Texas Children's Hospital and the Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
J Pediatr Surg. 2012 Aug;47(8):1537-41. doi: 10.1016/j.jpedsurg.2012.02.013.
Indications and timing for splenectomy in pediatric chronic immune thrombocytopenic purpura (cITP) are controversial because of high spontaneous remission rates and concern for overwhelming postsplenectomy infection. The objective of this study was to assess the risks, costs, and benefits of medical and surgical intervention for children with cITP.
After receiving institutional review board approval, medical records for all children with cITP who underwent splenectomy from 2002 through 2009 were retrospectively reviewed (n = 22). Preoperative and postoperative data were collected. Medical and surgical costs were calculated based on pharmacy charges per dose and hospital charges, respectively.
The median age at diagnosis was 11 years (range, 3-16 years). Medical management included steroids (n = 21), intravenous gamma globulin (n = 19), anti-D antibody (n = 19), or a combination of these therapies (n = 22). Nineteen patients (86%) reported side effects from medical therapy. Median age at splenectomy was 13 years (range, 6-18 years), and time to surgery was 23 months from diagnosis (range, 6-104 months). Splenectomy increased platelet counts in all children from a median of 25,500 to 380,000 postoperatively (P < .0001). One child experienced overwhelming postsplenectomy infection after a dog bite (n = 1). At the last follow-up (15 months; range, 1-79 months), 19 patients (86%) were asymptomatic with platelet counts greater than 50,000. Of the 3 children with persistent thrombocytopenia, 2 were diagnosed with secondary cITP. Median cost of splenectomy was significantly less than the cost of medical therapy ($20,803 vs $146,284; P < .0002).
Earlier surgical consultation for children with cITP may be justified given the high success rate and low morbidity, particularly given the significant complication rate and cost of continued medical treatment.
儿童慢性免疫性血小板减少性紫癜（cITP）行脾切除术的适应证和时机存在争议，这是因为其自发性缓解率高，且担心发生脾切除术后感染性并发症。本研究旨在评估儿童 cITP 行内科和外科治疗的风险、成本和获益。
在获得机构审查委员会批准后，回顾性分析了 2002 年至 2009 年间行脾切除术的所有 cITP 患儿（n=22）的病历资料。收集了术前和术后的数据。根据每剂量的药物费用和住院费用分别计算了医疗和手术成本。
中位诊断年龄为 11 岁（范围，3-16 岁）。内科治疗包括使用皮质激素（n=21）、静脉注射丙种球蛋白（n=19）、抗 D 抗体（n=19）或这些治疗的联合方案（n=22）。19 例（86%）患儿报告有药物治疗的副作用。脾切除术的中位年龄为 13 岁（范围，6-18 岁），从诊断到手术的时间为 23 个月（范围，6-104 个月）。脾切除术后所有患儿的血小板计数均从 25,500 增加到 380,000（P＜0.0001）。1 例患儿因被狗咬伤后发生脾切除术后感染性并发症（n=1）。末次随访时（15 个月；范围，1-79 个月），19 例（86%）患儿无症状且血小板计数＞50,000。3 例持续性血小板减少患儿中，2 例诊断为继发性 cITP。脾切除术的中位费用明显低于内科治疗的费用（$20,803 与 $146,284；P＜0.0002）。
鉴于高成功率和低发病率，儿童 cITP 行早期外科会诊可能是合理的，特别是考虑到持续内科治疗的显著并发症发生率和成本。
