腹腔镜脾切除术治疗免疫性血小板减少性紫癜的临床疗效

Clinical efficacy of laparoscopic splenectomy for immune thrombocytopenic purpura

目的探讨腹腔镜脾切除术治疗免疫性血小板减少性紫癜（ITP）的临床疗效。方法回顾性分析2007年1月至2014年1月重庆医科大学附属第一医院收治的84例ITP患者的临床资料。手术方式采用腹腔镜脾切除术。对可能是预测术后疗效的指标（性别、年龄、病程、术前对激素反应、术前PLT、手术时间、术中出血量、术后7d内PLT峰值）进行收集、整理、分析。手术疗效的评估参照美国血液学协会ITP疗效评判的标准。将完全反应和部分反应设为有效，将无反应设为无效。术后通过门诊和电话进行随访，随访内容包括PLT、有无出血表现、有无长期并发症、术后复发情况等，随访时间截至2014年12月。正态分布的计量资料采用置x±s表示，偏态分布的计量资料采用中位数M（范围）表示。Kaplan—Meier法评估患者术后长期有效率。单因素分析采用，检验。多因素分析采用Logistic回归模型。结果84例患者手术时间为（154±40）min，术中中位出血量为200mL（10～1000mL）；术中发现副脾11例，均予以切除。7例患者术后出现并发症，经对症支持治疗痊愈，无一例发生围术期死亡。84例患者平均随访时间为51个月（12～96个月），45例患者完全反应，18例患者部分反应，21例患者无反应。18例部分反应患者行内科对症治疗。21例无反应患者均继续服用泼尼松龙治疗，其中13例患者能稳定维持PLT〉30×10^9/L。随访期间所有患者无严重自发性脏器及颅内出血。随访期间84例患者中，1例完全反应患者术后2年因肺癌全身转移死亡，其余无死亡。4例患者发生肺炎，1例无反应女性患者长期反复发作化脓性胸膜炎，均予以对症支持治疗痊愈。其余患者未发生严重并发症，无凶险性脾切除术后感染发生。84例患者术后1、3、5、7年有效率分别为82．1％、77．6％、72．5％、67．9％。单因素分析结果显示：患者术前对激素反应、术前PLT、术后7d内PM’峰值是影响ITP患者长期疗效的相关因素（x^2=5．600，6．006，21．733，P〈0．05）；而患者性别、年龄、病程、手术时问、术中出血量不是影响ITP患者长期疗效的相关因素（，=0．018，2．684，0．000，0．064，0．397，P〉0．05）。多因素分析结果显示：患者术前对激素有反应和术后7d内PIJT峰值≥300×10^9／L是影响ITP患者长期疗效的独立保护因素（OR=5．426，19．454，95％可信区间：1．220～24．129，4．704—80．449，P〈0．05）。结论腹腔镜脾切除术治疗ITP安全、可行，长期有效率高；术前对激素反应、术后7d内PLT峰值可能是预测腹腔镜脾切除术治疗ITP长期疗效的指标。

Objective To investigate the clinical efficacy of laparoscopic splenectomy （LS） for immune thrombocytopenic purpura （ITP）. Methods The clinical data of 84 patients with ITP who underwent LS at the First Affiliated Hospital of Chongqing Medical University from January 2007 to January 2014 were retrospectively analyzed. The potential prognosing indexes （gender, age, course of diseas, preoperative response to steroid, preoperative PLT, operation time, volume of intraoperative blood loss and postoperative PLT peak within 7 days） were collected and analyzed. The evaluation of surgical efficacy was done according to the American Society of Hematology 2011 evidence-based practice guideline for ITP. The complete response and partial response were defined as effective and no response as void. All of the patients were followed up by outpatient examination and telephone interview till December 2014, the follow-up information included platelet count, bleeding performance, presence of long-term complications and postoperative recurrence, etc. Measurement data with normal distribution were presented as x ± s, and skew distribution data were described as M （range）. The postoperative long-termeffective rate was analyzed by Kaplan-Meier method. The univariate analysis and muhivariate analysis were done using the chi-square test and Logistic regression model, respectively. Results The operation time of 84 patients was （ 154±40）minutes with a median volume of intraoperative blood loss as 200 mL （ 10-1 000 mL）. Lienculus was detected in 11 patients and resected. Seven patients had complications and recovered after symptomatic and supportive treatment. There was no perioperative death. Among the 84 patients who were followed up for an average follow-up time of 51 months （12-96 months）, 45 patients had complete response, 18 patients had partial response and 21 had no response, without serious spontaneous visceral and intracranial hemorrhage. Eighteen partial-response patients underwent symptomatic medical therapy and 21 no-response patients took orally prednisolone, among which 13 had PLT 〉 30 × 10^9/L stably. During the follow-up, only one complete-response patient died of lung cancer with systemic metastasis at 2 years after surgery. Four patients had pneumonia, 1 no- response female patient had pyothorax repeatedly for a long time, and they all recovered after symptomatic and supportive treatments. There were no serious complications and overwhelming postsplenectomy infection in other patients. The 1-, 3-, 5-, 7-year effective rates were 82. 1% , 77.6% , 72. 5% and 67.9% , respectively. Univariate analysis showed that preoperative response to steroid, preoperative PLT and postoperative PLT peak within 7 days were related factors affecting long-term effecacy of patients with ITP （x^2= 5. 600, 6. 006, 21. 733, P 〈 0.05） , but gender, age, course of disease, operation time and volume of intraoperative blood loss were not related factors affecting long-term effecacy of patients with ITP （x^2=0. 018, 2. 684, 0. 000, 0. 064, 0. 397, P 〉 0. 05 ）. Muhivariate analysis showed that preoperative response to steroid and postoperative PLT peak within 7 days ≥300 × 10^9/L were independent protective factors affecting long-term efficacy （OR = 5. 426, 19. 454, 95% confidence interval： 1. 220-24. 129, 4. 704-80. 449, P 〈 0.05 ）. Conclusions LS is safe and feasible for the treatment of ITP with a high long-term effective rate. Preoperative response to steroid and postoperative PLT peak within 7 days may be the predictors of LS for ITP.