M. Neuwirth1, A. J. Sinnamon1, R. R. Kelz1, G. C. Karakousis1, M. K. Lee1 1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA
Introduction: Patients with sinistral portal hypertension frequently develop gastric varices and are therefore at risk of life-threatening hemorrhage. Splenectomy is the treatment of choice as it largely eliminates the bleeding risk, but these procedures likely carry increased risk relative to splenectomy performed for other reasons. We sought to compare the specific morbidity and mortality of splenectomy performed for sinis-tral portal hypertension versus other indications using a national cohort.
Methods: The American College of Surgeons National Surgical Quality Improvement Program (ASC NSQIP) was accessed from the years 2005-2014 for patients undergoing open or laparoscopic splenectomy. Patients with an operative diagnosis of gastric vari-ces were selected for inclusion in the case cohort. These patients were compared to two separate control groups: hypersplenism or splenomegaly, and all other indi-cations (OI) for splenectomy with 25 or more cases (excluding trauma). Pearson’s chi-squared or Wilcoxon rank-sum tests were applied to categorical variable com-parisons as indicated.
Results: Of the 7,522 splenectomies performed during the study period, we identified 28 performed for gastric varices, 1,186 performed for hypersplenism or splenomeg-aly, and 4,128 in the OI group. Notably, patients in the gastric varices group had lower rates of thrombocytopenia and were similar to the comparison groups with respect to their total bilirubin and INR. Compared to OI, patients with gastric vari-ces more often had dependent functional status (21.4 vs 5.9%, p < .001), ASA class > III (92.8 vs. 62.5%, p < .001), and albumin < 3 (57.1% vs 11.4%, p < 0.001). There was no difference in mortality for the varices group as compared with the splenomegaly group (3.6% vs 2.4%; p = 0.678) or OI (3.6% vs 2.4%; p = 0.671). As depicted in figure 1, serious morbidity was significantly increased in the varices group versus the control group (53.6% vs 19.7%; p < 0.001) and versus the sple-nomegaly group (53.6% vs 23.2%; p < 0.001). Most major post-operative compli-cations in the varices group were due to respiratory (39.2%), bleeding (42.9%) and sepsis (25.0%) related events.
Conclusion:Patients that undergo splenectomy for sinistral portal hypertension are at substan-tially increased risk for morbidity but not mortality as compared with splenectomy for splenomegaly or other indications. Most significant are risks of respiratory, renal, bleeding or sepsis-related events. Careful patient selection must be employed in this cohort.
