Perioperative management for a patient with chronic pancytopenia: a case of aplastic anemia with persistent neutropenia following preoperative administration of G-CSF

The patient, a 62-year-old male suffering from aplastic anemia for 6 years, was admitted in order to undergo laparoscopic cholecystectomy for cholecystitis. Results of laboratory tests at the time of admission revealed pancytopenia: white blood cell count, 1.94 × 10 3 /µl (neutrophil count, 1.23 × 10 3 /µl); red blood cell count, 2.09 × 10 6 /µl; Hb 7.5 g/dl; and platelet count, 3.7 × 10 4 /µl. The patient received supportive therapy prior to surgery, including blood transfusion of red blood cells, platelets and granulocyte colony-stimulating factor (G-CSF). On the day of surgery, the white blood cell count increased to 3.93 × 10 3 /µl (neutrophil count, 2.75 × 10 3 /µl). Surgery ended with no intraoperative complications, but neutropenia progressed and persisted postoperatively: the neutrophil count decreased to 180/µl at its lowest and stayed at about 400–600/µl. This suggests the possibility that repeated preoperative administration of G-CSF may lead to the depletion of granulocyte precursor cells and thus cause harm. Although the patient fortunately achieved a favorable outcome without severe infection, this case is a stark reminder of the difficulties involved in perioperative supportive therapy for patients with chronic pancytopenia.