EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Objectives: Hypersplenism (thrombocytopenia, leukopenia, anemia) syndrome and ascites occur after orthotopic liver transplant. These conditions can be treated by open splenectomy. Splenic artery embolization has been practiced as an alternative surgical method.

Materials and Methods: Between January 2013 and January 2015, twenty-one orthotopic liver transplants were performed at the National Scientific Medical Research Center, Astana, Kazakhstan. Of these patients, 3 subsequently received splenic artery embolization 12, 8, and 6 months after transplant: 2 patients who had been diagnosed with primary biliary cirrhosis and 1 patient with hepatitis B virus–related liver cirrhosis. Two patients received a right-lobe living orthotopic liver transplant, and 1 patient received a deceased donor transplant. Indications for splenic artery embolization (ascites, splenomegaly) were based on clinical and ultrasonographic investigation and laboratory findings (thrombocytopenia, platelet count < 60 × 10⁹/L, leukocytopenia, and white blood cell count < 2 ×10⁹/L). Two recipients had leukothrombocytopenia and refractory ascites, and 1 had only thrombocytopenia. Splenic artery embolization was performed via a percutaneous femoral artery approach under local anesthesia. Transcatheter splenic artery branch occlusion was performed by deploying occlusion material. Preoperative spleen size ranged from 17.5 × 8.0 cm to 22.0 × 12.5 cm; ascites volumes were > 1000 mL.

Results: In all patients, ascites and platelet levels decreased after splenic artery embolization. In 1 patient with leukopenia, white blood cell count normalized. After embolization, 1 patient had severe abdominal pain requiring analgesia medication, and 2 patients had fever that lasted 3 days. Patients were discharged 6 to 9 days after embolization. One patient developed a perisplenic abscess without fever 1 month after discharge, and the abscess was drained using an ultrasound-guided percutaneous procedure.

Conclusions: Splenic artery embolization is a safe and effective minimally invasive method for treating hypersplenism and ascites in orthotopic liver transplant recipients and an alternative to open splenectomy.

Key words : Ascites, Hypersplenism, Leukopenia, Orthotopic liver transplant, Thrombocytopenia

Hypersplenism (thrombocytopenia, leukocytopenia, anemia) syndrome and ascites are not infrequent complications after orthotopic liver transplant (OLT). Although these conditions can be treated by open splenectomy, this procedure has many adverse effects. As an alternative surgical treatment, splenic artery embolization (SAE) has been reported in previous studies. The first SAE procedure was performed in 1973 by Maddison in 1979 and the first partial SAE was performed by Spigos.^1,2,8 The indications for SAE are varied and include hypersplenism, portal hypertension, splenic vein thrombosis, and renal insufficiency as well as thalassemia, chronic idiopathic thrombocytopenic purpura, variceal bleeding, and splenic artery steal syndrome (after liver transplant).^3-5 Splenic artery embolization offers many advantages over open splenectomy^3-7 (Table 1).

However, few studies have been undertaken about SAE in liver transplant patients, and the treatment of hypersplenism by SAE is still not well established. For this study, we reviewed the partial SAE treatment of 3 patients with hypersplenism and ascites after liver transplant.

Materials and Methods

Between January 2013 and January 2015, we performed 21 OLT procedures at our center: 18 from living donors (1 from the left lobe of the liver, and 17 from the right lobe) and 3 from deceased donors. After OLT, 3 patients developed signs of hypersplenism and/or ascites and underwent partial SAE. Before OLT, 2 recipients (both women) had been diagnosed with primary biliary cirrhosis, and 1 recipient (man) had hepatitis B virus–related liver cirrhosis. Two patients had received a right-lobe living donor OLT, and 1 had received a deceased donor OLT (Table 2).

All recipients were given the 3-component immunosuppressive regimen consisting of a calcineurin inhibitor, mycophenolate mofetil, and a steroid. In 3 patients, partial SAE was performed after 382, 243, and 194 days. The indications for SAE (ascites, splenomegaly) were based on clinical and ultrasonography investigation and laboratory criteria (thrombocytopenia, platelet count < 60 × 10⁹/L, leukopenia, and white blood cell count < 2 × 10⁹/L). All 3 patients had thrombocytopenia (99 × 10⁹/L,55 × 10⁹/L, and 57 × 10⁹/L). One patient had leukopenia (cell count 1.2 × 10⁹/L).Two patients had refractory ascites (volume > 1000 mL), and 1 patient had thrombocytopenia only. Patients’ characteristic before SAE are listed in Table 3.

All patients were given preoperative antibiotic prophylaxis and desensitization medication. Then interventional radiologists performed SAE via a percutaneous right femoral artery approach in an operating room while the patient was under local anesthesia. After SAE, selective celiac and splenic arterial angiography images were obtained to determine the target splenic artery branches. Transcatheter splenic artery branch occlusion was performed by deploying a gelatin sponge slurry. Two patients had occluded superior and middle splenic artery branches, and 1 patient had occluded middle and inferior branches.

After SAE, the platelet count of patient 1significantly increased to 372 × 10⁹/L. However, her ascites resolved within 2 weeks, at which time her spleen size had decreased by 2 to 4 cm. The platelet count of patient 2 (who had only thrombocytopenia before SAE) increased to 141 × 10⁹/L, while the spleen size decreased to 14.0 × 7.5 cm. Patient 3 had an increased platelet count (to 116 × 10⁹/L) while his leukocyte count increased to normal and his ascites volume significantly reduced (from > 1500-300 mL). Patients 1, 2, and 3 were discharged 6, 8, and 9 days after SAE. The SAE outcomes and results after 2 weeks are presented in Table 4. The complications are presented in Table 5.

Patient 1 had severe abdominal pain and needed analgesic drugs. After 1 month following SAE, she developed perisplenic abscess and remained in the hospital. The abscess was drained using an ultrasound-guided percutaneous procedure, the patient received intravenous antibiotics, and then was successfully discharged. Patient 2 had a high temperature (≤ 38.5ºC) that lasted 3 days and experienced minimal brief abdominal pain. Patient 3 did not experience any significantly adverse effects or complications from SAE. No patients died after SAE.

Although our study was limited by the small number of cases, SAE appears to be a safe and effective minimally invasive method for treating hypersplenism and resistant ascites in patients after OLT. In addition, this procedure is justifiable in patients who have an immunosuppressed condition as an alternative to open total splenectomy.

Volume: 13 Issue: 3 November 2015 - Supplement - 3

FULL TEXT