IMMUNE THROMBOCYTOPENIA - SURGICAL THERAPY AND PREDICTORS OF RESPONSE

We have reviewed 40 patients with immune thrombocytopenia purpura (ITP) to assess current methods of preparation for surgery and to evaluate perioperative complications and response to splenectomy. Twenty-one patients had chronic ITP (> 1 year duration) and 19 patients had severe acute thrombocytopenia (platelet counts < 10,000). A progression of methods of pretreatment was seen in the 10-year period reviewed. Seventeen patients received no treatment before admission for surgery, and 10 of these received platelet transfusions. Seventeen patients received steroids immediately preceding surgery; 16 of these responded and 1 received a platelet transfusion. Recently, 5 patients received intravenous gamma globulin (IgG) preceding surgery with all patients responding and none receiving platelet transfusions. One patient received a combination of steroids and IgG with good response and did not require platelet transfusion. No major postoperative complications occurred (ie, pancreatitis, small bowel obstruction, or sepsis) except for one patient requiring a secondary exploration for an accessory spleen and recurrent thrombocytopenia. Eight patients (20%), 6 with severe ITP and 2 with chronic ITP (5 males and 3 females) developed recurrence of thrombocytopenia following surgery up to 1 1 2 years after splenectomy. These patients all required further medical therapy. Three additional patients (2 chronic and 1 severe) developed thrombocytopenia following viral illnesses, but required no further therapy. Of the 8 surgical failures, 4 failed to respond to prior treatment with steroids, 1 to IgG, and 2 failed to respond to combination therapy, while one surgical failure responded to both steroid and combination therapy. Of the responders to splenectomy (32 patients), only 3 failed to respond to prior treatment with steroids. In conclusion, response to steroids (20 patients), IgG (3 patients), or both ( 6 7 patients) was almost predictive of response to splenectomy (97%), whereas failure to respond to steroids or IgG predicted a 70% failure rate from splenectomy ( 7 10 patients) (Fisher's exact test, P < .001). IgG and steroids were equally effective in pretreatment, allowing less frequent use of platelet transfusion. Eighty percent of all patients achieved long-term response to splenectomy. © 1991.