BACKGROUND:Hepatocellular carcinoma (HCC) with cirrhotic hypersplenism creates a surgical dilemma because hepatectomy alone (HA) leaves cytopenia untreated, whereas hepatectomy plus splenectomy (HS) may increase operative and thrombotic risk. AIM:To compare HA, HS, and hepatectomy plus splenic arterial flow reduction (SAFR) in patients with HCC and cirrhotic hypersplenism undergoing curative-intent hepatectomy. METHODS:Six databases were searched to 31 March 2026. Comparative studies were pooled using pairwise meta-analysis and exploratory frequentist network meta-analysis. Risk of bias was assessed using ROBINS-I. RESULTS:Thirty studies involving 3967 patients were included. Eight-study primary analyses associated HS with longer overall survival (HR = 0.73, 95% CI 0.62-0.85) and recurrence-related survival (HR = 0.67, 95% CI 0.59-0.76) than HA, while HS was associated with more portal vein thrombosis (RR = 6.00, 95% CI 3.35-10.74) and major complications (RR = 1.57, 95% CI 1.10-2.23). In the exploratory network meta-analysis, both HS and SAFR were associated with greater postoperative platelet and white blood cell recovery than HA; evidence for SAFR was sparse and heterogeneity was substantial. CONCLUSION:HS was associated with longer survival and greater early hematological recovery than HA, but also with greater thrombotic and major-complication risks. SAFR was associated with improved early blood counts without a similar increase in thrombotic or complication risk, identifying it as a promising alternative to splenectomy. Although current evidence is limited, SAFR merits further prospective evaluation.
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