title: Palliative goals, patient selection, and perioperative platelet management: outcomes and lessons from 3 decades of splenectomy for myelofibrosis with myeloid metaplasia at the Mayo Clinic.
abstract: BACKGROUND
  Although splenectomy may palliate massive splenomegaly in patients with myelofibrosis with myeloid metaplasia, this procedure carries significant risks. The authors retrospectively analyzed their experience with splenectomy over the course of 30 years to analyze the impact of improved techniques, antimicrobials, and aggressive postoperative control of platelet counts on outcome.
  
  
  METHODS
  A total of 314 patients underwent splenectomy between 1976 and 2004 for mechanical symptoms (= 156 patients [49%]), anemia (= 78 patients [25%]), portal hypertension (= 47 patients [15%]), or thrombocytopenia (= 33 patients [11%]). Of a total of 91 patients studied during the last decade, 69 patients (76%) experienced a palliative benefit for their primary surgical indication for a median of 12 months (range, 1-91 months).
  
  
  RESULTS
  Perioperative complications occurred in 87 patients (27.7%) including infection (= 31 patients [9.9%]), thrombosis (= 31 patients [9.9%]), or bleeding (= 44 patients [14%]), 21 of which (6.7% of all patients) were fatal. Perioperative thrombohemorrhagic complications decreased in the last decade through the use of platelet apheresis and the prompt use of cytoreductive agents to counteract postsplenectomy thrombocytosis. Survival after splenectomy was found to be decreased in patients with preoperative thrombocytopenia (<100 x 10(9)/L [P = 0.006]) but not by indication, myelofibrosis with myeloid metaplasia (MMM) prognostic score, or the decade in which splenectomy was performed.
  
  
  CONCLUSIONS
  The lack of improvement in overall postsplenectomy survival over time may be a reflection on the failure of medical therapy to improve survival in patients with MMM.
authors.affiliation: Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA. mesa.ruben@mayo.edu
authors.forename: Ruben A
authors.initials: RA
authors.lastname: Mesa
authors.forename: David S
authors.initials: DS
authors.lastname: Nagorney
authors.forename: Susan
authors.initials: S
authors.lastname: Schwager
authors.forename: Jacob
authors.initials: J
authors.lastname: Allred
authors.forename: Ayalew
authors.initials: A
authors.lastname: Tefferi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006040:Goals; D006801:Humans; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D018579:Patient Selection; D019990:Perioperative Care; D010976:Platelet Count; D011183:Postoperative Complications / Q000517:prevention & control* / Q000628:therapy; D055728:Primary Myelofibrosis / Q000401:mortality* / Q000601:surgery; D012189:Retrospective Studies; D013156:Splenectomy; D013922:Thrombocytosis / Q000517:prevention & control* / Q000628:therapy; D016896:Treatment Outcome