Open Splenectomy in Chronic Immune Thrombocytopenia and Its Early Complications: Still a Safe Option in Resource Limited Setting

Splenectomy is frequently performed for a multitude of reasons. Among hematological disorders,Chronic ITP is one of the most common indications of splenectomy.Laparoscopic splenectomy has become the preferred modality of surgery.Limitations of expertise, availability and cost of the surgical procedure are the major constraints in the resource limited settings.Therefore, open splenectomy is still very commonly performed.Due to very low platelet counts at the time of surgery in Chronic ITP patients,there is hesitation on the part of the surgeons,leading to deferment and denial of splenectomy,which is the standard second line treatment option in steroid refractory chronic ITP patients.In this prospective,observational study we studied the Chronic ITP patients being treated with splenectomy and the early complications of open splenectomy.

In this prospective, observational study,Chronic ITP patients undergoing open splenectomy at our tertiary care hospital during the period from Jan 2012 to April 2014 were included.All complications occurring within the first 3 months post- surgery were recorded.All patients with chronic ITP were referred for splenectomy to the Department of Surgery of our hospital.Patients received triple immunization for Pneumococcus,H Influenza B and Meningococcus,at least 02 weeks prior to splenectomy.As all patients had a preoperative platelet count of less than 10,000/μL, two units of Single Donor Platelets (SDP) were arranged for perioperative use as per the surgeon's operative protocol.Two units of Packed RBCs were arranged for all patients preoperatively as per the standard surgical practice.All spleen specimens were sent for histopathological examination as per standard practice.

A total of 12 patients of chronic ITP underwent splenectomy during the study period.Sixty seven percent patients were females as against 33% males.The mean age of the patients undergoing splenectomy was 17.75 years.The mean duration of symptoms prior to splenectomy was 4.75 years with a median of at least 03 prior failed therapies, including steroids.All patients had a platelet count of < 10,000/μL preoperatively.The early complications secondary to splenectomy were categorized under 'BITMO' - Bleeding and/or transfusion requirements, Infections, Thrombosis, Mortality and Others.Immediate post-operative pain was not considered a major complication,unless it was disproportionate to the procedure and the standard pain relief being provided as per protocol and hence was not considered under complications.Eight percent (n=1) of the patients required blood transfusion in the immediate perioperative period.This was due to increased intraoperative blood loss.However, there were no cases of massive intra or postoperative bleeding leading to shock.No cases of sepsis or DIC secondary to infections were seen in the perioperative period.Also, no cases of OPSI were seen during the short follow up period of the study.None of the patients had DVT during the follow up.There were no deaths during the study period either related or unrelated to splenectomy.Immediate post-operative response (D+1 post-op) with platelet counts rising above 75,000/μL was seen in all patients undergoing splenectomy for chronic ITP.The median post op platelet count was 156,000/μL.Although immediate post op platelet counts do not predict long term response,it was noted with interest that the only two patients who had long term platelet response had an immediate post- op platelet count of > 450,000/μL. 58% (07/12) patients had a CR/PR at 03 months post splenectomy with no requirement of additional therapies to maintain a platelet count > 30,000/μL and remain free of bleeding symptoms.

To conclude,open splenectomy is a safe procedure and may be equivalent to laparoscopic splenectomy when done at a center doing these surgical procedures regularly.Open splenectomy is a viable option in patients of refractory chronic ITP who have failed multiple lines of previous therapy,including corticosteroids.