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PubMed2000

The response to splenectomy in pediatric patients with idiopathic thrombocytopenic purpura who fail high-dose intravenous immune globulin.

BACKGROUND: A recent article by Law et al concluded that patients with idiopathic thrombocytopenic purpura (ITP) who have a poor response to intravenous immune globulin (IgG) are unlikely to have a good or excellent response to surgical splenectomy. METHODS: The authors studied retrospectively 23 pediatric patients age 11.7 +/- 1.0 years with ITP who had been treated with IgG before undergoing splenectomy. As in the aforementioned article, the responses to the 2 treatments were classified on the basis of the platelet count as poor (<50,000/mm3), good (50,000 to 150,000/mm3), or excellent (>150,000/mm3). For patients who received multiple IgG treatments, both initial and final treatment responses were analyzed. RESULTS: Sixteen patients had an excellent or good initial response to IgG. Of these 16 patients, 14 had an excellent or good response to splenectomy. Among the 7 patients who had a poor response to IgG there were 3 who had an excellent or good response to splenectomy (43%), and 4 patients who had a poor response to splenectomy. A good or excellent response to initial treatment with IgG was associated with a significant probability of a good or excellent response to splenectomy (P = .045). CONCLUSIONS: A good or excellent response to IgG may be predictive of a favorable response to splenectomy. However, a poor response to IgG does not preclude a satisfactory response to splenectomy in pediatric patients with ITP.

Adolescent↗

PubMed1997

Prevention of post splenectomy sepsis: a population based approach.

BACKGROUND: The aim of the study was to prevent the occurrence of serious, overwhelming infection following splenectomy, by a district based initiative. Subjects were residents of Plymouth and Torbay District Health Authority (DHA) who had undergone splenectomy in the past and general practitioners (GPs) within the District. METHODS: District guidelines on the prevention of post splenectomy sepsis were developed and disseminated among local GPs and hospital doctors. Patients who had undergone operative splenectomy were actively traced through GP and hospital information systems so that they could be offered sepsis preventive measures in accordance with the guidelines. Data capture-recapture was used as an ascertainment adjustment method to estimate the district prevalence of alive patients who have had an operative splenectomy. A postal questionnaire of district GPs was undertaken after one year to determine their awareness and use of the guidelines. RESULTS: Eight-eight alive patients who had undergone splenectomy were not previously identified be their GP as being asplenic. They were traced so that they could be offered sepsis preventive measures in line with the local guidelines. The estimated district prevalence of individuals who had had an operative splenectomy after ascertainment adjustment using data capture-recapture is p = 9.75 per 10,000 population [95 per cent confidence interval (CI) (7.87, 11.64) per 10,000]. Out of 367 district GPs, 201 used the local guidelines after one year. CONCLUSIONS: Effective prevention of overwhelming infection following splenectomy requires an active population based approach.

Community Health Planning↗

PubMed1987

Splenic enlargement and hyperfunction as indications for splenectomy in chronic leukemia.

The chronic leukemias are associated with significant morbidity from splenic enlargement and hyperfunction. Although some patients with chronic leukemia benefit from splenectomy, the indications for operation are unclear. To identify those patients who benefit most from splenectomy, nine patients with chronic lymphocytic leukemia (CLL) and eight patients with chronic granulocytic leukemia (CGL) who had splenectomy to palliate the symptoms of massive splenic bulk or to improve the hematologic sequelae of splenic hyperfunction were studied. Splenectomy for bulk symptoms provided good palliation of symptoms, but the duration of the benefit was limited by the stage of the disease. Five of eight patients with CGL with bulk symptoms died within 6 months of operation. Splenectomy for hyperfunction was limited to a short-term hematologic response. In three of four patients with CLL who were Coombs positive, the presence of autoantibodies correlated with a recurrent transfusion requirement within 3 months of splenectomy. Thus, the benefit of splenectomy for bulk symptoms must be weighed against the risk of surgery and the patient's limited life expectancy. The benefit of splenectomy for treatment of splenic hyperfunction depends on the stimulus to hyperfunction and may not be beneficial for patients with refractory autoimmune anemias.

Adult↗

PubMed1995

Laparoscopic splenectomy and lymph node biopsy for hematologic disorders.

OBJECTIVE: The authors audit the introduction of laparoscopic splenectomy and laparoscopic intra-abdominal lymph node biopsy and compare outcomes with a parallel cohort of patients undergoing open splenectomy. SUMMARY BACKGROUND DATA: Laparoscopic splenectomy was first reported in 1992. It was introduced into clinical practice at the Royal Brisbane Hospital in 1991. Between June 1991 and March 1994, 24 patients have undergone laparoscopic splenectomies and 23 patients have had laparoscopic intra-abdominal lymph node biopsies. METHODS: Laparoscopic splenectomy was performed using a four- or five-port technique. The splenic hilum was secured using a linear stapler cutter, and the spleen was removed after placing it in a laparoscopic bag. Lymph node biopsy was performed using a three- or four-port technique, depending on the site and size of the lymphadenopathy. RESULTS: Laparoscopic splenectomy was completed in 22 patients (92%). Median hospital stay was 3 days (range 2-7 days) and morbidity occurred in two patients (8%). Lymph node biopsy was completed laparoscopically in 21 of 23 patients (91%), with morbidity in two cases (9%). Median hospital stay was 2 days (range 1-6 days), with a diagnostic accuracy of 90%. Comparison with open splenectomy revealed that the laparoscopic approach took significantly longer to perform (p = 0.0002), but resulted in a significantly shorter hospital stay (p = 0.0005). CONCLUSIONS: Both laparoscopic splenectomy and laparoscopic lymph node biopsy currently are used as the treatments of choice for hematologic disease in our institution.

Adolescent↗

PubMedDate not supplied

Elective splenectomy in children with idiopathic thrombocytopenic purpura.

PURPOSE: The aim of this study was to review the safety and efficacy of elective splenectomy in children with idiopathic (immune) thrombocytopenic purpura (ITP). METHODS: The authors reviewed the medical records of children with ITP treated with elective splenectomy at Children's Medical Center of Dallas since 1961. Indication for splenectomy was symptomatic thrombocytopenia unresponsive to medical management. RESULTS: Thirty-eight evaluable patients who had elective splenectomy for ITP were identified. Twenty-one (55%) were girls and 17 (45%) were boys. Twenty-two had splenectomy since January 1990. Age at diagnosis ranged from 6 months to 15.9 years (median 9 years), and age at splenectomy ranged from 3.6 to 16.4 years (median 11.8). Laparoscopic splenectomy was performed in 11 patients. No patient died and only one (2.6%) had postoperative hemorrhage. There were no other complications related to surgery. No cases of postsplenectomy sepsis were observed. At follow-up ranging from 1 month to 19.9 years (median 2.1 years), 29 patients (76.3%) had a normal platelet count (>150 x 109/L) and 4 (10.5%) had a platelet count between 50 and 150 x 109/L. Only two of the five (13.2%) remaining patients who continued to have a platelet count less than 50 x 109/L had hemorrhagic manifestations necessitating intermittent therapy with corticosteroids. CONCLUSION: Laparoscopic or open splenectomy is a safe and effective procedure for children with chronic or refractory ITP and should be considered when medical management fails or causes excessive toxicity.

Adolescent↗

PubMed2004

Outcome of splenectomy for thrombocytopenia associated with systemic lupus erythematosus.

OBJECTIVE: To determine the efficacy of splenectomy for treating thrombocytopenia associated with systemic lupus erythematosus (SLE). SUMMARY BACKGROUND DATA: The role of splenectomy has been controversial in this patient population. METHODS: Between 1975 and 2001, 25 consecutive adults with SLE underwent splenectomy specifically for thrombocytopenia. Surgical indications, operative mortality and morbidity, and hematological outcomes were followed in both the short-term (first 30 days) and the long-term (last recorded platelet count, last contact, or death). Response to splenectomy was rated as: complete (CR: platelets >/=150 x 10/L for at least 4 weeks), partial (PR: platelets 50-149 x 10/L for at least 4 weeks), or none (NR: platelets < 50 x 10/L at all times). Relapse occurred if platelets fell below 50 x 10/L after CR or PR. RESULTS: Indications for splenectomy included: thrombocytopenia refractory to (64%), dependent on (20%), or patient intolerance of (16%) medical treatments. Perioperative mortality was 0% and morbidity was 24%. After a median of 9.5 years, 9 patients (36%) had died, with only 1 death being secondary to bleeding. Early partial or complete response rate to splenectomy was 88%. After a median follow-up of 6.6 years, 16 (64%) patients had sustained complete or partial response without relapse. Eight (32%) of these patients required adjunctive medical therapy, whereas the other 8 (32%) did not. The remaining 9 (36%) patients relapsed, but 5 (20%) of the 9 patients were subsequently salvaged to at least partial response with further treatments. The overall PR or CR to splenectomy combined with medical therapy was 84%. CONCLUSION: Splenectomy should be considered safe and efficacious for thrombocytopenia associated with SLE.

Adolescent↗

PubMed1987

Evaluation of splenectomy in large granular lymphocyte leukaemia.

We performed splenectomy in four patients with severe neutropenia (less than 0.5 X 10(9)/l), recurrent infections, and splenomegaly associated with large granular lymphocyte leukaemia. Prior to splenectomy, elevated levels of neutrophil-reactive IgG were detected in sera of all three patients tested. In all patients, enlargement of the spleen was due to a characteristic lymphoid infiltration of red pulp cords. Splenectomy resulted in an increased neutrophil count greater than 0.5 X 10(9)/l in all patients; this response was sustained in two patients who benefited clinically by a dramatic reduction in frequency of infections. Poor clinical response was associated with elevated levels of antineutrophil antibody post-splenectomy. All four patients had an increase in number of circulating large granular lymphocytes post-splenectomy; one patient who had attained a sustained neutrophil response died of an accelerated lymphoproliferative disorder 19 months post-splenectomy. We conclude that splenectomy may be of value in correcting severe neutropenia and reducing infections in some patients with large granular lymphocyte leukaemia. However, splenectomy appeared to be of no value in treatment of the underlying lymphoproliferative disorder.

Evaluation Studies as Topic↗

PubMed2006

Redefining the role of splenectomy in patients with idiopathic splenomegaly.

BACKGROUND: Despite extensive work-up to establish the cause of splenomegaly, splenectomy may be required for diagnosis in certain situations. The aim of this study was to find out the role of diagnostic splenectomy in the current era. METHODS: Between January 1989 and June 2004, 211 patients underwent splenectomy for indications other than trauma. In 41 (19%) patients, splenectomy was carried out for diagnostic purposes. Retrospective analysis of these patients was done for the purpose of the study. RESULTS: All patients who underwent diagnostic splenectomy had a complete haemogram, biochemical tests for liver and renal function, bone marrow biopsy and abdominal ultrasonography before splenectomy. There were 28 (68%) men and 13 (32%) women with median age of 37 years (range, 6-62 years). The median duration of symptoms was 12 months (range, 1-180 months). Common presentations were fever (n = 27; 66%), malaise (n = 26; 63%), pallor (n = 33; 80%) and gross splenomegaly (n = 27; 66%). Thirty-two (78%) patients had hypersplenism. Splenic lesions were shown in 14 (34%) patients on ultrasonogram and in 16 (39%) patients on contrast-enhanced computed tomography scan of the abdomen. Open splenectomy was carried out in all patients. Seventeen (41%) patients had postoperative complications. Among these, three (7%) patients had postoperative bleeding. One patient died because of acute respiratory distress syndrome. Final histopathology of the spleen showed lymphoma in 15 (37%), tuberculosis in five (12%) and other lesions in five (12%) patients. Sixteen (39%) patients had only congestive splenomegaly. CONCLUSION: A high proportion of patients presenting with idiopathic splenomegaly will have underlying haematological malignancies even in tropical countries. The clinical presentation, laboratory profile and imaging findings were not helpful in differentiating between patients with haematological malignancies and non-malignant conditions. Splenectomy still has an important role in establishing the pathology in patients presenting with idiopathic splenomegaly.

Adolescent↗

PubMed1977

Decreased tuftsin concentrations in patients who have undergone splenectomy.

Serum tuftsin concentrations were measured, using a radioimmunoassay developed in Israel, in normal subjects and in patients who had undergone splenectomy. Concentrations in those who had undergone traumatic and elective splenectomy were much lower. The tuftsin concentration in 38 patients with Hodgkin's disease who had undergone splenectomy during staging laparotomy was not significantly different from the mean concentration in other patients who had had elective splenectomy. In four patients who underwent splenectomy for non-malignant haematological disorders measurements made before and after operation showed that tuftsin concentrations fell significantly in the days after operation. The increased susceptibility to overwhelming infections of patients with Hodgkin's disease and others who have undergone splenectomy may be related to the low tuftsin concentrations. As pre-splenectomy tuftsin concentrations in patients with Hodgkin's disease were normal, the practice of performing staging laparotomy and splenectomy in patients with Hodgkin's disease should perhaps be reconsidered.

Adult↗

PubMed2006

Decreased growth rate of lung metastatic lesions after splenectomy in mice.

BACKGROUND: The effect of splenectomy on hematogenous metastases of malignant tumors remains controversial. The aim of this study was to clarify the effect of splenectomy on hematogenous metastases in an animal model. METHODS: Colon 26 cancer cells were inoculated into the lateral tail vein of 90 mice. The mice were then assigned to a splenectomy group or a control group. Lung weight, number of lung metastases, size of metastatic nodules, and serum vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) levels after the surgical procedure were measured and compared between the two groups. RESULTS: The lung nodules were significantly smaller in the splenectomy group than in the control group. In both groups, the serum VEGF levels increased on day 1 and then decreased. The serum VEGF levels on day 5 were significantly lower in the splenectomy group than in the control group. The serum bFGF levels were significantly lower in the splenectomy group than in the control group on days 1 and 5. Immunohistochemical study showed that bFGF was produced by reticuloendothelial cells of the spleen. CONCLUSION: The growth rate of hematogenous metastatic lesions appears to decrease after splenectomy and may be associated with decreases in serum levels of VEGF and bFGF induced by splenectomy.

Adenocarcinoma↗

PubMed2003

Laparoscopic splenectomy: size matters.

BACKGROUND: Laparoscopic surgery is arguably the treatment of choice for patients undergoing elective splenectomy; however, for those patients with massive splenomegaly, laparoscopic surgery may prove difficult. PATIENTS AND METHODS: 6 years' experience of elective splenectomy was reviewed, in particular looking at the outcome of laparoscopic splenectomy in relation to the degree of splenomegaly. RESULTS: The conversion rate for laparoscopic splenectomy on patients with spleens weighing less than 1 kg was 0% whereas the conversion rate for those with spleens weighing more than 1 kg was 60%. In addition, a good correlation between both operative time and intra-operative blood loss in relation to splenic weight was observed. Open splenectomy on patients with spleens weighing more than 1 kg reduced the operative time and intra-operative blood loss without affecting hospital stay. CONCLUSIONS: Laparoscopic splenectomy is the method of choice for elective splenectomy in patients with splenic weight estimated to be < 1 kg; however, the operation takes longer, there is a high risk of conversion and there is an increase in blood loss/morbidity associated with massive splenomegaly (spleen > 1 kg) if splenectomy is attempted laparoscopically.

Blood Loss, Surgical↗

PubMed1999

Long-term results of laparoscopic splenectomy for immune thrombocytopenic purpura.

OBJECTIVE: To assess the results of laparoscopic splenectomy as a treatment for immune thrombocytopenic purpura (ITP). MATERIAL AND METHODS: We conducted a retrospective study of all patients who underwent laparoscopic splenectomy for ITP at our institution between August 1992 and May 1997. RESULTS: Of 27 patients who underwent attempted laparoscopic splenectomy for ITP at our institution during the study period, 26 had completion of the procedure without conversion to an open splenectomy. The median postoperative hospital stay was 1.5 days, and no postoperative deaths occurred. In one patient, pancreatitis developed postoperatively. In four patients, splenectomy failed--two initially and two subsequently--and reinstitution of medical therapy was necessary. The other patients have remained free of medication, and 19 patients have platelet counts greater than 100 x 10(9)/L. The 3-year actuarial success rate was 81.5%. Response to corticosteroid therapy preoperatively may be an indicator of success of splenectomy. CONCLUSION: Laparoscopic splenectomy is safe and allows prompt recovery. Long-term response rates are similar to those achieved with open splenectomy.

Actuarial Analysis↗

PubMedDate not supplied

Effect of splenectomy on T-cell subsets and plasma HIV viral titers in HIV-infected patients.

OBJECTIVE: In previous studies we have shown that removal of the spleen in HIV-infected people during the asymptomatic phase of disease results in slower time to AIDS and may also result in improved survival. In this paper, we examine whether splenectomy affects lymphocyte counts, T-cell subsets, and HIV plasma viremia in a manner that could explain the clinical benefits associated with this intervention. METHODS: 10 HIV-infected patients who underwent splenectomy and 23 HIV-infected controls with idiopathic thrombocytopenia purpura who did not undergo splenectomy were studied. These groups were compared for changes in cell subpopulations and HIV plasma viremia. RESULTS: Splenectomy resulted in increases in absolute lymphocyte numbers with rises in both CD4 and CD8 counts, whereas CD4 and CD8 percentage levels remained unchanged. In controls, absolute and percentage CD4+ T-cell counts declined with time from date of HIV infection. Plasma viremia decreased more than threefold, the limit of biologic variation, after splenectomy in 4 of 9 subjects and in only 1 of 18 controls. The proportion of subjects exhibiting reduced viremia following splenectomy was greater than that in HIV-infected patients that did not undergo splenectomy (chi 2 test, P = .015). CONCLUSIONS: Improved survival and time to AIDS in splenectomized HIV-infected patients is associated with temporary reduction of plasma viremia and increase in absolute CD4 and CD8 counts. These effects could not be attributed to antiretroviral therapy because subjects were either untreated or treated with antiretroviral monotherapy during the observation period. These observations may have importance in the understanding of T-cell dynamics and the potential for splenectomy as an HIV reservoir-debulking procedure.

Adult↗

PubMed1999

[Splenectomy indications at a general hospital].

BACKGROUND: To analyse the evolution of indications for splenectomy for a 11-year period. METHODS: A review was made of cases of splenectomy from clinical records and the records of the Pathology Service at Hospital General Universitario Gregorio Marañón from 1986 to 1996. Both adult and pediatric cases were included. RESULTS: From 1986 to 1996 there was a total of 354 patients (273 males and 162 females) who underwent splenectomy. Mean age of patients was 44.6 years (SD +/- 20.5 years) and there was an average of 39.5 cases per year. The most common causes were trauma (32%), "incidental" splenectomy (14%), thrombopenia (12%) and non Hodgkin lymphoma (11%). Compared with the other causes, the mean age of patients with trauma was lower than that of the other groups (p < 0.0001), in contrast with patients with non Hodgkin lymphoma or extra-splenic tumors, where it was higher (p < 0.0001 for both groups). A decline was observed of cases due to trauma from the first to the last year of the study (p = 0.0009), as well as an increase in the group of splenectomy related to extrasplenic tumors (p = 0.01). In the group of the HIV infected patients (n = 30), thrombopenia was the most common indication for splenectomy (11 cases). CONCLUSIONS: Although the average of splenectomy cases remains relatively constant, a decrease in cases due to trauma was observed and an increase of splenectomies on account of abdominal oncologic resections.

Adolescent↗

PubMed1976

Evaluation of splenectomy in chronic myelogenous leukemia.

Splenectomy was performed in 45 patients with chronic myelogenous leukemia; 23 were in the chronic phase and 22 in the acute phase. Indications for operation included inability to control the disease by chemotherapy or radiation therapy, severe thrombocytopenia, frequent need for blood transfusion and extensive splenomegaly causing discomfort. Median survival time for these patients was better than survival time of other reported groups of patients who did not have a splenectomy. According to our criteria, splenectomy was beneficial to 15 patients in the chronic phase as well as to eight in the acute phase of chronic myelogenous leukemia. Median survival time after splenectomy was higher in patients who had splenectomy within two years of the diagnosis as compared with those who had the operation after two years. Splenectomy did not prevent the future onset of fatal blastic crisis. Although significant abnormalities in coagulation studies were seen in 37 of the patients, intraoperative hemorrhage was not a major problem. Considering the poor general condition, inadequate healing and susceptibility to infection, the postoperative mortality and complication rates were comparable with those reported in series in which splenectomy was performed for other diseases. It seems that splenectomy benefits a selected group of patients with chronic myelogenous leukemia; however, a randomized series would furnish better data upon which to make decisions.

Adult↗

PubMed1975

[Segmental pancreatic lesions after partial or total splenectomy in rabbits].

Previous experiments on compensatory hypertrophy of the splenic parenchyma after partial splenectomy, permitted us to observe lesions of the part of the pancreas in contact with the spleen. This part of the gland is supplied only by the splenic artery and suffers from some degree of ischemia during splenectomy. The object of this research was to seek, as a routine, pancreatic disease after splenectomy. 32 adult rabbits were used. Partial splenectomy carried out in 15 cases, removed about 2/3rds of the spleen and involved ligature of 4 or 5 splenic and mesenteric arterio-venous pedicles. Total splenectomy, carried out in 17 cases, included ligature of the splenic arteriovenous trunk and 3 or 4 spleno-gastric and spleno-mesenteric arterio-venous pedicles. These operations were followed by more or less intense stasis extending to the splenic part of the pancreas. The animals were examined one week and 8 months afterwards. All the rabbits, except one, had pancreatic lesions. The most severe and extensive lesions, including large areas of cytosteato-necrosis with, in 11 cases, pseudo-cysts, with caseation, followed total splenectomy. Partial splenectomy gave rise to 6 pseudocysts including 2 containing blood and 9 cases with milder lesions including involution, rarefaction and sometimes disappearance of the gland which had suffered from ischemia. In these splenectomies, ligature of the splenic arterio-venous pedicles supplying the pancreas were responsible for pancreatic disease.

Animals↗

PubMedDate not supplied

The impact of splenectomy or splenic artery ligation on the outcome of a living donor adult liver transplantation using a left lobe graft.

BACKGROUND/AIMS: The aim of this study was to clarify the impact of splenectomy or splenic artery ligation on the outcome in living donor adult liver transplantation (LDALT) using a left lobe graft. METHODOLOGY: Forty-eight LDALT cases using a left lobe graft were enrolled in this study. The patients were classified into two groups: Group A (n=40), in which neither a splenectomy nor a splenic artery ligation was performed, and Group B (n=8), in which a splenectomy (n=6) or a splenic artery ligation (n=2) was performed. Indications for splenectomy were as follows: 1) demonstrating a hypersplenism and/or 2) having splenic aneurysms. RESULTS: None of the patients receiving a splenectomy or a splenic artery ligation experienced any septic complication in this series. The graft-recipient weight ratio in group B tended to be smaller than in group A. In group B, all patients were classified into Child's class C or B. The incidence of esophageal varices in group B was significantly higher than in group A. Moreover, the platelet count and the white blood cell count in group B were significantly lower than in group A. No statistical difference was found in postoperative functional cholestasis and intractable ascites. None of the participants in group B experienced both postoperative hyperbilirubinemia and intractable ascites, which were characterized as a small-for-size graft after LDALT. The patient survival rate in group B seems to be better than in group A. In a majority of the cases the portal pressure as well as the portal vein flow after a splenectomy decreased in comparison to that before the splenectomy. CONCLUSIONS: Splenectomy or splenic artery ligation is considered to be beneficial for improving the outcome in LDALT using a left lobe graft.

Adult↗

PubMed2004

Retrospective evaluation of long-term efficacy and safety of splenectomy in chronic idiopathic thrombocytopenic purpura in children.

AIM: To review the long-term efficacy and safety of splenectomy in children with chronic idiopathic thrombocytopenic purpura (cITP). PATIENTS AND METHODS: Data from 33 splenectomized children were retrospectively analysed (median follow up period: 18.8 y from the removal of the spleen). The median age of children at splenectomy was 12 y and the median ITP duration 3.3 y. Indications for splenectomy were: persistent severe thrombocytopenia with extensive purpura, epistaxis and/or gum bleeds, menorrhagia (n = 5) and severe or recurrent haemorrhage from various sites (n = 11). RESULTS: Eighty-five per cent of the patients showed an excellent (n = 26) or partial response to splenectomy. Five children (15%), all females, failed to respond. Of the responders, 25% experienced a transient recurrence of thrombocytopenia within 6 mo to 4 y from splenectomy. The mortality rate due to severe sepsis was 3%. However, the majority of the splenectomized patients have not so far suffered any severe or mild bacterial infection, despite incomplete vaccination and/or antibiotic prophylaxis. CONCLUSION: Splenectomy remains the only effective therapeutic modality for children with cITP, although it is associated with transient recurrence and rarely with post-splenectomy sepsis, which could be fatal. Nonetheless, splenectomy should be the last treatment option for the cITP patient, after all available therapeutic modalities have been exhausted and the child still remains profoundly thrombocytopenic and symptomatic.

Adolescent↗