Spleen management in hepatectomy for hepatocellular carcinoma with hypersplenism: a systematic review and network meta-analysis.

In 30 seconds

This systematic review and network meta-analysis compared hepatectomy alone (HA), hepatectomy plus splenectomy (HS), and hepatectomy plus splenic arterial flow reduction (SAFR) in patients with hepatocellular carcinoma and cirrhotic hypersplenism undergoing curative-intent surgery. Thirty comparative studies included 3967 patients. In eight-study primary analyses, HS was associated with longer overall survival than HA (HR = 0.73, 95% CI 0.62-0.85), but also with more portal vein thrombosis and major complications. Exploratory network analyses linked both HS and SAFR to better postoperative blood-count recovery than HA; SAFR evidence was sparse and heterogeneous.

Key findings

• Compared with HA, HS was associated with longer overall survival (HR = 0.73, 95% CI 0.62-0.85) and recurrence-related survival (HR = 0.67, 95% CI 0.59-0.76).
• HS was associated with more portal vein thrombosis than HA (RR = 6.00, 95% CI 3.35-10.74) and more major complications (RR = 1.57, 95% CI 1.10-2.23).
• Exploratory network analyses associated both HS and SAFR with greater postoperative platelet and white blood cell recovery than HA; SAFR evidence was sparse and heterogeneous.

Why it matters

Managing hypersplenism during curative-intent hepatectomy involves balancing hematological recovery against operative and thrombotic harms. These pooled findings suggest that splenectomy may be associated with better survival but also greater complications, while SAFR may improve early blood counts. The comparisons help frame this trade-off, but the evidence does not establish that either adjunct causes better outcomes.

What to keep in mind

The evidence came from comparative studies assessed with ROBINS-I, and the SAFR network evidence was sparse with substantial heterogeneity.