The platelet count started to increase the following day due to the effects of splenectomy, and exceeded the normal range on the fifth day. Post-splenectomy reactive thrombocytosis was diagnosed. The platelet count increased to over 1,300,000/mm3. We prescribed hydroxyurea and anagrelide to control the platelet count after consultation with a hematologist. A combination of hydroxyurea 1000 mg and anagrelide 1.0 mg was given twice a day. The platelet count returned to normal range 3 weeks after surgery.
Thrombosis is a common complication caused by an increased platelet count, but did not occur. The attached digits survived (Fig. 4) and the patient was discharged in satisfactory condition. Finger mobility and sensation returned to some extent with regular rehabilitation treatment.
Reactive thrombocytosis is a condition in which the platelet count is increased by causes including inflammation, hyposplenism, asplenia, hemorrhage, iron deficiency, and drugs, among others. Splenectomy is also one of the major causes of reactive thrombocytosis. After splenectomy, the platelet count exceeds the normal range. However, excessive platelets can cause complications such as gastrointestinal bleeding or thrombosis. Treatment of reactive thrombocytosis includes platelet-reducing medication and platelet pheresis. Over time, thrombocytosis resolves to some extent, and medication can be decreased or stopped.
Hydroxyurea reduces the platelet count and is used to prevent thrombosis, commonly in tandem with low-dose aspirin. Anagrelide is an orally administered imidazole-quinazoline derivative, and operates by a mechanism in which cyclic adenosine monophosphate phosphodiesterase (cAMP) is selectively inhibited to block platelet function.
The normal platelet count ranges between 150,000/mm3 and 450,000/mm3. In the present case, the platelet count increased to over 1,300,000/mm3 after splenectomy. Typically, arterial and venous circulation-related complications occur after splenectomy. Such complications include thrombosis, thromboembolism, vascular smooth muscle remodeling, vasospasm, and atherosclerosis. These are particularly damaging to reattached digits that are susceptible to thrombosis. The digital artery is prone to ischemia, which leads to necrosis in the extremity. This case was not an exception. The reattached digits were susceptible to ischemia due to thrombocytosis. To prevent this, hydroxyurea and anagrelide were administered after consultation with the department of hematology.
Immediate replantation was impossible due to splenectomy and the need to treat concomitant life-threatening traumatic injury. Finger replantation was delayed, leading to a 30-hour warm ischemic time. Typically, only 12 hours under warm ischemic conditions or 24 hours under cold ischemic conditions is allowed for finger replantation. The success rate of replantation decreases if the ischemic time extends beyond these limits. Although the ischemic time was prolonged, the operation was attempted because the patient was young and the amputated fingers were functionally critical index and middle fingers; more importantly, the vital signs became stable after emergency splenectomy.
Several factors contributed to the survival of the replanted digits in this case. The first was venorrhaphy, which has been reported by many studies to increase the success rate of replantation. The second was the use of hydroxyurea and anagrelide. Other factors, such as use of heparin, PGE1, a heat lamp, and proper postoperative management also contributed to the survival of both digits in this case.[4,7]
Even though thrombocytosis was expected, replantation succeeded. The results in our case may offer insights into methods that will guide policy-making strategies for better outcomes in patients with digital amputation.
Replantation can be attempted, even when thrombocytosis is expected, when requested by the patient. Furthermore, the platelet count should be actively controlled with medication to improve the survival rate of the reattached finger. These findings can be applied to the replantation of other body parts such as the hand, forearm, and upper arm.
Conceptualization: Jae H. Hwang.
Data curation: Dong W.n Kim.
Methodology: Dong W.n Kim.
Writing – original draft: Jae H. Hwang.
Writing – review & editing: Kwang S. Kim, Sam Y. Lee.
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Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
replantation; splenectomy; thrombocytosis; warm ischemia