Clinical Comparison of Spleen-Preserving Distal Pancreatectomy With or Without Splenic Vessel Preservation: A Systematic Review and Meta-Analysis

Long-term outcomes after spleen-preserving distal pancreatectomy with splenic vessels preservation or resection: A nationwide survey of the Japanese Society of Pancreatic Surgery

BACKGROUND

Spleen preserving distal pancreatectomy is achieved by either splenic vessel resection or splenic vessel preservation. However, the long-term outcomes of spleen-preserving distal pancreatectomy with splenic vessel resection and spleen-preserving distal pancreatectomy with splenic vessel preservation are not well known. This study aimed to evaluate the long-term outcomes of spleen-preserving distal pancreatectomy with splenic vessel resection and spleen-preserving distal pancreatectomy with splenic vessel preservation.

METHODS

The study included a total of 335 patients who underwent spleen-preserving distal pancreatectomy during the study period and underwent computed tomography or magnetic resonance imaging 3 and 5 years after surgery in the Japan Society of Pancreatic Surgery member institutions. We evaluated the diameter of the perigastric and gastric submucosal veins, patency of the splenic vessels, and splenic infarction. Preoperative backgrounds and short- and long-term outcomes were compared between the 2 groups.

RESULTS

Forty-four (13.1%) and 291 (86.9%) patients underwent spleen-preserving distal pancreatectomy with splenic vessel resection and spleen-preserving distal pancreatectomy with splenic vessel preservation, respectively. There were no significant differences in short-term outcomes between the 2 groups. Regarding long-term outcomes, the prevalence of perigastric varices was higher (P = .006), and platelet count was lower (P = .037) in the spleen-preserving distal pancreatectomy with splenic vessel resection group. However, other complications, such as gastric submucosal varices, postoperative splenic infarction, gastrointestinal bleeding, reoperation, postoperative splenectomy, and other hematologic parameters, were not significantly different between the 2 groups 5 years after surgery. In terms of the patency of splenic vessels in spleen preserving distal pancreatectomy with splenic vessel preservation cases, partial or complete occlusion of the splenic artery and vein was observed 5 years after surgery in 19 (6.5%) and 55 (18.9%) patients, respectively.

CONCLUSION

Perigastric varices and thrombocytopenia were observed more in spleen-preserving distal pancreatectomy with splenic vessel resection, yet late clinical events such as gastrointestinal bleeding and splenic infarction are acceptable for spleen-preserving distal pancreatectomy with splenic vessel preservation.

Recent trends in organ-preserving pancreatectomy: Its problems and clinical advantages compared with other standard pancreatectomies

In this review article, we focus on recent papers on organ-preserving pancreatectomy procedures published since 2010. When comparing central pancreatectomy (CP) and distal pancreatectomy (DP), most studies have concluded that the CP group exhibited significantly lower incidence of new-onset diabetes or diabetes exacerbation than the DP group postoperatively. However, because of increased incidence of morbidities such as pancreatic fistula, the surgeon faces a considerable trade-off between increased short-term morbidity and long-term preservation of endocrine function. When the outcomes of two types of spleen-preserving DP (Kimura and Warshaw procedures) are compared, most studies mentioned the low incidence of postoperative gastric varices and splenic infarction with the Kimura procedure. Although there are several reports regarding the effect of spleen preservation on prevention of postoperative infections, no report on the contribution of spleen preservation to the prevention of overwhelming post-splenectomy infection is seen. The advantages of duodenum-preserving pancreatic head resection (DPPHR) concerning endocrine and exocrine functions continue to be subjects of discussion, mainly due to the limited number of institutions that have adopted this approach; however, DPPHR should be presented as an option for patients due to its low incidence of postoperative cholangitis. Organ-preserving pancreatectomy requires meticulous surgical techniques, and postoperative complications may increase with this surgery compared with standard pancreatectomy, which may be influenced by the surgeon's skill and the surgical facility where the procedure is performed. Nonetheless, this technique has significant long-term advantages in terms of endocrine and exocrine functions and its wider adoption in the future is expected.

Preliminary experience with a new robotic technique to facilitate distal pancreatectomy with spleen preservation: left lateral approach in right lateral decubitus position

Spleen-preserving distal pancreatectomy (SP-DP), for patients with benign or small low-grade malignant tumors of the body or tail of the pancreas, is the ideal procedure although it is technically demanding. The robotic da Vinci system has been introduced to overcome these technical challenges and reduce operative risks. We report our experience of a new variation in surgical technique: the left lateral approach robotic spleen-preserving distal pancreatectomy (RSP-DP) in right lateral decubitus position. We performed this new variant of SP-DP, in five patients, using the da Vinci Xi system. Technical and clinical feasibility are described. The mean age and body mass index were 53.4 years and 31.4 kg/m², respectively. The mean total operative time was 323 min. The estimated mean blood loss was 240 ml. In all patients, the spleen could be preserved. In four patients, the splenic vessels were also preserved. One patient required a Warshaw technique due to significant fibrosis attached to the splenic vein. The postoperative period of all patients was uneventful except the presence of biochemical leak (BL) in two patients that only required maintenance of the drainage at home. The mean length of hospital stay was 6 days after surgery. The left lateral approach robotic SP-DP in right lateral decubitus position is a feasible and safe procedure for distal benign or small low-grade malignant tumors of the left pancreas. The right lateral decubitus position associated to robotic surgery can facilitate this complex procedure, especially when splenic vessels preservation is indicated, with a lower risk of conversion and shortening of the learning curve.

Short-term Outcomes After Spleen-preserving Minimally Invasive Distal Pancreatectomy With or Without Preservation of Splenic Vessels: A Pan-European Retrospective Study in High-volume Centers

OBJECTIVE

To compare short-term clinical outcomes after Kimura and Warshaw MIDP.

BACKGROUND

Spleen preservation during distal pancreatectomy can be achieved by either preservation (Kimura) or resection (Warshaw) of the splenic vessels. Multicenter studies reporting outcomes of Kimura and Warshaw spleen-preserving MIDP are scarce.

METHODS

Multicenter retrospective study including consecutive MIDP procedures intended to be spleen-preserving from 29 high-volume centers (≥15 distal pancreatectomies annually) in 8 European countries. Primary outcomes were secondary splenectomy for ischemia and major (Clavien-Dindo grade ≥III) complications. Sensitivity analysis assessed the impact of excluding ("rescue") Warshaw procedures which were performed in centers that typically (>75%) performed Kimura MIDP.

RESULTS

Overall, 1095 patients after MIDP were included with successful splenic preservation in 878 patients (80%), including 634 Kimura and 244 Warshaw procedures. Rates of clinically relevant splenic ischemia (0.6% vs 1.6%, P = 0.127) and major complications (11.5% vs 14.4%, P = 0.308) did not differ significantly between Kimura and Warshaw MIDP, respectively. Mortality rates were higher after Warshaw MIDP (0.0% vs 1.2%, P = 0.023), and decreased in the sensitivity analysis (0.0% vs 0.6%, P = 0.052). Kimura MIDP was associated with longer operative time (202 vs 184 minutes, P = 0.033) and less blood loss (100 vs 150 mL, P < 0.001) as compared to Warshaw MIDP. Unplanned splenectomy was associated with a higher conversion rate (20.7% vs 5.0%, P < 0.001).

CONCLUSIONS

Kimura and Warshaw spleen-preserving MIDP provide equivalent short-term outcomes with low rates of secondary splenectomy and postoperative morbidity. Further analyses of long-term outcomes are needed.

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.

Comparison of splenic vessel preserving distal pancreatectomy and the Warshaw technique for solid pseudopapillary neoplasm in children

PURPOSE

Spleen-preserving distal pancreatectomy (SPDP) such as splenic vessel preservation (SVP) for solid pseudopapillary neoplasms (SPNs) in the body or tail of the pancreas in children prevents post-splenectomy infection and hematologic disorders. However, SVP could be technically challenging, and the Warshaw technique (WT) could be an alternative technique that has been reported to be safe and effective in adults. We, therefore, compared the perioperative outcomes of SVP and WT in pediatric patients.

METHODS

We retrospectively reviewed the medical records of pediatric patients with SPN who underwent SPDP using SVP or WT between November 2002 and November 2018 at a large-sized tertiary referral center.

RESULTS

Twenty-eight patients were included. Sixteen (57.1%) patients underwent SVP and 12 (42.9%) patients underwent WT. There were no significant differences in the baseline characteristics between the two groups. Postoperative complications occurred in 8 patients each in the SVP (50%), and the WT (66.7%) groups. Two (12.5%) in the SVP group and 1 (8.3%) in the WT group required additional intervention. During a median follow-up duration of 49 months, there were no significant differences in the incidence of splenic infarctions or perigastric varices between the two groups.

CONCLUSIONS

There were no significant differences in the surgical outcomes between WT and SVP in pediatric patients with SPN. WT could be a safe and feasible alternative technique for SVP in challenging cases.

Systematic review and meta-analysis of risk factors of postoperative pancreatic fistula after distal pancreatectomy in the era of 2016 International Study Group pancreatic fistula definition

BACKGROUND

Risk factors for the development of clinically relevant POPF (CR-POPF) following distal pancreatectomy (DP) need clarification particularly following the 2016 International Study Group of Pancreatic Fistula (ISGPF) definition.

METHODS

A systemic search of MEDLINE, Pubmed, Scopus, and EMBASE were conducted using the PRISMA framework. Studies were evaluated for risk factors for the development CR-POPF after DP using the 2016 ISGPF definition. Further subgroup analysis was undertaken on studies ≥10 patients in exposed and non-exposed subgroups.

RESULTS

Forty-three studies with 8864 patients were included in the meta-analysis. The weighted rate of CR-POPF was 20.4% (95%-CI: 17.7-23.4%). Smoking (OR 1.29, 95%-CI: 1.08-1.53, p = 0.02) and open DP (OR 1.43, 95%-CI: 1.02-2.01, p = 0.04) were found to be significant risk factors of CR-POPF. Diabetes (OR 0.81, 95%-CI: 0.68-0.95, p = 0.02) was a significant protective factor against CR-POPF. Substantial heterogeneity was observed in the comparisons of pancreatic texture and body mass index. Seventeen risk factors achieved significance in a univariate or multivariate comparison as reported by individual studies in the narrative synthesis, however, they remain difficult to interpret as statistically significant comparisons were not uniform.

CONCLUSION

This meta-analysis found smoking and open DP to be risk factors and diabetes to be protective factor of CR-POPF in the era of 2016 ISGPF definition.

A retrospective comparative study of robotic distal pancreatectomy with or without splenic vessel and spleen preservation

BACKGROUND

Robotic distal pancreatectomy has been accepted to be safe and effective for pancreatic tail lesion. Whether spleen preservation by preserving the splenic vessels with robot assistance is feasible and beneficial remains controversial. Here we would like to compare the operative outcomes of robotic distal pancreatectomy and splenectomy (DPS) with robotic spleen preserving distal pancreatectomy by means of splenic vessel preservation (SVP).

METHODS

Between March 2011 and September 2019, 56 consecutive patients undergoing robotic distal pancreatectomy were identified, with 28 patients in each group. Patient demographics, histopathology findings and operative outcomes were prospectively collected and compared between the two groups. A subgroup analysis was made after excluding malignant and pancreatic lesions >6 cm in the DPS group.

RESULTS

The two groups had similar conversion rate, blood loss, morbidity and pancreatic fistula rate. There was no operative mortality. The SVP group had shorter median operative time (245 vs 303.5 min, P = 0.019) and shorter median hospital stay (5 vs 6 days, P = 0.019) than the DPS group. However, all malignant lesions occurred in the DPS group and lesion size in DPS group was significantly larger. After matching, there were 28 SVP and 15 DPS. The histopathology findings and lesion size became comparable. The SVP group still had shorter operative time (245 vs 290 min, P = 0.022) and shorter hospital stay (5 vs 7 days, P = 0.014) than the DPS group.

CONCLUSION

Apart from avoiding risk of overwhelming postsplenectomy sepsis, robotic SVP had additional advantage of shorter operative time and shorter hospital stay than robotic DPS.

Quantitative analysis of three-dimensional reconstruction data to guide the selection of methods for laparoscopic distal pancreatectomy

BACKGROUND/PURPOSE

To explore the risk factors of splenic vessel preservation in laparoscopic distal pancreatectomy (LDP) and to guide with the appropriate selection of surgical methods through three-dimensional (3D) reconstruction.

METHODS

Patients suffering from benign or low-grade malignant tumors of pancreatic body and tail having undergone LDP in Ningbo Medical Center Lihuili Hospital from January 2014 to September 2019 were selected for quantitative analysis of the anatomical data of patients' pancreas, tumors, splenic vessels and spleens by 3D reconstruction. According to the final surgical methods, the patients were divided into the laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation (lap-SVP) group and the non-lap-SVP group. Clinical data of the two groups were compared to assess the risk factors for surgical failure of lap-SVP and logistic regression model was applied to predict the choice of surgical methods.

RESULTS

A total of 218 patients were included in the study, including 144 in the lap-SVP group and 74 in the non-lap-SVP group. Multivariate analysis confirms that large tumor volume, large contact area between the pancreas to be resected and the splenic vein, and large maximum ratio of the circumference of the splenic vessel embedded in the pancreas to be resected to the circumference of the splenic vessel are independent risk factors for surgical failure of lap-SVP (OR > 1, P < .05). The prediction accuracy of lap-SVP operation by the logistic regression reaches up to 80.9%.

CONCLUSIONS

3D reconstruction can provide essential basis for the surgical method selection of laparoscopic distal pancreatectomy.

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.

How to divide the pancreatic parenchyma in patients with a portal annular pancreas: laparoscopic spleen-preserving distal pancreatectomy for serous cystic neoplasms

Background

Portal annular pancreas (PAP) is a rare pancreatic anomaly in which the uncinate process wraps annularly around the portal vein and fuses to the body of the pancreas. PAP is highly relevant to the development of postoperative pancreatic fistula (POPF) in pancreatic surgery. Here, we describe our experience and surgical technique of laparoscopic spleen-preserving distal pancreatectomy using Warshaw’s procedure for patients with the PAP.

Case presentation

A 49-year-old woman with PAP was referred to our hospital for a suspicious mucinous cystic neoplasms 1.5 cm in diameter in the pancreatic tail. Laparoscopic spleen-preserving distal pancreatectomy using Warshaw’s procedure was performed. Mobilization of the pancreatic tail was first performed, and then, the splenic artery was cut. After dividing the pancreatic tail from the splenic hilum, the ventral pancreatic parenchyma was divided using a stapler. After cutting the splenic vein, complete mobilization of the pancreatic body and tail enabled easy division of the PAP. Finally, the PAP was also divided using the stapler. Although grade B POPF occurred, she was discharged on the 9th postoperative day.

Conclusions

Surgeons should understand the anatomical characteristics of PAP and be aware of the possibility of POPF.

Warshaw Technique in Laparoscopic Spleen-Preserving Distal Pancreatectomy: Surgical Strategy and Late Outcomes of Splenic Preservation

Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) can be accomplished with either the preservation or the resection of splenic vessels; the latter is also known as Warshaw technique. Our study is designed to investigate the operation selection strategy when proceeding LSPDP and to evaluate the long-term outcomes of patients undergoing Warshaw surgery. The medical records and follow-up data of patients who underwent LSPDP in Qilu Hospital, Shandong University, were reviewed retrospectively. A total of thirty-five patients were involved in this study, including 17 cases of patients who were treated with Warshaw procedure (WT) while the other 18 cases had splenic vessels preserved (SVP). Compared with the SVP group, the operative time and intraoperative blood loss in WT group were improved significantly. The incidence of early postoperative splenic infarction was higher in WT group. However, there was no report of splenic abscess or second operation. Follow-up data confirmed that there was no significant difference in spleen phagocytosis and immune function compared with normal healthy population. Our study confirms that LSPDP-Warshaw procedure is a safe and efficient treatment for the benign or low grade malignant tumors in distal pancreas in selected patients. The long-term spleen function is normal after Warshaw procedure. Preoperative assessment and intraoperative exploration are recommended for the selection of operation approaches.

Long term outcome after minimally invasive and open Warshaw and Kimura techniques for spleen-preserving distal pancreatectomy: International multicenter retrospective study

BACKGROUND

The Warshaw (WT) and the Kimura (KT) techniques are both used for open or minimally invasive (MI) spleen preserving distal pancreatectomy (SPDP). Multicenter studies on long-term outcome of WT and KT are lacking.

METHODS

Multicenter retrospective study with transversal follow-up moment, including patients who underwent SPDP from 2000 to 2017 at three high-volume centers in Italy and the Netherlands. Primary endpoint was the incidence of short and long term complications. Patients without regular follow-up were interviewed about symptoms and complications.

RESULTS

In total, 164 patients were enrolled, 55 WT (33.5%) and 109 kT (66.5%), of which 95 (57.9%) MI. There was no 30-day mortality (0%).The only significant difference in short-term outcome was more delayed gastric emptying (DGE) after WT (9.1% vs 1.8%, p = 0.043). MI-SPDP was associated with less blood loss (median 150 vs 250 ml, respectively, p < 0.001), less DGE (0% vs 10%, p = 0.002), less abdominal abscesses (8.4% vs 18.4%, p = 0.03) and less splenic infarctions (3.2% vs. 13%, p = 0.042), than open SPDP. Long-term follow-up (median 41 months) was available for 111 patients (67.7%) of whom 18 (16.2%) had an SPDP-related long-term sequela, mostly perigastric varices (n = 11, 9%) but without differences between WT and KT. Less long-term sequelae were reported after MI as compared to open SPDP (12.5% vs 21.2%, p = 0.032).

CONCLUSIONS

In this international retrospective study, the WT and KT had comparable short- and long-term outcomes. If a KT does not seem feasible during SPDP, a WT is recommended, rather than performing a splenectomy. MI-SPDP was associated with less short- and long term complications as compared to an open SPDP.