Laparoscopic splenectomy for immune thrombocytopenia (ITP) patients with platelet counts lower than 1 × 109/L

Abstract

Laparoscopic splenectomy (LS) has become the gold-standard surgical intervention for the treatment of immune thrombocytopenia (ITP) and the patients who experienced medical relapse to steroid. Fewer series are available regarding LS for patients with an extremely low platelet count. The aim of this study is to investigate the feasibility and safety of laparoscopic splenectomy in the treatment of patients with a preoperative platelet count of less than 1 × 109/L. From April 2006 to Jan 2011, 10 patients were managed by laparoscopic splenectomy for idiopathic thrombocytopenia with an extremely low preoperative platelet count. Preoperative, perioperative, and postoperative medical management has been reviewed. Before laparoscopic splenectomy, all of the 10 patients had a platelet count of less than 1 × 109/L but a normal level of coagulation function. Emergency laparoscopic splenectomy was performed. The mean operating time was 157 min; the mean intraoperative blood loss was 44 mL. During the operations, transfusion was provided in two patients. No intraoperative complications ensued. The patients were followed up for a mean of 28 months and showed good recovery without any postoperative complications. Laparoscopic splenectomy is a feasible technique in the treatment of ITP patients, characterized by severe mucocutaneous bleeding, extremely low platelet count, and normal prothrombin time (PT) and activated partial thromboplastin time (APTT).

Laparoscopic Splenectomy for Benign Hematological Disorders in Adults: A Systematic Review

“…Depending on each study's methodology, the mean operative time was reported as being between 75 and 162 min, (6,7,9,10,13,14,25,44), the mean operative time between 150 and 165 min (17,19) and the median operative time between 109 and 144 min (18,20). However, splenomegaly (7), low platelet count (9), anterior approach (10), indications other than immune thrombocytopenic purpura (ITP) (18,20) and concomitant laparoscopic cholecystectomy (18,20), significantly prolonged the operative time.…”

“…LS can be performed with minimal blood loss (mean 36-60 ml) (6,13,17,19,25) and significantly less blood loss compared to OS (14). In the study of Vecchio et al, platelet transfusion was occasionally required (1 out of 12 patients) (6); in other studies, the need for packed erythrocyte transfusion was rare (9, 10), while intraoperative blood loss of more than 600 ml (9), as well as the anterior approach (10), almost always lead to packed erythrocyte transfusion.…”

“…In the presence of a normal coagulation profile, a low platelet count should not preclude LS any longer (9,(24)(25)(26)(27). In patients with massive splenomegaly and heavy spleens, LS should firstly be attempted (7,14), keeping in mind that the ports should be placed more caudally on the abdominal wall directly related to the lower pole of the spleen (30), the modification of hand-assisted technique might prove extremely helpful, but despite these maneuvers, the conversion rate remains high.…”

“…Studies with shorter durations of follow-up had significantly higher relapse rates than studies with longer follow-up. It was concluded that splenectomy may have higher initial relapse rates in the first 2 years after surgery, (20) Splenic bed collection, peripancreatic fluid collections, 0% 6.25% 0% bleeding from the splenic artery stump, symptomatic PVT Nobili et al (17) Hemoperitoneum 0% 10% 0% Chen et al (9) Bleeding, pneumonia, subphrenic fluid collection, left pleural effusion 0% 11% 0% Wu et al (25) Subphrenic hematoma, bleeding 0% 0% 0% Zheng et al (27) Subphrenic abscess, bleeding 0.6% 8.4% 0% Zheng et al (26) N/A N/A N/A N/A Wu et al (24) Subphrenic hematoma, bleeding 0% 0% 0% Al-Mulhim (7) Acute chest syndrome, left subphrenic hematoma, left pleural effusion 0% 8.4% 0% Patel et al (18) PE, DVT, pneumonia, MI 0% 10% 0% Corcione et al (10) Fluid collections in the splenic fossa, subphrenic 0.3% 13% 1% abscesses, bleeding, intestinal ischemia Fraser et al (11) PVT, sepsis, bleeding, intestinal ischemia 3.9% 21.1% N/A Monclova et al (16) Bleeding from a vessel of the greater omentum, 0% 15.6% 3% subphrenic fluid collection, pancreatic fistula. Li et al (13) Wound complications, sepsis, subhepatic abscess, respiratory complications 0% 6.67% 0% Marte et al (14) Bleeding, OPSI 2.08% 8.8-35.7% 0% Wang et al (23) Bleeding, PVT 0% 6.9% 6.9% Vecchio et al (6) Conversion to open surgery was required in one patient because of 0% 0% 0% lack of anatomic definition of Calot triangle's structures.…”

Successful Management of Chronic Refractory Immune Thrombocytopenia with Laparoscopic Splenectomy in a Patient with Acute Promyelocytic Leukemia

“…Since durable remissions have been achieved with splenectomy in patients with chronic refractory ITP [15,16], we planned to perform LS in our patient, which induced a durable remission. We did not administer anti-CD20 monoclonal antibody, since response to this treatment modality can be temporary, and we also had concerns about the long-term immunosuppression and reactivation of viral infections that can be caused by rituximab.…”