Splenectomy and increased subsequent cancer risk: a nationwide population-based cohort study

A retrospective, multicentric, nationwide analysis of the impact of splenectomy on survival of pancreatic cancer patients

OBJECTIVE

Splenectomy is regularly performed in total and distal pancreatectomy due to technical reasons, lymph node dissection and radicality of the operation. However, the spleen serves as an important organ for competent immune function, and its removal is associated with an increased incidence of cancer and a worse outcome in some cancer entities (Haematologica 99:392-398, 2014; Dis Colon Rectum 51:213-217, 2008; Dis Esophagus 21:334-339, 2008). The impact of splenectomy in pancreatic cancer is not fully resolved (J Am Coll Surg 188:516-521, 1999; J Surg Oncol 119:784-793, 2019).

METHODS

We therefore compared the outcome of 193 pancreatic cancer patients who underwent total or distal pancreatectomy with (Sp) or without splenectomy (NoSp) between 2015 and 2021 using the StuDoQ|Pancreas registry of the German Society for General and Visceral Surgery. In addition, we integrated our data into the existing literature in a meta-analysis of studies on splenectomy in pancreatic cancer patients.

RESULTS

There was no difference between the Sp and NoSp groups regarding histopathological parameters, number of examined or affected lymph nodes, residual tumor status, or postoperative morbidity and mortality. We observed a significantly prolonged survival in pancreatic cancer patients who underwent total pancreatectomy, when a spleen-preserving operation was performed (median survival: 9.6 vs. 17.3 months, p = 0.03). In this group, splenectomy was identified as an independent risk factor for shorter overall survival [HR (95%CI): 2.38 (1.03 - 6.8)]. In a meta-analysis of the existing literature in combination with our data, we confirmed splenectomy as a risk factor for a shorter overall survival in pancreatic cancer patients undergoing total pancreatectomy, distal pancreatectomy, or pancreatic head resection [HR (95%CI): 1.53 (1.11 - 1.95)].

CONCLUSION

Here, we report on a strong correlations between removal of the spleen and the survival of pancreatic cancer patients undergoing total pancreatectomy. This should encourage pancreatic surgeons to critically assess the role of splenectomy in total pancreatectomy and give rise to further investigations.

New insights on extramedullary granulopoiesis and neutrophil heterogeneity in the spleen and its importance in disease

Neutrophils are traditionally viewed as uncomplicated exterminators that arrive quickly at sites of infection, kill pathogens, and then expire. However, recent studies employing modern transcriptomics coupled with novel imaging modalities have discovered that neutrophils exhibit significant heterogeneity within organs and have complex functional roles ranging from tissue homeostasis to cancer and chronic pathologies. This has revised the view that neutrophils are simplistic butchers, and there has been a resurgent interest in neutrophils. The spleen was described as a granulopoietic organ more than 4 decades ago, and studies indicate that neutrophils are briefly retained in the spleen before returning to circulation after proliferation. Transcriptomic studies have discovered that splenic neutrophils are heterogeneous and distinct compared with those in blood. This suggests that a unique hematopoietic niche exists in the splenic microenvironment, i.e., capable of programming neutrophils in the spleen. During severe systemic inflammation with an increased need of neutrophils, the spleen can adapt by producing neutrophils through emergency granulopoiesis. In this review, we describe the structure and microanatomy of the spleen and examine how cells within the splenic microenvironment help to regulate splenic granulopoiesis. A focus is placed on exploring the increase in splenic granulopoiesis to meet host needs during infection and inflammation. Emerging technologies such as single-cell RNA sequencing, which provide valuable insight into splenic neutrophil development and heterogeneity, are also discussed. Finally, we examine how tumors subvert this natural pathway in the spleen to generate granulocytic suppressor cells to promote tumor growth.

Possible pathogenic mechanisms for doxorubicin-induced splenic atrophy in a human breast cancer xenograft mouse model

Doxorubicin-based chemotherapy is a widely used first-line treatment for breast cancer, yet it is associated with various side effects, including splenic atrophy. However, the pathogenic mechanisms underlying doxorubicin-induced atrophy of the spleen remain unclear. This study investigates that doxorubicin treatment leads to splenic atrophy through several interconnected pathways involving histological changes, an inflammatory response, and apoptosis. Immunohistochemical and western blot analyses revealed reduced size of white and red pulp, decreased cellularity, amyloidosis, and fibrotic remodeling in the spleen following doxorubicin treatment. Additionally, increased secretion of pro-inflammatory cytokines was detected using an antibody array and enzyme-linked immunosorbent assay (ELISA), which triggers inflammation through the regulation of signal transducer and activator of transcription 3 (STAT3) and nuclear factor-kappa B (NF-κB) signaling pathways. Further analysis revealed that the loss of regulators and effectors of the oxidative defense system, including sirtuin (Sirt)3, Sirt5, superoxide dismutase (SOD)1, and SOD2, was implicated in the upstream regulation of caspase-dependent cellular apoptosis. These findings provide insights on the pathogenic mechanisms underlying doxorubicin-induced splenic atrophy and suggest that further investigation may be warranted to explore strategies for managing potential side effects in breast cancer patients treated with doxorubicin.

Angioembolization in patients with blunt splenic trauma in Germany -guidelines vs. Reality a retrospective registry-based cohort study of the TraumaRegister DGU®

PURPOSE

Nonoperative management (NOM) for blunt splenic injuries (BSIs) is supported by both international and national guidelines in Germany, with high success rates even for severe organ injuries. Angioembolization (ANGIO) has been recommended for stabilizable patients with BSI requiring intervention since the 2016 German National Trauma Guideline. The objectives were to study treatment modalities in the adult BSI population according to different severity parameters including NOM, ANGIO and splenectomy in Germany.

METHODS

Between 2015 and 2020, a retrospective registry-based cohort study was performed on patients with BSIs with an Abbreviated Injury Score ≥ 2 in Germany using registry data from the TraumaRegister DGU® (TR DGU). This registry includes patients which were treated in a resuscitation room and spend more than 24-h in an intensive care unit or died in the resuscitation room.

RESULTS

A total of 2,782 patients with BSIs were included in the analysis. ANGIO was used in 28 patients (1.0%). NOM was performed in 57.5% of all patients, predominantly those with less severe organ injuries measured by the American Association for the Surgery of Trauma Organ Injury Scale (AAST) ≤ 2. The splenectomy rate for patients with an AAST ≥ 3 was 58.5%, and the overall mortality associated with BSI was 15%.

CONCLUSIONS

In this cohort splenic injuries AAST ≥ 3 were predominantly managed surgically and ANGIO was rarely used to augment NOM. Therefore, clinical reality deviates from guideline recommendations regarding the use of ANGIO and NOM. Local interdisciplinary treatment protocols might close that gap in the future.

Analysis of Factors Determining Spleen Preservation during Laparoscopic Distal Pancreatectomy - A Cohort Study

BACKGROUND

Spleen preservation during laparoscopic distal pancreatectomy (LSPDP) should be pursued if safe and oncologically justified. The aim of the presented study was to compare surgical outcomes and identify risk factors for unplanned splenectomy during laparoscopic distal pancreatectomy and evaluate short and long-terms outcomes.

METHODS

The following study is a retrospective cohort study of consecutive patients who underwent laparoscopic distal pancreatectomy, with the intention of preserving the spleen, for benign tumors of the body and tail of the pancreas between August 2012 and December 2022. Follow-up for patients' survival was completed in January 2023. In all, 106 patients were in total included in this study. Median age was 58 (41 to 67) years. The study population included 29 males (27.4%) and 77 females (72.6%).

RESULTS

Spleen preservation was possible in 67 (63.2%) patients. The tumor size was larger in the splenectomy group (respectively, 30 (16.5 to 49) vs. 15 (11 to 25); P <0.001). Overall, serious postoperative morbidity was 13.4% in the LSPDP group and 20.5% in the second group ( P =0.494). There were no perioperative deaths. The postoperative pancreatic fistula rate was 18% in the splenectomy group and 14.9% in the LSPDP group, while B and C fistulas were diagnosed in 15.4% and 10.5% of patients, respectively. In the multivariate logistic regression model, tumor size >3 cm was found to independently increase odds for unplanned splenectomy (OR 8.41, 95%CI 2.89-24.46; standardized for BMI).

CONCLUSION

Unplanned splenectomy during the attempt of LSPDP does not increase the risk for postoperative morbidity and postoperative pancreatic fistula. The independent risk factor for unplanned splenectomy during LSPDP is tumor size above 3 cm.

Distal Pancreatectomy for Body Pancreatic Ductal Adenocarcinoma: Is Splenectomy Necessary? A Propensity Score Matched Study

BACKGROUND

The value of splenectomy for body localization (≥ 5 cm from spleen hilum) of pancreatic ductal adenocarcinoma (B-PDAC) is uncertain. This study assessed spleen-preserving distal pancreatectomy (SPDP) results for B-PDAC.

PATIENTS AND METHODS

This single-center study included patients who underwent SPDP (Warshaw's technique) or distal splenopancreactomy (DSP) for B-PDAC from 2008 to 2019. Propensity score matching was performed to balance SPDP and DSP patients regarding sex, age, American Society of Anesthesiologists (ASA), body mass index (BMI), laparoscopy, pathological features [American Joint Committee on Cancer (AJCC)/tumor node metastasis classification (TNM)], margins, and neoadjuvant/adjuvant therapies.

RESULTS

A total of 129 patients (64 male, median age 68 years, median BMI 24 kg/m2) were enrolled with a median follow-up of 63 months (95% CI 52-96 months), including 59 (46%) SPDP and 70 (54%) DSP patients. A total of 39 SPDP patients were matched to 39 DSP patients. SPDP patients had fewer harvested nodes (19 vs 22; p = 0.038) with a similar number of positive nodes (0 vs 0; p = 0.237). R0 margins were achieved similarly in SPDP and DSP patients (75% vs 71%; p = 0.840). SPDP patients were associated with decreased comprehensive complication index (CCI, 8.7 vs 16.6; p = 0.004), rates of grade B/C postoperative pancreatic fistula (POPF, 14% vs 29%; p = 0.047), and hospital stay (11 vs 16 days; p < 0.001). SPDP patients experienced similar disease-free survival (DFS, 5 years: 38% vs 32%; p = 0.180) and overall survival (OS, 5 years 54% vs 44%; p = 0.710). After matching, SPDP patients remained associated with lower CCI (p = 0.034) and hospital stay (p = 0.028) while not associated with risks of local recurrence (HR 0.85; 95% CI 0.28-2.62; p = 0.781), recurrence (HR 1.04; 95% CI 0.61-1.78; p = 0.888), or death (HR 1.20; 95% CI 0.68-2.11; p = 0.556).

CONCLUSION

SPDP for B-PDAC is associated with less postoperative morbidity than DSP, without impairing oncological outcomes.

Laparoscopic spleen-preserving total pancreatectomy for the treatment of low-grade malignant pancreatic tumors: Two case reports and review of literature

BACKGROUND

Function-preserving pancreatectomy can improve the long-term quality of life of patients with benign or low-grade malignant tumors, such as intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms. However, there is limited literature on laparoscopic spleen-preserving total pancreatectomy (L-SpTP) due to technical difficulties.

CASE SUMMARY

Patient 1 was a 51-year-old male diagnosed with IPMN based on preoperative imaging, showing solid nodules in the pancreatic head and diffuse dilation of the main pancreatic duct with atrophy of the distal pancreas. We performed L-SpTP with preservation of the splenic vessels, and the postoperative pathology report revealed IPMN with invasive carcinoma. Patient 2 was a 60-year-old male with multiple cystic lesions in the pancreatic head and body. L-SpTP was performed, and intraoperatively, the splenic vein was injured and required ligation. Postoperative pathology revealed a mucinous cystic tumor of the pancreas with low-grade dysplasia. Both patients were discharged on postoperative day 7, and there were no major complications during the perioperative period.

CONCLUSION

We believe that L-SpTP is a safe and feasible treatment for low-grade malignant pancreatic tumors, but more case studies are needed to evaluate its safety, efficacy, and long-term outcomes.

Revealing splenectomy-driven microRNA hsa-7b-5p's role in pancreatic cancer progression

Splenectomy often accompanies distal pancreatectomy for pancreatic cancer. However, debates persist on splenic function loss impact. Prior studies in mice revealed splenectomy promotes pancreatic cancer growth by altering CD4/Foxp3 and CD8/Foxp3 ratios. The effect on other immune cells remains unclear. Clinical observations indicate splenectomy induces immunosuppression, heightening recurrence and metastasis risk. Here, we established an orthotopic pancreatic cancer model with splenectomy and observed a significant increase in tumor burden. Flow cytometry revealed elevated MDSCs, CD8+PD-1high+ T cells, and reduced CD4+ T cells, CD8+ T cells, and natural killer cells in tumors. Bulk sequencing identified increased MicroRNA (miRNA) hsa-7b-5p post-splenectomy, correlating with staging and immunosuppression. Similar results were obtained in vivo by constructing a KPC-miRNA hsa-7b-5p-sh cell line. These findings suggest that splenectomy enhances the expression of miRNA hsa-7b-5p, inhibits the tumor immune microenvironment, and promotes pancreatic cancer growth.

Autogenic splenic implantation versus splenectomy in patients undergoing distal pancreatectomy for benign or low-grade malignant lesions of the distal pancreas: study protocol for a multicentre, open-label, randomized controlled trial (RESTORE)

BACKGROUND

The spleen plays a significant role in the clearance of circulating microorganisms. Sequelae of splenectomy, especially immunodeficiency, can have a deleterious effect on a patient's health and even lead to death. Hence, splenectomy should be avoided and spleen preservation during elective surgery has become a treatment goal. However, this cannot be achieved in every patient due to intraoperative technical difficulties or oncological reasons. Autogenic splenic implantation (ASI) is currently the only possible way to preserve splenic function when a splenectomy is necessary. Experience largely stems from trauma patients with a splenic rupture. Splenic immune function can be measured by the body's clearing capacity of encapsulated bacteria. The aim of this study is to assess the splenic immune function after ASI was performed during minimally invasive (laparoscopic or robotic) distal pancreatectomy with splenectomy.

METHODS

This is the protocol for a multicentre, randomized, open-labelled trial. Thirty participants with benign or low-grade malignant lesions of the distal pancreas requiring minimally invasive distal pancreatectomy and splenectomy will be allocated to either additional intraoperative ASI (intervention) or no further intervention (control). An additional 15 patients who will undergo spleen-preserving distal pancreatectomy serve as the control group with normal splenic function. Six months postoperatively, after assumed restoration of splenic function, patients will be given a Salmonella typhi (Typhim Vi™) vaccine. The Salmonella typhi vaccine is a polysaccharide vaccine. The specific antibody titres immediately before and 4 to 6 weeks after vaccination will be measured. The ratio between pre- and post-vaccination antibody count is the primary outcome measure and secondary outcome measures include intraoperative details, length of hospital stay, 30-day mortality and morbidity.

DISCUSSION

This study will investigate the splenic immune function of patients who undergo ASI during minimally invasive distal pancreatectomy with splenectomy. The splenic immune function will be measured using the surrogate outcome of specific antibody titre after vaccination with a Salmonella typhi vaccine. The results will reveal details about splenic function after ASI and guide further treatment options for patients when a splenectomy cannot be avoided. It might eventually lead to a new standard of care making sometimes more demanding and time-consuming spleen-preserving procedures redundant.

TRIAL REGISTRATION

International Standard Randomized Controlled Trials Number (ISRCTN) ISRCTN10171587. Prospectively registered on 18 February 2019.

Minimally invasive vessel-preservation spleen preserving distal pancreatectomy-how I do it, tips and tricks and clinical results

BACKGROUND

Minimally invasive spleen-preserving distal pancreatectomy (SPDP) has emerged as a parenchyma-preserving approach and has become the standard treatment for pancreatic benign and low-grade malignant lesions. Nevertheless, minimally invasive SPDP is still technically challenging, especially when vessel preservation is intended. This study aims to describe the technique and outcomes of laparoscopic (LSPDP) and robot-assisted spleen-preserving distal pancreatectomy (RSPDP) with intended vessel preservation, highlighting the important tips and tricks to overcome technical obstacles and optimize surgical outcomes.

METHODS

A retrospective observational study of consecutive patients undergoing LSPDP and RSPDP with intended vessel preservation by a single surgeon in two different centers. A video demonstrating both surgical techniques is attached.

RESULTS

A total of 50 patients who underwent minimally invasive SPDP were included of which 88% underwent LSPDP and 12% RSPDP. Splenic vessels were preserved in 37 patients (74%) while a salvage vessel-resecting technique was performed in 13 patients (26%). The average surgery time was 178 ± 74 min for the vessel-preserving and 188 ± 57 for the vessel-resecting technique (p = 0.706) with an estimated blood loss of 100 mL in both groups (p = 0.663). The overall complication rate was 46% (n = 23) with major complications (Clavien Dindo ≥ III) observed in 14% (n = 7) of the patients. No conversions occurred. The median length of hospital stay was 4 days.

CONCLUSION

This study presented the results after minimally invasive SPDP with intended vessel preservation by a highly experienced pancreatic surgeon. It provided tips and tricks to successfully accomplish a minimally invasive SPDP, which can contribute to quick patient rehabilitation and optimal postoperative results.

Feasibility and outcome of spleen and vessel preserving total pancreatectomy (SVPTP) in pancreatic malignancies - a retrospective cohort study

INTRODUCTION

Total pancreatectomy (TP) is most commonly performed to avoid postoperative pancreatic fistula (POPF) in patients with high-risk pancreas or to achieve tumor-free resection margins. As part of TP, a simultaneous splenectomy is usually performed primarily for the reason of oncologic radicality. However, the benefit of a simultaneous splenectomy remains unclear. Likewise, the technical feasibility as well as the safety of spleen and vessel preserving total pancreatectomy in pancreatic malignancies has hardly been evaluated. Thus, the aims of the study were to evaluate the feasibility as well as the results of spleen and vessel preserving total pancreatectomy (SVPTP).

MATERIAL AND METHODS

Patient characteristics, technical feasibility, perioperative data, morbidity, and mortality as well as histopathological results after SVPTP, mainly for pancreatic malignancies, from patient cohorts of two European high-volume-centers for pancreatic surgery were retrospectively analyzed. Mortality was set as the primary outcome and morbidity (complications according to Clavien-Dindo) as the secondary outcome.

RESULTS

A SVPTP was performed in 92 patients, predominantly with pancreatic adenocarcinoma (78.3%). In all cases, the splenic vessels could be preserved. In 59 patients, the decision to total pancreatectomy was made intraoperatively. Among these, the most common reason for total pancreatectomy was risk of POPF (78%). The 30-day mortality was 2.2%. Major complications (≥ IIIb according to Clavien-Dindo) occurred in 18.5% within 30 postoperative days. There were no complications directly related to the spleen and vascular preservation procedure. A tumor-negative resection margin was achieved in 71.8%.

CONCLUSION

We could demonstrate the technical feasibility and safety of SVPTP even in patients mainly with pancreatic malignancies. In addition to potential immunologic and oncologic advantages, we believe a major benefit of this procedure is preservation of gastric venous outflow. We consider SVPTP to be indicated in patients at high risk for POPF, in patients with multilocular IPMN, and in cases for extended intrapancreatic cancers.

Liver transplantation with simultaneous splenectomy increases risk of cancer development and mortality in hepatocellular carcinoma patients

BACKGROUND

Splenectomy has previously been found to increase the risk of cancer development, including lung, non-melanoma skin cancer, leukemia, lymphoma, Hodgkin’s lymphoma, and ovarian cancer. The risk of cancer development in liver transplantation (LT) with simultaneous splenectomy remains unclear.

AIM

To compare hepatocellular carcinoma (HCC) recurrence and de novo malignancy between patients undergoing LT with and without simultaneous splenectomy.

METHODS

We retrospectively analyzed the outcomes of 120 patients with HCC within the University of California San Francisco criteria who received LT with (n = 35) and without (n = 85) simultaneous splenectomy in the Tri-Service General Hospital. Univariate and multivariate Cox regression analyses for cancer-free survival and mortality were established. The comparison of the group survival status and group cancer-free status was done by generating Kaplan–Meier survival curves and log-rank tests.

RESULTS

The splenectomy group had more hepatitis C virus infection, lower platelet count, higher -fetoprotein level, and longer operating time. Splenectomy and age were both positive independent factors for prediction of cancer development [hazard ratio (HR): 2.560 and 1.057, respectively, P < 0.05]. Splenectomy and hypertension were positive independent factors for prediction of mortality. (HR: 2.791 and 2.813 respectively, P < 0.05). The splenectomy group had a significantly worse cancer-free survival (CFS) and overall survival (OS) curve compared to the non-splenectomy group (5-year CFS rates: 53.4% vs 76.5%, P = 0.003; 5-year OS rate: 68.1 vs 89.3, P = 0.002).

CONCLUSION

Our study suggests that simultaneous splenectomy should be avoided as much as possible in HCC patients who have undergone LT.

High-fat diet activates splenic NOD1 and enhances neutrophil recruitment and neutrophil extracellular traps release in the spleen of ApoE-deficient mice

In the course of atherogenesis, the spleen plays an important role in the regulation of extramedullary hematopoiesis, and in the control of circulating immune cells, which contributes to plaque progression. Here, we have investigated the role of splenic nucleotide-binding oligomerization domain 1 (NOD1) in the recruitment of circulating immune cells, as well as the involvement of this immune organ in extramedullary hematopoiesis in mice fed on a high-fat high-cholesterol diet (HFD). Under HFD conditions, the absence of NOD1 enhances the mobilization of immune cells, mainly neutrophils, from the bone marrow to the blood. To determine the effect of NOD1-dependent mobilization of immune cells under pro-atherogenic conditions, Apoe^−/− and Apoe^−/−Nod1^−/− mice fed on HFD for 4 weeks were used. Splenic NOD1 from Apoe^−/− mice was activated after feeding HFD as inferred by the phosphorylation of the NOD1 downstream targets RIPK2 and TAK1. Moreover, this activation was accompanied by the release of neutrophil extracellular traps (NETs), as determined by the increase in the expression of peptidyl arginine deiminase 4, and the identification of citrullinated histone H3 in this organ. This formation of NETs was significantly reduced in Apoe^−/−Nod1^−/− mice. Indeed, the presence of Ly6G⁺ cells and the lipidic content in the spleen of mice deficient in Apoe and Nod1 was reduced when compared to the Apoe^−/− counterparts, which suggests that the mobilization and activation of circulating immune cells are altered in the absence of NOD1. Furthermore, confirming previous studies, Apoe^−/−Nod1^−/− mice showed a reduced atherogenic disease, and diminished recruitment of neutrophils in the spleen, compared to Apoe^−/− mice. However, splenic artery ligation reduced the atherogenic burden in Apoe^−/− mice an effect that, unexpectedly was lost in Apoe^−/−Nod1^−/− mice. Together, these results suggest that neutrophil accumulation and activity in the spleen are driven in part by NOD1 activation in mice fed on HFD, contributing in this way to regulating atherogenic progression.

Contrast-enhanced ultrasound of blunt abdominal trauma in children

Trauma is the leading cause of morbidity and mortality in children, and rapid identification of organ injury is essential for successful treatment. Contrast-enhanced ultrasound (CEUS) is an appealing alternative to contrast-enhanced CT in the evaluation of children with blunt abdominal trauma, mainly with respect to the potential reduction of population-level exposure to ionizing radiation. This is particularly important in children, who are more vulnerable to the hazards of ionizing radiation than adults. CEUS is useful in hemodynamically stable children with isolated blunt low- to moderate-energy abdominal trauma to rule out solid organ injuries. It can also be used to further evaluate uncertain contrast-enhanced CT findings, as well as in the follow-up of conservatively managed traumatic injuries. CEUS can be used to detect abnormalities that are not apparent by conventional US, including infarcts, pseudoaneurysms and active bleeding. In this article we present the current experience from the use of CEUS for the evaluation of pediatric blunt abdominal trauma, emphasizing the examination technique and interpretation of major abnormalities associated with injuries in the liver, spleen, kidneys, adrenal glands, pancreas and testes. We also discuss the limitations of the technique and offer a review of the major literature on this topic in children, including an extrapolation of experience from adults.

Outcomes of Infection and Risk of Mortality in Liver Transplant Patients with Simultaneous Splenectomy

PURPOSE

The purpose of this study was to compare the outcomes of infection between liver transplant patients with and without simultaneous splenectomy.

METHODS

We retrospectively analyzed the records of 211 patients who underwent liver transplantation in the Tri-Service General Hospital from 2012 to 2017. The frequency of blood cultures obtained after liver transplantation; incidence of bacteremia, pathogens, and complications; and overall survival rates were compared between the groups.

RESULTS

One hundred thirty-three of 211 patients underwent liver transplantation without simultaneous splenectomy. There were no significant differences in the frequency of blood cultures obtained after liver transplantation (non-splenectomy group and splenectomy group: 63% and 62%, respectively); incidences of bacteremia after liver transplantation (21% and 21%, respectively), repeat bacteremia (39% and 35%, respectively), cytomegalovirus infection (4% and 3%, respectively), herpes infection (6% and 7%, respectively), and fungal infection (3% and 3%, respectively); and overall survival rate between the two groups. However, there was a significant difference in infection-related deaths between the groups. Simultaneous splenectomy and episodes of antibody-related rejection were significant risk factors associated with infection-related death in multivariate analyses.

CONCLUSION

Although simultaneous splenectomy does not increase the incidence of infection, simultaneous splenectomy definitely carries risks of infection-related mortality in liver transplantation.

Changes in peripheral lymphocyte populations in patients with advanced/recurrent ovarian cancer undergoing splenectomy during cytoreductive surgery

BACKGROUND

To investigate changes in peripheral lymphocyte subsets after splenectomy during cytoreductive surgery for advanced or recurrent ovarian cancers.

METHODS

We enrolled 83 patients with advanced or recurrent ovarian cancer who underwent cytoreductive surgery. Twenty patients who also underwent splenectomy were assigned to the splenectomy cohort and the rest were assigned to the non-splenectomy cohort. Flow cytometry was used to measure peripheral lymphocyte subsets consisting of T cells, regulatory T cells, natural killer cells, B cells, and activation antigens before and after surgery.

RESULTS

There was no difference in the number and distribution of peripheral lymphocyte subsets between the two cohorts before surgery. After surgery, we observed elevated levels of T cells (CD3⁺, CD3⁺CD8⁺) in the splenectomy cohort compared to those in the non-splenectomy cohort, and the difference was statistically significant. CD8⁺CD28⁺ T cells had a significant decreasing tendency (P = 0.011) while CD3⁺/HLA-DR⁺ T cells showed the opposite trend (P = 0.001) in the splenectomy cohort. The proportion of Tregs (P = 0.005) and B cells (P < 0.001) including CD3^-/HLA-DR⁺ B cells (P = 0.007) increased after surgery, and the absolute number of T cells and NK cells decreased to different extents (P < 0.001) in the non-splenectomy cohort. The post-operative percentage of CD8⁺CD28⁺ T cells was less than the pre-operative percentage (P = 0.022), which was similar to the splenectomy cohort. There was no significant difference in progression-free survival or overall survival between the groups after a median follow-up time of 41 months.

CONCLUSIONS

The changes in peripheral lymphocyte populations were different between patients with and those without splenectomy during cytoreductive surgery for ovarian cancers. T cells were increased and activated in the splenectomy cohort, whereas, B cells were increased and activated in the non-splenectomy cohort.

Incidence, Risk Factors, and Outcomes from Conversion of Low-Grade to High-Grade Appendiceal Neoplasms for Patients Undergoing Multiple Cytoreductive Surgeries with Hyperthermic Intraperitoneal Chemotherapy

INTRODUCTION

Conversion from low-grade to high-grade disease is known to occur following repeat cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC); however, the incidence rate, risk factors, and outcomes have not been studied.

METHODS

We conducted a retrospective review of multiple CRS/HIPEC cases for patients originally diagnosed with low-grade appendiceal neoplasms, and compared converted cases with non-converters. Primary outcomes were the incidence rate and risk factors for conversion, while secondary outcomes were effect on cytoreduction, overall survival (OS), and disease-free survival (DFS).

RESULTS

Overall, 65 patients undergoing 134 cases of repeat CRS/HIPEC were identified; 11 patients converted to high-grade disease, an incidence rate of 16.92%. Converted cases averaged 4.4 years between CRS/HIPEC, versus 3.7 years for non-converters. Elevated baseline carcinoembryonic antigen (CEA) level, splenectomy at index CRS/HIPEC, and adjuvant chemotherapy utilization were statistically significant with conversion. Conversion had no impact on specific cytoreductive scores at repeat CRS/HIPEC (p = 0.435). Evaluating the effect on OS from the index CRS/HIPEC conversion had no impact. Mean OS was 9.5 and 8.8 years for cases that remained low-grade compared with those that converted, respectively (p = 0.668); however, when comparing OS from the time of conversion at repeat CRS/HIPEC, patients who progressed to high-grade disease had decreased survival at 4.4 versus 5.8 years (p = 0.0317). There was no difference in DFS between non-converters and converters at 4.1 and 3.6 years, respectively (p = 0.671).

CONCLUSION

Conversion had no impact on OS from the index CRS/HIPEC but resulted in inferior survival from repeat surgery. Conversion was insignificant in regard to DFS, and should not be considered a contraindication to repeat CRS/HIPEC. Adjuvant chemotherapy should be avoided.

Predicted limited redistribution of T cells to secondary lymphoid tissue correlates with increased risk of haematological malignancies in asplenic patients

The spleen, a secondary lymphoid tissue (SLT), has an important role in generation of adaptive immune responses. Although splenectomy remains a common procedure, recent studies reported poor prognosis and increased risk of haematological malignancies in asplenic patients. The high baseline trafficking of T lymphocytes to splenic tissue suggests splenectomy may lead to loss of blood-borne malignant immunosurveillance that is not compensated for by the remaining SLT. To date, no quantitative analysis of the impact of splenectomy on the human T cell trafficking dynamics and tissue localisation has been reported. We developed a quantitative computational model that describes organ distribution and trafficking of human lymphocytes to explore the likely impact of splenectomy on immune cell distributions. In silico splenectomy resulted in an average reduction of T cell numbers in SLT by 35% (95%CI 0.12–0.97) and a comparatively lower, 9% (95%CI 0.17–1.43), mean decrease of T cell concentration in SLT. These results suggest that the surveillance capacity of the remaining SLT insufficiently compensates for the absence of the spleen. This may, in part, explain haematological malignancy risk in asplenic patients and raises the question of whether splenectomy has a clinically meaningful impact on patient responses to immunotherapy.

Is splenic hilar lymph node dissection necessary for proximal gastric cancer surgery?

Advanced proximal gastric cancer sometimes metastasizes to the splenic hilar lymph nodes (No. 10 LN). Total gastrectomy combined with splenectomy is performed for complete removal of the No. 10 LN and was historically a standard procedure in Japan. However, splenectomy is associated with several disadvantages for patients, such as increased postoperative morbidity, risk of thrombogenic disease, fatal infection from encapsulated bacteria, and the development of other types of cancer in the long term because of loss of immune function. Therefore, splenectomy should only be performed when its estimated oncological effect exceeds such disadvantages. A Japanese randomized controlled trial (JCOG0110) clearly demonstrated that prophylactic splenectomy is not necessary unless the tumor has invaded the greater curvature; thus, splenectomy is no longer routinely performed in Japan. However, several retrospective studies have shown a comparatively high incidence of No. 10 LN metastasis and therapeutic value from LN dissection at that station in the tumors invading the greater curvature. Similar tendencies have also been reported in type 4 or remnant gastric cancer involving the greater curvature. In view of these facts, No. 10 LN dissection is presently recommended for such patients; however, robust evidence is lacking. In recent years, laparoscopic/robotic spleen-preserving splenic hilar dissection utilizing augmented visualization without pancreatic mobilization has been developed. This procedure is expected to replace prophylactic splenectomy and provide an equal oncological effect with lower morbidity. In Japan, a prospective phase-II study (JCOG1809) is currently ongoing to investigate the safety and feasibility of this procedure.

Distal pancreatectomy for pancreatic neoplasia: is splenectomy really necessary? A bicentric retrospective analysis of surgical specimens

BACKGROUND

While distal pancreatectomy with splenectomy (DPS) is the reference treatment for pancreatic body and tail neoplasia, oncological benefits of splenectomy have never been demonstrated. Involvement of spleen, splenic hilum and lymph nodes (LN) was therefore assessed on DPS specimens.

METHODS

All DPS pancreatic neoplasia specimens obtained in 2 Brussels University Hospitals over 15 years (2004-2018) were reviewed retrospectively, using both preoperative radiological imaging and postoperative pathological analyses of splenic parenchyma, hilar tissue and LN.

RESULTS

The total of 130 DPS specimens included 85 adenocarcinomas, 37 neuroendocrine neoplasms and 8 other carcinomas. Tumours involved the pancreatic body without tail invasion for 59 specimens (B, Body group), and the pancreatic tail with/without body for 71 (T, Tail group). At pathology, direct splenic and/or hilar involvement was observed in 13 T specimens (13/71, 18.3%), but in none belonging to the Body group. The observed numbers of splenic hilar LN (only reported in 49/130 patients) were low, only one T adenocarcinoma had positive splenic LN in addition to direct splenic involvement.

CONCLUSION

Splenectomy remains justified during pancreatectomy for neoplasia involving the pancreatic tail, but in case of pancreatic body tumours, its benefits should be questioned in the light of absent splenic LN/parenchymal involvement.

Decellularized Splenic Matrix as a Scaffold for Spleen Bioengineering

The spleen is considered a non-essential organ. However, its importance is increasingly clear, given the serious disorders caused by its absence or dysfunction, e.g., greater susceptibility to infections, thromboembolism and cancer. Surgical techniques to preserve the spleen and maintain splenic function have become increasingly common. However, the morbidity and mortality associated with its absence and dysfunction are still high. We used the decellularization technique to obtain a viable splenic scaffold for recellularization in vitro and propose the idea of bioengineered spleen transplantation to the host. We observed the maintenance of important structural components such as white pulp, marginal zone and red pulp, in addition to the network of vascular ducts. The decellularized scaffold presents minimal residual DNA and SDS, which are essential to prevent immunogenic responses and transplantation failure. Also, the main components of the splenic matrix were preserved after decellularization, with retention of approximately 72% in the matrisomal protein content. The scaffold we developed was partially recellularized with stromal cells from the spleen of neonatal rats, demonstrating adhesion, proliferation and viability of cells. Therefore, the splenic scaffold is very promising for use in studies on spleen reconstruction and transplantation, with the aim of complete recovery of splenic function.

Postoperative risk of pancreatic fistula after distal pancreatectomy with or without spleen preservation

INTRODUCTION

Outcomes after distal pancreatectomy with or without splenectomy are controversial. The present study aims to investigate differences in short-term and long-term outcomes between spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS).

METHODS

In this retrospective review of consecutive patients undergoing distal pancreatectomy with or without splenectomy from January 2011 until December 2017 for benign disease, the primary endpoint was to compare postoperative pancreatic fistula (POPF). The secondary endpoint was to compare duration of surgery, intraoperative blood loss, postoperative complications, length of hospital stay, and long-term outcomes.

RESULTS

Patients undergoing SPDP had a lower rate of POPF (13.6% vs 46.1%; p = 0.02). Patients undergoing SPDP (n = 22) were discharged earlier than patients undergoing DPS (n = 26) (8 [4-29] vs 12 [6.48] days; p = 0.003). No differences in other intraoperative and postoperative outcomes were found between groups.

CONCLUSION

Patients undergoing SPDP developed fewer POPF and were discharged earlier compared to patients undergoing DPS.

Generation of Myeloid Cells in Cancer: The Spleen Matters

Myeloid cells are key components of the tumor microenvironment and critical regulators of disease progression. These innate immune cells are usually short-lived and require constant replenishment. Emerging evidence indicates that tumors alter the host hematopoietic system and induce the biased differentiation of myeloid cells to tip the balance of the systemic immune activities toward tumor-promoting functions. Altered myelopoiesis is not restricted to the bone marrow and also occurs in extramedullary organs. In this review, we outline the recent advances in the field of cancer-associated myelopoiesis, with a focus on the spleen, the major site of extramedullary hematopoiesis in the cancer setting. We discuss the functional specialization, distinct mechanisms, and clinical relevance of cancer-associated myeloid cell generation from early progenitors in the spleen and its potential as a novel therapeutic target.

High-Dimensional Analysis of Postsplenectomy Peripheral Immune Cell Changes

Although the consequences of splenectomy are well understood in mice, much less is known about the immunologic changes that occur following splenectomy in humans. We sought to characterize the circulating immune cell populations of patients before and after elective splenectomy to determine if these changes are related to postsplenectomy survival outcomes. Retrospective clinical information was collected from 95 patients undergoing elective splenectomy compared with 91 patients undergoing pancreaticoduodenectomy (Whipple procedure). We further analyzed peripheral blood from five patients in the splenectomy group, collected before and after surgery, using single-cell cytometry by time-of-flight mass spectrometry. We compared pre- and postsplenectomy data to characterize both the major and minor immune cell populations in significantly greater detail. Compared with patients undergoing a Whipple procedure, splenectomized patients had significant and long-lasting elevated counts of lymphocytes, monocytes, and basophils. Cytometry by time-of-flight mass spectroscopy analysis demonstrated that the elevated lymphocytes primarily consisted of naive CD4⁺ T cells and a population of activated CD25⁺CD56⁺CD4⁺ T cells, whereas the elevated monocyte counts were mainly mature, activated monocytes. We also observed a significant increase in the expression of the chemokine receptors CCR6 and CCR4 on several cellular populations. Taken together, these data indicate that significant immunological changes take place following splenectomy. Whereas other groups have compared splenectomized patients to healthy controls, this study compared patients undergoing elective splenectomy to those undergoing a similar major abdominal surgery. Overall, we found that splenectomy results in significant long-lasting changes in circulating immune cell populations and function.

Romiplostim for the Treatment of Immune Thrombocytopenia: Spotlight on Patient Acceptability and Ease of Use

Immune thrombocytopenia (ITP) is an immune-mediated disorder resulting in platelet destruction and subsequent thrombocytopenia. Bleeding symptoms range from mild cutaneous bleeding to life-threatening hemorrhage. Romiplostim, a peptide-antibody fusion product, is a thrombopoietin receptor agonist (TPO-RA) indicated for use in patients with ITP. Romiplostim is US Food and Drug Administration (FDA) approved in children ≥1 year of age with ITP of >6 months' duration who have had an inadequate response to first-line therapies or splenectomy. FDA approval in adults with chronic ITP was expanded in October 2019 to include adults with newly diagnosed (<3 months' duration) and persistent (3-12 months' duration) ITP who demonstrated an inadequate response to first-line therapies, including corticosteroids and immunoglobulins, or splenectomy. The newly published 2019 American Society of Hematology ITP Guidelines place TPO-RAs, including romiplostim, as second-line therapies in both children and adults. Here, we review the use of romiplostim as second-line therapy with a spotlight on health-related quality of life, ease of use, and patient preference.

Disadvantages of Complete No. 10 Lymph Node Dissection in Gastric Cancer and the Possibility of Spleen-Preserving Dissection: Review

Splenic hilar lymph node dissection has been the standard treatment for advanced proximal gastric cancer. Splenectomy is typically performed as part of this procedure. However, splenectomy has some disadvantages, such as increased risk of postoperative complications, especially pancreatic fistula. Moreover, patients who underwent splenectomy are vulnerable to potentially fatal infection caused by encapsulated bacteria. Furthermore, several studies have shown an association of splenectomy with cancer development and increased risk of thromboembolic events. Therefore, splenectomy should be avoided if it does not confer a distinct oncological advantage. Most studies that compared patients who underwent splenectomy and those who did not failed to demonstrate the efficacy of splenectomy. Based on the results of a randomized controlled trial conducted in Japan, prophylactic dissection with splenectomy is no longer recommended in patients with gastric cancer with no invasion of the greater curvature. However, patients with greater curvature invasion or those with remnant gastric cancer still need to undergo splenectomy to facilitate splenic hilar node dissection. Spleen-preserving splenic hilar node dissection is a new procedure that may help delink splenic hilar node dissection and splenectomy. In this review, we examine the evidence pertaining to the efficacy and disadvantages of splenectomy. We discuss the possibility of spleen-preserving surgery for prophylactic splenic hilar node dissection to overcome the disadvantages of splenectomy.

The non-coding RNome after splenectomy

Splenectomy is a common surgical procedure performed in millions of people worldwide. Epidemiologic data show that splenectomy is followed by infectious (sepsis) and non-infectious complications, with unknown mechanisms. In order to explore the role of the non-coding transcripts involved in these complications, we analysed a panel of circulating microRNAs (miRNAs), which were previously reported to be deregulated in sepsis, in the plasma of splenectomized patients. MiR-223 was overexpressed immediately and late after splenectomy, while miR-146a was overexpressed immediately after splenectomy, returning latter to basal levels; and miR-16, miR-93, miR-26a and miR-26b were overexpressed only late after splenectomy, suggesting similarities with sepsis. We also explored the non-coding (nc)RNome of circulating peripheral blood leucocytes by performing a ncRNA full genome profiling. We observed a reorganization of the ncRNoma after splenectomy, characterized by up-regulation of miRNAs and down-regulation of transcribed pyknons (T-PYKs). Pathway analysis revealed that deregulated miRNAs control pathways involved in immunity, cancer and endothelial growth. We checked the expression of the ncRNAs in 15 immune cell types from healthy donors and observed that plasma miRNAs, cellular miRNAs and T-PYKs have a cell-specific expression pattern and are abundant in different types of immune cells. These findings suggest that the ncRNAs potentially regulate the immune changes observed after splenectomy.

Beyond the tumour microenvironment

In contrast to the once dominant tumour-centric view of cancer, increasing attention is now being paid to the tumour microenvironment (TME), generally understood as the elements spatially located in the vicinity of the tumour. Thinking in terms of TME has proven extremely useful, in particular because it has helped identify and comprehend the role of nongenetic and noncell-intrinsic factors in cancer development. Yet some current approaches have led to a TME-centric view, which is no less problematic than the former tumour-centric vision of cancer, insofar as it tends to overlook the role of components located beyond the TME, in the 'tumour organismal environment' (TOE). In this minireview, we highlight the explanatory and therapeutic shortcomings of the TME-centric view and insist on the crucial importance of the TOE in cancer progression.

Total pancreatectomy for pancreatic malignancy with preservation of the spleen

BACKGROUND

Total pancreatectomy may be necessary to achieve margin-negative resection for pancreatic cancer. However, despite the desirability of saving the spleen, the feasibility, safety, and oncological outcomes of spleen-preserving total pancreatectomy have not been studied in patients with malignancy involving the pancreatic neck or proximal body. The aim of this study was to report the efficacy of spleen-preserving total pancreatectomy using the Warshaw technique for patients with pancreatic malignancies.

METHODS

A retrospective analysis of patients who underwent total pancreatectomy for malignant pancreatic diseases between December 2006 and January 2018 focused on comparing the clinical outcomes between conventional operations with splenectomy and spleen-preserving total pancreatectomy using the Warshaw technique.

RESULTS

Thirty-eight patients among a total of 59 total pancreatectomies had the spleen preservation by the Warshaw operation. In this series, the pancreatic ductal adenocarcinomas resected with the Warshaw technique were of smaller tumor size but had greater rates of vascular invasion, resulting in the more frequent vascular resection. No patients had splenic complications requiring splenectomy, but two patients intended to have the Warshaw operation were converted to splenectomy because of splenic malperfusion. Asymptomatic perigastric varices were noted in 4 patients. Postoperative morbidity and mortality were comparable between the Warshaw and conventional operation groups. Recurrence-free and overall survival was similar in both groups.

CONCLUSION

In patients with pancreatic malignancy, total pancreatectomy with preservation of the spleen using the Warshaw technique achieves outcomes comparable with conventional total pancreatectomy with splenectomy in selected patients.

Evaluation the efficacy and safety of simultaneous splenectomy in liver transplantation patients: A meta-analysis

BACKGROUND

Simultaneous splenectomy during liver transplantation (LT) is debated. The present meta-analysis assessed the efficacy and safety of splenectomy on the outcome of LT patients.

METHODS

We searched PubMed, Embase, and Wanfang databases for relevant studies published until the date of July 15, 2017. Quality assessment of the included studies was performed using a modified Newcastle-Ottawa Scale judgment. The data were analyzed using RevMan5.3 software.

RESULTS

A total of 16 studies consisting of 2198 patients (892 patients received splenectomy during LT [SPLT group] and 1306 patients received LT only [LT group]) were included in the present meta-analysis. Efficacy analysis revealed that pooled hazard ratio for overall survival (OS) between 2 groups was not significantly different (hazard ratio = 1.03; 95% confidence interval [CI]: 0.71-1.50). SPLT group had less postoperative rejection (odds ratio [OR] = 0.63, 95% CI: 0.50-0.79) and small for size syndrome (OR = 0.23, 95% CI: 0.07-0.79). SPLT group had significantly lower preoperative platelet (mean difference [MD] = -17.23, 95% CI: -19.54, -14.91), but significantly higher postoperative platelet (MD = 170.45, 95% CI: 108.33-232.56). Conversely, SPLT group had significant higher preoperative portal pressure (MD = 1.54, 95% CI: 0.75-2.33) and significant lower postoperative portal pressure (MD = -1.17, 95% CI: -2.24, -0.11). Safety analysis revealed that SPLT group had significantly longer operation time (MD = 56.66, 95% CI: 35.96-77.35), more intraoperative blood loss (MD = 1.08, 95% CI: 0.25-1.91), and more intraoperative red blood cell (RBC) transfusion (MD = 3.77, 95% CI: 3.22-4.33). Furthermore, SPLT group had significantly higher incidence of postoperative hemorrhage (OR = 3.07, 95% CI: 1.92-4.91), postoperative thrombosis (OR = 3.63, 95% CI: 1.06-12.45), and perioperative infection (OR = 2.62, 95% CI: 1.76-3.90). In addition, perioperative mortality was significantly higher in the SPLT group (OR = 3.14, 95% CI: 1.31-7.52). Postoperative hospital stay did not differ significantly between 2 groups (OR = -1.75, 95% CI: -3.66-0.16).

CONCLUSIONS

Splenectomy benefits LT patients in increasing platelet count. However, splenectomy is a morbid procedure as splenectomy increases operation time, intraoperative blood loss, intraoperative RBC transfusion, and postoperative complications. Splenectomy does not improve OS but increase perioperative mortality. Therefore, splenectomy should be performed only in selective patients.

Laparoscopic Partial Splenectomy for Unknown Primary Cancer: A Stepwise Approach

BACKGROUND

Laparoscopic partial splenectomy (LPS) for focal splenic lesions is technically demanding and carries risk of hemorrhage. Nevertheless, it can be a valuable option, particularly for children and adults in whom attempt at preservation of splenic immunologic function outweighs risk associated with organ preservation.

PATIENT

A 58-year-old man was diagnosed with a focal splenic lesion at the upper splenic pole on surveillance imaging following axillary lymph node metastasis for cancer of unknown primary origin (CUP). After an interval of 8 months, repeat FDG-PET showed increase in size and PET-avidity without any evidence of new lesions. Due to isolated site and history of CUP, the patient was considered for a LPS.

TECHNIQUE

With the patient in reversed modified French position, the upper pole splenic vessels were controlled and a well-defined area of ischemia encompassing the lesion identified. Under intermittent inflow occlusion and ultrasonography guidance, the parenchymal transection was performed. Total operative time was 180 min, estimated blood loss was 175 cc, the patient was discharged on postoperative day 2, and final pathology confirmed an Epstein-Barr virus associated inflammatory pseudotumor.1 ^, 2 CONCLUSION: Safe LPS requires systematic pre-operative assessment of hilar vascular anatomy and a stepwise approach to controlling the vessels intra-operatively. Anatomic parenchymal transection and intermitted vascular isolation for lesions close to the demarcation zone minimizes blood loss. Risk/benefit stratification of LPS may be beneficial in select patients only. Whether in patients with CUP LPS may aid in preserving innate and adaptive immunity with potential clinical, including oncologic, benefits will require further investigations.3 ^- 5.

Effect of Splenectomy Combined with Resection for Gastric Carcinoma on Patient Prognosis

BACKGROUND For patients with stage IV gastric cancer, it is unclear whether splenectomy combined with palliative surgery is needed to reduce tumor load and relieve symptoms. The objective of the present study was to investigate the effect of splenectomy combined with palliative resection for stage IV gastric carcinoma on immunological dysfunction and patient prognosis. MATERIAL AND METHODS We retrospectively analyzed medical records of 106 stage IV gastric cancer patients who underwent palliative surgery; of these, 49 patients were treated with palliative resection for gastric carcinoma combined with splenectomy, while the other 57 patients retained their spleens. The immunologic function and prognosis in these 2 groups were examined and compared. RESULTS The immune function of patients in the group that retained their spleens was better later in the postoperative course than in the resection group. The groups did not show statistically significant differences in postoperative infectious complications, median survival time, and survival rate; however, the average postoperative hospitalization time of patients in the retained group was significantly shorter. CONCLUSIONS Splenectomy combined with gastric cancer resection did not improve the prognosis of the patients; patients who retained their spleens had faster recovery and improved immune function. However, whether retaining the spleen is an independent factor improving the prognosis needs further investigation.

Minimally Invasive Approach for Spleen-Preserving Distal Pancreatectomy: a Comparative Analysis of Postoperative Complication Between Splenic Vessel Conserving and Warshaw's Technique

BACKGROUND

Spleen-preserving distal pancreatectomy with Warshaw's technique (WT) was reported to have higher spleen-related complication. The aim of this study was to evaluate the postoperative complication between the splenic vessel-conserving technique (SVC) and the WT when they were performed by the minimally invasive approach.

METHODS

From January 2006 to June 2015, data of the patients who had laparoscopic or robotic-assisted spleen-preserving distal pancreatectomy for benign or borderline malignant tumors were retrospectively reviewed. Patients were divided into SVC and the WT group for comparison.

RESULTS

Of the 89 patients who had the spleen-preserving distal pancreatectomy, 63 were SVC, whereas 26 were WT. The CT scans showed that patients who had WT were found to have higher rate of splenic infarction (P < 0.001) and had significantly higher rate of collateral vessel formation at 1 year (P < 0.001). All the splenic infarctions were low grade and asymptomatic which resolved spontaneously. None of the patients with collateral formation experienced gastrointestinal bleeding. The postoperative complication of SVC and WT did not differ significantly.

CONCLUSION

SVC and WT were found to have comparable outcome. Both techniques can be used to achieve higher spleen-preserving rate.