100 godina nakon prve splenektomije u imunosnoj trombocitopeniji - je li laparoskopska splenektomija još i danas dobra terapijska metoda? Prikaz vlastitih iskustava [A hundred years after first splenectomy for immune thrombocytopenia, is laparoscopic splenectomy still valid as a treatment option? A single center experience]

Mitrović, Zdravko and Stipančić, Igor and Baković, Josip and Hariš, Višnja and Ajduković, Radmila and Jakšić, Ozren and Prka, Željko and Piršić, Mario and Knežević, Mario and Pejša, Vlatko (2018) 100 godina nakon prve splenektomije u imunosnoj trombocitopeniji - je li laparoskopska splenektomija još i danas dobra terapijska metoda? Prikaz vlastitih iskustava [A hundred years after first splenectomy for immune thrombocytopenia, is laparoscopic splenectomy still valid as a treatment option? A single center experience]. Liječnički vjesnik, 140 (9-10). pp. 248-253. ISSN 0024-3477

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Abstract

AIM: A single center experience with laparoscopic splenectomy (LS) in the treatmen t of immune thrombocytopenia (ITP) is presented in this paper. In addition, we discuss the role of splenectomy in the era of thrombopoietin receptor agonists (TPO-RAs). ----- PATIENTS AND METHODS: In this retrospective study, we present our 35 patients who underwent LS in the period of 12 years. There were 26 women and nine men with a median age of 50 years (ranging from 19 to 85 years). Prior to LS, all patients were treated with glucocorticoids +/- intravenous immunoglobulins (IVIG), whereas seven patients received also rituximab. The median time to splenectomy was seven months (ranging from one to 103 months). ----- RESULTS: Four (11%) patients failed to reach response after LS, and additional six patients relapsed during the follow up. After a median follow up of 33 months, the remaining 25 (71%) patients required no further treatment. The estimated sustained response rate at fi ve years was 59%. Patients who underwent splenectomy in the fi rst year after the diagnosis had better outcome when compared to patients with delayed splenectomy (P= 0.048). Sex and age did not infl uence the treatment outcome. Four patients had early serious postoperative complications of LS: portal vein thrombosis, deep vein thrombosis of the leg, sepsis, and intraperitoneal bleeding that required surgical revision. There were no deaths, nor late serious infections. Ten (29%) patients reported fatigue after LS. ----- CONCLUSION: Long-term cure rate of about 60% is comparable to other studies. However, we observed better response in patients who underwent splenectomy earlier. In our opinion, LS may still be considered as a safe, successful, and cost-effective second-line treatment of ITP, especially in patients who are in favor of fast and highly curative treatment. Nevertheless, the introduction of TPO-RAs will inevitably decrease the role of LS in Croatia, as in the western world.

Abstract in Croatian

CILJ ISTRAŽIVANJA: Prikazujemo vlastita isk ustva s laparoskopskom splenektomijom (LS) u liječenju imunosne trombocitopenije (ITP), uz osvrt na ulogu splenektomije u kontekstu primjene agonista trombopoetinskih receptora (TPO-RA). ----- ISPITANICI I METODE: U ovoj retrospektivnoj studiji prikazujemo rezultate liječenja 35 bolesnika operiranih tijekom razdoblja od 12 godina. Splenektomirano je 26 žena i 9 muškaraca s medijanom dobi od 50 godina (u rasponu između 19 i 85 godina). Svi su bolesnici prije splenektomije liječeni glukokortikoidima s dodatkom intravenskih imunoglobulina ili bez njih, a sedam bolesnika dobivalo je i rituksimab. Medijan vremena od postavljanja dijagnoze do LS-a jest sedam mjeseci (raspon od 1 do 103 mjeseca). ----- REZULTATI: U četiri (11%) bolesnika nije se povećao broj trombocita nakon LS-a, a šest ih je u kasnijem praćenju doživjelo recidiv bolesti. Tijekom praćenja (medijan 33 mjeseca) preostalih 25 bolesnika (71%) nije trebalo nikakvo daljnje liječenje. Procijenjena stopa petogodišnjeg odgovora iznosi 59%. Bolji dugotrajni odgovor imali su bolesnici splenektomirani do 12 mjeseci od postavljanja dijagnoze u odnosu prema onima kod kojih se sa splenektomijom čekalo dulje (P = 0,048). Nije bilo razlike u ishodu s obzirom na dob i spol. Četiri bolesnika imala su rane teške postoperativne komplikacije: trombozu portalne vene, duboku vensku trombozu, sepsu i krvarenje koje je nalagalo reviziju. Nije bilo letalnih ishoda ni kasnih teških infekcija. Na umor nakon operacije žalilo se deset (29%) bolesnika. ----- ZAKLJUČCI: Stopa izlječenja od oko 60% odgovara do sada objavljenim studijama, s time da je opažen bolji dugotrajni odgovor ako je splenektomija učinjena prije. Smatramo da je LS i dalje sigurna, uspješna i fi nancijski povoljna druga linija liječenja ITP-a, posebno za bolesnike koji žele brzo i u velikom postotku trajno izlječenje. Međutim, kao i u svijetu, primjena TPO-RA zasigurno će smanjiti broj splenektomija u Hrvatskoj.

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