Review article
Partial Splenic Embolization in the Treatment of Patients with Portal Hypertension: A Review of the English Language Literature

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This article reviews the existing literature on the use of partial splenic embolization in patients with portal hypertension. All articles published in the English language on splenic embolization or partial splenic embolization as a treatment for portal hypertension were identified with a PubMed search from 1973 through 2005. Partial splenic embolization appears to be efficacious in reducing episodes of variceal bleeding, improving hematologic parameters, enhancing hepatic protein synthesis, and reducing the severity of hepatic encephalopathy. Associated morbidity and mortality appear to be acceptable. The literature, however, is limited in quality. Given the potential benefits of partial splenic embolization, further investigation is warranted to allow evidence-based evaluation of its use.

Section snippets

History of Splenic Embolization

In 1973, Maddison was the first to report the use of splenic embolization in a human being. Dr. Maddison successfully used autologous clot to embolize the spleen of an actively bleeding farmer who had suffered from repeated bouts of gastrointestinal hemorrhage from esophageal varices. In 5 months of follow-up, no further episodes of gastrointestinal bleeding occurred (3). For several years after Maddison’s abstract was published, many investigators attempted to use splenic embolization in the

Efficacy of Splenic Embolization for Variceal Hemmorhage

Though the underlying mechanism eludes current understanding, much evidence exists that splenic embolization is effective in treating variceal hemorrhage. Table 1 summarizes the findings of those authors who have studied this outcome. It includes results from articles published in the English-language literature since 1973 that look at variceal bleeding outcomes in patients treated with PSE or with a combination of PSE and endoscopic variceal ligation (EVL). Not included are study results in

Efficacy of Splenic Embolization in Improving Liver Function

Splenic embolization also appears to improve the hepatic protein synthetic capabilities of patients with portal hypertension. In 1986, Hirai et al noted improved liver function tests in a cirrhotic patient treated with PSE (75). Ten years later, two different studies looked at liver function in a total of 40 portal-hypertensive patients treated with PSE. These investigations found significantly improved values of cholinesterase, total cholesterol, total protein, albumin, and prothrombin time

Efficacy of Splenic Embolization in Improving Hematologic Parameters

The efficacy of splenic embolization for improving hematologic parameters is well established. Significant and durable improvements have been shown in leukocyte count (62, 80, 81), red blood cell count (61), and platelet count (61, 62, 79, 80, 81) after PSE. Increased leukocyte count after splenic embolization is likely due to decreased splenic pooling of white blood cells (82). Increased red blood cell count after splenic embolization appears to be attributable to increased erythrocyte

Efficacy of Splenic Embolization for Hepatic Encephalopathy

The literature also suggests that splenic embolization may play a role in improving hepatic encephalopathy. Yoshida et al demonstrated that use of PSE in conjunction with obliteration of portal-systemic shunts in patients with hepatic encephalopathy resulted in decreased serum ammonia levels and lower grades of encephalopathy when compared with patients who underwent shunt obliteration but did not have PSE (84). Additionally, Uflacker et al demonstrated control of hepatic encephalopathy in two

Survival

Very few studies of PSE in patients with portal hypertension have looked at survival as an outcome. Those that have found mixed results. In Ohmoto’s nonrandomized comparison of patients treated with PSE and EVL with those treated with EVL alone, the relative risk of death in the PSE/EVL group was 0.193 (95% CI 0.053–0.699; P = .012) (70). Figure 2 shows the survival curve from Ohmoto’s study. Additionally, work done by Tajiri et al, while not showing a statistically significant difference in

Morbidity and Mortality

Given that significant complications were common in the early history of PSE and that these complications were likely responsible for the technique’s failure to become a mainstream treatment option for patients with portal hypertension, it is important to take a close look at the complications associated with more recent use of PSE. As was discussed at the opening of this article, improvement in associated morbidity and mortality is not unexpected given 30 years worth of advancement in

Conclusions

Management of the complications of portal hypertension is a major challenge for clinicians. This is especially the case for those patients who suffer from recurrent bleeding of gastroesophageal varices. PSE, either by itself or in conjunction with other therapies, shows promise as a useful intervention for achieving control of variceal hemorrhage. Though no randomized control trials have been conducted to investigate the potential of this technique, numerous case reports, case series reports,

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