Commentary on “Is simultaneous partial splenectomy during pediatric liver transplantation safe and effective for severe hypersplenism? A prospective cohort study” (Int J Surg 2021, 88:105926)

Dear Editor, Liver cirrhosis is a leading cause of liver disease-related morbidity and mortality worldwide. It is often associated with portal hypertension and splenomegaly. Liver transplantation (LT) is effective for most end-stage chronic liver diseases. Significant changes in visceral hemodynamics occur after LT, including improved portal resistance, reduced portal pressure, and shifting of accumulated blood from visceral to systemic circulation. These changes dramatically increase portal venous flow, thus gradually ameliorating splenic congestion, with resultant improvements in splenomegaly and hypersplenism [1]. However, hypersplenism persists in some patients after LT. Pancytopenia associated with persistent hypersplenism can interfere with management of immunosuppressive therapy. Splenomegaly can also lead to excessive portal pressure or splenic artery steal syndrome, with resulting decrease in hepatic artery inflow which may then affect liver graft function [2]. The most common treatments for splenomegaly and hypersplenism are total splenectomy during LT and selective splenic artery embolization after LT. However, both these procedures have considerable limitations. Total splenectomy increases the risk of postoperative complications including overwhelming post-splenectomy infection syndrome, reactive thrombocytosis, and portal venous system thrombosis. Selective splenic artery embolization, being a minimally invasive therapy and considered to be an effective alternative to total splenectomy, still carries a significant risk of infection and post-embolization syndrome [3]. In the recent issue of International Journal of Surgery, Wei et al. performed a prospective cohort study and concluded that simultaneous partial splenectomy during LT could serve as a feasible alternative to total splenectomy in selected patients with severe hypersplenism. The procedure achieved satisfactory long-term hematological outcomes [4]. To our knowledge, synchronous anatomic partial splenectomy during LT has never been performed in pediatric patients with severe hypersplenism and massive splenomegaly in preventing persistent hypersplenism after transplantation, and this is the first series reported in the medical literature. Partial splenectomy is based on the anatomic knowledge of the spleen having several segments, with each segment having its own independent hilar arterial blood supply and venous drainage. This procedure eliminates excessive splenic sequestration and destruction of peripheral blood cells, while corrects hypersplenism and avoids overwhelming post-splenectomy infection using splenic preservation [5]. Based on our initial experience with this infrequently used synchronous partial splenectomy in our institution, partial splenectomy during LT has been found to be a feasible procedure, with a slightly longer operative time. Postoperative outcomes, including beneficial effects and complications, were similar to those reported by Wei et al. However, postoperative adverse events were occasionally encountered, including hemorrhage from splenectomy beds, pancreatic fistula and/or abscess, portal venous thrombosis, and septic complications. Furthermore, patients after partial splenectomy can have residual splenic regeneration over time. Overall, simultaneous partial splenectomy during LT is beneficial in selected patients with severe hypersplenism. Further studies with high quality and large sample sizes are needed to confirm the effectiveness and safety of this procedure. Please state any conflicts of interest None. Please state any sources of funding for your research This work was supported by Scientific Research of Gansu Provincial Administration of Traditional Chinese Medicine (no.GZK-2018-37). Please state whether ethical approval was given, by whom and the relevant Judgement’s reference number Not Applicable. Research registration unique identifying number (UIN) Not applicable. Author contribution The author read and approved the final version of the letter to the Editor. Guarantor The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.