Laparoscopic splenectomy reverses thrombocytopenia in patients with hepatitis C cirrhosis and portal hypertension.

Abstract

Pegylated-interferon (IFN) plus ribavirin remains the most effective therapeutic regimen for patients with chronic hepatitis C infection. Thrombocytopenia is a common side effect of this treatment, often leading to discontinuation of a potentially curative therapy. We sought to determine the safety and efficacy of laparoscopic splenectomy in correcting thrombocytopenia, thus allowing completion of IFN therapy. Data were collected prospectively from September 2000 to May 2003 on all patients undergoing laparoscopic splenectomy for thrombocytopenia associated with IFN therapy and/or hepatitis C cirrhosis with portal hypertension. Demographic data, model of end-stage liver disease (MELD) score, platelet count, operative time, blood loss, spleen weight, complications, length of stay, and follow-up time were calculated. Eleven patients (7 men, 4 women) underwent laparoscopic splenectomy; their mean age was 45.4 years (range 27 to 55 years) and mean body mass index was 27 kg/m(2) (range 21 to 44 kg/m(2)). All patients were Child's class A, with a mean preoperative MELD score of 9.1 (range 6 to 11). Mean operative time was 189 minutes (range 70 to 245 minutes), and blood loss averaged 141 ml (range 10 to 600 ml). A hand-assisted laparoscopic technique was used in four cases. Six patients received empiric intraoperative platelet administration. None required transfusion with packed red cells. Splenic weight averaged 1043 g (range 245 to 1650 g). Average length of stay was 2.6 days (range 1 to 6 days). Four patients had the following minor postoperative complications: self-limited atrial fibrillation (n=1), trocar site cellulitis (n=1), and atelectasis (n=2). There have been no major complications over an average follow-up of 11 months (range 1 to 18 months). Mean postoperative MELD score was 8.3 (range 6 to 10). Platelet counts improved from a preoperative mean of 55000/ul (16000 to 88000/microl) to 439000/microl (200000 to 710000/microl) postoperatively and have remained above 100000/microl (104000 to 397000/microl) during subsequent pegylated-IFN therapy. Three patients have completed a full course of IFN therapy and have obtained a sustained virologic response. Treatment is ongoing in the remaining patients. Laparoscopic splenectomy is safe in the setting of portal hypertension and thrombocytopenia associated with chronic hepatitis C infection. It can be performed with little blood loss, no need for red cell transfusion, and minimal perioperative morbidity. Laparoscopic splenectomy appears to effectively reverse thrombocytopenia and may allow these patients to safely complete IFN therapy.