Review for 10.1186/s12876-021-01647-2 (2021)

Title: Efficacy and safety of laparoscopic splenectomy for hypersplenism secondary to portal
hypertension after transjugular intrahepatic portosystemic shunt
Version: 1 Date: 19 Nov 2020
Reviewer's report:
Dear authors,
you analyzed the feasability of splenectomy in patients with portal hypertension and TIPS. Since
the TIPS patency of the patients was not measured, it is not possible to evaluate the effect of
splenectomy in these patients! There are studies on spleen embolization and TIPS from Wan
YM et al. Eur Rad 2019 and Li YH et al. Academic Radiol 2020, which have to be discussed!
It is not unusual to perform splenectomy/spleen embolization in patients with hypersplenism
(after TIPS placement) although it is not reported in the literature. I think you should read the
literature and improve the following issues:
1.At least one relevant complication for splenectomy is missing: abscess! Add the number of
abscess!
2.In Background, you should add other major complications of TIPS such as heart failure and
liver failure (Background/page3)!
3.Did you mean "postoperative stay" and not "posthospital stay" (Background/page4)?
4.You mention the complication of portal vein thrombosis after splenectomy (background/
page4). In patients with TIPS portal vein thrombosis could result in life-threatening pulmonary
embolism! Have you considered this? Discuss this point!
5.In Background you describe that laparoscopic splenectomy and TIPS have not been reported in
the same patient in the literature (background/page4). Unfortunately, there are studies on spleen
embolization and TIPS (What about TIPS+PSE; cite Wan YM et al. Eur Rad 2019 and Li YH
et al. Academic Radiol 2020)! You have to discuss that!
6.In methods you say that "all patients were diagnosed with PHT and hepatitis B virus-
related cirrhosis." but Splenomegaly/Hypersplenism can be related to HBV-infection and not to
liver cirrhosis! Explain, why splenomegaly/hypersplenism in these patients is caused by liver
cirrhosis!
7.Patients with CHILD C were not enrolled in your study (methods/page5)and that is the reason
why you have no severe adverse events! In the study about TIPS+PSE (e.g. Wan YM et al. Eur
Rad 2019) patients had CHILD C. Discuss!
8.Color Doppler ultrasound was performed to examine the PVT(methods/page5). What about
the patency of the TIPS? If there was TIPS stenosis/occlusion, you can not say that splenectomy
had an additional effect! Explain, why you have not measured the TIPS patency!
9.Splenectomy is no correction for hypersplenism (discussion/page7), but partial spleen
embolization is! If you perform splenectomy, there is no spleen after it. When you do partial
spleen embolization, you have a spleen with normal size, which would be a correction! Correct
this!
10.In Discussion you can not compare spleen embolization with splenectomy! Patients
were different, because patients with CHILD C and severe liver disease were treated with
embolization and not with splenectomy! Abscess occurs in 10% of the patients receiving
splenectomy! The effect of the embolization depends on the volume and on the embolizing
agents (temporary/gelfoam vs. permanent/particles); abscess is not common in embolization