Functional, life-threatening disorders and splenectomy following liver transplantation

Splenectomy (SPL) in cirrhotic patients undergoing liver transplantation (L Tx) may resolve specific problems related to the procedure itself, in case of functional and life-threatening clinical situations often occurring as a result of liver cirrhosis and portal hypertension. Methods. A single-cente r experience of ten splenectomies in a series of 180 consecutive adult live r transplant patients over a period of 6 yr is reported. The mean patient a ge was 46.8 +/- 9.5 yr (range 25-57 yr). Indications for SPL were post-oper ative massive ascitic fluid loss (n = 3), severe thrombocytopenia (n = 3), acute intra-abdominal hemorrhage (n = 2), infarction of the spleen (n = 1), and multiple splenic artery aneurysms (n = 1). Results. Extreme ascites production due to functional graft congestion disa ppeared post-SPL, with an improvement of the hepatic and renal functions. S PL was also effective in cases of thrombocytopenia persistence post-LTx, le ading to an increase in the platelet count after about 1 wk. Bleeding episo des related to left-sided portal hypertension or trauma were also resolved. The rejection rate during hospitalization was 0%, and no other episodes we re recorded in the course of the long-term follow-up. However, sepsis with a fatal outcome occurred in 4 patients, i.e. between 2 and 3 wk post-SPL in three cases and 1 yr after the procedure as a result of pneumococcal infec tion in the last case. Fatal traumatic cranial injury occurred 3 yr post-LT x in another case. Five patients (50%) are still alive and asymptomatic aft er a median follow-up period of 36 months. Conclusions. The lowering of the portal flow appears to resolve unexplained post-operative ascitic fluid loss as a result of functional graft congesti on following LTx. However, because of the enhanced risk of SPL-related seps is, a partial splenic embolization (PSE) or a spleno-renal shunt could be u sed as an alternative procedure because it allows us to preserve the immuno logical function of the spleen. SPL is indicated in ease of post-transplant bleeding due to left-sided portal hypertension and trauma, spleen infarcti on, and to enable prevention of hemorrhage in liver transplant patients wit h multiple splenic artery aneurysms. Severe and persistent thrombocytopenia could be treated with PSE. Because the occurrence of fatal sepsis post-SPL is a major complication in LTx, functional disorders, such as ascites and thrombocytopenia, should be treated with a more conservative approach.