Randomized controlled trial to investigate the impact of anticoagulation on the incidence of splenic or portal vein thrombosis after laparoscopic splenectomy.

Splenic and portal vein thrombosis (SPVT) is an alarming and potentially life-threatening complication of splenectomy. Prospective and retrospective studies have shown the incidence of symptomatic SPVT to be between 0%1 and 19%.2 Since patients with SPVT can present with vague and nonspecific symptoms, identification of this condition is essential to allow for early treatment and to prevent complications, such as bowel infarction or portal hypertension if the occlusive splenic venous clot propagates beyond the splenoportal confluence. Several studies have looked at using contrast-enhanced computed tomography or Doppler ultrasonography for more sensitive early detection of asymptomatic SPVT in routine surveillance imaging postsplenectomy. The reported incidence of asymptomatic SPVT ranges from 5%3 to 52%,4 and the risk very clearly correlates with the degree of splenomegaly, with massive splenomegaly carrying the greatest risk. Patients with myeloproliferative and lymphoproliferative disorders and hereditary hemolytic anemia are also at increased risk for SPVT.5 There are currently no well-designed studies to compare the rate of SPVT in open splenectomy versus laparoscopic splenectomy; however, there is a trend suggesting a higher overall incidence of SPVT in the laparoscopic cohort (5%–19% open v. 10%–52% laparoscopic).5 Moreover, the administration of routine perioperative anticoagulation is not standardized. The 2008 clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) recommend perioperative anticoagulant prophylaxis with subcutaneous heparin for all patients.6 Recent surgical guidelines indicate that routine use of thromboprophylaxis is not recommended for laparoscopic procedures. For patients at increased risk for thrombosis, one or more of the following is recommended: low molecular weight heparin (LMWH), low-dose unfractionated heparin (LDUH), fondaparinux, intermittent pneumatic compression (IPC) or graduated compression stockings (GCS).7 Despite a body of literature on the incidence, diagnosis and treatment of SPVT, to our knowledge there have not been any studies examining whether prophylactic pre- and postoperative anticoagulation can prevent this serious complication. We therefore designed a prospective, randomized controlled trial (RCT) to address the impact of more aggressive prophylactic anticoagulation on the incidence of asymptomatic or symptomatic SPVT, detected on Doppler ultrasound, after laparoscopic splenectomy.