Predictive Factors for Successful Laparoscopic Spl

jamanetwork.com/journals/jamasurgery/fullarticle/396191

Just a study doing a multivariate analysis.

Splenectomy prediction score = 0.039 + {[Age (Years) × 0.047] – [Preoperative Platelet Count × 0.018]}.

All patients receive a score between –4 and +4. A negative score predicts a successful outcome after splenectomy, and a positive score indicates an increased risk of a failed response. Patients are subsequently classified into 3 categories. Patients with a negative score (<0) (n = 10) had a 100% success rate following LS. Patients with a moderate score (0-2) (n = 26) had a 65% rate of success, and patients with a high score (2-4) (n = 31) achieved a successful outcome in only 40% of cases. For example, a 50-year-old patient with a preoperative platelet count of 15 × 103/µL would have a score of 2.11, correlating to a 40% success rate.

Preoperative Platelet Count is the tricky part here-

One way is to just add all (weekly cbc counts)/n

Mine = (15+45+70+45+31+3+6+40+113+15+260+140+41)/13 =63

Plugging into the formula-

= 0.039 + {[42 × 0.047] – [63 × 0.018]}

= 0.039+(1.97-1.13)
= 0.879

So I have a 65% of success rate.

I'm calling BS on this one:

" In our study, multivariate analysis revealed that higher preoperative platelet levels were predictive of a successful response to LS regardless of how this level was achieved (ie, patients still receiving steroids or intravenous IgG)."

What they are saying is that if you use IVIG to increase preoperative platelet counts, then you can increase the likelihood of a successful splenectomy. This is irrational.

In jayinchicago's case, any platelet count between 1 and 111 yields a score between 0 and 2, for the same success probability of 65%, which tells us this test is not very sensitive!

One interesting implication of this formula is that splenectomy works best if you don't need one.

It seems that they only followed the patients for 22 months, that's less than 2 years. Response rates can fall as time goes on. The liver can take over destruction. They also said that patients with counts above 70k had better results....is that after treatment or with no treatment? That can make a difference.

They also include 'response to IVIG" as a good predictor of success. What defines a response?

There are also articles that state that splenectomy success cannot be determined. You probably came across those too.

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.

www.ncbi.nlm.nih.gov/pubmed/10676920



Unpredictability of response.

The response to splenectomy cannot be predicted using readily available clinical criteria (eg, previous response to steroids or intravenous immunoglobulin), other than “older” age, which is ill-defined. In a retrospective review of 111In-labeled autologous platelet sequestration studies, the complete response rate after splenectomy was 87% (median, 3.8 years follow-up) in patients having predominantly splenic sequestration as opposed to 35% in those with “mixed” or hepatic sequestration (odds ratio = 5.39; 95% confidence interval [CI], 1.3-21.6). Confirmatory studies are needed. Major limitations include restricted availability and technical difficulty.

www.bloodjournal.org/content/120/5/960?sso-checked=true

Rob16 wrote: I'm calling BS on this one:

" In our study, multivariate analysis revealed that higher preoperative platelet levels were predictive of a successful response to LS regardless of how this level was achieved (ie, patients still receiving steroids or intravenous IgG)."

What they are saying is that if you use IVIG to increase preoperative platelet counts, then you can increase the likelihood of a successful splenectomy. This is irrational.

Agree, Rob. No logic. I just skimmed the article. Didn't catch that one. I was looking for long-term follow-up.

The only true consistent predictive factor that I've seen over the years is age. Over 40 and chances of success go down. I have seen young people have failed surgeries and older people have seemingly successful ones though, so you never know.

There is also the Indium. However, that does not predict success; it can predict failure. I really don't like to see the word 'cure' used in conjunction with splenectomy. There is no cure, only remissions which may or may not last.

Jay, about Preoperative Platelet Count. That would be your count without any drugs. Aka, your 'base count'.

In my research of IVIG I've seen (old) articles claiming a link between IVIG response and splenectomy success - like this one. At one time, apparently this was the theory.

If you do some more research you should find later studies that debunk this theory/claim. That is, further investigative studies show there is no link between IVIG response and splenectomy.

Hello Hal,

They have defined preoperative platelet count as follows-

"In our study, multivariate analysis revealed that higher preoperative platelet levels were predictive of a successful response to LS regardless of how this level was achieved (ie, patients still receiving steroids or intravenous IgG)."



Why I like this study is that they have done univariate analysis and a multivariate analysis.
Then combined two variables which were more predictive value and then came up with a elegant mathematical model.

They also said that patients with counts above 70k had better results....is that after treatment or with no treatment? That can make a difference.


Hello Sandy,

Here is the answer-

"In our study, multivariate analysis revealed that higher preoperative platelet levels were predictive of a successful response to LS regardless of how this level was achieved (ie, patients still receiving steroids or intravenous IgG)."

Hello Rob,

As we say in statistics "CORRELATION DOES NOT CAUSATION"

Here they are reporting variables that form a correlation between variables.

But still I like this study because what they are saying is that-


If you are young (under 50) and respond to any medication then you have a high chance of splenectomy success.

If a person responds to medication, why would they need a splenectomy then?

Completely agree Sandi

Why because I cannot be taking 80mg of predisone all my life ?

Or Nplate all my life.


Imagine me atleast in the USA having to spend 50k in costs year after year.

It is a scary thought to be without insurance.


Or Going to Doctor weekly.

I want remission if the medicine cannot do it then Splenctomy is a decent option to try.

I realize that I am new to the ITP game but I do have an opinion on this issue.
1. Medications have side effects, some manageable some not.
2. No med works for everyone. Even dosage varies person to person.
3. There are a lot of meds available to try and find the golden one.
4. Medical side effects are most always reversible.
5. Removing the spleen is not reversible and carries its own list of side effects.
6. Spleen removal side effects require there own list of meds with there own side effects.

Seems like the spleen can cause a new journey in finding the right med.

Jay:

We have all been where you are right now, including me. ITP is not always forever. Many people attain remission. I did, and I never expected that. I battled up and down counts for 8 years before it happened though. I know, you're thinking, "But I don't want to do this for 8 years". You might not have to. ITP is frustrating as hell and it invades your life. I sure didn't like it either, but have since found that there are worse things to deal with. My Hemo brought up splenectomy several times and I considered it, but something bothered me about it. I just had a feeling that I was going to need that spleen one day and turns out, I did.

Here is something to seriously consider:

If it doesn't work and you still need treatment, you basically have two options. Immunosuppressants or TPO's. Without a spleen, immunosuppressants raise the risk of infection/sepsis. Some of us have gone on to develop other autoimmune disorders and need immunosuppressants to treat that. The statistics show that more people die from infection than bleeding.

There has recently been research that shows that ITP can also be a clotting disorder as well as a bleeding disorder. There are several reasons for that. Research has also shown that having a splenectomy raises the risk for blood clots. If you'd need to treat with TPO's after a failed splenectomy, the risk goes up even higher.

I know you want to get rid of this problem, but you could be trading it for another problem. There are people with ITP who need to be on blood thinners with low counts and if you think this is difficult to handle, try that. I've seen people go through it and that was always my worst fear. I recently had an e-mail from a man whose teenage daughter had recently had a failed splenectomy. She was experiencing blood clots and they were having a hard time balancing her out. It can occur at any age.

I am not here to talk you out of it, but I do want to be sure that you understand the risks. I can't tell you how many times I've heard from people who were not aware of risks and were very upset by outcomes. The top ITP Specialists are not recommending it any more due to the problems that can arise. Older articles do not reference any of it; this has just been the past 5 years or so. I can provide you with references. Most of the people here who have chosen not to have the surgery have done a lot of research before coming to that conclusion. We've also seen many poor outcomes and post surgery problems.

My sister also had ITP years before I did. She did not have a splenectomy and went into remission after a year. She's been in remission since....34 years now.

Ok Jay, you got me with the 'Preoperative Platelet Count' definition. I admit to not reading the article. So, now I have read it. Yes, from the tables in article you do seem to be rather well suited for LS.

For steroids you relapsed with taper, yes? Your age is good. Not sure about IVIG as I don't see the definition of 'successful response' for IVIG.

A couple of things bother me about the article.
- has there been additional reports by others to refine or justify the conclusions presented. If the author's peers find the data and conclusions accurate, others should pile on.

- The study limits itself to 22 months post LS. Specifically, this sentence bothers me 'However, long-term follow-up is required to document the efficacy of LS for ITP.'

If I were to 'hang my hat' on this study, I would investigate these matters. Also, the study mentions Danazol. How do evaluate the risks of Danazol treatment trial with the risks of LS? Better, worse?

I've been thinking about your blood/platelet donation count level pre ITP. Combined with the lack of a (normal) complete response to either steroids or IVIG makes the possibility of low platelet production more reasonable as to cause, or partial cause.

An LS success is quite rewarding and thus tempting. But D.Mann makes a strong point. The failure scenario is poor. Seems like you'd be better off taking NPlate until you are either in remission or it fails to help you. If it fails, then get a LS.

Jay have you seen this? www.haematologica.org/content/99/2/392

"Seems like you'd be better off taking NPlate until you are either in remission or it fails to help you"

Hello Hal,

Your thoughts and my Hema thoughts are one and the same.

I point blank told my Hema no matter what my count is Iam not going and getting an IVIG again in the hospital. I have 20% coinsurance which makes me pay $4000 everytime I get admitted, I have 3 young kids and a wife who does not work so this medication business will not work for me long term.

So nplate has been a god send and initial response has been promising. There are studies which show 30% of nplate users can go into long term remission.


My plan is get out of predisone very fast, already on 20mg, tinker with nplate to get the right dosage. Hope for a remission, if not go for splenectomy.

Jay I find this an appalling situation that you are in by having to choose treatments in relation to cost.

Hypothetically what happens if you have an splenectomy which fails?

Who pays for lifelong future treatment costs in that case?

Mrs. B - I did the same thing. I kept choosing Prednisone because it was cheap. I had two girls in college and a wedding on the way. I chose to put the money into my kids. I did end up having Rituxan nearly fully covered though, so eventually went with that years later.

Jay,
Please think long and hard about this. Take a look at my posts detailing my Daughter's Splenctomy and the train wreck that followed. Kimberly is an extreme story, but a real one that everyone considering surgery should read and then make their own decision.
Had we know the possibilities of severe clotting we never would have gone the Splenctomy route. Eight month ago Kimberly had a major brain hemorrhage. We almost lost her. This was the latest of no less than ten events all caused by the development of a clotting issue post splenctomy.
On a positive note she recently completed chemo, three months now and has not had a count below 200K. She still has the clotting problem requiring nightly injections and countless other supporting med's, but her ITP seems to be in remission.
So don't get frustrated, get educated and after all is said and done make an educated decision.

pdsa.org/forum-sp-534/6-general-itp-discussion/15206-post-splenectomy-portal-vien-thrombosis.html#15217

pdsa.org/forum-sp-534/6-general-itp-discussion/27278-article-re-splenectomy-and-treatments.html#32022

Nothing like a good plan Jay

With the Promacta versus LS analysis finalized, I think if you widen your research net a little you may well find that there is a whole set of drugs that are worth trying before having LS. Have you evaluated Rituxan or Danazol?

About the IVIG cost at hospital. Don't you have an (individual) out of pocket maximum ($6k maybe)? Wouldn't that kick in and limit the cost - no matter what the coinsurance?

Yes, Rituxan is next.

I told my hema to get approval for rituxan.

Iam going to try it out then possibly six months after that splenectomy if I dont get into remission.