The Effect of Splenectomy on Postoperative Morbidity and Survival in Patients with Peritoneal Carcinomatosis

Our plain-English summary of The Effect of Splenectomy on Postoperative Morbidity and Survival in Patients with Peritoneal Carcinomatosis, by S. Ademoğlu, İ.C. Aydın, A.O. Sunar, et al (Journal of Clinical Medicine, 2025).

The study

• Authors: S. Ademoğlu, İ.C. Aydın, A.O. Sunar, M.Ö. Özduman, U. Duman, M. Dinçer, E. Polat, M. Duman
• Journal: Journal of Clinical Medicine
• Published: 2025;14(22)
• Read it: PubMed · Publisher · Free full text

Abstract

Background/Objectives: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are effective treatment modalities for patients with peritoneal carcinomatosis (PC), though splenectomy is frequently required and its impact on outcomes remains unclear. Previous studies have evaluated splenectomy as a binary variable without distinguishing surgical indication, potentially obscuring important prognostic differences. This retrospective study aimed to evaluate the impact of splenectomy on postoperative morbidity and survival in patients undergoing CRS + HIPEC. Methods: A retrospective analysis was conducted on 149 patients who underwent CRS + HIPEC between 2018-2022 at a single tertiary center. The study examined patients with various cancer origins, including colorectal, ovarian, gastric, pseudomyxoma peritonei, and malignant peritoneal mesothelioma. Demographic characteristics, surgical procedures, complications, and survival outcomes were comprehensively analyzed. Patients were categorized by splenectomy and further stratified by surgical indication (iatrogenic injury, peritoneal implants, hilar tumor invasion). Results: Splenectomy was associated with longer ICU stay (median 1.5 vs. 1 day, p < 0.001) and hospitalization (median 12 vs. 9 days, p = 0.005). Individual pulmonary complications were more frequent in the splenectomy group, though major complication rates (Clavien-Dindo ≥ 3) were similar (34.7% vs. 21.7%, p = 0.086). When analyzed without stratification by indication, splenectomy showed no impact on OS (median 42.7 vs. 42.2 months, p = 0.665) or DFS (median 32.1 vs. 35.4 months, p = 0.138). However, stratification by indication revealed divergent prognostic effects: splenectomy for peritoneal implants independently predicted worse DFS (OR = 17.814, 95% CI: 3.025-104.894, p = 0.001), while splenectomy for hilar invasion was protective (OR = 0.136, 95% CI: 0.025-0.736, p = 0.021). PCI independently predicted both OS (OR = 1.150 per point, p = 0.006) and DFS (OR = 1.166 per point, p < 0.001). Primary tumor type was not independently prognostic after adjusting for PCI (OS p = 0.345, DFS p = 0.163). Conclusions: Splenectomy during CRS + HIPEC was associated with prolonged intensive care and hospital stays without increasing major complications. Peritoneal implant-related splenectomy predicts worse DFS, likely reflecting extensive disease burden, while hilar invasion-related splenectomy is protective, possibly reflecting more complete regional clearance achieved during en bloc resection to attain CC-0. Given the retrospective nature of this study and the heterogeneous patient population, these findings should be interpreted with caution. Further prospective research with larger, more homogeneous patient cohorts is warranted to definitively establish the long-term implications of splenectomy in CRS + HIPEC procedures.

In plain English

In this retrospective study at one Istanbul hospital, 149 patients with cancer spread through the abdominal lining had surgery plus heated abdominal chemotherapy (CRS + HIPEC). Most had colorectal cancer; 9 had malignant peritoneal mesothelioma. Asbestos exposure was not examined. It compared 52 patients whose spleen was removed with 97 whose spleen was not. Spleen removal was associated with longer intensive care and hospital stays and more pleural effusion. Major complications (34.7% vs. 21.7%) did not differ significantly. Excluding three early postoperative deaths, median overall survival was 42.7 months (95% CI 36.7 to 48.7) with spleen removal and 42.2 months (37.9 to 46.5) without, not a significant difference. In a Cox regression model, removal because of tumor implants was linked to worse disease-free survival (recurrence, progression or death) than no removal (17.814, 95% CI 3.025 to 104.894, labeled an odds ratio). Removal for tumor invading the splenic hilum was linked to better disease-free survival (0.136, 95% CI 0.025 to 0.736). The authors concluded the implant finding likely reflects greater disease burden, called the hilar finding hypothesis-generating, and urged caution given the mixed patients and retrospective design.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective cohort study of hospital records at a single center
• Who was studied: 149 patients who underwent CRS + HIPEC at the Department of Gastroenterological Surgery, Kosuyolu Training and Research Hospital, Istanbul, Türkiye. The Methods give the study period as 1 January 2018 to 31 December 2021; the abstract says 2018 to 2022. There were 78 with colorectal cancer, 24 with pseudomyxoma peritonei, 20 with gastric cancer, 18 with ovarian cancer and 9 with malignant peritoneal mesothelioma.
• Exposure: Splenectomy (removal of the spleen) during CRS + HIPEC: 52 patients with splenectomy vs. 97 without. Splenectomy was further grouped by indication: hilar tumor invasion, peritoneal implants, or iatrogenic injury. No asbestos or fiber exposure was studied.
• Main results:
  • Splenectomy patients had longer ICU stays than patients without splenectomy (median 1.5 vs. 1 day, p less than 0.001). They also had longer hospital stays (median 12 vs. 9 days, p = 0.005).
  • Major complications (Clavien–Dindo grade 3 or higher) occurred in 34.7% of the splenectomy group vs. 21.7% of the non-splenectomy group. The difference was not statistically significant (p = 0.086).
  • Some individual complications were more frequent in the splenectomy group than in the non-splenectomy group: pleural effusion 25.0% vs. 4.1% (p less than 0.001) and pancreatic fistula 15.4% vs. 1.1% (p = 0.001).
  • Three patients who died early after surgery were excluded from the survival analyses, leaving 146 patients.
  • Disease-free survival was defined as the time from surgery to first documented recurrence, progression, or death from any cause.
  • Independent predictors of overall and disease-free survival were identified with multivariate Cox proportional hazards regression models.
  • Without grouping by indication, median overall survival was 42.7 months with splenectomy vs. 42.2 months without (p = 0.665). Median disease-free survival was 32.1 vs. 35.4 months (p = 0.138). Neither difference was statistically significant.
  • In patients with splenectomy, the 95% confidence interval for median overall survival was 36.7 to 48.7 months.
  • In patients without splenectomy, the 95% confidence interval for median overall survival was 37.9 to 46.5 months.
  • In the multivariate Cox model for disease-free survival, splenectomy for peritoneal implants was associated with increased recurrence risk compared with no splenectomy. The estimate was 17.814 (95% CI 3.025 to 104.894, p = 0.001), and the article labels it an odds ratio.
  • In the multivariate Cox model, splenectomy for hilar tumor invasion was associated with improved disease-free survival compared with no splenectomy. The estimate was 0.136 (95% CI 0.025 to 0.736, p = 0.021), and the article labels it an odds ratio.
  • For overall survival, splenectomy for peritoneal implants showed a borderline association with increased mortality risk in multivariate analysis (labeled OR = 4.505, 95% CI 0.939 to 21.620, p = 0.060). This was not statistically significant.
  • The Peritoneal Cancer Index (PCI), a measure of disease burden, independently predicted overall survival (labeled OR = 1.150 per 1-point increase, 95% CI 1.041 to 1.270, p = 0.006).
  • Malignant mesothelioma was more frequent in the splenectomy group (7 of 52) than in the non-splenectomy group (2 of 97).
• The authors' conclusion: The authors concluded that splenectomy prolonged ICU and hospital stays but was not a risk factor for major complications. They concluded that the association between implant-related splenectomy and recurrence mainly reflects peritoneal disease burden rather than the splenectomy itself. They described the protective association of hilar-invasion splenectomy as hypothesis-generating and requiring prospective validation.
• Limitations the authors state:
  • Patients had different primary cancers, which made it difficult to separate the effect of splenectomy from the effect of the underlying disease.
  • The stratified analysis cannot establish causality.
  • Subgroups by splenectomy indication were small, giving wide confidence intervals and limited statistical power.
  • Survival analysis by tumor type, including mesothelioma (n = 9), was not feasible because the numbers were small.
  • Two different HIPEC chemotherapy protocols were used.
  • Some patients had less than 2 years of follow-up.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneal Mesothelioma.

Related studies

• Assessing morbidity, mortality, and survival in patients with peritoneal carcinomatosis undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy — J.S.A. Vallejo, F.L. Queiroz, et al. (2023)
• Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma — M. Infante, E. Morenghi, et al. (2016)
• Influence of the effectiveness of sarcopenia on postoperative major complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy: a retrospective cohort study — N. Havan, S. Gülmez, et al. (2025)
• Postoperative Complications Independently Predict Cancer-Related Survival in Peritoneal Malignancies — M.H.A. Choudry, Y. Shuai, et al. (2018)
• Preoperative Circulating Tumor DNA in Patients with Peritoneal Carcinomatosis is an Independent Predictor of Progression-Free Survival — J.M. Baumgartner, V.M. Raymond, et al. (2018)
• Postoperative morbidity and mortality after pneumonectomy: a 30-year experience of 2064 consecutive patients — C. Pricopi, P. Mordant, et al. (2015)

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