Gibson M, Sehon J K, White S, Zibari G B, Johnson L W
Department of Surgery, Louisiana State University Health Science Center-Shreveport, USA.
Am Surg. 2000 Oct;66(10):952-4; discussion 955.
Idiopathic thrombocytopenic purpura is a condition that is characterized by persistently low platelet counts. Idiopathic thrombocytopenic purpura results from splenic sequestration and accelerated platelet destruction mediated by antiplatelet antibody. Most cases arise in previously healthy patients, mostly women ages 20 to 40. Clinical symptoms consist of bruising, petechiae, mucosal bleeding, menorrhagia, and intracranial bleeding. Platelet-associated immunoglobulin G can be detected in 90 per cent of patients. Therapy for adults and children is somewhat different. Splenectomy in adults should be considered in patients who fail to respond to steroids, develop thrombocytopenia after taper, or develop steroid toxicity. Ninety per cent of children will maintain normal platelet counts in 9 to 12 months. Some will recover spontaneously without medical therapy. Splenectomy in children is recommended if idiopathic thrombocytopenic purpura persists for more than one year or fails to respond to steroids. Our purpose was to determine whether management of idiopathic thrombocytopenic purpura in patients who undergo splenectomy at our institutions is appropriate and effective. We undertook a 5-year retrospective review of 27 patients with idiopathic thrombocytopenic purpura which have undergone splenectomy. All of the 27 patients were referred to surgeons after initial medical management. The patients were divided into two groups on the basis of length of therapy: longer than 6 months and less than 6 months. The longer than 6 months group contained 15 patients. This group had a postoperative complication rate of 40 per cent. Those in the group with <6 months therapy had a complication rate of 7 per cent. Average follow-up for all patients was 20 months. Eighty-eight per cent of the patients had complete response. Three per cent had a partial response with platelet counts >50,000. The partial response group did not respond well to preoperative steroid boluses with a great rise in platelet counts. Eighteen per cent of patients received platelet transfusions. Sixty per cent of the transfusions were given for inappropriate reasons. A large percentage of our patients had prolonged medical therapy before splenectomy. The inappropriate use of platelets was a common error in management. Patients treated for more than 6 months had more postoperative complications. An initial increase in platelets after steroid bolus is a good indicator for favorable response to splenectomy. We conclude that splenectomy is a safe and effective method of treatment for idiopathic thrombocytopenic purpura with no deaths or postsplenectomy sepsis to date.
特发性血小板减少性紫癜是一种以血小板计数持续降低为特征的疾病。特发性血小板减少性紫癜是由脾扣押以及抗血小板抗体介导的血小板加速破坏所致。大多数病例发生在既往健康的患者中，主要是20至40岁的女性。临床症状包括瘀斑、瘀点、黏膜出血、月经过多和颅内出血。90%的患者可检测到血小板相关免疫球蛋白G。成人和儿童的治疗方法有所不同。对于对类固醇无反应、减量后出现血小板减少或出现类固醇毒性的成人患者，应考虑行脾切除术。90%的儿童在9至12个月内血小板计数将维持正常。一些患者无需药物治疗即可自发恢复。如果特发性血小板减少性紫癜持续超过一年或对类固醇无反应，建议对儿童行脾切除术。我们的目的是确定在我们机构接受脾切除术的特发性血小板减少性紫癜患者的治疗是否恰当且有效。我们对27例行脾切除术的特发性血小板减少性紫癜患者进行了为期5年的回顾性研究。这27例患者在初始药物治疗后被转诊至外科医生处。根据治疗时间长短将患者分为两组：治疗时间超过6个月和治疗时间少于6个月。治疗时间超过6个月的组有15例患者。该组术后并发症发生率为40%。治疗时间<6个月组的并发症发生率为7%。所有患者的平均随访时间为20个月。88%的患者获得完全缓解。3%的患者部分缓解，血小板计数>50,000。部分缓解组对术前类固醇冲击治疗反应不佳，血小板计数无明显升高。18%的患者接受了血小板输注。60%的输注是出于不恰当的原因。我们的大多数患者在脾切除术前接受了长时间的药物治疗。血小板的不恰当使用是治疗中的常见错误。治疗超过6个月的患者术后并发症更多。类固醇冲击治疗后血小板最初升高是对脾切除术反应良好的一个良好指标。我们得出结论，脾切除术是治疗特发性血小板减少性紫癜的一种安全有效的方法，迄今为止无死亡病例或脾切除术后败血症发生。
