Accessory Splenectomy Research Articles

Refractory immune thrombocytopenic purpura (ITP) after accessory splenectomy: A case report and literature review.

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by a platelet count of less than 100 x 109 /L, resulting from antibody-mediated platelet destruction. Treatment for ITP typically involves steroids, and intravenous immunoglobulins (IVIG) can be added. Splenectomy is performed in cases with refractory ITP. Rituximab can suppress immunity but has limited efficacy in ITP cases. Herein, we present a rare case of a 30-year-old female who was first diagnosed with ITP and underwent a splenectomy two years later. However, seven years after surgery, she was presented with symptoms of ITP. A splenic scan showed an accessory spleen in the spleen bed, for which she underwent accessory spleen removal surgery. Her laboratory tests three days post-operation showed a rise in platelet count and hence was discharged a few days later. The patient had recurrent attacks of ITP even after the removal of the normal and accessory spleen, suggesting that accessory spleen removal may not always be an effective treatment for ITP. The patient eventually died. While splenectomy is a common treatment for ITP, it may not always be effective in all cases, and other treatments such as bone marrow transplantation may be necessary.

Are accessory spleen screening and resection in refractory immune cytopenia an effective strategy or a waste of resources?

Splenectomy remains an effective treatment for refractory immune cytopenia (RIC), which encompasses immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA). Accessory spleens (AS) have been described without identifying specific risk factors. We retrospectively analyzed patients with RIC after splenectomy who underwent splenic scintigraphy (SS) at our institution. Seventy-one patients were included. Sixty-two patients had ITP, five had AIHA, and four had Evans syndrome. Seventy-five percent (n = 53) were women. Eleven patients (15.5%) had an AS detected by SS. A complete response (CR) to first-line steroids (odds ratio (OR) 5.75, 95% confidence interval (CI) 1.37-24.14, p = 0.017) and the absence of Howell-Jolly bodies (HJB) in peripheral blood smear (PBS) (OR 11.37, 95% CI 2.70-47.85, p = 0.001) were found to be risk factors. Patients with both elements had a higher rate of AS (83.3%) when compared to those with one or no factors (p < 0.001). Eight patients (73%) underwent an accessory splenectomy: seven (87.5%) achieved a CR, and none had perioperative complications. The presence of HJB in PBS changed from 25 to 87.5% after accessory splenectomy. We recommend the search for an AS via SS in patients with RIC due to ITP, who had a CR to corticosteroids and the absence of HJB in PBS. Accessory splenectomy is a safe and effective procedure.

Minimally invasive accessory splenectomy for recurrent gastric variceal bleeding due to left-sided portal hypertension: report of the first case

Upper gastrointestinal bleeding from esophagogastric varices is a common scenario, especially in patients with portal hypertension induced by liver cirrhosis or other diseases with thrombosis of the splenic vein. However, accessory spleen as pathophysiological cause of a regional, left-sided portal hypertension and consecutive development of isolated gastric varices is rare. We report a case of recurrent gastric variceal bleeding resulting from sinistral portal hypertension associated with an accessory spleen in a patient who had traumatic splenectomy many decades before. The accessory spleen is an extremely rare cause for the development of regional, left-sided portal hypertension leading to isolated gastric varices. Minimally invasive splenectomy is a safe and efficient treatment option.

Search for and Extraction of Accessory Spleen in Refractory Immune Cytopenias. Effective or a Waste in Resources?

Background: Splenectomy is an effective second line therapy for patients with immune cytopenias. Fifteen percent of patients are going to relapse after splenectomy. These patients are categorized as refractory and their treatment is challenging. The incidence of an accessory spleen diagnosed by gammagraphy is estimated to be 8-20% in this scenario. Current treatment guidelines do not address the issue of searching for an accessory spleen or performing accessory splenectomy as a treatment strategy for these patients. The aim of this study was to identify risk factors for the presence of accessory spleen diagnosed by gammagraphy in patients with refractory immune cytopenias and analyze the response rate of its removal. Methods: It is a case control, single center, retrospective study. We included adult patients with refractory immune cytopenias who underwent gammagraphy to search for an accessory spleen, from 1996 to 2016. Cases were patients with a positive gammagraphy, controls were those with a negative gammagraphy. Patients who failed to have at least one year of follow-up after splenectomy or accessory splenectomy, were excluded. A logistic regression was performed to determine factors associated with the presence of an accessory spleen. Results: We analyzed 71 refractory patients with a gammagraphy performed searching for an accessory spleen, 87.3% with a diagnosis of immune thrombocytopenia (IT), 7% autoimmune hemolytic anemia (AHA) and 5.6% Evans Syndrome. Fourteen percent of the patients had secondary immune cytopenias all of them due to autoimmune diseases. There was a predominance of women with 74.6% of the subjects studied. Patients received a median of 2 (0-4) lines of treatment before the splenectomy. The majority of patients (98.6%) had received, as first line of treatment corticosteroids, with an overall response rate (ORR) of 84% and a complete response (CR) rate of 38.6%. Of the 71 patients, splenectomy achieved an ORR of 83.1% with CR in 80.3%. The incidence of accessory spleen diagnosed by gammagraphy at their relapse was 15.5% (11 patients). In the multivariate analysis, we found two factors associated with positivity of the gammagraphy: CR to corticosteroids pre-splenectomy with an OR of 5.2 (CI 95% 1.24-21.78; p=0.021) and the presence of Howell Jolly bodies (HJb) with an OR of 0.088 (CI95% 0.02-0.37; p=0.001) as a protective factor. We developed a risk score consisting of: 0 risk factors, 1 risk factor (CR to corticosterois pre-splenectomy or abscense of HJb) and 2 risk factors. The percentage of patients who were positive by gammagraphy using this score was 83.3%, 25.6% and 3% for 2, 1 and no risk factors respectively (p&amp;lt;0.001) (Figure1). Eight patients underwent accesory splenectomy, all of them achieved responses with CR of 87.5%, and none experienced complications associated with the procedure. Seven patients acquired the presence of HJb after accesory splenectomy (Table 1). With a median follow-up of 60.2 months (1.54-194.56), 62.5% mantained the response obtained with the accesory splenectomy. One patient didn´t acquire HJb post accesory splenectomy, he relapsed and was diagnosed with a new accesory spleen. He underwent a second accesory splenectomy and is now in CR with the presence of HJb in the blood smear. Conclusions: The search for an accesory spleen in patients with refractory immune cytopenias with risk factors (absence of Howell Jolly bodies and or complete response to steroids as first line therapy) is usefull. Accesory splenectomy is a safe and effective therapeutic strategy in the treatment of these patients. Disclosures No relevant conflicts of interest to declare.

Accessory Splenectomy: the Keystone of Success in the Treatment for Refractory Immune Thrombocytopenia

Splenectomy is officially recognized as second-line treatment for immune thrombocytopenia. Accessory spleens are known to have a role in recurrence and laparoscopic exploration for detection is recommended by many. The aim of the study was to investigate on accessory splenectomy as resolutive treatment for refractory thrombocytopenia. A review of the literature was completed on PubMed looking for articles where at least one accessory splenectomy had been performed for refractory thrombocytopenia. Measures used for the statistical analysis were as follows: sex; age; surgical approach; latency to recurrence; radiological tests; identified, retrieved, and missed accessory spleens; location and size of accessory spleens; and follow-up. Outcome was evaluated in terms of platelet count, need for medical treatment, and response. Thirty-three articles from 1976 (95 patients) satisfied criteria for the analysis. In the young, accessory spleens were more frequently missed at imaging. Number and size of accessory spleens resulted to be inversely correlated. Smaller accessory spleens carried increased likelihood to be missed. Number of radiological tests used to detect accessory spleens yielded better outcomes, in particular, when ultrasonography, computed tomography and scintigraphy were used in combination. In the case of refractory immune thrombocytopenia, the presence of accessory spleens needs to be investigated. A special focus is required to young patients or those with multiple accessory spleens, where imaging fails to detect them more frequently. The use of combined radiological techniques has shown improved outcome and should be preferred. A meticulous laparoscopic exploration follows next and becomes crucial to achieve long-term response.

Management of Idiopathic Thrombocytopenic Purpura in Adult: A Review Article

Idiopathic thrombocytopenic purpiira (ITP), also known as primary immune or autoimmune thmmbocytopenic purpura, is a common cause of thrombocytopenia and bleeding complications in children and adults. It mav be confused with other causes of thrombocvtopenia and is treated with agents that varv in efjicacv, toxicity, and cost. Clinical presentation very in children and adult. In children, ITP is usually an acute, self-limited disorder that resolves spontaneously: in adults, it is typically a chronic disorder with a more insidious onset. In about one third of adults with ITP, the condition is persistent and relatively resistant to most treatments .Available evidence suggests that only about 5% of adults with chronic ITP have spontaneous remission. The principal therapeutic options for ITP include glucocorticoids, intravenous immunoglobulin and splenectomy. Other treatments have been used for refractory cases; these include intravenous anti-Rh (D), azathioprine, cyclophosphamide, danazol, vinca alkaloids, ascorbic acid, colchicine, interferon-alpha, combination chemotherapy, protein A, immunoadsorption, cyclosporine, epsilon-aminocaproic acid, plasma exchange, and accessory splenectomy. Journal of Shaheed Suhrawardy Medical College Vol 2No.1 June 2010 page 24-28 DOI: http://dx.doi.org/10.3329/jssmc.v2i1.12348

Accessory splenectomy for refractory immune thrombocytopenic purpura

Patients with immune thrombocytopenic purpura (ITP) will frequently relapse following splenectomy. The removal of residual spleens remains a therapeutic option in these patients though the effectiveness of this procedure remains unclear. We present a single institution study of outcomes in patients who underwent an accessory splenectomy (AS) for refractory ITP. The study cohort represents a consecutive group of splenectomized patients with ITP who underwent AS for refractory disease. Fourteen patients were identified: 10 adult and 4 pediatric patients. Response was assessed at 4 weeks using standard criteria for complete response (CR), partial response (PR), or no response (NR). Eight adult patients underwent open AS, and two underwent uneventful laparoscopic AS. Overall, 50% (5/10) of adult patients responded (CR or PR) to AS at 1 month. Fifty percent (2/4) of pediatric patients achieved response. Clinical determinants suggestive of a response to AS in adults were female gender, favorable response to prednisone at first exposure and absence of Howell-Jolly Bodies prior to AS. These data suggest that laparoscopic AS remains a viable treatment option for patients with refractory ITP following splenectomy. However, given the role for novel medical therapies for refractory ITP, the potential morbidity of this surgical procedure must be weighed against its effectiveness.

Laparoscopic accessory splenectomy: the value of perioperative localization studies

Laparoscopic splenectomy is an effective treatment for many patients with immune thrombocytopenic purpura (ITP) who fail or relapse after treatment with steroids. Patients with an incomplete response to splenectomy and those who experience recurrence of symptoms should be evaluated for the presence of an accessory spleen. The clinical effectiveness of laparoscopic excision of an accessory spleen after a previous splenectomy for ITP has varied in different studies. Laparoscopic intraoperative identification of an accessory spleen can be difficult. The authors report their experience with laparoscopic accessory splenectomy (LAS) and the use of perioperative localization methods for this procedure. This study reviewed seven consecutive patients who underwent LAS, after initial splenectomy failed to cure ITP, at a tertiary care center between April 9, 2003 and March 31, 2008. Demographics, diagnostic and localization studies, technical success, and the effect on thrombocytopenia were examined. The location of the accessory spleen also was recorded. A novel method for localizing accessory spleen was used. It consisted of preoperative computed tomography (CT)-guided injection of methylene blue at the accessory spleen's site, preoperative intravenous injection of 99m-technetium-labeled, heat-damaged red blood cells, or both. Intraoperatively, the dye was used for visual identification, and the gamma probe was used to aid in locating and confirming the presence of the accessory spleen in the excised specimen. Seven patients with recurrent ITP after initial failed splenectomy underwent LAS during the study period. Five of these patients had the initial splenectomy performed laparoscopically. All seven patients had successful laparoscopic removal of the accessory spleen based on a final pathologic examination. One patient required the second laparoscopic exploration with perioperative localization after a failed attempt without it. These perioperative localization methods were used in subsequent operations on other patients. These methods were found to be helpful in the intraoperative identification of the accessory spleens. The accessory spleens missed at initial splenectomy were found in unusual locations. Five of the seven patients had sustained improvement in platelet counts after LAS. One patient had a postoperative ileus that resolved with nonoperative management. No other complications or mortality was observed. The LAS procedure after previous splenectomy is feasible and safe. Perioperative localization methods aid in the intraoperative identification of an accessory spleen. Accessory spleens missed at initial splenectomy are generally found in unusual locations. Treatment of recurrent or unresolved ITP with LAS can be effective for some patients.

Spontaneous Rupture of Accessory Spleen Detected during Laparoscopic Cholecystectomy

Splenic rupture during laparoscopic cholecystectomy is a rare and unusual complication. We report a case of accessory splenic rupture that occurred during laparoscopic cholecystectomy. A 63-year-old male patient underwent laparoscopic cholecystectomy due to acute cholecystitis. After pneumoperitoneum was established, hemoperitoneum was detected. However, a bleeding focus was not found by laparoscopic whole abdominal exploration after laparoscopic cholecystectomy. Twenty-four hours later the patient became hypotensive and laparoscopic reexploration was performed. Hematoma and omental adhesion was detected around accessory spleen. Laparoscopic accessory splenectomy was performed. Distortion or stretching of perisplenic adhesion due to the induction of pneumoperitoneum possibly resulted in sudden splenic rupture and hemoperitoneum.

Accessory Splenectomy for Relapsed Idiopathic Thrombocytopenic Purpura.

Background: Patients with ITP will frequently relapse following splenectomy. The search for and subsequent removal of accessory spleens remains a common therapeutic option in these patients. Conflicting data limit the interpretation of the current literature regarding the effectiveness of this treatment. We present a single institution study of the outcomes and clinical correlates of response in patients with ITP who underwent an accessory splenectomy (AS)Patients & Methods: The study cohort consisted of a consecutive group of splenectomized patients (pts) with ITP evaluated at the Mayo Clinic between 1960 and 2006 who underwent AS for relapsed disease. Only those patients who met ASH guidelines for diagnosis of ITP were included. Criteria for response after AS at 1 month and at last follow-up were defined as a Complete Response (CR, platelets ≥ 150 x 109/L), a Partial Response (PR, platelets ≥ 30 but < than 150 x 109/L) and No Response (NR, platelets < 30 x 109/L).Results:i.Baseline Patient Characteristics: A total of 14 pts were identified that underwent AS for relapsed ITP -- 4 pediatric pts with a median age at diagnosis of 10 years (range 7–14) and 10 adult pts with a median age at diagnosis of ITP of 41 years (range 20–63). In all cases the accessory spleen was detected by radionuclide imaging. Among pediatric and adults pts, the mean number of therapies attempted prior to AS other than splenectomy was 2.3 (1–5) and 2.4 (1–7); platelet count at AS was 17 x 109/L (11–88), and 16 x 109/L (6–112), and median time from diagnosis to AS was 99.5 mos. (48–288) and 139 mos. (1–269) and respectivelyii.Response to AS in Pediatric pts: All 4 pts had open laparotomy with 1 post-operative complication. Among these pediatric patients 50% (2/4) pts achieved a CR, one a PR and 1 did not respond at 1 month follow up. With a median follow up of 63.5 mos. (16–137), two responders subsequently relapsed (one PR and one CR) at 14 and 6 mos. respectively.iii.Response to AS in Adults: Eight of 10 patients underwent open laparotomy, 3 of whom experienced significant post-operative complications, one resulting in death. The other 2 had laparoscopic AS. A median number of 1 (1–4) splenules was removed. Evidence of a splenectomized state (defined as the presence of Howell-Jolly bodies (HJB) on blood smear) was present in 66% (6/10) of pts pre-operatively and 100% (10/10) post operatively. Overall, 50% (5/10) of pts responded to AS: Two pts achieved a CR, 3 pts had a PR and 5 pts had NR at the initial evaluation period of 1 month. With a median follow-up period of 11 mos. (range 1–265), 3 pts remain in continued remission and two pts have relapsed at 1.6 and 45 mos., respectively and required additional therapy.iv.Clinical Determinants of Response in Adults: Clinical factors suggestive of correlation with response to AS included: female gender (4/5 vs 1/5 in males), favorable response to prednisone at first exposure (5/7 vs 0/3) and absence of HJB prior to AS (3/3 vs 2/6).There was no evidence of correlation between age at diagnosis of ITP or AS, prior response to splenectomy, number of prior therapies, nor volume of splenules.Conclusions : Laparoscopic accessory splenectomy remains a viable treatment option for pts with relapsed ITP following splenectomy, especially in those without HJB on the peripheral smear. However, given the evolving role for novel therapeutic agents, the potential morbidity of this invasive surgical procedure must be weighed against its effectiveness.

Laparoscopic Accessory Splenectomy Using Intraoperative Gamma Probe Guidance

In cases of accessory splenic tissue in postsplenectomy patients, it is of utmost importance to localize the accessory spleen prior to surgery. Several studies have shown the feasibility of laparoscopic resection of accessory splenic tissue using preoperative scintigraphy. We present the cases of three postsplenectomy patients with accessory splenic tissue causing relapsing hematologic disease. Accessory spleens were diagnosed and localized preoperatively by positive uptake of heat-damaged Tc99m-labeled red blood cells using scintigraphy. Two patients with relapse of immune thrombocytopenic purpura and one with hemolytic anemia underwent handheld gamma probe-assisted laparoscopic accessory splenectomy. One patient with immune thrombocytopenic purpura recovered his platelet count at 3-year follow-up. The other patient had a relapse of disease within 3 months despite successful removal of the accessory spleen. The patient with hemolytic anemia had postoperative relapse; two accessory spleens were identified on radionuclide investigation. The use of intraoperative nuclear imaging can greatly aid in localization and provide confirmation of complete laparoscopic excision of the nuclear focus. The technique is especially useful in cases of a small accessory spleen, by avoiding a major open procedure and contributing to good postoperative results.

Accessory Splenectomy with Gastroesophageal Devascularization for Recurrent Hypersplenism and Refractory Bleeding Varices in a Patient with Liver Cirrhosis: Report of a Case

We report a case of recurrent thrombocytopenia associated with symptomatic enlargement of an accessory spleen, 2 years after splenectomy, in a 36-year-old man with posthepatitic liver cirrhosis. The patient suffered three episodes of variceal bleeding, but the esophageal varices were not eradicated by two sessions of endoscopic injection sclerotherapy and endoscopic band ligation. Abdominal ultrasonography and computed tomography showed a giant accessory spleen (6 x 6 x 5 cm), gallbladder stones, and complete postsplenectomy splenomesoportal thrombosis. Subsequent 99mTc scintigraphy confirmed the presence of a functioning residual splenic nodule. Thus, we performed gastroesophageal devascularization (Hassab-Paquet procedure) with accessory splenectomy and cholecystectomy, after which the platelet count normalized and no further variceal bleeding occurred during 17 months of follow-up. To our knowledge, this is the first report in the English medical literature of accessory splenectomy for recurrent thrombocytopenia in a patient with liver cirrhosis.

Laparoscopic accessory splenectomy for recurrent idiopathic thrombocytopenic purpura and hemolytic anemia.

Laparoscopic splenectomy is an effective treatment for idiopathic thrombocytopenic purpura (ITP) and hemolytic anemia that has a remission rate of 80-90%. In some patients in whom the disease persists or recurs, a diagnosis of accessory spleen is made. The long-term efficacy of laparoscopic accessory splenectomy is unknown. Patients who underwent laparoscopic accessory splenectomy were followed in the outpatient clinic. The perioperative course, blood counts, and need for medical therapy to maintain a normal count were recorded. Eight patients underwent laparoscopic accessory splenectomy. All procedures were completed laparoscopically, and all patients were discharged on the 1st postoperative day. Patients were available for a follow-up period of 15 months range, (3-27). None of the ITP patients achieved a complete remission. Two of them had a partial remission, and five ITP patients are now being treated with chronic corticosteroids to maintain a platelet count of >100,000/ml. Laparoscopic accessory splenectomy is associated with a low rate of morbidity and a short hospital stay. Despite its success in removing all residual splenic tissue, most patients will probably not enjoy a complete remission.

Laparoscopic management of accessory spleens in immune thrombocytopenic purpura.

A disparity exists between the incidence of accessory spleens reported in the open (15-30%) versus the laparoscopic (0-12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP). Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications. Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective.

Accessory spleen in recurrent chronic immune thrombocytopenic purpura.

From 1969 to 1985 we discovered accessory spleens in 8 patients with chronic immune thrombocytopenic purpura (ITP) who relapsed or failed after splenectomy. Imaging of accessory spleen used a liver spleen scintigraphy with heat-treated RBC labeled with Tc-99m. Platelet kinetic studies with 51Cr or 111In, including sequestration index, were performed. Five patients had accessory splenectomy. Disappearance of bleeding symptoms was achieved in the 5 splenectomized patients but with only partial response of platelet counts. These results are discussed in the context of diagnosis and therapeutic management of accessory spleens in patients with chronic immune thrombocytopenic purpura who relapsed or failed after splenectomy.

Surgical treatment of immune thrombocytopenic purpura

The role of surgery in the treatment of immune thrombocytopenic purpura (ITP) is still discussed. The aim of this study was to verify our criteria of patient selection for splenectomy, to analyze the results of a protocol for the evaluation of the hemorrhagic risk, and to discuss long-term results of 70 patients with ITP who underwent surgical treatment from 1984 to 1990. All patients received steroid therapy. Sixty-two patients were given high doses of IgG (600 mg/kg/iv bolus) pre-operatively in order to obviate the need for intra-operative platelet transfusions. Forty-three patients showed a significant increase in the platelet count, 8 a moderate increase, while 11 patients did not respond. No operative mortality was observed, however postoperative minor complications occurred in 14 (20%) patients. Accessory spleens were found in 11 (15.7%) patients. Mean follow-up was 21 months. Response to splenectomy was considered as complete (platelets greater than 150,000 mm3 with no need for medical treatment) in 63 (90%) patients. No response was observed in 7 patients. In 2 of the non-responders postoperative indium-111 scan revealed accessory spleens and ITP remitted after accessory splenectomy. All non-responders were in the group of patients who did not respond to the pre-operative infusion of high dose IgG. It can be concluded that splenectomy is a safe and effective treatment for ITP and that response to pre-operative infusion of IgG may be considered as predictive for the outcome after splenectomy.

Splenectomy for primary and recurrent immune thrombocytopenic purpura (ITP). Current criteria for patient selection and results.

Of 565 patients with thrombocytopenia admitted to Duke University Hospital between 1975 and 1985, 100 had splenectomy. Ninety-eight patients had failed chronic immunosuppressive therapy and three patients had acute intracranial bleeding or total absence of platelets in the peripheral blood smear, and had urgent splenectomy. At primary splenectomy, accessory spleens were identified and resected in 18% of patients. There was no operative mortality. Fifty-eight patients had an excellent response to splenectomy and their steroids were tapered off within 3 weeks. Thirteen patients had a poor response to primary splenectomy of whom eight remitted spontaneously and five required accessory splenectomy resulting in complete remission in three patients. Twenty-nine patients were considered nonresponders, 25 of whom had radionuclide scanning for accessory spleens. Seven of these patients had accessory spleens identified but only four consented to accessory splenectomy. In three of the four patients, a complete remission was achieved. Neither platelet antibody titers nor measurements of platelet survival or turnover predicted platelet response to splenectomy. However, immune thrombocytopenic purpura (ITP) in older patients was significantly less likely to respond to splenectomy. These data support continuing use of splenectomy in selected patients with ITP and an aggressive search for accessory spleens in patients who relapse since they are easily localized at operation by hand-held isotope detector probe.

Management of splenectomy failures in chronic immune thrombocytopenic purpura: role of accessory splenectomy.

Accessory splenic tissue was demonstrated in four of eight patients with chronic immune thrombocytopenic purpura investigated following post-splenectomy relapses. Time from initial splenectomy to relapse of thrombocytopenia ranged from immediately to eight years and post-splenectomy changes were present on the peripheral blood films of all patients at time of relapse. Three scanning techniques were employed to demonstrate and localise residual splenic tissue. Conventional 99mTc scans were positive in three of the four patients whilst 99mTc-heat damaged red cell scans and computerised tomographic scans were each positive in three out of three patients including the one patient in whom a conventional 99mTc scan was negative. Histological confirmation of splenic tissue was obtained in all cases with the weights of the accessory spleens ranging from 0.6 g to 2 g. Two patients responded to accessory splenectomy and, without immunosuppressive therapy, have remained well with normal platelet counts for over four years. There was no correlation between length of initial remission and the response to removal of the accessory spleen. The presence of a functioning accessory spleen should be considered in all patients with chronic ITP who fail to respond to, or relapse following, initial splenectomy.

Accessory splenectomy for idiopathic thrombocytopenicpurpura: D. Wallace, D. Fromm, and D. Thomas. Surgery:91:134–136, (February), 1982

Accessory splenectomy for idiopathic thrombocytopenicpurpura: D. Wallace, D. Fromm, and D. Thomas. Surgery:91:134–136, (February), 1982