Laparoscopic splenic artery ligation for hypersplenism in cirrhosis: A case series.

BACKGROUND: Splenectomy for the treatment of hypersplenism in patients with cirrhosis (HIC) is related with complications. Laparoscopic splenic artery ligation (LSAL) may be an alternative treatment option. AIMS: To evaluate safety and feasibility of LSAL in the treatment of HIC. PATIENTS AND METHODS: Retrospective analysis of prospectively collected data of ten patients with HIC who were treated with LSAL from October 2012 to February 2015.
RESULTS: The median (range) age was 33.2 (13-56) years and sex distribution was equal. The median (range) leukocyte counts (×10(9)/L) before, and at 3, 6 and 12 months after LSAL were 2.2 (0.8-8.2) and 5.65 (2.78-10.7), 4.7 (2.8-7.8) and 4.95 (3.4-7.7) respectively. The median (range) platelet counts (×10(9)/L) before and at 3, 6 and 12 months after LSAL were 25.5 (11-65) and 75 (39-289), 74 (32-184) and 76 (56-251) respectively. Following LSAL, there was a significant improvement in total leucocyte count, platelet count and Model for End-Stage Liver Disease (MELD) score (P < 0.05). Two patients (20%) developed intraoperative bleeding and required conversion; one of these two patients developed splenic cyst that required radiological intervention. Four patients (40%) had post ligation syndrome (PLS) that was managed conservatively. During a median (range) follow-up of 19.5 (5-29) months, one patient (10%) required splenectomy due to inadequate response.
CONCLUSION: LSAL is a safe and feasible treatment option for the palliation of symptomatic HIC, however, further prospective trials are necessary for confirmation.

INTRODUCTION

Hypersplenism in patients with cirrhosis (HIC) is characterised by enlargement of the spleen and simultaneous reduction in blood cell counts. Splenectomy by open or laparoscopic method is the most common treatment for HIC.[12] Splenectomy not only corrects cytopaenia but also relieves symptoms related to size of the spleen; however, it is associated with postoperative and remote complications.[34] In order to avoid complications of splenectomy, partial splenic embolisation (PSE) has been accepted as the preferred treatment for HIC at various centres.[56] PSE has not gained wide acceptance in the Indian subcontinent due to difficult access to tertiary care hospitals, and limited availability of expertise. Moreover, results of PSE have been inconsistent and the rate of serious complication has been high.[78] Historically, open splenic artery ligation (OSAL) has been used for the palliation of hypersplenism and ascites related to portal hypertension and cirrhosis.[910] Laparoscopic splenic artery ligation (LSAL) may be a minimally invasive treatment option for the palliation of HIC; we hereby report our experience of ten such cases.

PATIENTS AND METHODS

This retrospective study included 10 patients with HIC who were considered for LSAL from October 2012 to February 2015. All the patients had radiological and/or histological evidence of cirrhosis, enlarged spleen, decreased blood cell counts and oesophageal varices. Portal vein was patent in all the patients. Preoperative investigations included haemoglobin, platelet count (PC), total leukocyte count (TLC), international normalised ratio (INR), renal function test (RFT), liver function test (LFT), viral markers for Hepatitis B and C, real time ultrasonography (USG) of the abdomen, contrast-enhanced computed tomography (CECT) of the abdomen and video gastroduodenoscopy. Size of the spleen was measured (in centimetres) on USG; Child-Turcotte-Pugh score (CTPS) and Model for end stage liver disease (MELD) scores were calculated online (www.medscape.com).

Procedure

The patient's position was supine position with legs spread apart (French position). Umbilical port was used for camera, epigastric port was used for the retraction and other two ports were used by the surgeon [Figure 1A]. Gastrocolic ligament was divided with ultrasonic shear (GEN-4, Ethicon, USA) to access lesser sac; right gastroepiploic arcade and 2-3 short gastric vessels were preserved. Splenic artery (SA) was identified along the superior border of the pancreas; enough length of the SA was exposed to apply Haemoclips (Teleflex) [Figure 1B]. Instant discolouration of the spleen and the loss of distal pulsations confirmed occlusion of the SA [Figure 1C].

Figure 1

(A) Port sites (B) Spleen colour before LSAL (C) Discoloured spleen after LSAL (D) CECT of same patient showing partial infarction of spleen

Follow-up

Patients were followed up at 6 week, 3 month, 6 month and 1 year intervals. Clinical examination and blood investigations were repeated at every visit; USG was advised at 3 months, 6 months and 1 year. CECT was advised at least once in a year or when indicated [Figure 1D].

Statistical analysis

Statistical software MedCalc version 15.2.2 (Medcalc, Ostend, Belgium) was used for analysis. Parametric numerical data were represented as mean ± standard deviation (SD), non-parametric numerical data and categorical data were represented as median and percentages respectively. Paired t-test and Wilcoxon signed-rank tests were used for comparison of means and medians respectively. P value (two-sided) <0.05 was considered significant.

RESULTS

Sex ratio was 1, median age was 31 years and cryptogenic cirrhosis was the most common (70%) cause of hypersplenism [Table 1]. LSAL was technically successful in eight patients (80%), whereas two patients (20%) developed intraoperative haemorrhage (IOH) and required conversion [Table 2]. One patient had haemorrhage from peripancreatic collateral while dissecting SA, whereas, other patients had IOH during pericardial devascularisation. Later, the patient (with pericardial devascularisation) developed splenic cyst in the follow-up period. The cyst was initially managed with ultrasound-guided needle aspiration (1600 mL serous and sterile fluid) that later transformed into an abscess and managed with percutaneous catheter drainage and parenteral antibiotics [Figure 2A–D]. Four patients (40%) developed pain in the abdomen and fever [post ligation syndrome(PLS)] in the postoperative period, all were managed conservatively [Table 2]. Nine patients (90%) showed persistent symptomatic relief along with improvement in blood counts and MELD score (P < 0.05); one patient (10%) required open splenectomy due to inadequate response [Tables 2 and 3].

Table 1

Demographic and clinical features

Table 2

Operative and postoperative details

Figure 2

(A) CECT of a patient showing spleen before LSAL (B) Splenic cyst following LSAL (C) Resolving splenic cyst (D) Completely resolved cyst with remnant spleen

Table 3

Important parameter before and after LSAL

DISCUSSION

SA occlusion results in ischemic necrosis and gradual atrophy of the spleen which is equivalent to functional splenectomy. Blain AW was first to perform OSAL for the treatment of hypersplenism related to Banti's syndrome, later on it was applied for the treatment of complications related to cirrhosis.[91011] LSAL has not been reported for the treatment of HIC; however it is reported for the treatment of conditions such as SA aneurysm.[12] LSAL may help in preservation of splenic functions along with alleviation of symptoms of HIC. Splenectomy is not only associated with high postoperative complications but also associated with lifelong risk of severe sepsis, cardiovascular diseases and malignancy.[34] In a series by Kedia et al.[1] 18 out of 33 (54.5%) patients developed major postoperative complications after splenectomy whereas in the present series one out of 10 patients (10%) had major complication; however number of patients in our series was small and follow up period was short.

PLS observed after LSAL closely mimics post embolisation syndrome (PEMS) which usually occurs after PSE. Incidence of PLS was not higher than reported incidence of PEMS.[13] Serious complications such as pleural effusion, hepatic encephalopathy, acute necrotizing pancreatitis and hepatic failure that are reported to occur after PSE were not encountered after LSAL.[781314] LSAL with pericardiac devascularisation may result in near complete necrosis and associated complication, therefore, 2-3 short gastric vessels should be preserved to avoid extensive necrosis of the spleen.[15] PSE is a technically demanding procedure because it requires selective occlusion of branches of the SA and necrosis of 50-70% of spleen otherwise it either results in failure or serious complications.[81314] Unlike other countries PSE has not gained popularity in Indian subcontinent due limited availability of resources and difficult access of tertiary health care to most of the population.

Splenectomy (open/laparoscopic) is still most common and most effective treatment of HIC but it is associated with disadvantages such as complete loss of splenic immune function, risk of portal vein thrombosis (PVT) and occurrence of overwhelming post splenectomy infection (OPSI).[34] Vaccination and prophylactic antibiotics may reduce incidence of OPSI but they have failed to nullify the risk of OPSI.[16] Increased risk of PVT after splenectomy adds an extra challenge to liver transplant surgeon. Recent trend to avoid asplenism, growing availability of liver transplant, and absence of an interventional radiologist encouraged us to search for a minimally invasive spleen preserving treatment for HIC (LSAL). Total splenic artery embolisation (TSAE) or PSE are gradually replacing splenectomy in other countries and same trend will followed in our subcontinent.[17] If facilities of an expert interventional radiologist are accessible then every patient should be receive SA embolisation as a first line treatment. Splenectomy (laparoscopic/open) may be offered to those patients with HIC who are otherwise unfit for liver transplantation. At tertiary care centres where facilities of interventional radiology are in transition phase and facilities of advance laparosopy are available, LSAL may be preferred over splenectomy. In patient with inadequate response to LSAL, splenectomy can always be performed and in patients with extensive necrosis of spleen results will be equivalent to a formal splenectomy. Proper surgical planning, gentle tissue handling, watchful dissection, and a low threshold of conversion is necessary to avoid iatrogenic complications during LSAL.

CONCLUSION

LSAL is a safe and feasible treatment option for the palliation of symptomatic HIC, however, further prospective trials are necessary for confirmation.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.