Splenectomy combined with devascularization for recurrent variceal bleeding in cirrhotic patients: a decade-long multicenter study

Recurrent variceal bleeding in cirrhosis carries a high rebleeding risk despite endoscopic thearpy, and the long-term role of splenectomy combined with devascularization is not well established. To determine whether prior splenectomy combined with devascularization reduces 1-year rebleeding after endoscopic therapy in patients with cirrhosis and recurrent variceal bleeding, and to develop a model for predicting rebleeding risk. This retrospective multicenter study included 288 patients with recurrent variceal bleeding (2010–2024) for model development and 128 patients from an independent center for external validation. Multivariable logistic regression, stabilized inverse probability of treatment weighting (IPTW), and doubly robust analyses estimated the association between splenectomy with devascularization and 1-year rebleeding. Candidate predictors were screened by LASSO regression and ranked by SHAP values from an XGBoost model; a nomogram was developed and validated internally and externally, with bootstrap internal validation. Splenectomy with devascularization was independently associated with lower 1-year rebleeding (adjusted OR 0.27, 95% CI 0.13–0.59; IPTW OR 0.25, 95% CI 0.10–0.62), without significant subgroup interactions. The SDPAH nomogram achieved AUCs of 0.763, 0.707, and 0.819 in the training, internal validation, and external validation cohorts, respectively. Portal vein diameter showed a U-shaped association with rebleeding (optimal threshold, 1.46 cm). Among patients with cirrhosis and recurrent variceal bleeding, prior splenectomy combined with devascularization was independently associated with a lower 1-year rebleeding risk after endoscopic endoscopic therapy. The SDPAH nomogram may help identify high-risk patients, although the retrospective design and perioperative risks warrant caution. Splenectomy combined with devascularization, a surgery to remove the spleen, can help prevent repeated dangerous bleeding in patients with recurrent variceal bleeding. A new risk prediction tool can identify who is most likely to experience rebleeding after treatment. However, the surgery carries its own risks, so doctors must carefully balance benefits and potential complications for each patient.Splenectomy combined with devascularization, a surgery to remove the spleen, can help prevent repeated dangerous bleeding in patients with recurrent variceal bleeding. A new risk prediction tool can identify who is most likely to experience rebleeding after treatment. However, the surgery carries its own risks, so doctors must carefully balance benefits and potential complications for each patient.