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Laparoscopic splenectomy for immune thrombocytopenia (ITP): long-term outcomes of a modern cohort

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Abstract

Background

The advent of newer second-line medical therapies (SLMT) for immune thrombocytopenia (ITP) has contributed to decreased rates of splenectomy, following a trend to avoid or delay surgery. We aimed to characterize the long-term outcomes of laparoscopic splenectomy (LS) for ITP at our institution, examining differences in LS efficiency when performed before or after SLMTs.

Methods

Adults with primary ITP who underwent LS between 2002 and 2016 were identified. Retrospective review of electronic medical records was supplemented with telephone interviews. Treatment response was defined according to current guidelines as complete responders (CR), responders (R), and non-responders (NR). Kaplan–Meier estimates assessed relapse-free rates, and predictors of long-term response were investigated using logistic regression.

Results

109 patients met inclusion criteria, from which 42% were treated with an SLMT before referral to LS. LS was completed in all cases, with no conversions or intraoperative complications. The perioperative morbidity was 7.3%, including 3 deep vein and 2 portal vein thrombosis, one reoperation for bleeding, and no mortalities. Splenectomy was initially effective in 99 patients (CR + R = 90.8%), and 10 patients were NR. At a median 62-month follow-up, 25 patients relapsed, resulting in a 68% CR + R rate. Proportion of CR + R was similar in patients who previously received SLMT and those who did not (61 vs. 76.7%, p = 0.08). CR + R patients were younger (45 vs. 53, p = 0.03), had higher preoperative platelet counts (36 vs. 19, p = 0.01), and experienced a higher increment in platelet counts during hospital stay (117 vs. 38, p < 0.001) as well as 30-days postoperatively (329 vs. 124, p < 0.001). Only a robust response in platelet count at 30-days postoperatively was independently associated with long-term response (OR 1.005, p = 0.006).

Conclusion

LS was curative in 68% of patients, with no statistically significant difference when performed before or after SLMTs. Outcomes remain challenging to predict preoperatively, with only a robust increase in platelet counts on short term being associated with long-term response.

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Authors and Affiliations

  1. Comprehensive Hernia Center, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA

    Luciano Tastaldi, David M. Krpata, Ajita S. Prabhu, Clayton C. Petro, Ivy N. Haskins, Arielle J. Perez, Hemasat Alkhatib, Michael J. Rosen & Steven Rosenblatt

  2. Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA

    Chao Tu

  3. Department of Hematology and Medical Oncology, Taussig Cancer Center, The Cleveland Clinic Foundation, Cleveland, OH, USA

    Alan Lichtin

  4. Department of Hematology and Medical Oncology, Hospital Amaral Carvalho, Jau, Brazil

    Iago Colturato

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  1. Luciano Tastaldi
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Correspondence to Luciano Tastaldi.

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Disclosures

Drs. Luciano Tastaldi and Ivy Haskins have received a resident research grant from the Americas Hernia Society Quality Collaborative not related to the presented work. Dr. Ajita Prabhu received personal fees from Medtronic and a research grant from Intuitive Inc. not related to the presented work. Dr. Michael J. Rosen receives salary support from the Americas Hernia Society Quality Collaborative, has received research grants from Intuitive Inc., Miromatrix, and Pacira Pharmaceuticals, and received personal fees from Bard Davol and Gore. None are related to the presented work. Mr. Chao Tu, Drs. David Krpata, Clayton Petro, Arielle Perez, Hemasat Alkhatib, Iago Colturato, Alan Lichtin, and Steven Rosenblatt have no conflicts of interest or financial ties to disclose.

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Tastaldi, L., Krpata, D.M., Prabhu, A.S. et al. Laparoscopic splenectomy for immune thrombocytopenia (ITP): long-term outcomes of a modern cohort. Surg Endosc 33, 475–485 (2019). https://doi.org/10.1007/s00464-018-6321-y

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