Accessory Splenectomy: the Keystone of Success in the Treatment for Refractory Immune Thrombocytopenia

Splenectomy is officially recognized as second-line treatment for immune thrombocytopenia. Accessory spleens are known to have a role in recurrence and laparoscopic exploration for detection is recommended by many. The aim of the study was to investigate on accessory splenectomy as resolutive treatment for refractory thrombocytopenia. A review of the literature was completed on PubMed looking for articles where at least one accessory splenectomy had been performed for refractory thrombocytopenia. Measures used for the statistical analysis were as follows: sex; age; surgical approach; latency to recurrence; radiological tests; identified, retrieved, and missed accessory spleens; location and size of accessory spleens; and follow-up. Outcome was evaluated in terms of platelet count, need for medical treatment, and response. Thirty-three articles from 1976 (95 patients) satisfied criteria for the analysis. In the young, accessory spleens were more frequently missed at imaging. Number and size of accessory spleens resulted to be inversely correlated. Smaller accessory spleens carried increased likelihood to be missed. Number of radiological tests used to detect accessory spleens yielded better outcomes, in particular, when ultrasonography, computed tomography and scintigraphy were used in combination. In the case of refractory immune thrombocytopenia, the presence of accessory spleens needs to be investigated. A special focus is required to young patients or those with multiple accessory spleens, where imaging fails to detect them more frequently. The use of combined radiological techniques has shown improved outcome and should be preferred. A meticulous laparoscopic exploration follows next and becomes crucial to achieve long-term response.