Minimally invasive preservation versus splenectomy during distal pancreatectomy: a systematic review and meta-analysis

Meta-analysis of laparoscopic spleen-preserving distal pancreatectomy versus laparoscopic distal pancreatectomy with splenectomy: An insight into confounding by indication

AIMS

To evaluate comparative outcomes of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and laparoscopic distal pancreatectomy with splenectomy (LDPS).

METHODS

A systematic search of multiple electronic data sources and bibliographic reference lists were conducted. Comparative studies reporting outcomes of LSPDP and LDPS were considered followed by evaluation of the associated risk of bias according to ROBINS-I tool. Perioperative complications, clinically important postoperative pancreatic fistula (POPF), infectious complications, blood loss, conversion to open, operative time and duration of hospital stay were the investigated outcome parameters.

RESULTS

Nineteen studies were identified enrolling 3739 patients of whom 1860 patients underwent LSPDP and the remaining 1879 patients had LDPS. The patients in the LSPDP and LDPS groups were of comparable age (p = 0.73), gender (p = 0.59), and BMI (p = 0.07). However, the patient in the LDPS group had larger tumour size (p = 0.0004) and more malignant lesions (p = 0.02). LSPDP was associated with significantly lower POPF (OR:0.65, p = 0.02), blood loss (MD:-28.30, p = 0.001), and conversion to open (OR:0.48, p < 0.0001) compared to LDPS. Moreover, it was associated with significantly shorter procedure time (MD: -22.06, p = 0.0009) and length of hospital stay (MD: -0.75, p = 0.005). However, no significant differences were identified in overall perioperative (OR:0.89, p = 0.25) or infectious (OR:0.67, p = 0.05) complications between two groups.

CONCLUSIONS

LSPDP seems to be associated with lower POPF, bleeding and conversion to open compared to LDPS in patients with small-sized benign tumours. Moreover, it may be quicker and reduce hospital stay. Nevertheless, such advantages are of doubtful merit about large-sized or malignant tumours. The available evidence is subject to confounding by indication.

Analysis of long-term outcomes after minimally invasive spleen-preserving distal pancreatectomy under the 'Kimura-first' strategy

INTRODUCTION

Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation.

PATIENTS AND METHODS

The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up.

RESULTS

A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group ( P = 0.02). We also found less blood loss for patients who underwent KT ( P = 0.02). The occurrence of gastric varices was significantly higher in the WT group ( P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group ( P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.

CONCLUSIONS

The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.

Laparoscopic spleen-preserving distal pancreatectomy: A novel technique with splenic artery resection and splenic vein preservation

INTRODUCTION

Laparoscopic spleen-preserving distal pancreatectomy (LSDP) is widely performed to treat benign and low-grade malignant diseases. Although preservation of splenic vessels may be desirable considering the risk of postoperative complications, it is sometimes difficult due to tumor size, inflammation, and proximity of the tumor and splenic vessels. Herein, we present the first case of LSDP with splenic artery resection and splenic vein preservation.

MATERIALS AND SURGICAL TECHNIQUE

A 40-year-old woman with a pancreatic tumor was referred to our hospital. Contrast-enhanced computed tomography (CT) revealed a tumor in the pancreatic tail that was in contact with the splenic artery and distant from the splenic vein. The splenic artery and vein were separated from the pancreas near the dissection line. The splenic artery was resected after pancreatic dissection using a linear stapler. After the pancreatic tail was separated from the splenic hilum while preserving the splenic vein, the distal side of the splenic artery was resected, and the specimen was removed. The postoperative course was uneventful and the patient was discharged on postoperative Day 9. Four months after surgery, postoperative follow-up CT findings showed neither splenic infarction nor gastric varices.

DISCUSSION

This technique is an alternative method of splenic preservation when there is no attachment of the tumor to the splenic vein or uncontrolled expected bleeding of the splenic artery using the Kimura technique.

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.

Learning curve of robotic-assisted splenic vessel-preserving spleen-preserving distal pancreatectomy by one single surgeon: a retrospective cohort study

AIM

Splenic vessel-preserving spleen-preserving distal pancreatectomy (SVP-SPDP) has a lower risk of splenic infarction than the splenicvessel-sacrificing SPDP, but it is more technically demanding. Learning curve of robotic-assisted SVP-SPDP (RSVP-SPDP) remains unreported. This study sought to analyze the perioperative outcomes and learning curve of RSVP-SPDP by one single surgeon.

METHODS

Seventy-four patients who were intended to receive RSVP-SPDP at the First Affiliated Hospital of Sun Yat-sen University between May 2015 and January 2023 were included. The learning curve were retrospectively analyzed by using cumulative sum (CUSUM) analyses.

RESULTS

Sixty-two patients underwent RSVP-SPDP (spleen preservation rate: 83.8%). According to CUSUM curve, the operation time (median, 318 vs. 220 min; P < 0.001) and intraoperative blood loss (median, 50 vs. 50 mL; P = 0.012) was improved significantly after 16 cases. Blood transfusion rate (12.5% vs. 3.4%; P = 0.202), postoperative major morbidity rate (6.3% vs. 3.4%; P = 0.524), and postoperative length-of-stay (median, 10 vs. 8 days; P = 0.120) improved after 16 cases but did not reach statistical difference. None of the patients had splenic infarction or abscess postoperatively.

CONCLUSION

RSVP-SPDP was a safe and feasible approach for selected patients after learning curve. The improvement of operation time and intraoperative blood loss was achieved after 16 cases.

Prospective minimally invasive pancreatic resections from the IGOMIPS registry: a snapshot of daily practice in Italy on 1191 between 2019 and 2022

This retrospective analysis of the prospective IGOMIPS registry reports on 1191 minimally invasive pancreatic resections (MIPR) performed in Italy between 2019 and 2022, including 668 distal pancreatectomies (DP) (55.7%), 435 pancreatoduodenectomies (PD) (36.3%), 44 total pancreatectomies (3.7%), 36 tumor enucleations (3.0%), and 8 central pancreatectomies (0.7%). Spleen-preserving DP was performed in 109 patients (16.3%). Overall incidence of severe complications (Clavien-Dindo ≥ 3) was 17.6% with a 90-day mortality of 1.9%. This registry analysis provided some important information. First, robotic assistance was preferred for all MIPR but DP with splenectomy. Second, robotic assistance reduced conversion to open surgery and blood loss in comparison to laparoscopy. Robotic PD was also associated with lower incidence of severe postoperative complications and a trend toward lower mortality. Fourth, the annual cut-off of ≥ 20 MIPR and ≥ 20 MIPD improved selected outcome measures. Fifth, most MIPR were performed by a single surgeon. Sixth, only two-thirds of the centers performed spleen-preserving DP. Seventh, DP with splenectomy was associated with higher conversion rate when compared to spleen-preserving DP. Eighth, the use of pancreatojejunostomy was the prevalent reconstruction in PD. Ninth, final histology was similar for MIPR performed at high- and low-volume centers, but neoadjuvant chemotherapy was used more frequently at high-volume centers. Finally, this registry analysis raises important concerns about the reliability of R1 assessment underscoring the importance of standardized pathology of pancreatic specimens. In conclusion, MIPR can be safely implemented on a national scale. Further analyses are required to understand nuances of implementation of MIPR in Italy.

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.

[Spleen-preserving total pancreatectomy for low-grade tumors]

OBJECTIVE

To justify organ-preserving variants of total pancreatectomy.

MATERIAL AND METHODS

We retrospectively analyzed the results of classic and modified total pancreatectomy between September 2010 and March 2021. Implementing pylorus-sparing total pancreatectomy with preservation of stomach, spleen, gastric and splenic vessels, we thoroughly analyzed exocrine/endocrine disorders after total pancreatectomy and changes in immune status after splenectomy. Serum C-reactive protein and ferritin were assessed in 1, 3, 5, 7, 14 and 30 days after surgery in both groups. We also estimated daily glycemic profile after total pancreatectomy in classical and organ-preserving modifications.

RESULTS

We performed 37 total pancreatectomies including 12 pylorus-preserving total pancreatectomies with preservation of stomach, spleen, gastric and splenic vessels. General and specific postoperative complication rate was significantly lower after modified surgery compared to classic total pancreatectomy with gastric resection and splenectomy.

CONCLUSION

Modified total pancreatectomy is preferable for low-grade pancreatic tumors.

[Stomach and spleen preserving total pancreatectomy]

INTRODUCTION

Pancreatic surgery expands the indications and the use of total pancreatectomy. Considering a rather high rate of postoperative complications, the search for the ways to improve its outcomes is extremely relevant. The purpose of this study is justification and implementation of organ-preserving variants of total pancreatectomy.

MATERIAL AND METHODS

Retrospective analysis of treatment results after classic and modified total pancreatectomy in the surgical clinic of Botkin Hospital was performed from September 2010 to March 2021. During the development and implementation of pylorus-preserving total pancreatectomy with preservation of the stomach, spleen, gastric and splenic vessels, we thoroughly analyzed aspects of exocrine/endocrine disorders and changes of the immune status after performing the modified technique.

RESULTS

We performed 37 total pancreatectomies, including 12 pylorus-preserving total pancreatectomies with preservation of the stomach, spleen, gastric, and splenic vessels. General and specific postoperative complication rate in patients after the modified operation was significantly lower compared to the results of classic total pancreatectomy with gastric resection and splenectomy.

CONCLUSION

Modified total pancreatectomy is a method of choice for pancreatic tumors of low malignant potential.

Impact of spleen preservation on the incidence of postoperative pancreatic fistula after distal pancreatectomy: Is less more?

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a major complication after distal pancreatectomy (DP) with a significant impact on patients' quality of life. There is limited evidence that preservation of the spleen reduces the risk of POPF. Therefore, we aimed to investigate the impact of splenectomy on perioperative outcome.

METHODS

Data from patients who underwent DP for malignant and benign disease at our institution between 2004 and 2021 were reviewed. Patients were grouped according to spleen preservation (SP-DP) and splenectomy (DPS). Intraoperative parameters and postoperative outcomes were compared between groups. Univariable and multivariable analyses were used to investigate factors that influence the occurrence of clinically relevant (cr)POPF.

RESULTS

A total of 199 patients were included, of whom 61 (30.7%) patients underwent SP-DP. Patients who underwent SP-DP had a significantly lower rate of crPOPF (p = 0.022), shorter hospital stay (p = 0.003), and less readmissions (p = 0.012). On multivariate analysis, obesity (OR 2.88, p = 0.021), benign lesions (OR 2.35, p = 0.018), postoperative acute pancreatitis (OR 2.53, p = 0.028), and splenectomy (OR 2.83, p = 0.011) were independent risk factors associated with the onset of crPOPF.

DISCUSSION

Preservation of the spleen reduces the risk of crPOPF in patients undergoing distal pancreatectomy for benign and malignant disease.

Laparoscopic splenic vessel-preserving distal pancreatectomy after laparoscopic pylorus-preserving gastrectomy: A case report

A 77-year-old woman who had undergone laparoscopic pylorus-preserving gastrectomy for gastric cancer showed dilatation of the main pancreatic duct in the distal pancreas on ultrasonography during postoperative surveillance. Detailed examination revealed that she had a main-duct type intraductal papillary mucinous neoplasm with high-risk stigmata. As invasive malignancy was not suggested, laparoscopic splenic vessel-preserving distal pancreatectomy was performed to preserve the remnant stomach. Although adhesions around the gastroduodenostomy and splenic artery were severe, the magnified laparoscopic view facilitated the identification of appropriate dissection layers, resulting in limited blood loss. The distal pancreas was successfully resected without sacrificing blood flow to the remnant stomach. The postoperative course was uneventful. The pathological diagnosis was low-grade intraductal papillary mucinous neoplasm. Laparoscopic splenic vessel-preserving distal pancreatectomy for benign or low-grade malignant disease of the distal pancreas can be useful for preserving the remnant stomach in patients with a history of gastrectomy.

401 consecutive minimally invasive distal pancreatectomies: lessons learned from 20 years of experience

BACKGROUND

This study aimed to discuss and report the trend, outcomes, and learning curve effect after minimally invasive distal pancreatectomy (MIDP) at two high-volume centres.

METHODS

Patients undergoing MIDP between January 1999 and December 2018 were retrospectively identified from prospectively maintained electronic databases. The entire cohort was divided into two groups constituting the "early" and "recent" phases. The learning curve effect was analyzed for laparoscopic (LDP) and robotic distal pancreatectomy (RDP). The follow-up was at least 2 years.

RESULTS

The study population included 401 consecutive patients (LDP n = 300, RDP n = 101). Twelve surgeons performed MIDP during the study period. Although patients were more carefully selected in the early phase, in terms of median age (49 vs. 55 years, p = 0.026), ASA class higher than 2 (3% vs. 9%, p = 0.018), previous abdominal surgery (10% vs. 34%, p < 0.001), and pancreatic adenocarcinoma (PDAC) (7% vs. 15%, p = 0.017), the recent phase had similar perioperative outcomes. The increase of experience in LDP was inversely associated with the operative time (240 vs 210 min, p < 0.001), morbidity rate (56.5% vs. 40.1%, p = 0.005), intra-abdominal collection (28.3% vs. 17.3%, p = 0.023), and length of stay (8 vs. 7 days, p = 0.009). Median survival in the PDAC subgroup was 53 months.

CONCLUSION

In the setting of high-volume centres, the surgical training of MIDP is associated with acceptable rates of morbidity. The learning curve can be largely achieved by several team members, improving outcomes over time. Whenever possible resection of PDAC guarantees adequate oncological results and survival.

Safety and Feasibility of Single-incision Laparoscopic Distal Pancreatectomy

BACKGROUND

Comparative studies regarding single-incision laparoscopic distal pancreatectomy (SILS-DP) are limited. This study aimed to compare the short-term outcomes of SILS-DP with conventional laparoscopic DP (C-LDP) under strict indication criteria.

MATERIALS AND METHODS

We retrospectively reviewed the patient characteristics and surgical outcomes of those who underwent either SILS-DP or C-LDP at National Taiwan University (NTU) and C-LDP at Nara Medical University (NMU) between 2009 and 2019. SILS-DP was indicated for benign or low-grade malignant pancreatic tail tumors and was performed along with splenectomy.

RESULTS

We compared 12 cases of SILS-DP with 31 of C-LDP from NTU and 17 of C-LDP from NMU. Patients in the SILS-DP group had significantly less blood loss than the C-LDP group at NTU (P=0.028). Postoperative outcomes, including the postoperative hospital stay and clinically relevant pancreatic fistula, were not significantly different between the 2 groups. Although SILS-DP was performed by a surgeon who was well-experienced with laparoscopic surgeries, the first few cases had a larger amount of blood loss, longer operation time, and a higher rate of complications. Such unfavorable outcomes were likely to be resolved shortly. No reoperations and deaths were noted.

CONCLUSION

SILS-DP is feasible when performed by an experienced surgeon and in carefully selected patients.

Current status and perspectives of the future of pancreatic surgery: Establishment of evidence by integration of "art" and "science"

Pancreatic cancer surgery continues to be associated with a high operative morbidity rate, poor long-term survival outcomes, and various challenges in obtaining high-level evidence. Not only is the early postoperative morbidity rate high, but also late morbidity involves lifelong nutritional support for long-term survivors. Due to poor survival outcomes even after curative surgery, pancreatic surgeons have doubts about the role of surgery as the definitive treatment for pancreatic cancer. Additionally, conducting clinical trials to obtain high-level evidence in the field of pancreatic surgery is difficult, and the results have only had a moderate impact on clinical practice due to skepticism regarding their quality. Therefore, quality evidence regarding the extent of resection, mode of approach to dissection, reconstruction methods for pancreatico-enteric anastomosis, determination of resectability, timing of surgery, and the definition of the resection margin is lacking. However, numerous innovative pancreatic surgical procedures have been developed, which may aptly have been called "art" when they were first introduced, regardless of whether they subsequently were supported by scientific evidence. In this review, we provide recent examples of the integration of art and science in the field of pancreatic surgery, which illustrate how the creative ideas of pancreatic surgeons evolved into generally accepted clinical practice. Pancreatic surgeons should be considered "surgical artists," "surgical scientists," and "surgical practitioners." We look forward to more "surgical artists" educating future "surgical artists and scientists" to create a richer "spirit of innovation," leading to a more beautiful integration of art and science in the field of pancreatic surgery.

International Expert Consensus on Precision Anatomy for minimally invasive distal pancreatectomy: PAM-HBP Surgery Project

BACKGROUND

Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy-based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021).

METHODS

Twenty-five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting.

RESULTS

Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts.

CONCLUSIONS

The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.

Indocyanine green (ICG) fluorography and digital subtraction angiography (DSA) of vessels supplying the remnant stomach that were performed during distal pancreatectomy in a patient with a history of distal gastrectomy: a case report

A 68-year-old man who had undergone distal gastrectomy for gastric cancer 3 years previously, presented to our hospital for examination of dilatation of the main pancreatic duct on follow-up computed tomography and magnetic resonance cholangiopancreatography. After examination, he was diagnosed with early-stage pancreatic cancer and distal pancreatectomy (DP) was planned. With informed consent, we performed indocyanine green (ICG) fluorography during DP and digital subtraction angiography (DSA) of vessels supplying the remnant stomach immediately before and after DP. On ICG fluorography, the remnant stomach gradually became fluoresced starting at the area of the lesser curvature, and the fluorescence eventually intensified over the entire area of the remnant stomach to the same brightness as that of the liver and duodenum. On DSA following DP, the terminal branches of the left inferior phrenic artery (LIPA) were distributed to more than half of the area of the remnant stomach, centering around the proximal area. It is useful to confirm blood flows to the remnant stomach by ICG fluorography using a near-infrared imaging camera during DP. We found that the LIPA played an important role in maintaining the blood supply to the remnant stomach in the absence of the left gastric artery and splenic artery.

Short- and long-term outcomes after minimally invasive versus open spleen-saving distal pancreatectomies

Introduction:

This study aimed to compare the perioperative outcomes of patients who underwent minimally invasive spleen-preserving distal pancreatectomy (MI-SPDP) versus open surgery SPDP (O-SPDP). It also aimed to determine the long-term vascular patency after spleen-saving vessel-preserving distal pancreatectomies (SSVDPs).

Methods:

A retrospective review of 74 patients who underwent successful SPDP and met the study criteria was performed. Of these, 67 (90.5%) patients underwent SSVDP, of which 38 patients (21 open, 17 MIS) had adequate long-term post-operative follow-up imaging to determine vascular patency.

Results:

Fifty-one patients underwent open SPDP, whereas 23 patients underwent minimally invasive SPDP, out of which 10 (43.5%) were laparoscopic and 13 (56.5%) were robotic. Patients who underwent MI-SPDP had significantly longer operative time (307.5 vs. 162.5 min, P = 0.001) but shorter hospital stay (5 vs. 7 days, P = 0.021) and lower median blood loss (100 vs. 200 cc, P = 0.046) compared to that of O-SPDP. Minimally-invasive spleen-saving vessel-preserving distal pancreatectomy (MI-SSVDP) was associated with poorer long-term splenic vein patency rates compared to O-SSVDP (P = 0.048). This was particularly with respect to partial occlusion of the splenic vein, and there was no significant difference between the complete splenic vein occlusion rates between the MIS group and open group (29.4% vs. 28.6%, P = 0.954). The operative time was statistically significantly longer in patients who underwent robotic surgery versus laparoscopic surgery (330 vs. 173 min, P = 0.008).

Conclusion:

Adoption of MI-spleen-preserving distal pancreatectomy (SPDP) is safe and feasible. MI-SPDP is associated with a shorter hospital stay, lower blood loss but longer operation time compared to O-SPDP. In the present study, MI-SSVDP was associated with poorer long-term splenic vein patency rates compared to O-SSVDP.

Surgical approaches for minimally invasive distal pancreatectomy: A systematic review

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) was initially performed for benign tumors, but recently its indications have steadily broadened to encompass other conditions including pancreatic malignancies. Thorough anatomical knowledge is mandatory for precise surgery in the era of minimally invasive surgery. However, expert consensus regarding anatomical landmarks to facilitate the safe performance of MIDP is still lacking.

METHODS

A systematic literature search was performed using keywords to identify articles regarding the vascular anatomy and surgical approaches/techniques for MIDP.

RESULTS

All of the systematic reviews revealed that MIDP was not associated with an increase in postoperative complications. Moreover, most showed that MIDP resulted in less blood loss than open surgery. Regarding surgical approaches for MIDP, a standardized stepwise procedure improved surgical outcomes, including blood loss, operative time, and major complications. There are two approaches to the splenic vessels, superior and inferior; however, no study has ever directly compared them with respect to clinical outcomes. The morphology of the splenic artery affects the difficulty of approaching the artery's root. To select an appropriate dissecting layer when performing posterior resection, thorough knowledge of the anatomy of the fascia, left renal vein/artery, and left adrenal gland is needed.

CONCLUSIONS

In MIDP, a standardized approach and precise knowledge of anatomy facilitates safe surgery and has the advantage of a shorter learning curve. Anatomical features and landmarks are particularly important in cases of radical MIDP and splenic vessel preserving MIDP.

Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP.

METHODS

A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology.

RESULTS

Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found.

CONCLUSIONS

The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.

Laparoscopic real-time vessel navigation using indocyanine green fluorescence during the laparoscopic-Warshaw technique: First clinical experience

Background:

Laparoscopic-Warshaw technique (lap-WT) may be selected as a function-preserving operation for malignant border lesions in the tail region of the pancreas. However, previous reports showed that there are complications such as infection and abscess formation due to lack of blood flow to the spleen after surgery. To overcome the problems, we have performed real-time vessel navigation by using indocyanine green (ICG) fluorescence during lap-WT.

Materials and Methods:

We report our experience of three patients with pancreatic tumour who underwent real-time vessel navigation during lap-WT at Hokkaido University from May 2017 to September 2018.

Results:

The median operating time was 339 min (174–420). The median intraoperative bleeding was 150 ml (0–480). There were no incidences of complications. There were no cases with post-operative spleen ischaemia or abscess formation and varices formation.

Conclusion:

We believe that laparoscopic real-time vessel navigation using indocyanine green fluorescence during lap-WT could contribute in reducing the post-operative spleen-related complications.

"Kimura-first" strategy for robotic spleen-preserving distal pancreatectomy: experiences from 61 consecutive cases in a single institution

Background

Robotic spleen-preserving distal pancreatectomy (RSPDP) is an ideal procedure for benign and low-grade malignant tumors in the distal pancreas, and two splenic preservation techniques (the Kimura and Warshaw techniques) can be used for RSPDP. This study aimed to evaluate the feasibility and safety of the "Kimura-first" strategy for RSPDP and to investigate the risk factors affecting the preservation of the spleen and splenic vessels.

Methods

The electronic medical records of patients who underwent robotic distal pancreatectomy (RDP) between October 2016 and December 2019 at our institution were retrospectively reviewed. Univariate and multivariate analyses were conducted to identify the risk factors influencing preservation of the spleen and splenic vessels during RDP.

Results

Sixty-one patients scheduled for RSPDP who received RDP were included in this study [Kimura technique, 41 patients; Warshaw technique, 11 patients; and robotic distal pancreatectomy with splenectomy (RDPS), 9 patients]. The overall splenic preservation rate with RDP was 85.2% (52/61). The preservation rate of splenic vessels with the Kimura technique with RSPDP was 78.8% (41/52). The RSPDP group had remarkably less estimated blood loss (EBL; median 50 vs. 300 mL, P=0.000) and a lower morbidity rate (13.5% vs. 44.4%, P=0.047) than the RDPS group. The logistic regression models showed that obvious splenic vessel compression by the tumor was an independent risk factor for splenic vessel preservation with RSPDP (OR 0.021, 95% CI: 0.002-0.271, P=0.003) and RDP (OR 0.019, 95% CI: 0.002-0.176, P=0.000).

Conclusions

The "Kimura-first" strategy is feasible and safe for RSPDP, with high rates of splenic and splenic vessel preservation. Obvious splenic vessel compression by the tumor can be used as a predictor of splenic vessel preservation with planned RDP.

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.

Application of a preoperative image scoring system in laparoscopic spleen-preserving distal pancreatectomy

BACKGROUND

A reasonable surgical plan is crucial to laparoscopic spleen-preserving distal pancreatectomy. This study proposed a preoperative image classification and scoring system, then evaluated the predictive value in creating a spleen-preserving strategy.

METHODS

Data for patients who underwent laparoscopic spleen-preserving distal pancreatectomy at our hospital were collected from a prospective database. Clinical parameters and preoperative images were reviewed and analysed.

RESULTS

We included 58 cases, and patients underwent the Kimura procedure (n = 29) or the Warshaw procedure (n = 29). According to the relationship between the tumour and the splenic vein in preoperative images, we proposed an image classification constituting four types. In the univariate analysis, age, tumour size, length of the distal pancreas to the left of the tumour and the image classification were significantly associated with spleen-preservation methods. Multivariate analysis indicated that tumour size and image classifications were independent factors. We established a scoring system by combining these two factors and scored and classified patients into four groups as 0, 61, 100 and 161 points. The probabilities of spleen-preservation procedures corresponding to different points were then calculated.

CONCLUSION

This preoperative image classification and scoring system might be helpful when creating a spleen-preserving strategy during laparoscopic distal pancreatectomy.

Comparison of clinical outcomes and quality of life between laparoscopic distal pancreatectomy with or without spleen preservation

BACKGROUND

The studies comparing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and laparoscopic distal pancreatosplenectomy (LDPS) are limited. This study aimed to compare clinical outcomes and quality of life of patients undergoing LSPDP and LDPS.

METHODS

Between March 2004 and December 2014, patients who underwent laparoscopic distal pancreatectomy were reviewed. Patients were divided into 2 groups as LSPDP and LDPS. Data considered for comparison analysis were patient demographics, intraoperative variables, morbidity, postoperative hospital stay, mortality, pathologic findings, and quality of life (SF-36 questionnaire).

RESULTS

A total of 110 patients (50 LSPDP and 60 LDPS) were included in the final analysis. Baseline characteristics were similar in the 2 groups. The LSPDP group had a significantly shorter operative time(153.3 ± 46.2 vs. 179.9 ± 54.1 min, p = 0.015) than the LDPS group. Also in analysis of propensity-matched population(LSPDP:LDPS = 35:35, 1:1 matching), LSPDP group still had a significantly shorter operative time (159.3 ± 36.2 vs. 172.9 ± 44.1 min, p = 0.045) than the LDPS group.There were no significant differences with respect to estimated blood loss, first flatus time, diet start time, and postoperative hospital stay. Postoperative outcomes, including morbidity, pancreatic fistula rates, and mortality, were similar in the LSPDP and LDPS group. On the follow-up survey, the total quality of life score (635.8 ± 50.7 vs. 596.1 ± 92.1)was higher in the LSPDP group compared with the LDPS group. However, the differences were not statistically significant(p > 0.05). The score in vitality (82.5 ± 14.4 vs. 68.9 ± 11.4, p = 0.046) was significantly higher in LSPDP group and not statistically significant in other areas (p > 0.05).Similar results of quality of life assessment were found in analysis of propensity-matched population.

CONCLUSIONS

Compared to LDPS, LSPDP had shorter operating time and better quality of life with similar morbidity and recovery period.

Laparoscopic spleen-preserving distal pancreatectomy for a solid-cystic intraabdominal desmoid tumor at a gastro-pancreatic lesion: a case report

Background

We report a case of an intraabdominal desmoid tumor that occurred at a gastro-pancreatic lesion with spontaneous cystic features, and present the successful laparoscopic resection of the tumor.

Case presentation

A 20-mm retroperitoneal cystic mass with a solid component was found adjacent to the stomach and pancreatic body in a 52-year-old woman with no history of familial adenomatous polyposis. Laparoscopic spleen-preserving distal pancreatectomy with wedge resection of the stomach was performed, and complete resection was achieved without intraoperative and postoperative complications. Histopathological examination by immunohistochemistry enabled diagnosis of a desmoid tumor that had originated from the stomach and invaded the pancreatic parenchyma with a spontaneous cystic change. We herein report an extremely rare case of an intraabdominal desmoid tumor with a spontaneous cystic change.

Conclusion

Regardless of its rarity, desmoid tumor should be included in the preoperative differential diagnosis of a cystic intraabdominal mass, and laparoscopic function-preserving surgery may be an optimal treatment option.

The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors

This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.

LAPAROSCOPIC DISTAL PANCREATECTOMY WITH OR WITHOUT SPLEEN PRESERVATION: COMPARATIVE ANALYSIS OF SHORT AND LONG-TERM OUTCOMES

Background:

Laparoscopic distal pancreatectomy (LDP) is the preferred approach for resection of tumors in the distal pancreas because of its many advantages over the open approach.

Aim:

To analyse and compare short and long-term outcomes from LDP performed through two different techniques: with splenectomy vs. spleen preservation and splenic vessel preservation.

Method:

Fifty-eight patients were operated and subsequently divided between two groups: Group 1, LDP with splenectomy (LDPS); and Group 2, LDP with spleen preservation and preservation of splenic vessels (LDPSPPSV).

Results:

The epidemiological characteristics were statistically similar between the two groups (age, gender, BMI and lesion size). Both the mean of operative time (p=0.04) and the mean of intra-operative blood loss (p=0,03) were higher in Group 1. The mean of resected lymph nodes was also higher in Group 1 (p<0.000). There were no statistic differences between the groups in relation to open conversion, morbidity or early postoperative mortality. The mean hospital stay was similar between groups. Pancreatic fistula (grade B and C) was similar between the groups. The mean of overall follow-up was 37.6 months (5-96). Late complications were similar between the groups.

Conclusion:

Both techniques were superimposable; however, LDPS presented, respectively, higher intra-operative bleeding, longer duration of the operation and higher number of lymph nodes resected. No differences were observed in the studied period in relation to the appearance of infections or neoplasm related to splenectomy during follow-up. Maintenance of the spleen avoided periodic immunizations in patients in LDPSPSV. It is indicated in small pancreatic lesions with indolent course.

A multicenter prospective registration study on laparoscopic pancreatectomy in Japan: report on the assessment of 1,429 patients

BACKGROUND

Prospective studies are needed to understand the safety and feasibility of laparoscopic pancreatectomy. The aim of the present study was to describe laparoscopic pancreatectomy currently undertaken in Japan, using a prospective registration system.

METHODS

Patient characteristics and planned operations were registered preoperatively, and then the performed operation and outcomes were reported using an online system. Collected data were also compared between institutions based on their level of experience. This study was registered with UMIN000022836.

RESULTS

Available data were obtained from 1,429 patients at 100 Japanese institutions, including 1,197 laparoscopic distal pancreatectomies (LDPs) and 232 laparoscopic pancreatoduodenectomies (LPDs). The rates of completion for planned operations were 92% for LDP and 91% for LPD. Postoperative complication rates after LDP and LPD were 17% and 30%, and 90-day mortality rates were 0.3% and 0.4%, respectively. Shorter operation time, less blood loss, and lower incidence of pancreatic fistula were observed in institutions experienced in LDP. A higher rate of pure laparoscopic procedure and shorter operation time were noted in institutions experienced with LPD.

CONCLUSION

LDPs and LPDs are performed safely in Japan, especially in experienced institutions. Our data could support the next challenges in the field of laparoscopic pancreatectomy.

Position of the Pancreas Division Line and Postoperative Outcomes After Distal Pancreatectomy

BACKGROUND

In distal pancreatectomy (DP), the position of the pancreas division line (PDL) changes depending on the location or nature of the tumor. Here, we investigated the relationship between PDL and postoperative complications after DP.

METHODS

We retrospectively analyzed data of 140 patients who underwent DP at Tokyo Medical and Dental University Hospital between January 2011 and September 2018. PDL was defined as the distance from the left margin of the portal vein to the edge of the pancreatic stump on the coronal plane of computed tomography.

RESULTS

The mean PDL was 15.1 (range 0-74.3) mm. PDL was significantly longer in patients with portal venous system thrombosis (PVST) than in those without PVST (47.6 vs. 0 mm, p < 0.001). The PDL_long (≥ 20 mm) group underwent surgery with a significantly shorter duration (253 vs. 294 min, p < 0.001) and experienced a lower volume of blood loss (20 vs. 256.5 mL, p < 0.001) than the PDL_short (< 20 mm) group. Six months after surgery, the increase in HbA1c level was significantly higher in the PDL_short group than in the PDL_long group (0.5 vs. 0.35%, p = 0.041). Except for PVST, there was no significant difference in postoperative complications between the two groups.

CONCLUSIONS

In DP, pancreas resection with a longer PDL resulted in a significantly shorter duration of surgery, lower estimated blood loss, and superior glucose tolerance than that with a shorter PDL.

Central pancreatectomy: a comprehensive, up-to-date meta-analysis

BACKGROUND

Central pancreatectomy (CP) is the alternative to distal pancreatectomy (DP) for specific pathologies of the mid-pancreas. However, the benefits of CP over DP remain controversial. This study aims to compare the two procedures by conducting a meta-analysis of all published papers.

METHODS

A systematic search of original studies comparing CP vs. DP was performed using PubMed, Scopus, and Cochrane Library databases up to June 2018. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was followed.

RESULTS

Twenty-one studies were included (596 patients with CP and 1070 patients with DP). Compared to DP, CP was associated with significantly higher rates of overall and severe morbidity (p < 0.0001), overall and clinically relevant pancreatic fistula (p < 0.0001), postoperative hemorrhage (p = 0.02), but with significantly lower incidences of new-onset (p < 0.0001) and worsening diabetes mellitus (p = 0.004). Furthermore, significantly longer length of hospital stay (p < 0.0001) was observed for CP patients.

CONCLUSIONS

CP is superior to DP regarding the preservation of pancreatic functions, but at the expense of significantly higher complication rates and longer hospital stay. Proper selection of patients is of utmost importance to maximize the benefits and mitigate the risks of CP.

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.

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.

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.

Precision Technique for Splenectomy Limits Mouse Stress Responses for Accurate and Realistic Measurements for Investigating Inflammation and Immunity

Splenectomy in an animal model requires a standardized technique utilizing best practice to avoid variability which can result in adverse impact to the animal resulting in flawed physiologic responses simply due to technique rather than to the studied variables. In the case of the spleen, often investigators are analyzing the animal immune or inflammatory responses. Surgical splenectomy involves many variables from the training and expertise of the surgeon, which directly correlates to surgical technique to the length of operation and ease of the procedure. This operation, in turn, impacts blood loss and insensible fluid losses, sterile technique, unintended trauma to the spleen and surrounding organs, the length of the incision and the duration of the operation with more prolonged exposure to anesthetic agents. All these variables ultimately play a significant role in the experiment since they directly affect the response of the model in terms of inflammation, immune activation, or even suppression. Undesired variables such as these go unnoticed and lead to inaccurate and misleading data.