Re: JSLS. 2018;22(4):1-9. Prediction of Success Following Laparoscopic Splenectomy for Immune Thrombocytopenic Purpura Seems Still so far from to be Understood.

Dear Editor,

We read with great interest the paper entitled “Predictive factors for success of laparoscopic splenectomy for ITP” by Nyilas A et al. published in JSLS 2018;22(4):1–9.[1] We think that the article is of great interest but we would like to discuss some issues that need, in our opinion, to be pointed out.

The authors emphasize that younger age and response to preoperative steroids were predictive factors for the long-term success of splenectomy. Of course, predicting results after splenectomy is of great advantage to select patients with idiopathic thrombocytopenic purpura who might respond to surgery. However, this issue is still controversial in the literature. In our previous report,[2] we were able to demonstrate only that a higher increase of postoperative percent platelet count may be predicted in patients with a low preoperative platelet count. When we made a comparison between the laparoscopic and the open approach for removal of the spleen, laparoscopic splenectomy seemed to be superior to the open approach in patients with a longer diagnosis-to-splenectomy interval.[2] On the other hand, in our group of patients,[2] we failed to demonstrate that age, sex, and length of preoperative steroid therapy might predict postoperative positive results.

The authors did not mention the role that accessory spleens might have as factor for success after laparoscopic splenectomy performed for idiopathic thrombocytopenic purpura. Various articles have been published on accessory splenectomy for recurrence of immune thrombocytopenic purpura after spleen removal.

For most surgeons, a meticulous laparoscopic exploration remains the most accurate method to detect residual splenic tissue[3] and to achieve the best results after surgery. In our technique, we also pay attention not to injure the splenic capsule, avoiding accidental heterotopic autotransplantation with splenosis.

In our experience on 40 patients,[2] accessory spleens were found and removed in six patients (15%), and this probably might explain why in our study success rate after surgery was as high as 90,9% in the group of patients with less than 30.000 preoperative platelets/μL and 72,2% when preoperative platelet count was superior to 30.000/μL. In the report of Nyilas et al., there is no mention for preoperative or intraoperative detection of accessory spleen. Did they perform a diagnostic workup for this purpose? If so, did they find no accessory spleens or did they have cases with a potential splenosis? Finally, might not-detected accessory spleens influence their results?