Splenectomy is reserved for refractory thrombocytopenia with life-threatening hemorrhage in acute ITP or after recurrent severe thrombocytopenia in chronic ITP. Other immunomodulatory therapies are also discussed. Publication types
Full Answer
What are splenectomies for ITP?
Splenectomies have been used to treat ITP since 1913. There are two types of splenectomies: laparoscopic where the spleen is removed through a few small holes in the abdomen and open, requiring a large incision.
Is splenectomy an effective treatment option for intrauterine thrombosis?
Splenectomy is one of the treatment options that needs to be weighed in the treatment of ITP, particularly in cases that have shown response failure to medical modalities such as prednisone, i.v.Ig, or anti-D globulin therapy. Although most studies demonstrate good early response following splenectomy, the long-term outcome is less favorable.
What is the role of the spleen in the pathogenesis of ITP?
The spleen plays a critical role in the pathogenesis of ITP (Figure 1). For most patients, the spleen is the primary site of platelet clearance.
What is a splenectomy?
A splenectomy is the surgical removal of the spleen, a small, hand-sized organ located in front of the left kidney and behind the stomach.
Why do you do a splenectomy for ITP?
Why remove the spleen? In people with ITP the immune system treats platelets as foreign and destroys them. The spleen is responsible for removing these damaged platelets and therefore removal of the spleen can help to keep more platelets circulating in the body.
Does removing the spleen cure ITP?
While a splenectomy may raise the platelet count, it does not eliminate ITP since the antibody-coated platelets remain in circulation.
Why splenectomy is done?
It helps fight infection and filters unneeded material, such as old or damaged blood cells, from your blood. The most common reason for splenectomy is to treat a ruptured spleen, which is often caused by an abdominal injury.
How does a splenectomy affect platelet count?
Platelet counts after splenectomy have been reported to increase 30% to 100%, with a peak reached at 7 to 20 days postoperatively (3). Common complications of thrombocytosis include thrombosis and hemorrhage.
What is the function of the spleen?
The spleen has some important functions: it fights invading germs in the blood (the spleen contains infection-fighting white blood cells) it controls the level of blood cells (white blood cells, red blood cells and platelets) it filters the blood and removes any old or damaged red blood cells.
Why does the spleen destroy platelets?
Trapped platelets Normally, your spleen works to fight infection and filter unwanted material from your blood. An enlarged spleen — which can be caused by a number of disorders — can harbor too many platelets, which decreases the number of platelets in circulation.
Why does splenectomy help with anemia?
cases of acquired hemolytic anemia splenectomy will remove the major site of red cell destruction and in turn increase the hemoglobin concentration and abolish the need for an accelerated rate of red cell production.
Which hematologic disorders are benefited by splenectomy?
Patients with various hematologic disorders may benefit from splenectomy. Splenomegaly (see the image below) is observed in conditions such as idiopathic (immune) thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP), and hereditary spherocytosis.
How does splenectomy help hemolytic anemia?
Several studies indicate that partial splenectomy reduces the rate of hemolysis and increases red blood cell lifespan while maintaining efficient splenic phagocytic function.
What is the success rate of a splenectomy for ITP?
Splenectomy has a success rate that remains nearly identical (about 50% to 60%) whether it is performed soon after diagnosis or several months or years later. As yet, there is no consistently effective method to predict an individual ITP patient's response to splenectomy.
How is spleen removed from ITP?
There are two types of splenectomies: laparoscopic where the spleen is removed through a few small holes in the abdomen and open, requiring a large incision. The laparoscopic splenectomy is preferred, when possible, since the healing time is reduced.
What diseases can a splenectomized patient recover from?
Because of this, splenectomized patients have a more difficult time recovering from pneumonia, meningitis, Hib flu, 3 sepsis, 9 hospital-based infections, 7 malaria and other parasitic diseases, 5 babesiosis (a tick-borne disease) 10 and gram-negative bacterial diseases from animal bites. 11.
What is the function of the spleen?
The spleen acts like a large lymph node, helping to maintain a healthy immune system and cleaning the blood of foreign matter. In ITP, the antibody-coated platelets are often removed from circulation by the spleen. Theoretically, if the spleen is removed, the platelets will remain in the blood stream. The spleen can also be the site of antibody ...
Which organ removes platelets from the bloodstream?
Although the spleen is often the major site of antibody-coated platelet destruction, platelets may also be removed from circulation by the liver, by a combination of the spleen and liver, or within the blood stream.
Does removing the spleen reduce the amount of anti-platelet antibodies?
Theoretically, if the spleen is removed, the platelets will remain in the blood stream. The spleen can also be the site of antibody production. Therefore removing the spleen may reduce the amount of anti-platelet antibodies in addition to removing the antibody-coated platelets. Although the spleen is often the major site ...
What is the term for the destruction of platelets?
Immune thrombocytopenia ( ITP) is characterized by immune-mediated destruction of circulating platelets and suppression of platelet production. 1 ITP occurs either as a primary disorder or secondary to underlying neoplasia, infection, or autoimmune disease; in the latter case, there may be more profound immune dysregulation. 2
Is splenectomy a steroid?
Splenectomy is an effective therapy for steroid-refractory or dependent immune thrombocytopenia (ITP). With the advent of medical alternatives such as rituximab and thrombopoietin receptor antagonists, the use of splenectomy has declined and is generally reserved for patients that fail multiple medical therapies.
Is ITP a complication of lymphoproliferative disorders?
ITP is a well-recognized complication of lymphoproliferative disorders such as chronic lymphocytic leukemia (CLL), non-Hodgkin lymphoma, and Hodgkin disease and is frequently autoantibody mediated, although there is no evidence that the malignant clone is the source of the autoantibodies. 106 These disorders are also associated with impaired B-cell differentiation and skewing of B-cell subsets, and ITP associated with lymphoproliferative disorders is often less responsive to first-line treatment with corticosteroids. 2 For example, in a cohort of 1278 patients with newly diagnosed CLL of which 64 developed ITP, steroids and/or IVIg had a response rate (complete response and partial response) of only 48.4% (16 of 33 patients). 107 The addition of CLL-directed cytotoxic therapy improved response rate (16 of 22; 72.7%). 107 Splenectomy appears to be safe in individuals with lymphoproliferative disorders, 108 although these individuals are often older with comorbidities, and surgical risks must be considered. Splenectomy has been reported to be effective in some cases of CLL-associated ITP 109-111 ; however, as with other causes of secondary ITP, treatments directed at the underlying disorder should be attempted before splenectomy.
Can ITP be used during pregnancy?
Primary approaches to ITP in pregnancy involve corticosteroids and/or IVIg. 91 Other agents, such as azathioprine and cyclosporine, have been used safely; however, even when effective, these may take considerable time to raise the platelet count. Rituximab is not teratogenic but may cause prolonged B-cell lymphopenia in offspring. 91 Splenectomy is rarely used in pregnant patients with ITP; when it is, the optimal time is in the mid–second trimester to minimize the risk of premature labor and provide access to the spleen before it is obscured by the gravid uterus.
Is TPO RA approved for ITP?
TPO-RAs are approved for treatment of ITP in children and adults. As with rituximab, the place of TPO-RA in the sequence of ITP therapy is not established. TPO-RAs have class-specific toxicities, in particular bone marrow reticulin fibrosis in 2% to 4% of patients. 86 Eltrombopag is associated with elevated transaminase levels, which in rare patients may progress to hepatotoxicity. 87 Response to either eltrombopag or romiplostim occurs in 80%, and the development of resistance is uncommon. 86, 88 Although it was not expected that these agents should induce remission, a recent report suggests that ∼30% of early stage ITP patients are able to discontinue these agents and maintain stable platelet counts. 89, 90 Similar to rituximab, some of these remissions may reflect the natural history of ITP.
Does splenectomy increase the risk of stroke?
An early study of veterans who underwent splenectomy for trauma reported a twofold increased risk of death from ischemic heart disease. 74 Subsequent reports confirmed higher rates of stroke and myocardial infarction in adults with hereditary spherocytosis who underwent splenectomy, with an incidence of 22% to 32% by age 70. 75 The rate of ATE is 3.2% to 4.5% in patients with chronic ITP, 67, 76 and Ruggeri et al reported that splenectomy increased this risk (HR = 3.2 [95% CI, 1.2-8.6]). 67 However, in a recent population-based study, the rates of myocardial infarction (1.13% vs 1.30%) and stroke (2.09% vs 2.56%) were similar for ITP patients who did or did not undergo splenectomy. 77 Thus, although splenectomy may increase the risk of ATE overall, the effect in ITP patients is unclear. 71, 77
Is splenectomy a predictor of response?
Predictors of response to splenectomy. The success of splenectomy is difficult to predict, and statistics on response rates apply to populations rather than individuals. Predictors of splenectomy response that have been evaluated follow below.
Why do you need to remove the spleen?
Why remove the spleen?#N#In people with ITP the immune system treats platelets as foreign and destroys them . The spleen is responsible for removing these damaged platelets and therefore removal of the spleen can help to keep more platelets circulating in the body. Splenectomy used to be the standard treatment for ITP before drug therapies were developed, and it is still carried out in patients with chronic severe ITP (troublesome ITP for a year or more). In the UK leading ITP specialists only carry out splenectomy when all other options have been exhausted, and it has been preceded by an indium labelled platelet spleen scan (performed in the nuclear medicine department of certain hospitals) to investigate whether the platelets are being destroyed in the spleen. If this test shows that platelets are mainly being destroyed elsewhere in the immune system a splenectomy is unlikely to raise the platelet count.
Do asplenics need antibiotics?
Asplenics (people without a spleen) in the UK are advised by the Department of Health to take antibiotics for life, but in many other countries a standby dose of antibiotics is issued to carry at all times and take at the first sign of infection.
Is spleen surgery open or laparoscopic?
Splenectomy is often carried out as a laparoscopic procedure (keyhole surgery) which has the advantage of a shorter hospital stay and quicker recovery time. However, in some patients the surgeon may need to revert to open surgery if the spleen is particularly large or there are other complications.
Is spleenectomy a treatment for ITP?
Splenectomy used to be the standard treatment for ITP before drug therapies were developed, and it is still carried out in patients with chronic severe ITP (troublesome ITP for a year or more).
Can a child have a spleenectomy?
Children rarely have a splenectomy unless their ITP is particularly troublesome, as most recover from ITP, and the risk of infection without a spleen is far higher until the immune system becomes fully developed in teenage years.