Splenic vessel preservation versus splenic vessel resection in laparoscopic spleen-preserving distal pancreatectomy

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.

Comparing the Warshaw technique with vessel-preservation in laparoscopic spleen preserving distal pancreatectomy: is there a better approach?

BACKGROUND

Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) can be accomplished with either resection of the splenic vessels via the Warshaw Technique (WT) or via preservation of the splenic vessels (SVP). Our study aims to compare outcomes for the two methods of LSPDP.

METHODS

We performed a retrospective chart review with intent-to-treat analysis of adults undergoing LSPDP at a single institution from 2009 to 2021. We compared demographic characteristics, operative parameters, oncologic pathology review, and postoperative outcomes.

RESULTS

There were 102 consecutive cases of LSPDP (59 WT, 43 SVP) over 12 years. The rate of successful spleen preservation was not significantly different between the two groups (76.3%WT, 65.1%VSP,p = 0.27). Rates of conversion to laparotomy, postoperative complications including pancreatic fistulas and splenic infarcts and amount of intraoperative blood loss were similar between the groups. Median operative time was significantly shorter with the WT (141 vs. 177 min, p < 0.05). The median length of stay in hospital was not significantly different among the groups.

CONCLUSION

Both techniques are safe and effective in preserving the spleen in laparoscopic distal pancreatectomy. Our experience suggests that the Warshaw Technique may be more efficient with respect to the use of limited operative resources.

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.

Laparoscopic splenic vessels and spleen-preserving extended distal pancreatectomy for single metastatic renal cell carcinoma

Laparoscopic splenic vessels and spleen-preserving (SVSP) distal pancreatectomy has been recommended to reduce long-term risk of developing infectious complications. Due to its technical challenge, most cases relate to <50% of the pancreatic gland being excised. We present our first case of a patient incidentally found to have a solitary pancreatic metastatic renal cell carcinoma (RCC), following left nephrectomy for kidney cancer 15 years ago. He underwent laparoscopic SVSP-extended distal pancreatectomy (EDP). Final histopathology confirmed the diagnosis and margins were clear. He made a good recovery and despite loosing >70% of his pancreas, hasn’t developed new-onset diabetes. No adjuvant chemotherapy was necessary, but he will require long-term follow-up. This case suggests that even when the pancreatic lesion is located more proximally, near or at the pancreatic neck, laparoscopic SVSP-EDP may still be considered a safe and preferable option despite its greater complexity, increased intraoperative bleeding risk and longer operative time.