To evaluate the short- and long-term safety and efficacy of splenectomy for the treatment of chronic immune thrombocytopenia (ITP).

A cohort of ITP patients who underwent splenectomy between 2005 and 2020 was included and followed for up to 10 years. Descriptive analyses of complications (related to the procedure, infections, and thrombosis) and response to treatment were performed.

Out of the 87 patients included, 80.5% were women, median age at diagnosis was 33 years (IQR 24 – 50), 28.7% had hypertension and 20.7% had antiphospholipid antibodies. The median time from diagnosis to splenectomy was 19 months (IQR 6.0 – 50.0) and median follow-up duration was 61 months (27 – 108). Post-procedure complications, such as fistula, surgical site infection and bleeding requiring transfusion, occurred in 6 (7%) patients and hospital-associated thrombosis (thrombosis occurring within 90 days after splenectomy) in 3 (3.4%). Two patients had abdominal thrombosis and 1 had abdominal and deep vein thrombosis. During the follow-up, 3 patients had infections requiring hospitalization, resulting in a 5-year cumulative risk of infections of 3.4% (95% CI 0.9 – 9.1). Regarding thrombotic events after splenectomy, the 5-year cumulative incidence was 12.6% (95 CI% 6.8 – 20.9) and the median time from splenectomy to thrombosis was 20 months (IQR 1 – 42). In the subgroup analysis, patients with cardiovascular risk factors, such as hypertension, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, and cerebrovascular disease, showed higher risk for developing a thrombotic event during follow-up. Sixty days after splenectomy, 72 patients (82.5%) had an overall response, of which 55 were complete (63.2%) and 17 partial response (19.3%). The median time for relapse was 12.5 months (IQR 4 - 45.3) and the 5-year treatment free survival was 55.3% (95% CI 45.8 – 66.4). At the end of the follow-up, 77 patients (88.5%) had partial or complete response and 2 (2.3%) had died.

This study represents a cohort of patients with ITP from a single center in Brazil that evaluated the short- and long-term safety of splenectomy, in addition to its efficacy. The recent guidelines on ITP treatment recommend splenectomy as one of the main second-line therapies following failure or relapse after corticosteroid use, along with thrombopoietin receptor agonist or rituximab. The perioperative complication rate and mortality in the presented cohort were as low as those described in previous cohort studies. The institution protocol includes pre-splenectomy vaccination but not long-term antibiotic prophylaxis in adults with ITP and, even with this approach, cumulative incidence of infection requiring hospitalization in the current cohort was approximately three times lower than that in previous cohort studies. The rate of venous thromboembolism was similar to another cohort studies and seems to be associated with underlying comorbidities.

Splenectomy is an efficacious well-tolerated treatment. The response rate is high, even for those requiring further ITP treatment, suggesting that splenectomy modulates future therapy response. In conclusion, splenectomy-associated rates of efficacy outweigh its rates of complications, which underscores that splenectomy should be regarded as one of the main approaches for long-term ITP remission.