An analysis of outcomes and treatment costs for children undergoing splenectomy for chronic immune thrombocytopenia purpura.
OBJECTIVE
Indications and timing for splenectomy in pediatric chronic immune thrombocytopenic purpura (cITP) are controversial because of high spontaneous remission rates and concern for overwhelming postsplenectomy infection. The objective of this study was to assess the risks, costs, and benefits of medical and surgical intervention for children with cITP.


METHODS
After receiving institutional review board approval, medical records for all children with cITP who underwent splenectomy from 2002 through 2009 were retrospectively reviewed (n = 22). Preoperative and postoperative data were collected. Medical and surgical costs were calculated based on pharmacy charges per dose and hospital charges, respectively.


RESULTS
The median age at diagnosis was 11 years (range, 3-16 years). Medical management included steroids (n = 21), intravenous gamma globulin (n = 19), anti-D antibody (n = 19), or a combination of these therapies (n = 22). Nineteen patients (86%) reported side effects from medical therapy. Median age at splenectomy was 13 years (range, 6-18 years), and time to surgery was 23 months from diagnosis (range, 6-104 months). Splenectomy increased platelet counts in all children from a median of 25,500 to 380,000 postoperatively (P < .0001). One child experienced overwhelming postsplenectomy infection after a dog bite (n = 1). At the last follow-up (15 months; range, 1-79 months), 19 patients (86%) were asymptomatic with platelet counts greater than 50,000. Of the 3 children with persistent thrombocytopenia, 2 were diagnosed with secondary cITP. Median cost of splenectomy was significantly less than the cost of medical therapy ($20,803 vs $146,284; P < .0002).


CONCLUSIONS
Earlier surgical consultation for children with cITP may be justified given the high success rate and low morbidity, particularly given the significant complication rate and cost of continued medical treatment.
Texas Children's Hospital and the Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
Natalie R
NR
Gwilliam
David A
DA
Lazar
Mary L
ML
Brandt
Donald H
DH
Mahoney
David E
DE
Wesson
Mark V
MV
Mazziotti
Jed G
JG
Nuchtern
Timothy C
TC
Lee
D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D000818:Animals; D001733:Bites and Stings / Q000150:complications; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease; D003131:Combined Modality Therapy; D004285:Dogs; D016527:Drug Costs / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D016867:Immunocompromised Host; D016756:Immunoglobulins, Intravenous / Q000191:economics / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000191:economics / Q000627:therapeutic use; D007518:Isoantibodies / Q000191:economics / Q000627:therapeutic use; D010535:Laparoscopy / Q000191:economics / Q000706:statistics & numerical data*; D008297:Male; D010976:Platelet Count; D011183:Postoperative Complications / Q000453:epidemiology; D016553:Purpura, Thrombocytopenic, Idiopathic / Q000097:blood / Q000188:drug therapy / Q000191:economics / Q000601:surgery* / Q000628:therapy; D012189:Retrospective Studies; D018029:Rho(D) Immune Globulin; D013156:Splenectomy / Q000009:adverse effects / Q000191:economics / Q000706:statistics & numerical data*; D014946:Wound Infection / Q000209:etiology
D000305:Adrenal Cortex Hormones; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D007518:Isoantibodies; C061961:RHO(D) antibody; D018029:Rho(D) Immune Globulin