Laparoscopic splenectomy for immune thrombocytopenia in patients with a very low platelet count

Successful kidney transplantation from a live donor with immune thrombocytopenia: a case report

Organ transplantation from donors with immune thrombocytopenia (ITP), a condition involving the autoantibody-mediated destruction of platelets, is a topic of debate due to the potential for transplantation-mediated autoimmune thrombocytopenia (TMAT), a rare but potentially fatal complication. Previous reports have described transplants from deceased liver donors with ITP who had very low platelet counts and disease largely refractory to treatment. Here, we present the first case of living kidney transplantation from a donor with ITP who underwent preoperative treatment, with concurrent splenectomy performed to reduce the long-term risk of spontaneous hemorrhage. To ensure the safety of the procedure, we monitored perioperative rotational thromboelastometry parameters and platelet counts, leading to the normalization of the donor's platelet levels. The recipient experienced an uneventful recovery of renal function without perioperative bleeding or the development of TMAT. Our report suggests that kidney transplantation from a donor with well-managed ITP is safe, and such a condition should not be considered a contraindication for donation.

Romiplostim use in immune thrombocytopenia: Experience in Cuenca, Ecuador

Introduction. The international consensus and the American Society of Hematology guidelines from 2019 established thrombopoietin analogues as the second-line therapy for primary immune thrombocytopenia cases. Objectives. To describe romiplostim usefulness in patients with immune thrombocytopenia in a third-level hospital in Cuenca, Ecuador. Materials and methods. We conducted a descriptive and retrospective study in patients with immune thrombocytopenia treated with romiplostim. We evaluated the following variables: age, gender, previous therapies to romiplostim, dose, frequency, complications, change of thrombopoietin analogue, and treatment discontinuation. Results. We included 21 patients with immune thrombocytopenia treated with romiplostim, with a median age of 49 years. All patients received corticosteroids as first-line treatment. Three patients required longer administration intervals (over a week), with weekly doses lower than those recommended (< 1 μg/kg). Due to lack of efficacy, six patients replaced elthrombopag with romiplostim. Of the total, three suffered thrombotic complications: two had portal venous thrombosis, and one had pulmonary thromboembolism; five of the patients discontinued romiplostim scheme without resuming it. Conclusions. Romiplostim constitutes a convenient second-line therapy in immune thrombocytopenia. Despite the small sample size, romiplostim early use can minimize toxicities and infectious risks.

Totally extraperitoneal inguinal hernia repair in patients with hemophilia and von Willebrand disease. Prospective controlled study

Introduction

Laparoscopic surgery is associated with several advantages. Surgical procedures in hemophilia or von Willebrand patients without replacement therapy (RT) to correct clotting factor deficiency may result in serious, life-threatening hemorrhagic episodes. Clotting factor concentrates improve hemostatic control but bleeding risk in major invasive procedures remains high.

Aim

Evaluation of totally extraperitoneal inguinal hernia repair (TEP-IHR) in patients with congenital hemorrhagic disorders (H) and comparison with results for non-hemophiliacs (NH) with regard to bleeding, postoperative pain, hernia recurrence, surgery time, demand for painkillers, hospital stay and recovery time.

Material and methods

The prospective controlled trial included 67 consecutive male patients scheduled for TEP-IHR between January 2010 and December 2018. Surgery was performed in groups H (n = 22) and NH (n = 45). Full study inclusion criteria were met by 65 patients (22 and 43 in H and NH groups respectively). Follow-up was carried out on the 1^st, 2^nd, and 7^th day and in the 1st and 3rd month postoperatively.

Results

TEP-IHR was successful for all patients. No life-threatening bleeding occurred and no patient required red blood cell transfusions or reoperation. No hernia recurrence was reported. No statistically significant differences were observed between the groups with regard to surgery duration, postoperative hematoma frequency and demand for painkillers. In the H group, pain intensity was significantly higher during the first postoperative month and hospitalization and recovery were significantly longer.

Conclusions

TEP-IHR in hemophiliacs with RT is feasible and as effective for preventing hernia recurrence as in NH-patients. In hemophiliacs risk of bleeding complications and demand for painkillers are comparable to non-hemophiliacs although pain is more intense.

Laparoscopic selective esophagogastric devascularization and splenectomy for patients with cirrhotic portal hypertension

Introduction

The role of laparoscopic selective esophagogastric devascularization and splenectomy (LSEGDS) in the treatment of esophagogastric variceal bleeding and hypersplenism in patients with cirrhotic portal hypertension has not been well studied.

Aim

To investigate the safety and efficacy of LSEGDS for esophagogastric variceal bleeding and hypersplenism in patients with cirrhotic portal hypertension.

Material and methods

From May 2011 to December 2014, 74 patients with portal hypertension resulting from liver cirrhosis underwent surgery for gastroesophageal variceal bleeding and hypersplenism. Forty-one of these patients underwent laparoscopic esophagogastric devascularization and splenectomy (LEGDS), and the others underwent LSEGDS. A retrospective comparative analysis of clinical data was conducted between the two groups, including clinical characteristics, laboratory data, operative morbidity and mortality, and outcomes of follow-up.

Results

The operation was completed successfully in all the patients, except that conversion was required in one patient in the LEGDS group. The operating time was similar in both groups (p = 0.579). The intraoperative blood loss was lower in the LSEGDS group (p = 0.011). Postoperative complications showed no significant difference between the two groups regarding mortality rate, pleural effusion, pancreatic injury, pulmonary infection, liver dysfunction, or postoperative abdominal bleeding. Postoperative platelet counts increased significantly more in the LEGDS group than in the LSEGDS group (p = 0.004). There were no significant differences in the long-term follow-up data, such as incidence of rebleeding, portal vein thrombosis, hepatic encephalopathy and survival (p > 0.05).

Conclusions

The LSEGDS is a safe and effective procedure for management of cirrhotic portal hypertension, especially in patients with visible paraesophageal veins.

Prognostic Factors for Immune Thrombocytopenic Purpura Remission after Laparoscopic Splenectomy: A Cohort Study

Background and Objectives: Laparoscopic splenectomy (LS) has become the gold standard for patients with immune thrombocytopenic purpura (ITP). The total remission rate after splenectomy is 70%–90%, of which 66% is long-term. Despite this high response rate, some patients do not benefit from surgery. It is therefore important to try to identify risk factors for an unsatisfactory clinical response. The aim of this study was to assess long-term outcomes of LS for ITP and identify factors associated with increased disease remission rates. Materials and Methods: We retrospectively studied consecutive patients with ITP undergoing LS in a tertiary referral surgical center prospectively recorded in a database. Inclusion criteria were: Elective, laparoscopic splenectomy for diagnosed ITP, and complete follow-up. The cohort was divided into two groups—Group 1 (G1) patients with ITP remission after splenectomy and Group 2 (G2) patients without remission. There were 113 G1 patients and 52 G2 patients. Median follow-up was 9.5 (IQR: 5–15) years. Results: In univariate analysis, patient’s age, body mass index (BMI), preoperative platelet count, the need for platelet transfusions, and presence of hemorrhagic diathesis were shown to be statistically significant factors. Next, we built a multivariate logistic regression model using factors significant in univariate analysis. Age <41 years (odds ratio (OR) 4.49; 95% CI: 1.66–12.09), BMI < 24.3 kg/m² (OR: 4.67; 95% CI: 1.44–15.16), and preoperative platelet count ≥97 × 10³/mm³ (OR: 3.50; 95% CI: 1.30–9.47) were shown to be independent prognostic factors for ITP remission after LS. Conclusions: The independent prognostic factors for ITP remission after LS revealed in our study are: age <41 years, BMI < 2 4.3 kg/m², and preoperative platelet count ≥97 × 10³/mm³. Duration of the ITP and the time of treatment are not related to remission after LS.

Platelet count on preoperative day 1 predicts the long-term responses to laparoscopic splenectomy for Chinese patients with medically refractory idiopathic thrombocytopenic purpura

Background

Laparoscopic splenectomy (LS) is regarded as a second-line treatment for medically refractory idiopathic thrombocytopenic purpura (ITP), but the predictive factors for the long-term postoperative responses to ITP are still a matter of debate. We aimed to investigate the factors that can predict the long-term response after LS for Chinese patients with medically refractory ITP.

Methods

From January 2011 to September 2016, 78 Chinese patients with ITP who underwent LS were retrospectively analyzed. Twelve parameters were analyzed by univariate and multivariate methods.

Results

Univariate analysis revealed that platelet count on preoperative day (PRD) 1 (P < 0.001) and operative time (P = 0.011) were significantly associated with long-term response of ITP after LS. Multivariate analysis revealed that platelet count on PRD 1 was a predictive factor of long-term response (P < 0.001). Furthermore, a long-term, stable response of platelet count on PRD 1 of > 30.0 × 10⁹/L was easier to achieve than a platelet count on PRD 1 ≤ 30.0 × 10⁹/L after LS for ITP.

Conclusions

LS is a valuable and effective option in the treatment of medically refractory ITP. Platelet count on PRD 1 is an independent predicting factor for long-term response after LS for Chinese patients with ITP.