Long-term outcome of splenectomy for idiopathic thrombocytopenic purpura.

Idiopathic thrombocytopenic purpura (ITP) is an illness of primary acquired thrombocytopenia occurring in the absence of marrow failure. Splenectomy was first used as a treatment for ITP in 1913. However, with the realization that opsonin (critical for the optimal killing of invasive micro-organisms by white blood cells) is manufactured only in the spleen, spontaneous splenic removal was reevaluated and questioned. Splenectomy has a success rate that remains nearly identical (about 50% to 60%) whether it is performed soon after diagnosis or several months or years later. As yet, there is no consistently effective method to predict an individual ITP patient's response to splenectomy. As the time since splenectomy increases, however, the rate of excellent response decreases. Despite pneumococcal vaccination prior to splenectomy, fatal fulminant sepsis is an omnipresent possibility. Because a number of published studies, including the Johns Hopkins experience, have questioned the long-term outcome of splenectomy, splenectomy should not be the first treatment option for ITP patients. It should be performed only after all other therapeutic modalities have been exhausted, and the patient has a platelet count less than 25,000/microL and is hemorrhaging. Once patients have undergone splenectomy, they are Ineligible for potentially excellent treatment such as anti-D globulin or oral tolerance therapy.