What are the indications for splenectomy (removal of the spleen) or splenic ligation in patients undergoing Living Donor Liver Transplantation (LDLT) surgery?

Indications for Splenectomy or Splenic Artery Ligation in Living Donor Liver Transplantation (LDLT)

Splenectomy or splenic artery ligation should be performed in LDLT when there is portal hyperperfusion risk, particularly with small-for-size grafts, to prevent small-for-size syndrome and improve graft survival. 1

Primary Indications for Portal Inflow Modulation in LDLT

• Small-for-size grafts: When graft-to-recipient weight ratio (GRWR) is <0.8%, portal inflow modulation should be considered to prevent small-for-size syndrome 1, 2
• High portal venous pressure: Post-reperfusion portal venous pressure ≥15 mmHg indicates need for intervention 1
• High portal venous flow: Post-reperfusion flow ≥250 mL/min/100g of graft weight requires modulation 1
• Low hepatic arterial flow: Peak systolic velocity ≤20 cm/s suggests need for splenic intervention 1
• Graft-to-spleen volume ratio ≤1: Indicates higher risk of portal hyperperfusion 1
• Severe portal hypertension: In RAPID procedure (staged hepatectomy followed by partial graft implantation), splenic intervention may be needed when portal hypertension is significant 3

Preferred Approach to Portal Inflow Modulation

First-Line Options

• Splenic artery ligation: Should be performed as first-line intervention for portal inflow modulation in LDLT 3

  • Significantly reduces portal hyperperfusion
  • Decreases early allograft dysfunction (8.8% vs. 26.2% compared to no intervention) 1
  • Reduces small-for-size syndrome incidence 1
  • Improves 1-year survival rates 1

• Somatostatin or analogs: Can be used as medical first-line therapy for portal inflow modulation 3

Second-Line Options

• Splenectomy: Should be considered as second-line option for portal inflow modulation 3

  • Caution: Associated with 33.3% risk of portal vein thrombosis post-LDLT 4
  • Should be reserved for cases where first-line interventions fail 3

• Portosystemic shunts: Alternative second-line option when first-line interventions are insufficient 3

Additional Specific Indications for Splenectomy

• Hepatitis C with severe thrombocytopenia: Splenectomy may be indicated to improve platelet counts 4
• Splenic artery aneurysms: Multiple splenic artery aneurysms may require splenectomy for prevention of hemorrhage 5
• Massive post-operative ascites: When due to functional graft congestion, splenectomy may resolve the condition 5
• Splenic infarction: Requires splenectomy as definitive treatment 5
• Acute intra-abdominal hemorrhage: Related to left-sided portal hypertension 5

Timing Considerations

• In the RAPID procedure (staged hepatectomy followed by partial graft implantation), the optimal timing of native liver removal is between 2-4 weeks following the initial stage, considering interstage GRWR >0.80% and adequate function 3, 6

Risks and Contraindications

• Portal vein thrombosis: Major risk following splenectomy (33.3% incidence), especially with lower final portal venous pressure 4
• Overwhelming post-splenectomy infection: Potentially fatal complication, with reported sepsis rate of 40% in liver transplant recipients 5
• Alternative approaches: Consider partial splenic embolization or spleno-renal shunt to preserve immunological function of the spleen when appropriate 5

Monitoring After Intervention

• Daily liver profile tests should be performed 6
• Weekly volumetric analysis using cross-sectional imaging is recommended 6
• Close follow-up for early detection of portal vein thrombosis is essential, particularly after splenectomy 4

Portal inflow modulation through splenic artery ligation or splenectomy is a critical component of LDLT management, especially with small-for-size grafts, but must be performed with careful consideration of the associated risks and benefits.