HEMONC: Systemic thromboembolic complications after laparoscopic splenectomy for idiopathic thrombocytopenic purpura in comparison to open surgery in the absence of anticoagulant prophylaxis Systemic thromboembolic complications after laparoscopic splenectomy for idiopathic thrombocytopenic purpura in comparison to open surgery in the absence of anticoagulant prophylaxis ================================================================================

Said Yousuf Mohamed, Ibrahim Abdel-Nabi, Ahmed Inam, Mohammad Bakr, Khaled El Tayeb, Abu Jafar M. Saleh, Hazaa Alzahrani, Said H. Abdu

on 14/06/2010 08:08:00 Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease characterized by development of autoantibodies that bind platelet membrane glycolproteins and active complement activation, leading to rapid clearance of the platelet-antibody complex via the hemophagocytic system mainly in the spleen. In adults, initial treatment with steroids and/or intravenous immunoglobulins can induce a response. However, upon withdrawal or tapering of steroids the majority relapse.1 Splenectomy represents a strategic curative procedure for the majority of patients with chronic ITP who fail to respond or relapse after primary medical treatment.2 Although laparoscopic splenectomy (LS) has been introduced relatively recently (in 1990s), its application has witnessed a larger scale use at many centers due to its advantage of being “endoscopic’, less traumatic, and less disfiguring with a relatively short stay; it is also supposed to be associated with fewer complications,3-5 including life threatening events and peri-operative mortality.6 Its application is ideal when the splenic size is small or nonpathologic as in cases of ITP. When splenectomy is done via an open approach and in clonal disorders, precautions for deep vein thrombosis (DVT) prophylaxis are usually applied due to the heightened risk of venous thromboembolism (VTE) that is associated with the underlying disease. However, due to the bleeding tendency with ITP and the relatively short duration of the procedure when the laparoscopic approach is taken, no prophylactic anticoagulants are usually administered.7,8 Due to an absence of prospective studies discussing the need for thromboprophylaxis in such a situation in this target population of patients, universal guidelines for VTE prophylaxis in ITP are lacking although they are sorely needed.9 Thromboembolic complications, including DVT, pulmonary embolism, portal vein thrombosis, inferior vena caval thrombosis and mesenteric vein thrombosis may occur in an average of 10% of patients with hematological diseases undergoing splenectomy. However, the incidence may range between 1% to 75%, depending on the underlying hematological disease and the clinical situation as well as the occurrence of postoperative complications like infections and prolonged recumbency.8,10 The advantages of the laparoscopic approach in ITP patients that have been reported are shorter operation time, decreased estimated blood loss, decreased length of hospital stay and less chance of conversion to open splenectomy (OS) than in any patients with any other diagnosis.11 Therefore, LS has become the procedure of choice for patients with medically refractory ITP requiring removal of the spleen. Surgeons who are seeking to undertake, or who currently are practicing this procedure, should be aware that it is considered an advanced laparoscopic procedure and is associated with a significant learning curve that has yet to be defined.12 Much of the pertinent data published in the surgical journals are focused mainly on the effectiveness in curing ITP, hospital stay, cost effectiveness or postoperative infectious complications or bleeding and/or thrombosis.13-15 Few studies have comprehensively reported systemic thromboembolic complications, like DVT and or pulmonary embolism without detailed mention of factors contributing to such events or suggestions for preventive measures.13 However, most of the available studies suffer from a small sample size (less than 20 patients), lack long-term follow up and sometimes include other hematological disorders with unclear thromboprophylaxis strategy.5 The current study was undertaken to study the systemic thromboembolic complications of LS in comparison to OS done for patients with ITP who did not received anticoagulant thromboprophylaxis at Ain Shams University Hospitals, Cairo, Egypt and North West Armed Forces Hospitals, Saudi Arabia with a minimum follow up of 2 years (range 2-4 years).