Place of Splenectomy (SE) in the Treatment of Immune Thrombocytopenic Purpura (ITP)

Introduction

Proposed in 1916 by Shlofferom Katznelson, splenectomy has been widely used since then in the treatment of immune thrombocytopenic purpura.

ITP seems to be the most common indication for SE. According to the available literature up to 50-80% of laparoscopic SEs are being performed in patients with ITP, in our Centre - up to 20%. Laparoscopic SE should be considered as the treatment of choice for recurrent thrombocytopenic purpura after the initial response to steroid therapy.

Indications for SE include all forms of immune thrombocytopenic purpura, requiring repeated courses of hormone therapy, as well as the cases of developed life-threatening complications, as for example intracranial hemorrhage. Earlier indications for splenectomy included lack of the hormone replacement therapy effect for 6 months.

The dimensions of the spleen in patients with ITP are usually within normal or slightly increased limits. Thus these patients may get all the benefits of minimally invasive surgery.

Goal: 1. to assess the results of the SE in the treatment of ITP 2. to clarify its place in the treatment of ITP. 3. to investigate the influence of the multiple lines drug therapy on the efficiency of SE in patients with ITP.

Materials and Methods

87 SE have been performed in patients with ITP in 2008 – 2013, among them 63 female, 24 male. Median age 28 years old. Duration of the disease before surgery was from one month to 51 years, in 69 patients - over 6 months.

62 patients (71.3%) before SE received only corticosteroids.

25 (28.7%) received besides corticosteroids:

14 - GCS + immunoglobulin

5 - GCS + rituximab

7 - GCS + romiplostim

3 - GCS + cyclosporine

1 - GCS + eltrombopag

1 - GCS + azathioprine

Results and Discussion

Average duration of the laparoscopic SE was 109 min (from 50 to 250 min), on the average 100 min with the mean blood loss of 300 ml (median 200 ml). In 20 patients intraoperative blood loss was negligible, in 14 – over 500 ml. In patients treated with only corticosteroids blood loss over 500 ml was in 16%, in pretreated- in 20%.

Intraoperative complications (5.7%):

• pneumothorax-1

• intraoperative bleeding led to conversion-2

• acute respiratory failure-1

• bleeding from the bed of the spleen, stopped by conservative measures-1

Postoperative complications occurred in 13,8% (n = 12):

•patients treated with corticosteroids 11.3%

•patients receiving multiple lines of therapy - 24%.

•thrombotic complications (3.4%)

•portal vein thrombosis 1

•tibial vein thrombosis 1

•ischemic stroke 1

•pneumonia 8 (9%)

•intestinal bleeding-1 (1.1%)

In 13 (14.9%) patients, operated on with thrombocytopenia < 20x10⁹/l, average blood loss was 320 ml (100-1200 ml). The operation was complicated in 2 patients by intraoperative bleeding required conversion. One patient in the postoperative period developed acute adrenal failure, pneumonia, septic shock.

In 49 (56.3%) patients, operated on with thrombocytopenia 20-100x10⁹/l, mean blood loss was 240 ml (0-1100 ml). Postoperative complications developed in 7 (14%) of them (1 portal vein thrombosis, acute respiratory failure 1, pneumonia 5).

In 26 (29.8%) patients, operated on with the platelet count of more than 100x10, average blood loss was 370 ml (0-2000 ml). One intraoperative complication - injury to the diaphragm. Postoperative complications (1 bleeding, pneumothorax, 1, 1 pneumonia, thrombosis of the saphenous veins of the lower extremities 1) developed in 4 (15%) pts.

In 69 patients with the duration of the disease over 6 months the efficiency of SE was 84%.

In 17 patients with the duration of the disease less than 6 months - 70.6%.

In patients treated with corticosteroids, efficiency of SE was estimated as 85.5%

In pretreated - 60%.

Nonefficient SEs were observed in 10 pts.

In 10 patients the platelets count after SE remained <20x10⁹/l

Administration of romiplostim (n = 7) led to an increase of the platelets count up to 60-80 x 10⁹/l in 7 patients (100%) in the first week after surgery

Conclusion

• SE results in a full or partial response in 79.6% of patients with ITP

• Optimal time for SE is 6 - 12 months after the onset of the disease

• Risk of complications of the procedure increases with the delay of SE

• A history of multiple lines of drug therapy reduces the efficiency of SE in ITP from 79.6% to 60.0%.