option for patients with portal hypertension, offering a minimally invasive approach with reduced morbidity and mortality 5.
• The procedure can be performed safely and effectively, with significant improvements in platelet count and quality of life, and can be combined with other treatments, such as endoscopic variceal ligation or sclerotherapy, to manage variceal bleeding and other complications 2, 3, 6.