Next Article in Journal
Denosumab Dosage and Tooth Extraction Predict Medication-Related Osteonecrosis of the Jaw in Patients with Breast Cancer and Bone Metastases
Previous Article in Journal
Solid Pseudopapillary Neoplasm of the Pancreas: A Comprehensive Review Focusing on the Role of Endoscopic Ultrasound-Guided Radiofrequency Ablation as an Alternative Treatment
Previous Article in Special Issue
Propofol Total Intravenous Anesthesia for Pediatric Proton Radiotherapy and Its Effect on Patient Outcomes
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Cancers
Volume 17
Issue 13
10.3390/cancers17132241
cancers-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Splenectomy in Onco-Hematologic Patients: A Retrospective Study of Early Complications and 1-Year Mortality

by
Marion Faucher
1,
Stanislas Ravot
1,
Loïc Barthes
1,
Jean Manuel de Guibert
1,
Laurent Chow-Chine
1,
Frédéric Gonzalez
1,
Magali Bisbal
1,
Luca Servan
1,
Marie Tezier
1,
Maxime Tourret
1,
Sylvie Cambon
1,
Camille Pouliquen
1,
Damien Mallet
1,
Lam Nguyen Duong
1,
Florence Ettori
1,
Jacques Ewald
2,
Marc Léone
3,
Antoine Sannini
1,
Jonathan Garnier
2 and
Djamel Mokart
1,*
1
Department of Anesthesiology and Critical Care, Paoli-Calmettes Institute, 13009 Marseille, France
2
Department of Surgery, Paoli-Calmettes Institute, 13009 Marseille, France
3
Department of Anesthesiology and Critical Care, Hôpital Nord, 13009 Marseille, France
*
Author to whom correspondence should be addressed.
Cancers 2025, 17(13), 2241; https://doi.org/10.3390/cancers17132241
Submission received: 26 May 2025 / Revised: 28 June 2025 / Accepted: 30 June 2025 / Published: 4 July 2025
(This article belongs to the Special Issue Perioperative Management and Cancer Outcome)
Browse Figures
Versions Notes

Simple Summary

The spleen helps protect the body from infections, especially those caused by encapsulated germs like Streptococcus pneumoniae. In some cancer patients, the spleen must be surgically removed—a procedure called splenectomy. We studied 179 patients with blood cancers or solid tumors who had undergone this operation. Almost half of them experienced serious complications within three months, and over 20% died within one year. Many patients developed infections or required invasive mechanical ventilation. The risk of complications was higher in the patients who had lost weight before surgery, were in poor general condition, or underwent open (rather than minimally invasive) surgery. Interestingly, patients whose spleen was removed as part of a planned cancer surgery to remove isolated metastases had fewer problems. Although the patients received vaccines and antibiotics, infections still occurred—mostly caused by hospital bacteria, not encapsulated germs. These findings show that splenectomy remains a high-risk procedure in cancer patients, especially those with blood diseases. Improving pre-surgery health, preventing infections, and providing close monitoring may help reduce complications.

Abstract

Background: Splenectomy remains necessary in selected oncologic and hematologic indications but is associated with significant postoperative morbidity and mortality. The data on outcomes in this high-risk population remain limited, particularly in mixed cohorts. Methods: We conducted a retrospective cohort study including all patients undergoing splenectomy for oncologic or hematologic causes between 2009 and 2022 at a cancer referral center. The primary outcomes were the occurrence of major complications at day 90 and the 1-year all-cause mortality. Multivariate logistic regression was used to identify independent predictors. Results: Among the 8503 ICU admissions from surgical wards, 204 splenectomies were performed; 179 patients were analyzed. The median age was 64 years, and 100 patients (55.9%) were female. Splenectomy was performed for hematologic malignancies in 76 cases (42.5%) and for oncologic causes in 103 cases (57.5%). Laparotomy was used in 154 cases (86.0%), and metastasectomy was performed in 54 patients (30.2%). At day 90, 86 patients (48.0%) developed a major complication: 12 deaths (6.7%), 44 surgical complications (24.6%), and 71 episodes of sepsis (39.7%). In a multivariate analysis, weight loss (OR 3.39, 95% CI [1.32–8.70], p = 0.011), laparotomy (OR 4.38 [1.09–17.60], p = 0.038), and a higher SAPS II score (OR 1.08 per point [1.03–1.13], p = 0.003) were associated with complications, while metastasectomy was protective (OR 0.23 [0.08–0.67], p = 0.007). At one year, the mortality reached 22.4%. Independent predictors of death were sepsis at one year (OR 5.04, 95% CI [1.30–25.96], p = 0.029), the Charlson Comorbidity Index (OR 1.30 per point, 95% CI [1.04–1.68], p = 0.030), invasive mechanical ventilation (OR 14.94, 95% CI [2.83–118.93], p = 0.003), and a performance status >1 (OR 7.84, 95% CI [2.38–27.75], p < 0.001). Encapsulated bacteria were not isolated; sepsis was mainly due to Gram-negative and enterococcal organisms. Conclusions: Splenectomy in onco-hematologic patients is associated with high rates of sepsis and mortality. In addition to surgical factors, frailty, immune status, and infection independently contribute to the patients’ outcomes. These results support risk-adapted perioperative strategies and long-term infectious surveillance in immunocompromised patients.

1. Introduction

The spleen plays a central role in host immunity and hematologic homeostasis. Indeed, it contributes to both innate and adaptive immune responses by filtering bloodborne pathogens, removing opsonized bacteria—particularly encapsulated organisms—and serving as a reservoir for memory B cells and marginal zone macrophages. Its removal disrupts this immune surveillance, which may explain the increased incidence of severe infections and sepsis observed in certain splenectomized patients, especially those with underlying hematologic malignancies [1,2].
Although splenectomy has become less frequent in the era of targeted therapies and minimally invasive surgery, it remains necessary in selected oncologic and hematologic indications, including diagnostic, therapeutic, or hemostatic purposes [3]. However, in immunocompromised patients—particularly those with cancer—the procedure carries a significant burden of postoperative morbidity and long-term mortality [4]. Postoperative complications are a major concern in surgical oncology. Among them, sepsis is particularly feared, not only for its short-term severity but also for its impact on long-term outcomes, including survival and the oncologic trajectory. Postoperative infections may delay adjuvant treatments, impair immune surveillance, and potentially contribute to disease recurrence or death, although supporting evidence remains limited [5]. In hematologic malignancies, this risk is amplified by cytopenias, prior chemotherapy, and profound immune dysfunction [6]. Although overwhelming post-splenectomy infection (OPSI) has become rare thanks to antibiotic prophylaxis and vaccination, severe infections remain common and often involve hospital-acquired or opportunistic organisms, reflecting a more complex form of immunosuppression [7,8]. Beyond infection, other perioperative parameters such as frailty, comorbidities, and surgical complexity also modulate the patients’ outcomes [9]. However, their assessment remains underexplored in splenectomy cohorts, especially in populations that include both solid tumor and hematologic malignancies [10,11]. Few studies have examined the interplay between early postoperative events and 1-year mortality in this population [4,12,13]. Whether short-term complications such as sepsis or respiratory failure are isolated events or indicators of a longer-term prognosis remains an open question. Moreover, the differential outcomes between patients with solid tumors and those with hematologic malignancies undergoing splenectomy have yet to be clearly described. In this context, we conducted a retrospective cohort study of patients undergoing splenectomy for oncologic and hematologic indications at a comprehensive cancer center. Our aim was to describe the early and late postoperative outcomes and to identify the risk factors—particularly infectious and functional—that predict major complications at 90 days and mortality at one year.

2. Materials and Methods

2.1. Study Design

We conducted a retrospective observational study at the Institut Paoli-Calmettes, a comprehensive cancer center in Marseille, France. All adult patients undergoing total splenectomy for solid tumors or hematologic indications, whether elective or emergency, between 9 February 2009 and 17 June 2022, were included. The study was approved by the Institutional Review Board (Splenecthor 2023-012) and conducted in accordance with the principles of the Declaration of Helsinki. In our institution, all patients scheduled for splenectomy are admitted to the intermediate care unit or the intensive care unit (IMC/ICU) for standard monitoring and postoperative care for a minimum of 2 days before their transfer to the surgical ward, except in the event of complications.

2.2. Inclusion and Exclusion Criteria

The eligible patients were ≥18 years of age and had undergone total splenectomy for an oncologic or hematologic indication, whether curative, diagnostic, or hemostatic. All patients admitted postoperatively to either the intensive care unit (ICU) or the intermediate care unit (IMC) were included. Patients undergoing partial splenectomy or splenectomy for non-oncologic, non-hematologic indications were excluded. Cases managed exclusively in conventional surgical wards could not be reliably captured and were therefore not included.

2.3. Data Collection

The clinical data were extracted from the electronic medical records using the institutional hospital and IMC/ICU information systems. All relevant preoperative, intraoperative, and postoperative information was collected through a review of surgical reports, anesthesia files, IMC/ICU records, and multidisciplinary tumor board decisions.
The preoperative variables included demographic data (age, sex), body mass index (BMI), weight loss of more than 3 kg during the 6 months before the intervention, preexisting comorbidities (including hypertension, diabetes, chronic respiratory or renal disease), previous corticosteroid or chemotherapy exposure, and preoperative hemoglobin level. The comorbidity burden was assessed using the Charlson Comorbidity Index (CCI) [4] and the American Society of Anesthesiologists (ASA) physical status. The functional status was documented through the Eastern Cooperative Oncology Group (ECOG) performance status (PS) and the metabolic equivalents of task (MET) [4]. We applied commonly used thresholds for risk stratification: an ASA > 2 to indicate moderate to severe systemic disease, an MET < 4 to reflect a limited exercise tolerance and increased perioperative risk, and an ECOG-PS > 1 to identify patients with functional impairment beyond minor symptoms. These cut-offs are frequently used in the perioperative period to define vulnerable populations. The presence of splenomegaly, a transfusion history within the month prior to surgery, and the vaccination status against encapsulated organisms was also recorded.
The intraoperative data included the surgical approach (laparotomy vs. laparoscopy), type of surgery (elective vs. emergency), indication (curative, diagnostic, metastasectomy), procedure duration, blood loss, transfusion requirement, and use of vasopressors. When splenectomy was performed for diagnostic purposes, the definitive indication was determined by a pathological examination. Cases involving metastasectomy were considered curative procedures when appropriate.
The postoperative data included the Simplified Acute Physiology Score (SAPS II) and the Sequential Organ Failure Assessment (SOFA) score (at admission and day 2), the IMC/ICU and hospital length of stay, and the need for organ support therapies, including vasopressors, oxygen > 5 L/min, high-flow nasal oxygen (HFNC), non-invasive ventilation (NIV), invasive mechanical ventilation (IMV), or renal replacement therapy (RRT). Infectious prophylaxis, antibiotic coverage, and thromboembolic prophylaxis or therapeutic anticoagulation were also recorded. Postoperative complications were classified as surgical or medical and graded according to the Clavien–Dindo classification. Sepsis was defined according to the Sepsis-2. When possible, microbiological documentation was obtained from blood cultures or site-specific sampling. Thromboembolic events (deep vein thrombosis, pulmonary embolism, arterial thrombosis, myocardial infarction, stroke) were identified up to one year postoperatively.
Two primary outcomes were evaluated. The first was the occurrence of major complications within 90 days after surgery. This composite outcome included any of the following: death, a Clavien–Dindo grade > II surgical complication, or the occurrence of one or more major organ failures requiring support (vasopressors, IMV, RRT, etc.). The second outcome was the all-cause mortality at one year following splenectomy, based on the medical records and national mortality registry data.
The patients were monitored for one year post-surgery using the hospital’s electronic system, which records all of the procedures, visits, laboratory tests, vital signs, and other relevant data, complete with dates and unique identifiers. The Paoli-Calmettes Institute adheres to a policy of regular follow-ups, scheduling at least one visit every three months following a major oncological surgery. In the cases of patients lost to follow-up, the INSEE database was employed to ascertain their deceased status (https://arbre.app/insee, last accessed on 15 February 2024).

2.4. Statistical Analysis

The data are presented as percentages for the qualitative variables and as medians [1st and 3rd quartiles] for the quantitative variables. The data were first compared between two patient groups: the presence or absence of a major complication within 90 days. The comparisons were made using the Mann–Whitney test for the continuous variables and the Chi-square or Fisher’s exact tests for the categorical variables. All p-values < 0.05 were considered statistically significant. Binary logistic regression analyses were used to identify the independent variables associated with major complications, measured by estimated odds ratios (ORs) and 95% confidence intervals (95% CIs). The variables with significance or borderline significance (p < 0.1) in the univariate analyses and those considered relevant from the literature were included in a multivariate regression model using stepwise backward selection. We chose 0.1 as the critical value for the model entry and exit. Statistical significance was set at p < 0.05. The Hosmer–Lemeshow test was used to verify the fit of the logistic model. The factors associated with 1-year mortality were analyzed using the same statistical method and R software, version 4.3. All tests were two-sided, and p-values < 0.05 were considered significant.

3. Results

Between 9 February 2009 and 17 June 2022, 8503 patients were admitted to the ICU from surgical wards, among whom 204 underwent splenectomy. Of these, 20 did not meet the inclusion criteria. A total of 184 patients were included in the study, and 5 were excluded due to missing data. Therefore, 179 patients were analyzed (Figure 1).

3.1. Patient Characteristics (Table 1)

The median age was 64 years [55.5–71.0], and 100 (55.9%) were female. A total of 62 patients (34.6%) had an ASA score > 2. Obesity (BMI > 30) was present in 25 patients (14.0%). Weight loss was reported in 69 cases (38.6%) and a performance status > 1 in 26 cases (14.5%). Preoperative anemia was common, with a median hemoglobin level of 11.85 g/dL [10.23–13.00].
Table 1. Baseline characteristics according to occurrence of major complications at day 90, with univariate analysis.
Table 1. Baseline characteristics according to occurrence of major complications at day 90, with univariate analysis.
Patient CharacteristicsTotal Population (n = 179)No Complication (n = 93)Severe Complication (n = 86)p-Value
Age (years)64 [55–71]63 [54–71]65 [58–70]0.400
Sex—Female100 (55.9)61 (65.6)39 (45.3)0.010
Sex—Male79 (44.1)32 (34.4)47 (54.7) 
BMI (kg/m2)23.9 [21.7–27.1]23.6 [21.3–27.1]23.9 [22.3–27.1]0.284
Obesity (BMI > 30) 25 (14.0)13 (14.0)12 (14.0)1.000
Weight loss69 (38.6)27 (29.0)42 (48.8)0.010
ASA score > 262 (34.6)23 (24.7)39 (45.3)0.006
MET < 414 (7.8)1 (1.1)13 (15.1)0.001
ECOG-PS > 126 (14.5)7 (7.5)19 (22.1)0.011
Charlson Comorbidity Index5 [3–7]6 [4–8]5 [3–7]0.106
Solid vs. Hematology Cancer103 (57.5)57 (61.3)46 (53.5)0.366
 Pancreas31 (17.3)12 (12.9)19 (22.1)0.154
 Ovarian24 (13.4)17 (18.3)7 (8.1)0.077
 Uterus11 (6.1)7 (7.5)4 (4.7)0.625
 Gastric11 (6.1)6 (6.5)5 (5.8)1.000
 Colon7 (3.9)4 (4.3)3 (3.5)1.000
 Peritoneal disease8 (4.5)4 (4.3)4 (4.7)1.000
 Other solid15 (8.4)7 (7.5)8 (9.3)0.874
 Lymphomas48 (26.8)28 (30.1)20 (23.3)0.301
 Leukemias13 (7.3)4 (4.3)9 (10.5)0.112
 Myelofibrosis17 (9.5)5 (4.4)12 (14.0)0.051
Preoperative Anticancer Treatments    
 Chemotherapy 109 (60.9)58 (62.4)51 (59.3)0.790
 Radiotherapy 15 (8.4)9 (9.7)6 (7.0)0.703
 Corticosteroids 25 (14.0)7 (7.5)18 (20.9)0.018
Preoperative hemoglobin (g/dL)11.8 [10.0–13.0]12.0 [10.6–13.0]11.0 [9.3–12.6]0.010
Splenomegaly 96 (53.6)44 (47.3)52 (60.5)0.107
Spleen length (cm)13 [11–23]12 [11–18]14 [11–25]0.051
Antibiotic prophylaxis175 (97.8)93 (100.0)82 (95.3)0.107
 Penicillins 161 (90.0)84 (90.3)77 (95.1)0.370
 Others 14 (8.4)10 (10.8)4 (4.9)0.260
Vaccination165 (92.2)92 (98.9)73 (84.9)0.012
Intraoperative Period    
Laparotomy154 (86.0)75 (80.6)79 (91.9)0.052
Laparoscopy37 (20.7)24 (25.8)13 (15.1)0.114
Elective surgery162 (90.5)93 (100.0)69 (80.2)<0.001
Emergency surgery17 (9.5)0 (0.0)17 (19.8)<0.001
Metastasectomy54 (30.2)39 (41.9)15 (17.4)0.001
Surgical Indication    
 Invasion42 (23.5)19 (20.4)23 (26.7)0.388
 Symptomatic splenomegaly40 (22.4)16 (17.2)24 (27.9)0.124
 Thrombocytopenia38 (21.2)18 (19.4)20 (23.3)0.649
 Diagnosis30 (16.8)13 (14.0)17 (19.8)0.403
 Bleeding18 (10.1)5 (5.4)13 (15.1)0.052
Duration of surgery (hours)3.5 [2.4–5.5]3.4 [2.6–5.5]4.0 [2.1–5.8]0.932
Use of vasopressors 37 (20.7)11 (11.8)26 (30.2)0.003
Blood loss (mL)300 [150–675]300 [100–500]400 [200–850]0.013
Results are expressed as numbers (percentages) for categorical variables and as medians [interquartile ranges] for continuous variables. BMI = body mass index; ASA = American Society of Anesthesiologists; MET = metabolic equivalent of task; ECOG-PS = Eastern Cooperative Oncology Group—performance status; SAPS II = Simplified Acute Physiology Score II; SOFA = Sequential Organ Failure Assessment.

3.2. Causal Disease Leading to Splenectomy (Table 1)

Surgery was performed for oncologic causes in 103 patients (57.5%) and for hematologic causes in 76 patients (42.5%). The median delay between the cancer diagnosis and splenectomy was 295 days [90–1232]. Splenomegaly was present in 96 cases (53.6%). Two patients had overlapping hematologic diagnoses (both leukemia and lymphoma), which explains the discrepancy between the total number of hematologic patients and the sum of the individual malignancy types.

3.3. Intraoperative Period (Table 1)

Laparotomy was the approach in 154 cases (86.0%), while laparoscopy was used in 25 cases (14.0%). Emergency surgery was performed in 17 cases (9.5%). Surgery was scheduled in 162 cases (90.5%) and performed for curative intent in 128 cases (71.5%). Metastasectomy was performed in 54 patients (30.2%). The median surgery duration was 3.5 h [2.39–5.50], and the median intraoperative blood loss was 300 mL [150–675]. Intraoperative vasopressors were used in 37 cases (20.7%), and transfusion was required in 42 patients (23.5%).

3.4. Postoperative Period (Table 2)

The median SOFA score at ICU admission was 2 [1–5], and the SAPS II score was 27 [21.25–35.00]. The ICU length of stay was 5 days [3–7], and the hospital length of stay was 11 days [8–16]. Surgical complications occurred in 68 patients (38.0%), of which 44 (24.6%) were Clavien–Dindo grade > 2. Reoperation was required in 23 patients (12.9%). Medical complications were reported in 96 cases (53.6%).
Table 2. Outcomes according to occurrence of major complications at day 90, with univariate analysis.
Table 2. Outcomes according to occurrence of major complications at day 90, with univariate analysis.
OutcomesTotal Population (n = 179)No Complication (n = 93)Severe Complication (n = 86)p-Value
Postoperative Period    
SAPS II score27 [21–35]26 [21–30]30 [23–39]0.003
SOFA at ICU admission2 [1–5]1 [1–2]3 [2–7]<0.001
Surgical complications 68 (38.0)21 (22.6)47 (54.7)<0.001
 Clavien–Dindo grade > 2 44 (24.6)0 (0.0)44 (51.2)<0.001
 Reoperation 23 (12.9)0 (0.0)23 (26.7)<0.001
Medical complications96 (53.6)29 (31.2)67 (77.9)<0.001
Sepsis at day 3054 (30.2)0 (0.0)54 (62.8)<0.001
Sepsis at day 90 71 (39.7)0 (0.0)71 (82.6)<0.001
Thromboembolic event at Day 90 12 (6.7)0 (0.0)12 (15.6)0.001
 DVT 7 (3.9)0 (0.0)7 (9.1)0.020
 PE4 (2.2)0 (0.0)4 (5.2)0.086
 Myocardial infarction2 (1.1)0 (0.0)2 (2.6)0.395
 Stroke 1 (0.6)0 (0.0)1 (1.3)0.924
 Arterial thrombosis1 (0.6)0 (0.0)1 (1.3)0.924
Preventive anticoagulation 140 (78.2)78 (90.7)62 (84.9)0.383
Organ Failure at Day 90    
 Vasopressors 24 (13.4)0 (0.0)24 (27.9)<0.001
 Renal replacement therapy8 (4.5)0 (0.0)8 (9.3)0.015
 O2 > 5 L/min21 (11.7)0 (0.0)21 (24.4)<0.001
 High-flow oxygen 9 (5.0)0 (0.0)9 (10.5)0.008
 Non-invasive ventilation 11 (6.1)0 (0.0)11 (12.8)0.001
 Invasive mechanical ventilation 12 (6.7)0 (0.0)12 (14.0)0.001
Time to severe complication (days)2 [0–12]NA2 [0–12]NA
IMC/ICU length of stay (days)5 [3–7]3 [0–5]6 [3–8]<0.001
Hospital length of stay (days)11 [8–16]9 [7–12]16 [11–26]<0.001
Death at day 9012 (6.7)0 (0.0)12 (14.0)0.001
Results are expressed as numbers (percentages) for categorical variables and as medians [interquartile ranges] for continuous variables. ICU = intensive care unit; IMC = intermediate care unit; DVT = deep vein thrombosis; PE = pulmonary embolism; O2 > 5 L/min = oxygen flow rate greater than 5 L per minute.

3.5. Prophylaxis and Supportive Care (Table 2)

Antibiotic prophylaxis was administered in 175 patients (97.8%), most commonly penicillin (161 patients, 90.0%). Vaccination against encapsulated organisms was documented in 165 patients (92.2%). Thromboprophylaxis was provided in 140 patients (78.2%).

3.6. Sepsis and Microbiological Documentation (Table 2)

Sepsis occurred in 54 patients (30.2%) within 30 days and in 94 patients (52.5%) within 1 year. Microbiological documentation was available in most cases. The main organisms isolated were Escherichia coli: 21 patients (11.7%), Klebsiella pneumoniae: 9 (5.0%), Pseudomonas aeruginosa: 7 (3.9%), Enterobacter cloacae: 5 (2.8%), Enterococcus faecalis: 5 (2.8%), and Enterococcus faecium: 5 (2.8%). No infections due to encapsulated organisms were identified. Notably, no encapsulated organisms such as Streptococcus pneumoniae or Haemophilus influenzae were isolated in any of the postoperative infections.

3.7. Organ Failures by Day 90 (Table 2)

Vasopressors were required in 24 patients (13.4%), RRT in 8 (4.5%), oxygen therapy > 5 L/min in 21 (11.7%), HFNC in 9 (5.0%), NIV in 11 (6.1%), and IMV in 12 (6.7%).

3.8. Thromboembolic Events (Table 2)

At day 90, thromboembolic events were observed in 12 patients (6.7%). At one year, 21 patients (11.7%) had experienced at least one thromboembolic event: deep vein thrombosis in 14 patients (7.8%), pulmonary embolism in 4 (2.2%), stroke in 1 (0.6%), myocardial infarction in 2 (1.1%), and arterial thrombosis in 1 (0.6%).

3.9. 30- and 90-Day Mortality (Table 2)

The mortality rate at 30 days was 8 cases (4.5%), and at 90 days, 12 patients (6.7%) had died.

3.10. Major Complications at Day 90 (Table 2)

At day 90, 86 patients (48.0%) had experienced at least one major complication. The median time to complication was 2 days [0–12]. This included 12 deaths (6.7%), 44 surgical complications classified as Clavien–Dindo grade > II (24.6%), and 23 reoperations (12.9%). Hemodynamic and respiratory support was frequently required: 13.4% needed vasopressors, 4.5% underwent renal replacement therapy, and 6.7% required invasive mechanical ventilation. Sepsis occurred in 71 patients (39.7%), and thromboembolic events were reported in 12 cases (6.7%). In the univariate analysis, several factors were significantly associated with major complications, including preoperative weight loss (48.8% vs. 29.0%, p = 0.010), an ASA score >2 (45.3% vs. 24.7%, p = 0.006), and an MET < 4 (15.1% vs. 1.1%, p = 0.001). Corticosteroid use, lower preoperative hemoglobin, hypertension, and intraoperative vasopressor use were also more frequent among patients with complications. Laparotomy was more common in this group (95.3% vs. 77.4%, p = 0.002), and SAPS II and SOFA scores were significantly higher postoperatively. Interestingly, metastasectomy was more frequent in the patients without complications (41.9% vs. 17.4%, p < 0.001). In the multivariate analysis, four variables remained independently associated with major complications at 90 days: weight loss (OR 3.39, 95% CI [1.32–8.70], p = 0.011), laparotomy (OR 4.38 [1.09–17.60], p = 0.038), a higher SAPS II score (OR 1.08 per point [1.03–1.13], p = 0.003), and metastasectomy, which remained a protective factor (OR 0.23 [0.08–0.67], p = 0.007).

3.11. 1-Year Mortality and Follow-Up (Table 3)

At one year, 40 patients (22.4%) had died. The median follow-up duration for the cohort was 31.1 months [12.67–67.90], with a total mortality rate of 54.8% at the last contact. No patients were lost to follow-up. The univariate analysis identified several clinical and perioperative variables significantly associated with 1-year mortality. An ASA score > 2 was present in 24 of 40 deceased patients (60.0%) compared to 38 of 139 survivors (27.3%, p < 0.001). A functional limitation (MET < 4) was recorded in 9 of 40 patients who died (22.5%) versus 5 of 139 survivors (3.6%, p < 0.001). Similarly, a performance status >1 was found in 13 deceased patients (32.5%) compared to 13 survivors (9.4%, p = 0.001). Comorbidities also played a major role: hypertension was observed in 24 of 40 patients who died (60.0%) versus 41 of 139 survivors (29.5%, p = 0.001), and diabetes in 13 patients (32.5%) versus 16 survivors (11.5%, p = 0.003). Corticosteroid exposure was more frequent among the deceased (25.0% vs. 10.8%, p = 0.043). The Charlson Comorbidity Index was significantly higher in the deceased patients (median 6.0 [4.0–8.0]) than in the survivors (median 5.0 [3.0–7.0], p = 0.002). The preoperative hemoglobin levels were significantly lower in the patients who died (median 10.45 g/dL) compared to the survivors (12.00 g/dL, p = 0.001). Regarding perioperative infectious prevention, suboptimal vaccination coverage (<100%) was more common in the mortality group: 30 of 40 patients (75.0%) versus 135 of 139 survivors (97.1%, p < 0.001). Sepsis within 30 days occurred in 21 of 40 deceased patients (52.5%) compared to 33 of 139 survivors (23.7%, p = 0.002). The need for vasopressors in the postoperative period was also more frequent in the mortality group (32.5% vs. 7.9%, p < 0.001), as was the requirement for invasive mechanical ventilation (IMV), which affected 10 of 40 deceased patients (25.0%) versus only 2 of 139 survivors (1.4%, p < 0.001). Among the 40 patients who died within 1 year of splenectomy, the disease status at the hospital discharge was stable in 27 patients (67.5%), in relapse in 4 (10%), in remission in 2 (5%), and progressing in 7 (17.5%). At 1 year, 23 patients (57.5%) were receiving palliative care. Among them, 12 were still receiving chemotherapy, while 11 had no ongoing treatment. Overall, 19 patients (47.5%) were on active chemotherapy at 1 year; of these, 7 were not in palliative care. Five additional patients were under surveillance with stable disease and no chemotherapy. For the remaining five patients, information on the care status at 1 year was unavailable. Notably, 30 of the 40 patients (75%) had an ECOG-performance status of 4 shortly before death, indicating severe functional deterioration.
In the multivariate analysis, four variables remained independently associated with 1-year mortality: sepsis at 1 year (OR 5.04, 95% CI [1.30–25.96], p = 0.029), the Charlson Comorbidity Index (OR 1.30 per point, 95% CI [1.04–1.68], p = 0.030), the use of invasive mechanical ventilation (OR 14.94, 95% CI [2.83–118.93], p = 0.003), and a performance status >1 (OR 7.84, 95% CI [2.38–27.75], p < 0.001) (Figure 2).
Table 3. Baseline characteristics according to 1-year vital status, with univariate analysis.
Table 3. Baseline characteristics according to 1-year vital status, with univariate analysis.
Patient CharacteristicsTotal Population (n = 179)Alive at 1 Year (n = 139)Death at 1 Year (n = 40)p-Value
Age (years)64 [55–71]64 [55–70]66 [59–73]0.077
Sex—Female100 (55.9)80 (57.6)20 (50.0)0.505
Sex—Male79 (44.1)59 (42.4)20 (50.0) 
BMI (kg/m2)23.9 [21.7–27.1]24.2 [21.9–27.4]23.2 [21.1–24.3]0.111
Obesity (BMI > 30)25 (14)19 (13.7)6 (15)1.000
Weight loss69 (38.6)49 (35.3)20 (50.0)0.132
ASA score > 262 (34.6)38 (27.3)24 (60.0)<0.001
MET < 414 (7.8)5 (3.6)9 (22.5)<0.001
ECOG-PS > 126 (14.5)13 (9.4)13 (32.5)0.001
Charlson Comorbidity Index5 [3–7]5 [3–7]6 [4–7]0.093
Solid vs. Hematology Cancer103 (57.5)80 (57.6)23 (57.5)1.000
 Pancreas31 (17.3)23 (16.5)8 (20.0)0.786
 Ovarian24 (13.4)20 (14.4)4 (10.0)0.649
 Uterus11 (6.1)10 (7.2)1 (2.5)0.474
 Gastric 11 (6.1)7 (5.0)4 (10.0)0.436
 Colon7 (3.9)7 (5.0)00.325
 Peritoneal disease8 (4.5)7 (5.0)1 (2.5)0.803
 Other solid15 (8.4)9 (6.5)6 (15.0)0.164
 Lymphomas48 (26.8)37 (26.6)11 (27.5)0.903
 Leukemias13 (7.3)9 (6.5)4 (10)0.681
 Myelofibrosis17 (9.5)14 (10.1)3 (7.5)0.855
Preoperative Anticancer Treatments    
 Chemotherapy109 (60.9)84 (60.4)25 (62.5)0.958
 Radiotherapy15 (8.4)12 (8.6)3 (7.5)1.000
 Corticosteroids25 (14.0)15 (10.8)10 (25.0)0.043
Preoperative hemoglobin (g/dL)11.8 [10.2–13]12 [10.5–13]10.4 [9–12.2]0.001
Splenomegaly96 (53.6)44 (47.3) 52 (60.5) 0.107
Spleen length (cm)13 [11–23]13 [11–21]13 [11–25]0.590
Antibiotic prophylaxis175 (97.8)139 (100.0)36 (90.0)0.001
 Penicillins 161 (90.0)129 (92.8)32 (80.0)1.000
 Others14 (8.4)10 (7.2)4 (10.0)1.000
Vaccination165 (92.2)135 (97.1)30 (75.0)<0.001
Intraoperative Period    
 Laparotomy154 (86.0)115 (82.7)39 (97.5)0.034
 Laparoscopy37 (20.7)30 (21.6)7 (17.5)0.734
 Elective surgery 162 (90.5)131 (94.2)31 (77.5)0.004
 Emergency surgery17 (9.5)8 (5.8)9 (22.5)0.004
Metastasectomy 54 (30.2)49 (35.3)5 (12.5)0.010
Surgical Indication    
 Invasion42 (23.5)29 (20.9)13 (32.5)0.159
 Symptomatic splenomegaly40 (22.4)27 (19.4)13 (32.5)0.125
 Thrombocytopenia38 (21.2)27 (19.4)11 (27.5)0.378
 Diagnosis30 (16.8)25 (18.0)5 (12.5)0.563
 Bleeding18 (10.1)10 (7.2)8 (20.0)0.033
Duration of surgery (hours)3.5 [2.4–5.5]3.5 [2.5–5.3]4.2 [2.4–6.5]0.143
Use of vasopressors37 (20.7)24 (17.3)13 (32.5)0.043
Bleeding (mL)300 [150–675]300 [125–500]500 [225–950]0.017
Intraoperative transfusion42 (23.5)24 (17.3)18 (45.0)<0.001
SAPS II score27 [21–35]26 [21–32]34.5 [21–43]0.032
SOFA score at ICU admission2 [1–5]2 [1–3]5 [2–9]0.001
Surgical complications68 (38.0)46 (33.1)22 (55.0)0.029
 Clavien–Dindo grade > 244 (24.6)25 (18.0)19 (47.5)<0.001
 Reoperation23 (12.9)14 (10.1)9 (22.5)0.062
Medical complications 96 (53.6)64 (46.0)32 (80.0)<0.001
Sepsis at 1 year 94 (52.5)65 (46.8)29 (72.5)<0.001
Thromboembolic event at 1 year 21 (11.7)17 (12.2)4 (10.0)0.085
 DVT—n (%)14 (7.8)12 (8.6)2 (5.0)1.000
 PE—n (%)4 (2.2)2 (1.4)2 (5.0)0.002
 Myocardial infarction4 (2.2)3 (2.2)1 (2.5)0.468
 Stroke1 (0.6)0 (0.0)1 (2.5)0.034
 Arterial thrombosis1 (0.6)1 (0.7)0 (0.0)1.000
Preventive anticoagulation140 (78.2)112 (80.6)28 (70.0)0.900
Organ Failure at Day 90    
Vasopressors 24 (13.4)11 (7.9)13 (32.5)<0.001
Renal replacement therapy 8 (4.5)1 (0.7)7 (17.5)<0.001
 Oxygen > 5 L/min 21 (11.7)7 (5.0)14 (35.0)0.003
 High-flow oxygen 9 (5.0)5 (3.6)4 (10.0)0.786
 Non-invasive ventilation 11 (6.1)4 (2.9)7 (17.5)0.002
 Invasive mechanical ventilation 12 (6.7)2 (1.4)10 (25.0)<0.001
IMC/ICU length of stay (days)5 [3–7]4 [1.5–6]7 [3–8]0.001
Hospital length of stay (days)11 [8–16]1 [8– 14]17 [10–26]<0.001
Results are expressed as numbers (percentages) for categorical variables and as medians [interquartile ranges] for continuous variables. BMI = body mass index; ASA = American Society of Anesthesiologists; MET = metabolic equivalent of task; ECOG-PS = Eastern Cooperative Oncology Group—performance status; SAPS II = Simplified Acute Physiology Score II; SOFA = Sequential Organ Failure Assessment; ICU = intensive care unit; IMC = intermediate care unit; DVT = deep vein thrombosis; PE = pulmonary embolism; O2 > 5 L/min = oxygen flow rate greater than 5 L per minute.

3.12. Hematology Malignancy vs. Solid Tumor (Table 4)

Table 3 presents a comparison between the patients with hematologic malignancies (n = 76) and those with solid tumors (n = 103). The patients with hematologic cancers appeared more frail prior to surgery, with a higher proportion of an ASA score > 2 (47.4% vs. 25.2%, p = 0.004), an MET < 4 (14.5% vs. 2.9%, p = 0.010), and an ECOG-PS > 1 (25.0% vs. 6.8%, p = 0.001). These patients also had a higher rate of sepsis at day 90 (43.8% vs. 28.4%, p = 0.051) and at 1 year (66.7% vs. 44.3%, p = 0.006). Interestingly, the 90-day mortality was significantly higher in the hematologic group (11.8% vs. 2.9%, p = 0.040), while the 1-year mortality did not differ between the groups (22.4% vs. 22.3%, p = 1.000).
Table 4. Baseline characteristics according to cancer type (hematology vs. solid tumor cancers).
Table 4. Baseline characteristics according to cancer type (hematology vs. solid tumor cancers).
Patient CharacteristicsTotal Population (n = 179)Hematology (n = 76)Solid Tumors (n = 103)p-Value
Age (years)64 [55–71]64 [56–70]64 [55–71]0.550
Sex—Female100 (55.9)37 (48.7)63 (61.2)0.131
Sex—Male79 (44.1)39 (51.3)40 (38.8) 
BMI (kg/m2)23.9 [21.7–27.1]23.9 [21.5–26.7]23.9 [21.8–27.8]0.557
Obesity (BMI > 30)25 (14.0)3 (3.9)22 (21.4)0.002
Weight loss69 (38.6)23 (30.3)46 (44.7)0.072
ASA score > 262 (34.6)36 (47.4)26 (25.2)0.004
MET < 414 (7.8)11 (14.5)3 (2.9)0.010
ECOG-PS > 126 (14.5)19 (25.0)7 (6.8)0.001
Charlson Comorbidity Index5 [3–7]24 [18–29]11 [10–13]<0.001
Preoperative Anticancer Treatments    
Chemotherapy109 (60.9)49 (64.5)60 (58.3)0.491
Radiotherapy15 (8.4)8 (10.5)7 (6.8)0.537
Corticosteroids25 (14.0)24 (31.6)1 (1.0)<0.001
Preoperative hemoglobin (g/dL)11.8 [10–13.0]10.4 [9.0–12.2]12.2 [11–13.3]<0.001
Splenomegaly96 (53.6)68 (89.5)28 (27.2)<0.001
Spleen length (cm)13 [11–23]12 [11–18]14 [11–25]0.051
Antibiotic prophylaxis175 (97.8)75 (98.7)100 (97.1)0.849
Penicillins161 (90.0)68 (94.4)97 (97.0)0.571
Others14 (8.4)8 (10.8)6 (6.0)0.383
Vaccination165 (92.2)92 (98.9)73 (84.9)0.656
Intraoperative Period    
Laparotomy154 (86.0)54 (71.1)100 (97.1)<0.001
Laparoscopy37 (20.7)29 (38.2)8 (7.8)<0.001
Elective surgery162 (90.5)69 (90.8)92 (89.3)0.943
Emergency surgery17 (9.5)6 (7.9)11 (10.7)0.711
Metastasectomy54 (30.2)7 (9.2)47 (45.6)<0.001
Surgical Indication    
Invasion42 (23.5)0 (0.0)42 (40.8)<0.001
Symptomatic splenomegaly40 (22.4)16 (17.2)24 (27.9)0.124
Thrombocytopenia38 (21.2)38 (50.0)0 (0.0)<0.001
Diagnosis30 (16.8)28 (36.8)2 (1.9)<0.001
Bleeding18 (10.1)4 (5.3)14 (13.6)0.120
Duration of surgery (hours)3.5 [2.4–5.5]2.5 [2.0–3.2]5.0 [3.3–6.5]<0.001
Use of vasopressors37 (20.7)4 (5.3)33 (32.0)<0.001
Blood loss (mL)300 [150–675]300 [100–800]350 [162–575]0.868
Intraoperative transfusion42 (23.5)23 (30.7)19 (18.4)0.086
Postoperative Period    
SAPS II score27 [21–35]29 [24–39]26 [20–33]0.081
SOFA at ICU admission2 [1–5]3 [2–5]2 [1–3]0.025
Severe complications86 (48)40 (52.6)46 (44.7)0.291
Surgical complications68 (38.0)25 (32.0)43 (41.7)0.242
Clavien–Dindo grade > 244 (24.6)16 (21.1)28 (27.2)0.444
Reoperation23 (12.9)7 (9.3)16 (15.5)0.321
Medical complications96 (53.6)42 (54.7)54 (52.4)0.886
Sepsis at day 3054 (30.2)21 (28.0)32 (31.1)0.783
Sepsis at day 9071 (39.7)32 (43.8)29 (28.4)0.051
Sepsis at 1 year91 (51%)48 (66.7)43 (44.3)0.006
Thromboembolic event at day 9012 (6.7)5 (6.5)7 (7.0)1
DVT7 (3.9)4 (4.4)3 (3.0)0.952
PE4 (2.2)2 (2.9)2 (2.0)1.000
Myocardial infarction2 (1.1)0 (0.0)2 (2.0)0.654
Stroke1 (0.6)0 (0.0)1 (1.0)1.000
Arterial thrombosis1 (0.6)0 (0.0)1 (1.0)1.000
Thromboembolic event at 1 year21 (11.7)7 (9.8)14 (16.7)0.350
Preventive anticoagulation140 (78.2)58 (95.1)82 (83.7)0.057
Organ Failure at Day 90    
Vasopressors24 (13.4)7 (9.2)17 (16.5)0.095
Renal replacement therapy8 (4.5)2 (2.7)5 (4.9)0.726
O2 > 5 L/min21 (11.7)7 (9.2)14 (13.6)0.506
High-flow oxygen9 (5.0)5 (6.5)4 (3.9)0.940
Non-invasive ventilation11 (6.1)3 (4.0)8 (7.8)0.474
Invasive mechanical ventilation12 (6.7)4 (4.4)8 (7.8)0.474
Time to severe complication (days)2 [0–12]2 [0–15]2 [0–8]0.980
IMC/ICU length of stay (days)5 [3–7]2 [0–4]5 [3–7]<0.001
Hospital length of stay (days)11 [8–16]9 [6–12]14 [9–18]<0.001
Death at day 9012 (6.7)9 (11.8)3 (2.9)0.040
Death at 1 year40 (22.3)17 (22.4)23 (22.3)1
Results are expressed as numbers (percentages) for categorical variables and medians [interquartile ranges] for continuous variables. BMI = body mass index; ASA = American Society of Anesthesiologists; MET = metabolic equivalent of task; ECOG-PS = Eastern Cooperative Oncology Group—performance status; SAPS II = Simplified Acute Physiology Score II; SOFA = Sequential Organ Failure Assessment; ICU = intensive care unit; IMC = intermediate care unit; DVT = deep vein thrombosis; PE = pulmonary embolism; O2 > 5 L/min = oxygen flow rate greater than 5 L per minute.

4. Discussion

In this retrospective cohort of 179 patients undergoing splenectomy in an onco-hematologic setting, nearly half developed a major complication by day 90, and more than one-fifth died within one year. The multivariate analyses identified four independent predictors of 90-day complications and four of 1-year mortality, each of which reveals clinically meaningful insights.

4.1. Nutritional Status and Prehabilitation

Weight loss was strongly associated with short-term complications, likely reflecting preoperative malnutrition and frailty [14]. Nutritional status is known to correlate with adverse surgical outcomes, particularly in oncologic and hematologic patients [15,16]. Indeed, malnourished individuals demonstrate impaired wound healing, reduced immune competence, and diminished physiological reserve [17]. These findings are consistent with a recent study that emphasized the importance of preoperative nutritional status in elderly cancer patients undergoing major abdominal surgery [9]. Although direct evidence is scarce in this specific population, adapting selected ERAS principles—such as nutritional screening and prehabilitation—might help optimize the outcomes in oncologic and hematologic patients undergoing splenectomy. Similarly, structured postoperative strategies inspired by ICU bundles like ABCDEF could hold potential benefits for these often frail and immunocompromised individuals and deserve further investigation. These patients, often frail and immunocompromised, may particularly benefit from a structured, anticipatory approach [18,19].

4.2. Surgical Approach and Disease Context

An open surgical approach was independently associated with postoperative complications. This finding is in line with previous studies reporting increased morbidity with laparotomy compared to minimally invasive surgery, particularly regarding infection, bleeding, and prolonged recovery [20]. In our cohort, the high rate of laparotomy likely reflects the technical challenges posed by massive splenomegaly, hemorrhagic risk, or advanced disease—especially in hematologic malignancies, where minimally invasive access is often not feasible. This pattern reinforces prior observations in hematologic patients undergoing urgent abdominal surgery, where open procedures are frequently necessitated by the disease complexity and anatomical constraints [6]. Indeed, the high proportion of open splenectomies observed in our cohort reflects both clinical and technical considerations [21]. Our hematologic patients were frequently frail and affected by splenomegaly, which, while the primary indication in 22.4% of cases, was present in over half of the patients (53.6%). Moreover, splenectomy was often performed as part of complex surgical procedures—such as duodenopancreatectomy—in which laparoscopic approaches are not routinely used at our institution due to their limited applicability and technical complexity. In contrast, metastasectomy was associated with a lower risk of complications. All splenectomies performed in this setting were part of an oncologic strategy targeting isolated or oligometastatic disease, in patients with solid tumors, and notably without peritoneal carcinomatosis. These conditions likely contribute to favorable surgical and physiological profiles: the elective surgery timing, controlled tumor burden, limited need for extended cytoreduction, and better-preserved immune function. This contrasts sharply with the findings from ovarian cancer surgery, where splenectomy frequently signals a high tumor burden and an upper abdominal extension, and it is often performed within the context of extensive cytoreduction. As demonstrated in the study by Karlsson et al., splenectomy in ovarian cancer patients—particularly when associated with a high Peritoneal Cancer Index (PCI)—is a marker of high surgical complexity and is independently associated with increased postoperative complications and reduced overall survival rates [22]. In our cohort, the absence of carcinomatosis and the elective nature of metastasectomy suggest that splenectomy, in this context, is not a surrogate for aggressive disease but rather a reflection of localized, surgically manageable pathology. This may explain the paradoxical finding of a protective association between metastasectomy and complications and supports the idea that the tumor biology and surgical context should be jointly considered when interpreting the prognostic implications of splenectomy.

4.3. Immediate Postoperative Severity

We found that the effective and early management of organ failure, from the operating room admission to the first postoperative day, as evaluated using the SAPS II score, was critical in reducing the postoperative severe complications. Indeed, the SAPS II score was associated with early complications, reflecting the burden of acute illness at the IMC/ICU admission. It parallels the SOFA score in many ways, as both capture systemic dysfunctions that portend worse outcomes. Prior studies have shown that SAPS II and SOFA scores are independently associated with postoperative outcomes in onco-surgical patients [4,9,12]. Our observed 90-day mortality (6.7%) and complication (48%) rates are consistent with the published data on splenectomy in oncologic and hematologic populations, which report complication rates ranging from 17% to over 60% and mortality rates between 1.1% and 9%, depending on the disease severity and surgical context [23,24]. Importantly, all of the patients in our cohort were admitted postoperatively to an intermediate care unit, where enhanced monitoring allows for the early recognition and diagnosis of complications. This systematic high-acuity follow-up likely increases the detection rates compared to conventional surgical wards and may contribute to a higher reported incidence of complications—an observation we have previously documented [4]. Although sepsis could not be independently analyzed as a risk factor for severe complications—since it was included in their definition—it represented 39.7% of all severe events at day 90. This finding underscores the critical role of infectious complications in early postoperative morbidity and further justifies the emphasis on infection surveillance and prevention strategies in this high-risk population.

4.4. Immunity, Sepsis, and Long-Term Mortality

Sepsis within the first year was the strongest predictor of 1-year mortality. Despite excellent prophylactics, over 50% of the patients developed sepsis at one year, although no OPSI was documented. This highlights the effectiveness of vaccination and the lack of encapsulated organisms, in line with the literature reviews on post-splenectomy sepsis prevention [25]. However, the pathogens involved—mostly Gram-negative bacilli and enterococci—reflect a deeper immunodeficiency typical of cancer patients, combining postoperative asplenia and chemotherapy-induced immunosuppression [2,6,26]. In a recent study, postoperative sepsis was significantly associated with long-term mortality and cancer recurrence [12]. These findings echo earlier work showing that post-aggressive immunosuppression may foster tumor progression [4]. Along this line, IMV also emerged as a strong predictor of mortality. It often reflects severe sepsis, pulmonary complications, or multiorgan failure. In cancer patients, IMV is frequently needed for acute respiratory failure caused by infection, alveolar hemorrhage, or leukemic infiltration [27]. The association between postoperative IMV and sepsis supports a model of early infectious decompensation driving downstream mortality [4,12]. These findings advocate for intensive early monitoring and aggressive infection control strategies. As part of a sensitivity analysis, we compared the outcomes between patients with hematologic malignancies and those with solid tumors. The patients with hematologic cancers exhibited significantly more preoperative frailty and immunosuppression, and this translated into a higher incidence of sepsis at both day 90 and 1 year. These infections were associated with a significantly higher 90-day mortality, although the 1-year mortality did not differ between the groups. These findings suggest that early postoperative sepsis may disproportionately impact short-term outcomes in hematologic patients. This highlights the need for differentiated perioperative strategies, including optimized infection surveillance and possibly prehabilitation, tailored to the specific vulnerabilities of each oncologic subgroup. Finally, the indications for splenectomy in hematologic malignancies must be interpreted in light of the inclusion period of our study (2009–2022), during which the therapeutic options evolved substantially. At the beginning of the study period, splenectomy was more commonly used for diagnostic clarification, symptomatic splenomegaly, or refractory thrombocytopenia, particularly in conditions such as myelofibrosis or refractory thrombocytopenia. However, over time, the emergence of targeted therapies, including rituximab, ruxolitinib, and thrombopoietin receptor agonists, has progressively replaced surgery in many of these contexts [23,28,29,30]. Similarly, in indolent lymphomas or myeloproliferative neoplasms, effective systemic therapies can now reduce the splenic size and symptoms without surgical risk [31]. Our findings, particularly the higher 90-day mortality in hematologic patients, support a cautious, individualized approach, ideally involving a multidisciplinary discussion to reassess the benefit–risk balance of splenectomy in an era of expanding non-surgical options [32].

4.5. Comorbidity Burden and Performance Status

The CCI and the baseline ECOG-PS were both independently associated with 1-year mortality. These factors have practical implications, as they are assessable preoperatively and amenable to intervention [33,34]. Comorbidities and a poor ECOG-PS decrease physiological reserves, compromise tolerance to infections or chemotherapy, and are well-known predictors of poor survival in both oncologic and hematologic populations. The overlap between the CCI and the ECOG-PS argues for a unified approach to the preoperative assessment, combining geriatric, functional, and medical screenings. Both the CCI and the PS suggest a shared actionable axis: identifying vulnerable patients who may benefit from prehabilitation, comorbidity optimization, and targeted perioperative planning.

4.6. Limitations

This study has several limitations. First, its retrospective and observational design inherently carries a risk of selection bias. The patient inclusion was dependent on the availability and completeness of medical records, which may have excluded the most complex or undocumented cases. Moreover, unmeasured confounding factors may have influenced both the treatment decisions and the outcomes, despite the multivariate adjustments. As with all retrospective analyses, causal inferences should be made with caution. Finally, we did not use competing risk models such as the Fine–Gray model due to the absence of precise timing for postoperative complications in our dataset; however, the low 90-day mortality rate (6.7%) likely limited the impact of this limitation.

5. Conclusions

Our study offers a comprehensive perspective on splenectomy outcomes across both solid tumor and hematologic malignancy patients. The protective effect of metastasectomy underscores the generally more favorable surgical context of oncology patients—elective procedures, preserved immunity, and a lower perioperative risk. In contrast, hematologic patients remain highly vulnerable, with a sustained burden of infectious and respiratory complications despite optimal prophylaxis. By integrating the surgical parameters, immunological status, and validated severity scores, we provide a structured framework for perioperative risk stratification. These findings highlight the need for tailored pathways in hematology, where cytopenia, immunosuppression, and functional frailty converge to amplify the postoperative risk. Ultimately, the study advocates for a multidisciplinary strategy that includes immune profiling, comorbidity management, and prehabilitation—particularly in immunocompromised hosts. Incorporating such measures into the routine practice and institutional pathways may help reduce the preventable complications and improve the outcomes in this complex and diverse patient population.

Author Contributions

Conceptualization, M.F. and D.M. (Djamel Mokart); Methodology, M.F., S.R., L.C.-C., F.E., M.L., A.S. and D.M. (Djamel Mokart); Validation, F.G., M.T. (Maxime Tourret), C.P., D.M. (Damien Mallet), L.N.D., F.E., M.L. and J.G.; Formal analysis, M.F., L.C.-C., M.B., L.S., M.T. (Maxime Tourret), C.P., L.N.D., F.E., J.E., J.G. and D.M. (Djamel Mokart); Investigation, J.M.d.G., L.C.-C., M.T. (Marie Tezier), S.C. and A.S.; Resources, L.B., J.M.d.G., L.C.-C., F.G., M.B., L.S., M.T. (Marie Tezier), M.T. (Maxime Tourret), S.C., C.P., D.M. (Damien Mallet), L.N.D., J.E. and A.S.; Data curation, S.R. and L.B.; Writing—original draft, S.R.; Writing—review & editing, M.F. and D.M. (Djamel Mokart); Visualization, M.T. (Marie Tezier). All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was approved by the Institutional Review Board (Splenecthor 2023-012) and conducted in accordance with the principles of the Declaration of Helsinki. The IRB waived the requirement for written informed consent due to the retrospective nature of the study, in accordance with French legislation. All patients were informed about the use of their data, and none expressed opposition to participation.

Informed Consent Statement

Patient consent was waived due to the retrospective nature of this study.

Data Availability Statement

Data cannot be shared publicly because consent for publication of raw data was not obtained from study participants. Data are available from the Internal Review Board (IRB) of Institut Paoli Calmettes (contact via UTSI@ipc.unicancer.fr) for researchers who meet the criteria for access to confidential data.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Mebius, R.E.; Kraal, G. Structure and Function of the Spleen. Nat. Rev. Immunol. 2005, 5, 606–616. [Google Scholar] [CrossRef] [PubMed]
  2. Di Sabatino, A.; Carsetti, R.; Corazza, G.R. Post-Splenectomy and Hyposplenic States. Lancet 2011, 378, 86–97. [Google Scholar] [CrossRef]
  3. Kuter, D.J.; Ghanima, W.; Cooper, N.; Liebman, H.A.; Zhang, L.; Hu, Y.; Miyakawa, Y.; Homenda, W.; Morales Galindo, L.E.E.; Basquiera, A.L.; et al. Safety and Efficacy of Rilzabrutinib vs Placebo in Adults with Immune Thrombocytopenia: The Phase 3 LUNA3 Study. Blood 2025, 145, 2914–2926. [Google Scholar] [CrossRef] [PubMed]
  4. Mokart, D.; Giaoui, E.; Barbier, L.; Lambert, J.; Sannini, A.; Chow-Chine, L.; Brun, J.-P.; Faucher, M.; Guiramand, J.; Ewald, J.; et al. Postoperative Sepsis in Cancer Patients Undergoing Major Elective Digestive Surgery Is Associated with Increased Long-Term Mortality. J. Crit. Care 2016, 31, 48–53. [Google Scholar] [CrossRef] [PubMed]
  5. Yamashita, K.; Kurokawa, Y.; Yamamoto, K.; Hirota, M.; Kawabata, R.; Mikami, J.; Masuzawa, T.; Takiguchi, S.; Mori, M.; Doki, Y. Risk Factors for Poor Compliance with Adjuvant S-1 Chemotherapy for Gastric Cancer: A Multicenter Retrospective Study. Ann. Surg. Oncol. 2017, 24, 2639–2645. [Google Scholar] [CrossRef]
  6. Mokart, D.; Penalver, M.; Chow-Chine, L.; Ewald, J.; Sannini, A.; Brun, J.P.; Bisbal, M.; Lelong, B.; Delpero, J.R.; Faucher, M.; et al. Surgical Treatment of Acute Abdominal Complications in Hematology Patients: Outcomes and Prognostic Factors. Leuk. Lymphoma 2017, 58, 2395–2402. [Google Scholar] [CrossRef]
  7. Kristinsson, S.Y.; Gridley, G.; Hoover, R.N.; Check, D.; Landgren, O. Long-Term Risks after Splenectomy among 8,149 Cancer-Free American Veterans: A Cohort Study with up to 27 Years Follow-Up. Haematologica 2014, 99, 392–398. [Google Scholar] [CrossRef]
  8. Sinwar, P.D. Overwhelming Post Splenectomy Infection Syndrome—Review Study. Int. J. Surg. 2014, 12, 1314–1316. [Google Scholar] [CrossRef]
  9. Canac, J.; Faucher, M.; Depeyre, F.; Tourret, M.; Tezier, M.; Cambon, S.; Ettori, F.; Servan, L.; Alisauskaite, J.; Pouliquen, C.; et al. Factors Associated with 1-Year Mortality in Elderly Patients (Age ≥ 80 Years) with Cancer Undergoing Major Abdominal Surgery: A Retrospective Cohort Study. Ann. Surg. Oncol. 2023, 30, 8083–8093. [Google Scholar] [CrossRef]
  10. Fallah, J.; Olszewski, A.J. Diagnostic and Therapeutic Splenectomy for Splenic Lymphomas: Analysis of the National Cancer Data Base. Hematology 2019, 24, 378–386. [Google Scholar] [CrossRef]
  11. Filippova, O.T.; Kim, S.W.; Cowan, R.A.; Chi, A.J.; Iasonos, A.; Zhou, Q.C.; Broach, V.; Zivanovic, O.; Long Roche, K.; Sonoda, Y.; et al. Hematologic Changes after Splenectomy for Ovarian Cancer Debulking Surgery, and Association with Infection and Venous Thromboembolism. Int. J. Gynecol. Cancer 2020, 30, 1183–1188. [Google Scholar] [CrossRef]
  12. Faucher, M.; Dahan, S.; Morel, B.; de Guibert, J.M.; Chow-Chine, L.; Gonzalez, F.; Bisbal, M.; Servan, L.; Sannini, A.; Tezier, M.; et al. The Effect of Postoperative Sepsis on 1-Year Mortality and Cancer Recurrence Following Transhiatal Esophagectomy for Esophageal-Gastric Junction Adenocarcinomas: A Retrospective Observational Study. Cancers 2025, 17, 109. [Google Scholar] [CrossRef] [PubMed]
  13. Farid, S.G.; Aldouri, A.; Morris-Stiff, G.; Khan, A.Z.; Toogood, G.J.; Lodge, J.P.A.; Prasad, K.R. Correlation Between Postoperative Infective Complications and Long-Term Outcomes After Hepatic Resection for Colorectal Liver Metastasis. Ann. Surg. 2010, 251, 91–100. [Google Scholar] [CrossRef] [PubMed]
  14. Cederholm, T.; Jensen, G.L.; Correia, M.I.T.D.; Gonzalez, M.C.; Fukushima, R.; Higashiguchi, T.; Baptista, G.; Barazzoni, R.; Blaauw, R.; Coats, A.; et al. GLIM Criteria for the Diagnosis of Malnutrition—A Consensus Report from the Global Clinical Nutrition Community. Clin. Nutr. 2019, 38, 1–9. [Google Scholar] [CrossRef]
  15. GlobalSurg Collaborative and NIHR Global Health Unit on Global Surgery. Impact of Malnutrition on Early Outcomes after Cancer Surgery: An International, Multicentre, Prospective Cohort Study. Lancet Glob. Health 2023, 11, e341–e349. [Google Scholar] [CrossRef] [PubMed]
  16. Ettori, F.; Henin, A.; Zemmour, C.; Chow-Chine, L.; Sannini, A.; Bisbal, M.; Gonzalez, F.; Servan, L.; de Guibert, J.M.; Faucher, M.; et al. Impact of a Computer-Assisted Decision Support System (CDSS) on Nutrition Management in Critically Ill Hematology Patients: The NUTCHOCO Study (Nutritional Care in Hematology Oncologic Patients and Critical Outcome). Ann. Intensive Care 2019, 9, 53. [Google Scholar] [CrossRef]
  17. Thomas, M.N.; Kufeldt, J.; Kisser, U.; Hornung, H.-M.; Hoffmann, J.; Andraschko, M.; Werner, J.; Rittler, P. Effects of Malnutrition on Complication Rates, Length of Hospital Stay, and Revenue in Elective Surgical Patients in the G-DRG-System. Nutrition 2016, 32, 249–254. [Google Scholar] [CrossRef]
  18. Ely, E.W. The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Crit. Care Med. 2017, 45, 321–330. [Google Scholar] [CrossRef]
  19. Brindle, M.; Nelson, G.; Lobo, D.N.; Ljungqvist, O.; Gustafsson, U.O. Recommendations from the ERAS® Society for Standards for the Development of Enhanced Recovery after Surgery Guidelines. BJS Open 2020, 4, 157–163. [Google Scholar] [CrossRef]
  20. Balan, N.; deVirgilio, C.M.; Ozao-Choy, J.; Moazzez, A. Association of Laparoscopic Approach With Improved Short-Term Outcomes in Patients With Hematologic Malignancy Undergoing Splenectomy. Am. Surg. 2023, 89, 4160–4165. [Google Scholar] [CrossRef]
  21. Lopez Monclova, J.; Targarona Soler, E.; Peraza Solis, Y.; Vidal Gonzalez, P.; Balague Ponz, C.; Rodriguez Luppi, C.; Trias Folch, M. Laparoscopic Approach for Isolated Splenic Metastasis: Comprehensive Literature Review and Report of 6 Cases. Surg. Laparosc. Endosc. Percutan Tech. 2013, 23, 21–24. [Google Scholar] [CrossRef] [PubMed]
  22. Karlsson, E.; Vorobii, O.; Silins, I.; Sundström Poromaa, I.; Stålberg, K.; Lomnytska, M. Splenectomy as an Indicator for Ovarian Cancer Spread and Complete Cytoreduction. Gynecol. Oncol. 2025, 197, 121–128. [Google Scholar] [CrossRef]
  23. McAneny, D.; LaMorte, W.W.; Scott, T.E.; Weintraub, L.R.; Beazley, R.M. Is Splenectomy More Dangerous for Massive Spleens? Am. J. Surg. 1998, 175, 102–107. [Google Scholar] [CrossRef]
  24. Qu, Y.; Ren, S.; Li, C.; Qian, S.; Liu, P. Management of Postoperative Complications Following Splenectomy. Int. Surg. 2013, 98, 55–60. [Google Scholar] [CrossRef] [PubMed]
  25. El-Alfy, M.S.; El-Sayed, M.H. Overwhelming Postsplenectomy Infection: Is Quality of Patient Knowledge Enough for Prevention? Hematol. J. 2004, 5, 77–80. [Google Scholar] [CrossRef]
  26. Tahir, F.; Ahmed, J.; Malik, F. Post-Splenectomy Sepsis: A Review of the Literature. Cureus 2020, 12, e6898. [Google Scholar] [CrossRef]
  27. Azoulay, E.; Mokart, D.; Kouatchet, A.; Demoule, A.; Lemiale, V. Acute Respiratory Failure in Immunocompromised Adults. Lancet Respir. Med. 2019, 7, 173–186. [Google Scholar] [CrossRef] [PubMed]
  28. Kalpadakis, C.; Pangalis, G.A.; Angelopoulou, M.K.; Sachanas, S.; Vassilakopoulos, T.P. Should Rituximab Replace Splenectomy in the Management of Splenic Marginal Zone Lymphoma? Best. Pract. Res. Clin. Haematol. 2018, 31, 65–72. [Google Scholar] [CrossRef]
  29. Carey, P.; Pardanani, A.D.; Starlinger, P.; Tefferi, A.; Gangat, N. Outcome of Splenectomy in JAK2 Inhibitor Treated Patients with Myelofibrosis: A Mayo Clinic Experience in 34 Consecutive Cases. Blood 2024, 144, 6662. [Google Scholar] [CrossRef]
  30. Lucchini, E.; Zaja, F.; Bussel, J. Rituximab in the Treatment of Immune Thrombocytopenia: What Is the Role of This Agent in 2019? Haematologica 2019, 104, 1124–1135. [Google Scholar] [CrossRef]
  31. Assi, R.; Kantarjian, H.M.; Garcia-Manero, G.; Cortes, J.E.; Pemmaraju, N.; Wang, X.; Nogueras-Gonzalez, G.; Jabbour, E.; Bose, P.; Kadia, T.; et al. A Phase II Trial of Ruxolitinib in Combination with Azacytidine in Myelodysplastic Syndrome/Myeloproliferative Neoplasms. Am. J. Hematol. 2018, 93, 277–285. [Google Scholar] [CrossRef] [PubMed]
  32. Fernández-Ananin, S.; Novelli, S.; Cambeiro Cabré, L.; Vila Riera, C.; Ballester Vàzquez, E.; Julià Verdaguer, E.; Targarona, E.M. Elective Splenectomy for Hematological Diseases: A Vanishing Indication. Surg. Endosc. 2024, 38, 6332–6337. [Google Scholar] [CrossRef] [PubMed]
  33. Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery: A Randomized Clinical Trial. JAMA Surg. 2018, 153, 1081–1089. [CrossRef]
  34. Hughes, M.J.; Hackney, R.J.; Lamb, P.J.; Wigmore, S.J.; Christopher Deans, D.A.; Skipworth, R.J.E. Prehabilitation Before Major Abdominal Surgery: A Systematic Review and Meta-Analysis. World J. Surg. 2019, 43, 1661–1668. [Google Scholar] [CrossRef] [PubMed]
Cancers 17 02241 g001
Figure 1. Patient flowchart for inclusion in the study cohort undergoing splenectomy for oncologic or hematologic malignancies (2009–2022).
Figure 1. Patient flowchart for inclusion in the study cohort undergoing splenectomy for oncologic or hematologic malignancies (2009–2022).
Cancers 17 02241 g001
Cancers 17 02241 g002
Figure 2. Forest plot of independent predictors of 1-year mortality following splenectomy. OR (95% CI): odds ratio with its 95% confidence interval.
Figure 2. Forest plot of independent predictors of 1-year mortality following splenectomy. OR (95% CI): odds ratio with its 95% confidence interval.
Cancers 17 02241 g002
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Faucher, M.; Ravot, S.; Barthes, L.; de Guibert, J.M.; Chow-Chine, L.; Gonzalez, F.; Bisbal, M.; Servan, L.; Tezier, M.; Tourret, M.; et al. Splenectomy in Onco-Hematologic Patients: A Retrospective Study of Early Complications and 1-Year Mortality. Cancers 2025, 17, 2241. https://doi.org/10.3390/cancers17132241

AMA Style

Faucher M, Ravot S, Barthes L, de Guibert JM, Chow-Chine L, Gonzalez F, Bisbal M, Servan L, Tezier M, Tourret M, et al. Splenectomy in Onco-Hematologic Patients: A Retrospective Study of Early Complications and 1-Year Mortality. Cancers. 2025; 17(13):2241. https://doi.org/10.3390/cancers17132241

Chicago/Turabian Style

Faucher, Marion, Stanislas Ravot, Loïc Barthes, Jean Manuel de Guibert, Laurent Chow-Chine, Frédéric Gonzalez, Magali Bisbal, Luca Servan, Marie Tezier, Maxime Tourret, and et al. 2025. "Splenectomy in Onco-Hematologic Patients: A Retrospective Study of Early Complications and 1-Year Mortality" Cancers 17, no. 13: 2241. https://doi.org/10.3390/cancers17132241

APA Style

Faucher, M., Ravot, S., Barthes, L., de Guibert, J. M., Chow-Chine, L., Gonzalez, F., Bisbal, M., Servan, L., Tezier, M., Tourret, M., Cambon, S., Pouliquen, C., Mallet, D., Nguyen Duong, L., Ettori, F., Ewald, J., Léone, M., Sannini, A., Garnier, J., & Mokart, D. (2025). Splenectomy in Onco-Hematologic Patients: A Retrospective Study of Early Complications and 1-Year Mortality. Cancers, 17(13), 2241. https://doi.org/10.3390/cancers17132241

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop