Laparoscopic Splenectomy and Azygoportal Disconnection May Prevent HCC in Cirrhotic Portal Hypertension

Laparoscopic splenectomy and azygoportal disconnection (LSD) is a dependent protective predictor of hepatocellular carcinoma (HCC) incidence in patients with cirrhotic portal hypertension (CPH), gastroesophageal variceal bleeding, and secondary hypersplenism compared with endoscopic therapy (ET), according to a study in the Journal of Gastroenterology.

Researchers compared the incidence density of HCC for LSD vs ET in patients with CPH from April 2012 to April 2021 from a hepatobiliary pancreatic center.

Participants were aged 18 years and older, fit Child-Pugh class A or B, had liver cirrhosis diagnosed by computed tomography (CT), gastroesophageal variceal bleeding, or hypersplenism. The follow-up was 10 years.

Inverse probability of treatment weighting (IPTW) was used to control for confounding factors, and Kaplan-Meier curves and logistic regression were used to evaluate the association of therapy methods with the risk of HCC after weighting.

A total of 595 patients were included — 345 in the LSD group (mean [SD] age, 54.77[10.22] years; men, 59%) and 250 in the ET group (mean age, 61.11[11.69] years; men, 57%). After IPTW adjustment, a significant statistical difference was observed in HCC incidence between the ET (83.3%) and LSD groups (94.9%; P =.001).

Regardless of before or after IPTW, Kaplan-Meier analysis showed that patients who had LSD had higher survival benefit than those who underwent ET (all P <.001).

Postoperative HCC occurred in 7.6% of participants — 11.2% of those in the ET group and 4.9% of those in the LSD group. The difference in incidence between male and female patients was not statistically significant (8.9% vs 5.7%, P =.188). After adjustment with IPTW, the difference was statistically significant (9.2% vs 4.4%, P =.031). At the end of follow-up, patients with ET had an increased HCC incidence density compared with the LSD group (28.1/1000 vs 9.6/1000 person-years; rate ratio [RR], 2.922; 95% CI, 1.599-5.338).

After weighting, logistic regression analyses demonstrated that LSD was an independent protective predictor of HCC incidence compared with ET (odds ratio [OR], 0.440; 95% CI, 0.316-0.612; P <.001).

Among ET participants, paired within-group comparisons regarding preoperative white blood cell, neutrophil, lymphocyte, eosinophil, basophil, and monocyte counts and those at postoperative month 3 had no significant increases for all counts (all P >.05). For the LSD group, these comparisons showed significant increases for all counts (all P <.001).

Limitations include background and selection biases, as patients who received ET were significantly older than those who had LSD. Also, the common starting point for follow-up for all participants in both groups was the time of first gastroesophageal variceal bleeding. In addition, although all patients with CPH were required to have a physical examination every 6 months after they were discharged from the hepatobiliary pancreatic center, the time of HCC diagnosis for some who had low compliance may have been delayed.

“Considering the better postoperative survival and the ability to prevent HCC, it is worth popularizing LSD, especially in situations where liver donors are scarce,” the study authors noted. “Hence, [in] CPH patients with secondary hypersplenism and splenectomy, especially minimally invasive laparoscopic splenectomy or LSD, can be considered the preferred option.”