Splenectomy in patients with idiopathic thrombocytopenic purpura: Analysis of 109 cases

Öz

Objectives: Splenectomy is performed in order to provide the treatment in the patients with severe idiopathic throm-bocytopenic purpura, refractory to medical treatment. In this study, we aimed to investigate the postoperatif and long-term outcomes in the patients who underwent splenectomy with the diagnosis of idiopathic thrombocytopenic pur-pura. Materials and Methods: Between 2001-2010 at Dicle University Medical Faculty, General Surgery Department, a retrospective review of the 109 patients who had undergone splenectomy for ITP was reviewed. Age, gender, pres-ence of accessory spleens and location, duration of the operation, number of preoperative platelet tranfusion, number of preoperative and postoperative blood transfusion, length of hospital stay, long-term outcomes, morbidity and mor-tality were recorded. Results: The mean age was 37.10 ± 16.62 (16-72), and there were 88 (80.7%) female and 21 (19.3%) male patients. The mean operation time was 44.87 ± 10:32 (30-120) minutes. The average postoperative blood and preoperative platelet transfusion were 1.63 ± 0.85 (0-3) and 2.01 ± 0.71 (1-3) units, respectively. The accessory spleens were en-countered in 20 (18.3%) patients at the ultrasonographic examination. And also the accessory spleens were encoun-tered in 23 (21.1%) patients during operation and confirmed with histopathologic examination. The most common lo-calization of accessory spleens were splenic hilus. The postoperative complications were occurred in 16 patients (14.7%) and the most complication was atelectasia. The mean length of hospital stay was 4:56 ± 2:45 (2-12) days. Patients were followed for an average of 28 (9-48) months. At the follow-up period, 1 (0.9 %) patient had died. Conclusion: Splenectomy can be performed safely in the treatment of the patients with idiopathic thrombocytopenic purpura unresponsive to medical treatment. Long-term good results can be obtained with splenectomy in these pa-tients. The accessory spleens should not be overlooked to prevent recurrences.

Anahtar Kelimeler

• Idiopathic thrombocytopenic purpura, splenectomy, accessory spleen.

Splenectomy in patients with idiopathic thrombocytopenic purpura: Analysis of 109 cases

Öz

Amaç: Splenektomi, medikal tedaviye dirençli ve şiddetli seyreden İdiopatik trombositopenik purpuralı hastalarda te-davi sağlamak amacıyla yapılmaktadır. Bu çalışmada İdiopatik trombositopenik purpura tanısıyla splenektomi uygu-lanan hastalarda postoperatif ve uzun dönem sonuçların irdelenmesi amaçlandı. Gereç ve Yöntem: Dicle Üniversitesi Tıp Fakültesi Genel Cerrahi Kliniğinde 2002-2010 tarihleri arasında İdiopatik trombositopenik purpura tanısıyla splenektomi uygulanan 109 hasta retrospektif olarak değerlendirildi. Hastalarda yaş, cinsiyet, aksesuar dalak varlığı ve yerleşimi, operasyon süresi, preoperatif transfüzyone edilen trombosit ünite sayısı, preoperatif ve postoperatif kan transfüzyon ünite sayısı, hastanede yatış süresi, takip süresi ve sonuçları, morbidite ve mortalite kaydedildi. Bulgular: Hastaların 88\'i (%80.7) kadın, 21\'i (%19.3) erkek idi. Yaş ortalamaları 37.10±16.62 (16-72) yıl idi. Ortalama ameliyat süresi 44.87 ± 10.32 (30-120) dakika idi. Ortalama kan transfüzyonu ve trombosit süspansiyonu sırasıyla 1.63±0.85(0-3) ve 2.01±0.71(1-3) ünite idi. Preoperatif USG ile 20 (%18.3) hastada aksesuar dalak tanımlandı. Has-talarda laparotomide 23\'ünde (%21.1) patoloji tarafından doğrulanan aksesuar dalak tespit edildi. İntraoperatif en sık aksesuar dalak yerleşimi dalak hilusunda saptandı. Hastaların 16\'sında (%14.7) postoperatif dönemde komplikasyon gelişti. En sık görülen komplikasyon atelektazi idi. Hastaların ortalama hastanede yatış süresi 4.56±2.45(2-12) gün idi. Hastalar medyan 28 (9-48) ay takip edildi. Hastaların 1\'inde (%0.9) mortalite gelişti. Sonuç: Splenektomi İdiopatik trombositopenik purpura tedavisinde medikal tedaviye yanıtsız olgularda güvenle uygu-lanabilen bir cerrahi girişimdir ve splenektomiyle bu hastalarda uzun süreli yanıt almak mümkündür. Nüksü engelle-mek için aksesuar dalak gözden kaçırılmamalıdır.

Anahtar Kelimeler

• İdiopatik trombositopenik purpura, splenektomi, aksesuar dalak.

Kaynakça

1. British Committee for Standards in Haematology General Haematology Task Force. Guidelines for the investiga- tion and management of idiopathic thrombocytopenic pur- pura in adults, children and in pregnancy. Br J Haematol 2003;120(4): 574-96.
2. Balague C, Targarona EM, Cerdan G, et al. Long-term out- come after laparoscopic splenectomy related to hematolog- ical diagnosis. Surg Endosc 2004; 18(8):1283-7.
3. Durakbasa CU, Timur C, Sehiralti V, Mutus M, Tosyali N, Yoruk A. Pediatric splenectomy for hematological diseases: outcome analysis. Pediatr Surg Int 2006;22(8):635-9.
4. Pamuk GE, Pamuk ON, Başlar Z, et al. Overview of 321 patients with idiopathic thrombocytopenic purpura. Ret- rospective analysis of the clinical features and response to therapy. Ann Hematol 2002; 81(8): 436-40.
5. Watson D, Coventry B, Chin T, Gill G, Malycha P. Laparo- scopic versus open splenectomy for immune thrombocyto- penic purpura. Surgery 1997;121(1): 18-22.
6. Trias M, Targarona EM, Espert JJ, et al. Impact of hemato- logical diagnosis on early and late outcome after laparo- scopic splenectomy: an analysis of 111 cases. Surg Endosc 2000; 14(6): 556-60.
7. David PW, Williams DA, Shamberger RC. Immune throm- bocytopenia: surgical therapy and predictors of response. J Pediatr Surg 1991;26(4): 407-13.
8. Arnoletti JP, Karam J, Brodsky J. Early postoperative com- plications of splenectomy for hematologic disease. Am J Clin Oncol 1999; 22(2):114-8.

9. Bisharat N, Omari H, Lavi I, Raz R. Risk of infection and death among post-splenectomy patients. J Infect 2001;43(3):182-6.
10. Harlak A, Sücüllü İ, Demirbaş S, Yiğit T, Özdemir Y. Elek- tif splenektomilerde açık ve laparoskopik cerrahi sonuçları- mız. Gülhane Tıp Dergisi 2009; 51(4): 239-43.
11. Schwartz J, Leber MD, Gillis S, Giunta A, Eldor A, Bussel JB. Long term follow-up after splenectomy performed for immune thrombocytopenic purpura (ITP). Am J Hematol 2003; 72(2): 94-8.
12. Dolan JP, Sheppard BC, DeLoughery TG. Splenectomy for immune thrombocytopenic purpura: Surgery for the 21st century. Am J Hematol 2008;83(2):93-6.
13. Hoffbrand AV, Pettit JE. Essential Haematology, 3rd edn. Bilbao: Blackwell Scientific Publications, 1993: 318-331.
14. George JN, Woolf SH, Roskob GE, et al. Idiopathic throm- bocytopenic purpura: A practice guideline developed by explicit methods for the American Society of Hematology. Blood 1996; 88(1): 3-40.
15. Jacir NN, Robertson FM, Crombleholme TM, Harris BH. Recurrence of immune thrombocytopenic purpura after splenectomy. J Pediatr Surg 1996;31(1): 115-6.
16. Aydoğdu İ,Tayfun E, Akan H, ve ark. İdiopatik trombosito- penik purpurada klnik seyir: 62 Hastalık bir seyir. J Turgut Özal Medical Center 1996;3(3):165-8.
17. Girgin S, Gedik E, Baç B, Taçyıldız Hİ. Benign Hemato- lojik Hastalıklarda Splenektomi Sonuçlarımız. Akademik Acil Tıp Dergisi 2008;4(7) :42-5.
18. Sampath S, Meneghetti AT, MacFarlane JK, Nguyen NH, Benny WB, Panton ON. An 18-year review of open and laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Am J Surg 2007; 193(5): 580-84.
19. Targarona EM, Trias M. Laparoscopic surgery of the spleen. World J Surg 2007; 31(6): 1363-4.
20. Stanton CJ. Laparoscopic splenectomy for idiopathic thrombocytopenic purpura. A five-year experience. Surg Endosc 1999; 13(11): 1083-6.
21. Mehta SS, Gittes GK. Lesions of the pancreas and spleen. In: Ashcraft KW, Whitfield Holcomb G, Murphy JP (eds) Pediatric Surgery, Elsevier Saunders, Philadelphia, 2005:639-58.
22. van’t Riet M, Burger JW, van Muiswinkel JM, Kazemier G, Schipperus MR, Bonjer HJ. Diagnosis and treatment of portal vein thrombosis following splenectomy. Br J Surg 2000;87(9): 1229-33.
23. Winslow ER, Brunt LM, Drebin JA, Soper NJ, Klingen- smith ME. Portal vein thrombosis after splenectomy. Am J Surg 2002;184(6):631-5.
24. Tefferi A, Mesa RA, Nagorney DM, Schroeder G, Silver- stein MN. Splenectomy in myelofibrosis with myeloid metaplasia: a singleinstitution experience with 223 patients. Blood 2000;95(7): 2226-33.
25. Rodeghiero F, Frezzato M, Schiavotto C, Castaman G, Dini E. Fulminant sepsis in adults splenectomized for idiopathic thrombocytopenic purpura. Haematologica 1992;77(3):253-6.
26. Zarrabi MH, Rosner F. Serious infections in adults fol- lowing splenectomy for trauma. Arch Intern Med 1984;144(7):1421-4.
27. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: Work- ing Party of the British Committee for Standards in Hae- matology Clinical Haematology Task Force. British Med J 1996;312(7028): 430-4.
28. Davies JM, Barnes R, Milligan D. Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. Clin Med: J Royal Coll Phys London 2002;2(5): 440-3.