Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair (Br J Surg 2010; 97: 600–608)

Sir We read with interest this manuscript in which the authors demonstrated that only spleen diameter and consequent decreased portal venous flow were risk factors for the development of portal vein thrombosis (PVT) after splenectomy in patients with cirrhosis. Despite this finding we believe that patients with cirrhosis are characterized by specific risk factors for PVT after splenectomy owing to their peculiar problems related to haemostasis. In fact, the incidence of 24 per cent of PVT after splenectomy in patients with cirrhosis is higher than that in patients with underlying thrombophilic conditions (1·7–12·8 per cent)1. This could be due to the reset haemostatic balance which has been demonstrated recently to be shifted towards hypercoagulability in patients with Child’s grade C disease. In addition, patients with PVT have been shown to have increased levels of factor VIII, which can cause imbalance in haemostasis with a tendency towards thrombosis. In fact, Kawanaka et al.2 recently showed that administration of antithrombin III after splenectomy was likely to decrease the incidence of PVT by restoring the equilibrium between procoagulant and anticoagulant factors. Moreover, the rise in the platelet count after splenectomy (not described by the authors) could be an additional risk factor for PVT as demonstrated in a recent trial of the use of thrombopoietin before invasive procedures in patients with cirrhosis3. Finally, genetic thrombophilic defects have been shown in up to 69 per cent of cases4. Thus, screening for thrombophilia could be useful before surgical procedures, such as splenectomy, in patients with a high risk of thrombosis. In conclusion, patients with liver cirrhosis may stand even a greater risk of PVT after splenectomy than patients without cirrhosis and this could strongly suggest the need for thromboprophylaxis after surgery. M. Senzolo, K. Rodriguez, E. Nadal and P. Burra Department of Gastroenterology, University Hospital of Padua, Padua, Italy (e-mail: marcosenzolo@hotmail.com) DOI: 10.1002/bjs.7239