Right portal vein thrombosis after splenectomy for trauma

Portal vein thrombosis may complicate splenectomy in patients with hemolytic anemia and myeloproliferative disease, whereas the frequency of portal vein thrombosis in case of trauma is not defined. A case of right portal vein thrombosis after splenectomy for trauma is reported in this paper. Hematologic workup did not reveal an underlying platelet or coagulation disorder. The patient was promptly anticoagulated with complete recanalization of the portal vein. We conclude that mild symptoms, like abdominal pain and fever, after splenectomy should be investigated with a color Doppler ultrasonography to confirm or rule out a diagnosis of portal thrombosis and to anticoagulate the patient with thrombosis, thus preventing bowel infarction and secondary portal hypertension. Routine postoperative color Doppler might also be justified in all postsplenectomy patients (without hematologic diseases) for early detection of a portal vein thrombosis.     

Percutaneous treatment of portal vein thrombosis in a child who has undergone splenectomy

Thrombosis of the portal venous system is a well-recognized and potentially lethal complication after open or laparoscopic splenectomy. A 7-year-old girl with idiopathic thrombocytopenic purpura developed a portal vein thrombosis after open splenectomy. The portal vein thrombosis was diagnosed by color Doppler sonography. A percutaneous transhepatic thromboaspiration of the acute thrombus was done on the third postoperative day. Anticoagulation was continued for 6 months. The presented patient is the youngest patient to undergo percutaneous thromboaspiration of an acute thrombus via the transhepatic route. Percutaneous thromboaspiration via the transhepatic route is an effective means of treating a portal vein thrombosis.     

High incidence of thrombosis of the portal venous system after laparoscopic splenectomy: a prospective study with contrast-enhanced CT scan

OBJECTIVE: The aims of this prospective study were to investigate the true incidence of portal or splenic vein thrombosis (PSVT) after elective laparoscopic splenectomy using contrast-enhanced computed tomography (CT) scan, and outcome of anticoagulant therapy for PSVT. SUMMARY BACKGROUND DATA: Although rare, thrombosis of the portal venous system is considered a possible cause of death after splenectomy. The reported incidence of ultrasonographically detected PSVT after elective open splenectomy ranges from 6.3% to 10%. METHODS: Twenty-two patients underwent laparoscopic splenectomy (LS group), and 21 patients underwent open splenectomy (OS group). Preoperative and postoperative helical CT with contrast were obtained in all patients, and the extent of thrombosis was investigated. Prothrombotic disorder was also determined. RESULTS: PSVT occurred in 12 (55%) patients of the LS group, but in only 4 (19%) of the OS group. The difference was significant (P = 0.03). Clinical symptoms appeared in 4 of the 12 LS patients. Thrombosis occurred in the intrahepatic portal vein (n = 9), extrahepatic portal vein (n = 2), mesenteric veins (n = 1), proximal splenic vein (n = 4), and distal splenic vein (n = 8). Prothrombotic disorder was diagnosed in 1 patient. Anticoagulant therapy was initiated once the diagnosis was established, and complete recanalization, except for distal splenic vein, was observed without any adverse event. Patients with splenomegaly were at high risk of PSVT. CONCLUSIONS: PSVT is a more frequent complication of laparoscopic splenectomy than previously reported but can be treated safely following early detection by CT with contrast.     

Long‐term outcomes of transmesenteric portal vein recanalization for the treatment of chronic portal vein thrombosis after pediatric liver transplantation

Portal vein thrombosis (PVT) may occur at any time following liver transplantation. We describe our experience with portal vein recanalization in cases of thrombosis after liver transplantation. Twenty‐eight children (5%) out of 566 liver transplant recipients underwent portal vein recanalization using a transmesenteric approach. All children received left hepatic segments, developed PVT, and had symptoms or signs of portal hypertension. Portal vein recanalization was performed via the transmesenteric route in all cases. Twenty‐two (78.6%) patients underwent successful recanalization and stent placement. They received oral anticoagulants after the procedure, and clinical symptoms subsided. Symptoms recurred due to portal vein restenosis/thrombosis in seven patients. On an intention‐to‐treat basis, the success rate of the proposed treatment was 60.7%. Only 17 out of 28 children with posttransplant chronic PVT retained stent patency (primary + assisted) at the end of the study period. In cases of portal vein obstruction, the transmesenteric approach via minilaparotomy is technically feasible with good clinical and hemodynamic results. It is an alternative procedure to reestablish the portal flow to the liver graft that can be performed in selected cases and a therapeutic addition to other treatment strategies currently used to treat chronic PVT.     

Diagnosis and treatment of portal vein thrombosis following splenectomy

BACKGROUND: Portal vein thrombosis is a rare but potentially fatal complication of splenectomy. The aim of this study was to assess the incidence, risk factors, treatment and outcome of portal vein thrombosis after splenectomy in a large series of patients. METHODS: All patients who had undergone a splenectomy in the University Hospital, Rotterdam, between 1984 and 1997 were reviewed retrospectively. Splenectomy that was followed by symptomatic portal vein thrombosis was selected for analysis. Risk factors for portal vein thrombosis were sought. RESULTS: Of 563 splenectomies, nine (2 per cent) were complicated by symptomatic portal vein thrombosis. All these patients had either fever or abdominal pain. Two of 16 patients with a myeloproliferative disorder developed portal vein thrombosis after splenectomy (P = 0.03), and four of 49 patients with haemolytic anaemia (P = 0.005). Treatment within 10 days after splenectomy was successful in all patients, while delayed treatment was ineffective. CONCLUSION: Portal vein thrombosis should be suspected in a patient with fever or abdominal pain after splenectomy. Patients with a myeloproliferative disorder or haemolytic anaemia are at higher risk; they might benefit from early detection and could have routine Doppler ultrasonography after splenectomy.     

脾切除联合贲门周围血管离断术后门静脉系统血栓发生率及其防治

目的 探讨门静脉高压症术后门静脉系统血栓（portal venous system thrombosis,PVST）形成的原因及其防治措施。方法 对132例门静脉高压症患者行脾切除联合贲门周围血管离断术,术中均经胃网膜右静脉置入导管测压并留置导管,其中36例患者（设为试验组,其余设为对照组）术中增加脾静脉近端结扎。术后早期经导管滴注肝素盐水预防血栓,或发生血栓后滴注尿激酶溶栓,出院后口服华法林,使预防和治疗血栓的效果分别达到国际标准化比值（INR）维持于1.5~2.0和2.0~3.0,并直至血小板数量恢复正常。结果 术后2周内发生PVST共132例（100%）,血栓分布：残余脾静脉血栓132例（100%）,门静脉血栓（PVT）39例（29.5%）。在39例PVT中,门静脉主干血栓33例,主干血栓均与残余脾静脉血栓相连,其中15例血栓最大横截面积<50%,14例血栓最大横截面积≥50%,4例为完全性血栓;肠系膜上静脉血栓6例,其中4例合并门静脉主干血栓并与肠系膜上静脉血栓相连,2例存在门静脉分支血栓且肠系膜上静脉血栓与脾静脉血栓相连。39例PVT中,门静脉左支血栓21例,门静脉右支血栓18例;PVT 2处及以上者25例。在试验组36例脾静脉近端结扎的患者中,发生门静脉主干血栓1例（2.8%）;在对照组未采用脾静脉近端结扎的96例中发生PVT 38例（39.6%）,两者对比差异有统计学意义（P<0.001）。对39例PVT采用抗凝及溶栓治疗,其中33例在术后6个月获得随访并进行CT检查,发现血栓消失、机化再通和海绵样变各23例、7例和3例。结论 肝硬化门静脉高压症行脾切除联合贲门周围血管离断术后早期残余脾静脉内易形成血栓,残余脾静脉血栓向门静脉内蔓延是发生术后PVT的主要原因。脾静脉近端结扎的预防效果显著,经胃网膜右静脉留置导管,术后滴注肝素盐水和溶栓剂兼具预防和治疗双重作用,口服华法林效果确切但需检测凝血功能。     

Endovascular management of early portal vein thrombosis caused by coronary vein steal after liver transplantation and its outcome

Early portal vein thrombosis (PVT), after orthotopic liver transplantation (OLT), is relatively uncommon and is a serious complication that can compromise graft and patient survival. The factors predisposing to PVT after OLT include rejection, technical problems during the surgery, use of vein grafts and conduits, preoperative PVT, previous portasystemic shunts and splenectomy, hypercoagulable state, and significant development of gastroesophageal collaterals. Among them, few cases of PVT caused by coronary vein (CV) steal after OLT have been reported. Herein, we present a case with early PVT caused by CV steal after OLT, which is treated by a percutaneous transportal approach, with a review of the relevant literature.     

Portal vein thrombosis following laparoscopic splenectomy for beta-thalassemia: a case study

Portal vein thrombosis is a rare but well-recognized complication of splenectomy. We present the case of a 31-year-old woman with transfusion-dependent b-thalassemia who underwent a laparoscopic splenectomy to reduce her transfusion requirements. Postoperatively, she developed portal vein thrombosis, diagnosed by abdominal CT scanning on postoperative day 4. After being treated with anticoagulation and antibiotic therapy, she obtained prompt resolution of her symptoms. This report summarizes the first reported incidence of portal vein thrombosis following laparoscopic splenectomy and presents the current theories regarding the etiology and treatment of postsplenectomy portal vein thrombosis.     

门静脉高压症行腹腔镜脾切除术后门静脉系统血栓形成预测因子的研究进展

腹腔镜脾切术后门静脉系统血栓(PVST)形成具有高发生率、隐匿性与危害性。然而,腹腔镜脾切术后PVST的最佳的诊断方式、治疗方案以及预测因子在国内外尚未形成统一意见。目前认为脾切除术后PVST发生的机制可能与血液高凝状态及血流动力学改变有关,其形成的原因大致为全身系统疾病和引起血流动力学变化的因素。全身性疾病包括恶性肿瘤、血液性疾病、自身免疫性疾病等,引起血流动力学变化的因素包括手术方式及时长、血浆D-二聚体、血小板计数、脾脏体积、脾脏最长直径、术前脾静脉直径及门静脉直径等。笔者对门静脉高压症行腹腔镜脾切除术后PVST形成预测因子的相关研究结果做一综述,旨在方便广大临床工作者对腔镜脾切后PVST形成进行风险评估,从而更加精准地把握抗凝时机,减少此并发症引起的严重后果,同时加快患者术后康复。     

Portal vein thrombosis after laparoscopic splenectomy in benign hematologic diseases

INTRODUCTION: Portal vein thrombosis is an unfrequent, but potentially deadly, complication of the laparoscopic splenectomy procedure. The laparoscopic approach has shortened the duration of hospital stay; portal vein thrombosis may appear after the patient has left the hospital, determining a later diagnosis. Because of the mild, nonspecific symptoms, the diagnosis can even be missed and only achieved when chronic complications take place. OBJECTIVES: In this study, we aimed to determine the appearance of portal vein thrombosis in a consecutive series of patients who underwent laparoscopic splenectomy by performing a contrast-enhanced computed tomography (CT) scan postoperatively. MATERIALS AND METHODS: A transversal study was established, performing in 2005 a contrast-enhanced CT scan on 20 patients who underwent laparoscopic splenectomy between 1999 and 2005 at Ramón y Cajal University Hospital (Madrid, Spain). The presence of thrombosis in the splenoportomesenteric axis was investigated. Results: Two (2) cases (10%) of portal vein thrombosis were detected: 1 symptomatic case, 7 days after surgery, was treated with anticoagulation, resulting in the disappearance of the thrombus in a new CT scan 6 months later; the second case was asymptomatic and was discovered during the performance of this study. CONCLUSIONS: The contrast-enhanced CT scan shows the best accuracy for the diagnosis of portal vein thrombosis, and it must be performed when any clinical manifestation appear; also, it must still be determined if a contrast-enhanced CT scan should be systematically performed in high-risk thromboembolic patients. An ultrasound Doppler may present many diagnostic errors. It is probably advisable to prolong the antithromboembolic prophylaxis.     

Portal vein thrombosis. A multifactorial clinical entity

Portal vein thrombosis usually appears in the course of acute abdominal septic complications or after splenectomy, though in 50% of cases no aetiological factors can be identified. In our department we recently treated two patients affected by portal vein thrombosis, the first after splenectomy for haematological disease, and the second after sigmoid diverticulitis. When portal vein thrombosis occurs after splenectomy for haematological reasons, the increased viscosity of the blood due to thrombocytosis is the main factor regarded as being the cause. In the first case, acute abdominal pain appeared 15 days after splenectomy and the diagnosis was suspected and confirmed by Doppler ultrasonography. The clinical course in the second case was less typical, because, although the sigmoid diverticular disease was known, the symptomatology presented with high fever but no clear subjective or objective abdominal picture. The diagnosis was achieved by computed tomography. The clinical picture may vary greatly but usually abdominal pain, fever and intestinal ischaemia are present. Nowadays the diagnosis has improved as a result of the extensive use of Doppler ultrasonography and computed tomography. Fibrinolytic therapy and acetylsalicylic acid are the treatment of choice and in our experience the clinical picture tends to clear up rapidly. When the patient presents a number of risk factors, prophylaxis of portal vein thrombosis should be planned.     

Elective laparoscopic splenectomy and thrombosis of the spleno-portal axis: a prospective study with ecocolordoppler ultrasound

Thrombosis of the portal system is a potentially life-threatening but otherwise underappreciated complication after splenectomy. Nonspecific and mild onset symptoms are the cause of delay in diagnosis, and the short hospital stay after laparoscopic approach could even contribute to the difficulty of early detection of this condition. The aim of this study was to verify if planned imaging controls are able to discover this complication leading to a prompt treatment. Thirty-eight patients (19 males and 19 females with a mean age of 24 years) who underwent laparoscopic splenectomy at our institution were studied to identify clinical signs of thrombosis of the portal venous system and eventually associated factors. All the patients were enrolled in a protocol of imaging surveillance using a doppler ultrasound method. Postoperative thrombosis of the spleno-portal axis occurred in 7 patients (18.9%) of the series. In 3 cases (8.1%) the thrombus extended from the splenic vein to occlude the portal axis. The complication was symptomatic in 4 cases (10.8%), whereas in 3 cases, the thrombosis was an ultrasonographic surprise in totally asymptomatic patients. Thrombosis occurred even as late as 2 months after splenectomy. Splenomegaly was the only significant factor predictive of thrombosis. Only those patients who had an early detection of portal or splenic vein thrombosis had a recanalization of the veins with anticoagulant therapy.Patients with splenomegaly who underwent laparoscopic splenectomy are at risk of thrombosis of the portal system and should undergo strict imaging surveillance and aggressive anticoagulation therapy.     

Thrombosis in the portal venous system after elective laparoscopic splenectomy

Background The occurrence of thrombosis in the portal system is an underappreciated complication of splenectomy. Presenting symptoms are usually mild and nonspecific. The short hospital stay associated with the laparoscopic approach could delay the early diagnosis of this condition unless routine imaging controls are planned after discharge.Methods The records of 40 patients who underwent laparoscopic splenectomy at our institution were reviewed for clinical signs of thrombosis in the portal system and associated factors. All patients were also enrolled in a color Doppler ultrasound surveillance program.Results Nine patients (22.5%) developed thrombosis of the splenic vein, progressing to the portal vein in five cases (12.5%). Six patients (15%) were symptomatic. Thrombosis occurred even as late as 4 months after splenectomy. Spleen weight was the only significant factor predictive of postoperative thrombosis. The combination of splenomegaly and an elevated preoperative platelet count was associated with a 75% incidence of this complication.Conclusion The high risk of thrombosis after the laparoscopic resection of large spleens should prompt strict postoperative imaging surveillance, combined with a more aggressive anticoagulation prophyaxis.     

完全腹腔镜脾切除术16例报告

目的:探讨腹腔镜脾切除术的可行性及安全性。方法:回顾分析2010年3月至2011年2月16例完全腹腔镜脾切除术的临床资料。结果:16例均成功完成手术;术中未发生意外损伤周围脏器或难以控制的大出血从而被迫中转开腹,无手术死亡病例;手术时间60～210 min,平均140 min;术中出血量20～400 ml,平均163 ml。3例脾外伤患者回输自体血800～1500 ml,3例肝硬化脾功能亢进症患者因术前贫血与凝血异常分别输红细胞悬液600 ml、冰冻血浆400 ml;1例脾血管瘤患者术后并发脾窝包裹性积液,在B超引导下穿刺抽液治愈;1例脾功能亢进症患者术后并发门静脉系统血栓形成,予以融栓抗凝治疗恢复。均于术后第2天下床活动,24 h拔除胃管并进全流质饮食,术后住院5～14 d,平均7.3 d。结论:完全腹腔镜脾切除术安全可行,具有微创、美容、患者康复快等优点,值得在有条件的单位推广应用。     

Portal vein thrombosis after laparoscopic splenectomy: an ongoing clinical challenge.

OBJECTIVES: Portal vein thrombosis (PVT) following open splenectomy is a potentially lethal complication with an incidence of up to 6%. The objective of this report is to describe our management of a recent laparoscopic case, discuss current therapies, and consider antiplatelet therapy for prophylaxis. METHODS: Medical records, laboratory studies, and imaging studies pertaining to a recent case of a laparoscopic splenectomy were examined. Current literature related to this topic was reviewed. RESULTS: A 16-year-old girl underwent laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Her preoperative platelet count was 96K. She was discharged on postoperative day 1 after an uneventful operation including division of the splenic hilum with an endoscopic linear stapler. On postoperative day 20, she presented with a 5-day history of epigastric pain, nausea, and low-grade fevers without peritoneal signs. Her white blood cell count was 17.3; her platelets were 476K. Computed tomography demonstrated thrombosis of the splenic, superior mesenteric, and portal veins propagating into the liver. Heparinization was begun followed by an unsuccessful attempt at pharmacologic and mechanical thrombolysis by interventional radiology. Over the next 5 days, her pain resolved, she tolerated a full diet, was converted to oral anticoagulation and sent home. Follow-up radiographic studies demonstrated the development of venous collaterals and cavernous transformation of the portal vein. DISCUSSION: No standard therapy for PVT exists; several approaches have been described. These include systemic anticoagulation, systemic or regional medical thrombolysis, mechanical thrombolysis, and surgical thrombectomy. Unanswered questions exist about the most effective acute therapy, duration of anticoagulation, and the potential efficacy of routine prophylaxis with perioperative antiplatelet agents. PVT following splenectomy occurs with both the open and laparoscopic approach.     

脾切除术后门静脉系统血栓形成的相关因素分析及早期抗凝效果分析

目的探讨门静脉高压行脾切除术后门静脉系统血栓形成（portalveinthrombosis,PVT）的相关因素,及早期抗凝治疗的预防作用。方法回顾分析102例门静脉高压行脾切除术患者临床资料．观察性别、年龄、术前肝功能Child—Paph分级、门静脉直径、术前和术后2周血小板计数、联合贲门周围血管离断术、抗凝等临床指标与PVT形成的相关性。结果102例患者脾切除术后PVT发生率16．7％（17例）,其中抗凝患者PVT发生率9．1％（5／55）,低于未抗凝治疗患者的25．5％（12／47）,差异有统计学意义（X^2=4．932,P〈0．05）。单因素分析显示PVT组与无PVT组贲门周围血管离断术（64．7％与36．5％）、门静脉内径[（13．8±2．1）mm与（15．2±2．2）mm]和抗凝治疗（29．4％与58．8％）存在统计学差异（P〈0．05）。多因素分析显示门静脉内径（OR=2．448,P=0．029）及是否抗凝治疗（OR=1．610,P=0．032）与术后PVT形成有关。结论脾切除术后PVT形成与门静脉内径增宽、是否抗凝治疗有关。术后早期给予低分子肝素抗凝治疗能降低PVT发生率。     

肝硬化脾切除术后门静脉系统血栓形成的原因分析

目的 探讨肝硬化门静脉高压患者行脾脏切除+贲门周围血管离断术后门静脉系统血栓(portal vein thrombosis,PVT)形成的原因.方法 回顾性分析我院2004年1月至2010年1月204例肝炎后肝硬化门静脉高压症行手术治疗患者的临床资料.结果 其中150例行脾切除+贲门周围血管离断术,54例行脾脏部分切除术+贲门周围血管离断术.术后发生PVT30例,未发生PVT174例;发生PVT患者的门静脉和脾静脉直径、术后门静脉血液流速及术后并发症与未发生PVT患者有显著性差异(P<0.05),脾脏部分切除术后患者PVT的发生率明显比脾脏切除患者低,有显著性差异(P<0.05).结论 门静脉和脾静脉直径、门静脉血液流速及术后并发症是肝硬化门脉高压症脾切+贲门周围血管离断术后PVT形成的危险因素,脾脏部分切除术可有效减少断流术后PVT的发生.     

Successful minimally invasive management of late portal vein thrombosis after splenectomy due to splenic artery steal syndrome following liver transplantation: a case report

Portal vein thrombosis (PVT) after liver transplantation (OLT), which occurs in 1% to 2.7% of cases, can compromise patient and graft survival. Percutaneous transhepatic portal vein angioplasty offers an option to treat PVT, diminishing surgically related morbidity and the need for retransplantation. We describe a case of late PVT after OLT, which was successfully treated by a minimally invasive percutaneous transhepatic approach using both mechanical fragmentation and pharmacologic lysis of the thrombus followed by anticoagulation. The patient has had a good clinical course with normal graft function and patent portal blood flow at 6-month follow-up. This case report confirms the possibility of successful recanalization of the portal vein in a patient with late PVT after liver transplantation. Sustained anticoagulation/antiaggregation therapy for at least 6 months after the procedure is advisable.     

Portal vein thrombosis following splenectomy: identification of risk factors

Portal vein thrombosis (PVT) following splenectomy is a potentially life-threatening complication, and the true incidence of PVT in splenectomized patients is unknown. The objective of this study was to determine the incidence of symptomatic PVT after splenectomy. The hospital database was searched to identify cases of PVT associated with splenectomy from January 1990 to May 2002. Six hundred eighty-eight patients underwent splenectomy during this period, 321 of them for hematologic diseases. Eleven of the 688 patients had PVT associated with splenectomy, and the charts of these patients were reviewed. Six patients developed PVT after splenectomy. Five had hematologic diseases. Symptoms were abdominal pain (6), ileus (5), fever (3), or diarrhea (2). Diagnosis was confirmed by computed tomography (CT) (4), duplex ultrasonography (1), and magnetic resonance imaging (1). The indications for splenectomy included hemolytic anemia (3), thalassemia (1), and myelofibrosis (1). One patient had an incidental splenectomy during gastrectomy. There were four laparoscopic and two open splenectomies. The median interval between splenectomy and diagnosis of PVT was 40 days (range, 13-741). One patient died of pulmonary embolism. Five of six patients with postsplenectomy PVT had splenomegaly and hemolysis. We conclude that the risk of PVT is higher in patients with hematologic conditions associated with splenomegaly and hemolysis.     

Portal vein thrombosis after splenectomy in pediatric hematologic disease: risk factors, clinical features, and outcome

Background/Purpose

A retrospective study was performed to evaluate risk factors, clinical features, and treatment modalities of portal vein thrombosis (PVT) after splenectomy in pediatric hematologic disease.

Methods

Sixty-eight patients who underwent splenectomy for various hematologic diseases were evaluated with regard to age, sex, blood count, and splenic mass. Patients who developed PVT were also reviewed for clinical features, treatment modalities, and outcome.

Results

Patients with PVT (n = 4, 5.88%) and without PVT (n = 64, 94.2%) had a mean age and female/male ratio of 13.2 years (range, 10-16 years) and 4:0, and 10.2 years (range, 1-16 years) and 29:35, respectively. Postoperative thrombocyte levels and splenic mass with and without PVT was 804 × 10³/mm³ and 752.5 g, and 465.2 × 10³/mm³ and 441g, respectively. Three patients with PVT presented with abdominal pain, fever, and vomiting. The diagnosis of PVT was made by Doppler ultrasonography in all patients including the asymptomatic case. Protein C, protein S, and antithrombin III levels were mostly decreased and/or normal and di-dimer levels were increased and/or normal after the development of PVT. Antiplatelet (acetylsalicylic acid) and antithrombotic therapy (low molecular weight heparin) were treatment agents. None of the patients needed surgery. During a mean follow-up period of 55.5 months, by Doppler ultrasonography, 1 patient was found to be free of thrombosis, whereas 1 had partial thrombosis. Two patients developed cavernomatous transformation leading to portal hypertension.

Conclusions

Portal vein thrombosis is a rare but significant complication of splenectomy done for hematologic diseases. According to our results, female gender and decreased levels of coagulation inhibitors seem to be risk factors in addition to previously mentioned thrombocytosis and greater splenic mass. Doppler ultrasonography may be performed in all patients after splenectomy to screen PVT. In the presence of well-known risk factors, prophylactic antiplatelet and antithrombotic therapy should be considered after splenectomy.