| 【Background】As splenomegaly often occurs in cirrhotic patients with portal hypertension(PHT),the efficacy and accuracy of the conventional measurement for the splenic volume in these patients is controversial.Here,we developed a novel approach to assess the true splenic volume more precisely.Laparoscopic splenectomy and esophagogastric devascularization(LSED)are minimal invasive,effective and safe in treating esophageal-fundic variceal bleeding with portal hypertension.Removal of the spleen blocks the interaction between the spleen and the liver in the pathological state.How this affects liver regeneration and function deserves further exploration.Although hepatectomy plus splenectomy is not regularly recommended for hepatocellular carcinoma(HCC)with portal hypertension related hypersplenism due to the high risk accompanied with surgical procedures for now.Many researchers still believe that hypersplenism is a controversial adverse prognostic factor for HCC patients.Therefore,the main objective of this study was to determine the impact of hypersplenism on the prognosis of patients with hepatitis B-associated hepatocellular carcinoma after hepatectomy and to reveal the value of hypersplenism for prognosis in order to provide new prognostic risk factors and a more evidence-based rationale.【Aims】1.To provide a more accurate and convenient method for the assessment of splenomegaly in patients with liver cirrhosis and portal hypertension.Can better guide clinical treatment.2.To explore the effect of laparoscopic splenectomy combined with pericardial vascular detachment after spleen removal on liver function,especially liver regeneration.Uncover the link between the liver and spleen.3.To explore the effect of hypersplenism on the prognosis after hepatectomy for hepatitis B-related liver cancer.Provide more evidence-based basis for the risk factors of liver cancer prognosis and the formulation of clinical treatment plan.【Methods】1.High-quality thin-slice computed tomography(CT)data of 112 cirrhotic patients with PHT were obtained and reviewed.Both the conventional measurement and a novel formula obtained from three-dimensional(3D)reconstruction software were used to calculate estimated splenic volume,of which the accuracy was compared and verified.2.Sixty-three patients were retrospectively analyzed.Liver volume(LV)was measured by a 3-D simulation imaging system.Clinical data and long-term follow-up data were recorded.3.A total of 335 patients with HBV-related HCC who underwent surgical resection as primary intervention were included in this study and categorized into three groups.Group A consisted of 226 patients without hypersplenism,Group B included 77 patients with mild hypersplenism,and Group C contained 32 patients with severe hypersplenism.The influence of hypersplenism on the outcome during the perioperative and long-term follow-up periods was analyzed.The independent factors were identified using the Cox proportional hazards regression model.【Results】1.In the first part of the study,65.2%of our cases had hepatitis B cirrhosis,9.8%had hepatitis C cirrhosis,11.6%had idiopathic cirrhosis,8.9%had autoimmune cirrhosis,0.9%had alcoholic cirrhosis,1.8%had cholestatic cirrhosis,and 1.8%had drug-induced cirrhosis.The spleen volume calculated by conventional methods in patients with PHT was significantly smaller than that measured by 3D softwarec.We found that spleen volume was significantly and positively correlated with splenic indicators such as length(L),thickness(T),width(W),and splenic vein diameter.Using these indicators,a new formula for estimating spleen volume was obtained by the software:SV=69.686×L+53.077×W+103.525×T+314.510×splenic vein diameter-2266.209(P<0.01,R~2=0.805)and a simplified version:SV′=0.504×L×W×Τ+319.762×splenic vein diameter-81.66(P<0.01,R~2=0.784).2.In the second part of the study,66.7%of our cases had hepatitis B cirrhosis,11.1%had hepatitis C cirrhosis,15.8%had idiopathic cirrhosis,4.8%had autoimmune cirrhosis,and 1.6%had alcoholic cirrhosis.Enlarged liver volume was found in 45 of the 63 patients included in the study after surgery.Portal hemodynamics,hypersplenism and liver function were improved after splenectomy.Patients with longer spleen length and higher albumin levels had a high probability of increased liver volume postoperatively.Anticoagulation therapy administered postoperatively also contributes to the increase in liver volume.3.In the third part of the study,the presence of hypersplenism resulted in a longer hospital stay,an increased number of patients requiring postoperative blood transfusions,and an increased incidence of complications.It also significantly decreased overall survival(OS)as well as recurrence-free survival(RFS)of patients.Mild hypersplenism(HR=2.063,P<0.01),severe hypersplenism(HR=3.754,P<0.01),positive HBV-DNA copy(HR=1.571,P=0.020),serum AFP level>400ng/m L(HR=1.950,P<0.01),tumor size>5 cm(HR=2.215,P<0.01)were independent prognostic factors for overall survival in patients with HBV-associated hepatocellular carcinoma.Mild hypersplenism(HR=1.778,P<0.01),severe hypersplenism(HR=3.183,P<0.01)and tumor size>5 cm(HR=1.635,P=0.002)were independent prognostic factors for recurrence-free survival in patients with HBV-associated hepatocellular carcinoma.In addition,the more severe hypersplenism was associated with shorter survival time.It was demonstrated that hypersplenism was an important independent prognostic risk factor for OS and RFS.【Conclusions】1.Traditional formulas are not suitable for estimating the volume of enlarged spleens in patients with cirrhosis combined with PHT.We have developed two new formulae for calculating spleen volume based on clinical data that are closer to the true spleen volume.2.LSED in patients with cirrhotic PHT improved pancytopenia,liver function,and portal vein hemodynamics.Patients with huge splenomegaly and higher albumin levels combined with postoperative anticoagulation therapy were expected to have more chance of LV increase and liver function improvement.3.Severe hypersplenism prolonged the hospital stay,increased the rate of postoperative blood transfusion,and elevated the incidence of complications.Furthermore,hypersplenism predicted lower overall and disease-free survivals. |
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