Proposal for splenectomy-omitting radical distal pancreatectomy in well-selected left-sided pancreatic cancer: multicenter survey 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.

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.

Clinical course of pancreas cancer diagnosed after spleen-preserving distal pancreatectomy with borderline lesion: two case reports

Distal pancreatectomy with splenectomy is considered the standard operation for pancreas tail and body cancer. However, splenectomy may be option for benign or low-grade malignant tumors including mucinous cystadenoma and intraductal papillary mucinous neoplasm. If spleen-preserving distal pancreatectomy (SPDP) with borderline lesion is performed and pancreas cancer is diagnosed on postoperative pathologic finding, if it is R0 resection, the necessity of additional splenectomy remains questionable. The authors would like report two clinical cases diagnosed as pancreatic cancer on postoperative pathology after SPDP and under observation without additional splenectomy.

Spleen-preserving pancreatectomy with removal of splenic vessels: impact on splenic parenchyma ?

BACKGROUND

While outcomes after spleen-preserving distal pancreatectomy (SP-DP) have been widely reported, impacts on splenic parenchyma have not been well studied. This study aimed to compare postoperative outcomes, particularly spleen-related outcomes, by assessing splenic imaging after SP-DP with or without splenic vessels removal.

METHODS

Data for all patients who underwent SP-DP with splenic vessels removal (Warshaw technique, WDP) or preservation (Kimura technique, KDP) between 2010 and 2022 in two tertiary centres were retrospectively analysed. Splenic ischemia and volume at early/late imaging and postoperative outcomes were reviewed.

RESULTS

Eighty-seven patients were included, 51 in the WDP and 36 in the KDP groups. Median Charlson's Comorbidity Index was significantly higher in the WDP group compared with the KDP group. Postoperative morbidity was similar between groups. There was more splenic ischemia at early imaging in the WDP group compared to the KDP group (55% vs. 14%, p = 0.018), especially severe ischemia (23% vs. 0%). Partial splenic atrophy was observed in 29% and 0% in the WDP and KDP groups, respectively (p = 0.002); no complete splenic atrophy was observed. Platelet levels at POD 1, 2 and 6 were significantly higher in the WDP group compared to KDP group. At univariate analysis, age, Charlson Comorbidity Index, platelet levels at POD 6, and early splenic infarction were prognostic factors for development of splenic atrophy. No episodes of overwhelming post-splenectomy infection or secondary splenectomy were recorded after a median follow-up of 9 and 11 months in the WDP and KDP groups, respectively.

CONCLUSIONS

Splenic ischemia appeared in one-half of patients undergoing SP-DP with splenic vessels removal at early imaging, and partial splenic atrophy in almost 30% at late imaging, without clinical impact or complete splenic atrophy. Age, Charlson Comorbidity Index, platelet levels at POD 6, and early splenic infarction could help to predict the occurrence of splenic atrophy.

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.

Appropriate Lymph Node Dissection Sites for Cancer in the Body and Tail of the Pancreas: A Multicenter Retrospective Study

Distal pancreatectomy (DP) with lymphadenectomy is the standard surgery for pancreatic body-tail cancer. However, the optimal lymph node (LN) dissection area for DP remains controversial. Thus, we evaluated the frequency and patterns of LN metastasis based on the tumor site. In this multicenter retrospective study, we examined 235 patients who underwent DP for pancreatic cancer. Tumor sites were classified as confined to the pancreatic body (Pb) or pancreatic tail (Pt). The efficacy index (EI) was calculated by multiplying the frequency of metastasis to each LN station by the five-year survival rate of patients with metastasis to that station. LN metastasis occurred in 132/235 (56.2%) of the patients. Patients with Pb tumors showed no metastasis to the splenic hilum LN. Distal splenic artery LNs and anterosuperior/posterior common hepatic artery LNs did not benefit from dissection for Pb and Pt tumors, respectively. In multivariate analysis, splenic artery LN metastasis was identified as an independent predictor of poor overall survival in patients with pancreatic body-tail cancer. In conclusion, differences in metastatic LN sites were evident in pancreatic body-tail cancers confined to the Pb or Pt. Spleen-preserving pancreatectomy might be feasible for Pb cancer.

Extensive (subtotal) distal pancreatectomy for pancreatic ductal adenocarcinoma: a propensity score matched cohort study of short- and long-term outcomes compared with those of conventional distal pancreatectomy

PURPOSE

Extensive distal pancreatectomy (ExDP) can transect the pancreatic parenchyma more from the right side than conventional distal pancreatectomy (CDP) can. This study aimed to evaluate the short- and long-term outcomes of ExDP for pancreatic ductal adenocarcinoma (PDAC) of the pancreatic body, located adjacent to the portal vein (PV).

METHODS

Medical records of 98 patients who underwent ExDP (n = 15) or CDP (n = 83) for PDAC were retrospectively reviewed. Short- and long-term outcomes of the two groups were compared. Propensity score matched analysis was additionally performed to minimize the impact of treatment allocation bias.

RESULTS

In the total cohort, the CDP group had a significantly higher proportion of pancreatic tail lesions (P < 0.01), higher proportion of males, and larger tumor size. Of the 15 patients who underwent ExDP, 11 could be matched. These differences of patients' characteristics were not observed after matching. Before and after matching, the duration of surgery, blood loss, rate of morbidity including pancreatic fistula, and postoperative course were comparable between the groups. The rate of recurrence and recurrence pattern were also not significantly different between the groups. ExDP for PDAC of the pancreatic body near the PV did not increase local or lymph node recurrence. The disease-free and overall survival did not differ between the groups.

CONCLUSIONS

Surgical and oncological outcomes after ExDP for PDAC were acceptable and comparable to those after CDP. ExDP is a feasible procedure, and could be an option for the treatment of PDAC of the pancreatic body near PV.

Feasibility and safety of robotic-assisted total pancreatectomy: a pilot western series

This study was designed to demonstrate non-inferiority of robot-assisted total pancreatectomy (RATP) to open total pancreatectomy (OPT) based on an intention-to-treat analysis, having occurrence of severe post-operative complications (SPC) as primary study endpoint. The two groups were matched (2:1) by propensity scores. Assuming a rate of SPC of 22.5% (non-inferiority margin: 15%; α: 0.05; β: 0.20; power: 80%), a total of 25 patients were required per group. During the study period (October 2008–December 2019), 209 patients received a total pancreatectomy. After application of exclusion and inclusion criteria, matched groups were extracted from an overall cohort of 132 patients (OPT: 107; RATP: 25). Before matching, the two groups were different with respect to prevalence of cardiac disease (24.3% versus 4.0%; p = 0.03), presence of jaundice (45.8% versus 12.0%; p = 0.002), presence of a biliary drainage (23.4% versus 0; p  = 0.004), history of weight loss (28.0% versus 8.0%; p = 0.04), and vein involvement (55.1% versus 28.0%) (p = 0.03). After matching, the two groups (OTP: 50; RATP: 25) were well balanced. Regarding primary study endpoint, SPC developed in 13 patients (26.0%) after OTP and in 6 patients (24.0%) after RATP (p = 0.85). Regarding secondary study endpoints, RATP was associated with longer median operating times [475 (408.8–582.5) versus 585 min (525–637.5) p = 0.003]. After a median follow-up time of 23.7 months (10.4–71), overall survival time [22.6 (11.2–81.2) versus NA (27.3–NA) p = 0.006] and cancer-specific survival [22.6 (11.2–NA) versus NA (27.3–NA) p = 0.02] were improved in patients undergoing RATP. In carefully selected patients, robot-assisted total pancreatectomy is non-inferior to open total pancreatectomy regarding occurrence of severe post-operative complications.

Human splenic TER cells: A relevant prognostic factor acting via the artemin-GFRα3-ERK pathway in pancreatic ductal adenocarcinoma

Splenectomy is routinely performed during distal or total pancreatectomy (DP or TP) for pancreatic ductal adenocarcinoma (PDAC), but information about its oncological value is limited. TER cells, nonimmune cells discovered in the spleens of tumour-bearing mice, are elicited by tumours and promote tumour progression, while their role in the clinical outcomes of patients with PDAC remains unclear. In our study, postoperative specimens from 622 patients who underwent DP or TP with splenectomy were analysed by flow cytometry or immunofluorescence, and the relationship between splenic TER cell count and clinical parameters was calculated. We also purified human TER cells for functional experiments and mechanistic studies. We found that TER cell numbers were increased only in the spleens of patients with PDAC but not in PDAC tissue and adjacent pancreatic tissue. High splenic TER cell counts independently predicted poor prognosis (P < .001) and indicated large tumour size, lymph node metastasis, advanced 8th AJCC/mAJCC stage and high CA19-9 classification (all P < .050) in patients with PDAC. Mechanistic analysis showed that TER cells express artemin, which facilitates the proliferation and invasion of PDAC cells by activating GFRα3-ERK signalling. Our study reveals that TER cell count is an indicator of poor prognosis of PDAC, while splenectomy during pancreatic surgery might provide oncological benefits in addition to ensuring the radical resection of PDAC.

Improvement in distal pancreatectomy for tumors in the body and tail of the pancreas

Background

Pancreatic resections are complex and technically challenging surgical procedures. They often come with potential limitations to high-volume centers. Distal pancreatectomy is a relatively simple procedure in most cases. It facilitates the development of up-to-date minimally invasive surgical procedures in pancreatic surgery including laparoscopic distal pancreatectomy and robot-assisted distal pancreatectomy.

Main body

To obtain a desirable long-term prognosis, R0 resection and adequate lymphadenectomy are crucial to the surgical management of pancreatic cancer, and they demand standard procedure and multi-visceral resection if necessary. With respect to combined organ resection, progress has been made in evaluating and determining when and how to preserve the spleen. The postoperative pancreatic fistula, however, remains the most significant complication of distal pancreatectomy, with a rather high incidence. In addition, a safe closure of the pancreatic remnant persists as an area of concern. Therefore, much efforts that focus on the management of the pancreatic stump have been made to mitigate morbidity.

Conclusion

This review summarized the historical development of the techniques for pancreatic resections in recent years and describes the progress. The review eventually looked into the controversies regarding distal pancreatectomy for tumors in the body and tail of the pancreas.

Partial pancreatic tail preserving subtotal pancreatectomy for pancreatic cancer: Improving glycemic control and quality of life without compromising oncological outcomes

BACKGROUND

Total pancreatectomy (TP) is usually considered a therapeutic option for pancreatic cancer in which Whipple surgery and distal pancreatectomy are undesirable, but brittle diabetes and poor quality of life (QoL) remain major concerns. A subset of patients who underwent TP even died due to severe hypoglycemia. For pancreatic cancer involving the pancreatic head and proximal body but without invasion to the pancreatic tail, we performed partial pancreatic tail preserving subtotal pancreatectomy (PPTP-SP) in selected patients, in order to improve postoperative glycemic control and QoL without compromising oncological outcomes.

AIM

To evaluate the efficacy of PPTP-SP for patients with pancreatic cancer.

METHODS

We retrospectively reviewed 56 patients with pancreatic ductal adenocarcinoma who underwent PPTP-SP (n = 18) or TP (n = 38) at our institution from May 2014 to January 2019. Clinical outcomes were compared between the two groups, with an emphasis on oncological outcomes, postoperative glycemic control, and QoL. QoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30 and EORTC PAN26). All patients were followed until May 2019 or until death.

RESULTS

A total of 56 consecutive patients were enrolled in this study. Perioperative outcomes, recurrence-free survival, and overall survival were comparable between the two groups. No patients in the PPTP-SP group developed cancer recurrence in the pancreatic tail stump or splenic hilum, or a clinical pancreatic fistula. Patients who underwent PPTP-SP had significantly better glycemic control, based on their higher rate of insulin-independence (P = 0.014), lower hemoglobin A1c (HbA1c) level (P = 0.046), lower daily insulin dosage (P < 0.001), and less frequent hypoglycemic episodes (P < 0.001). Global health was similar in the two groups, but patients who underwent PPTP-SP had better functional status (P = 0.036), milder symptoms (P = 0.013), less severe diet restriction (P = 0.011), and higher confidence regarding future life (P = 0.035).

CONCLUSION

For pancreatic cancer involving the pancreatic head and proximal body, PPTP-SP achieves perioperative and oncological outcomes comparable to TP in selected patients while significantly improving long-term glycemic control and QoL.

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.

Reappraisal of nodal staging and study of lymph node station involvement in distal pancreatectomy for body-tail pancreatic ductal adenocarcinoma

BACKGROUND

The pattern of nodal spread in body-tail pancreatic ductal adenocarcinoma (PDAC) has been poorly investigated. This study analyzed the characteristics of lymph node (LN) involvement and the prognostic role of nodal metastases stratified by LN stations.

METHODS

All upfront distal pancreatectomies (DPs) for PDAC (2000-2017) with complete information on station 8,10,11, and 18 were included. Clinico-pathological correlates and survival were investigated using uni- and multivariable analyses.

RESULTS

Among 100 included patients, 28 were N0, 42 N1 and 30 N2. The median number of examined LN was 32 (IQR 26-44). Tumor size at preoperative imaging increased across N-classes. Preoperative size >27.5 mm was associated with N2 status. The frequency of nodal metastases at stations 8, 9, 10, 11, and 18 was 12.0%, 10.9%, 3.0%, 71.0%, and 19%, respectively. The pattern of LN spread was independent from primary tumor location (with tail tumors metastasizing to station 8/9 and body tumors to station 10), while it was highly associated with N-class. At multivariable analysis, tumor grading, adjuvant treatment, station 9 and 10 metastases were independent prognostic factors in node-positive patients.

CONCLUSIONS

In patients undergoing upfront DP for PDAC preoperative tumor size is associated with the degree of nodal spread. While station 11 was the most frequently involved, only station-9 and 10 metastases were independent prognostic factors. The site of nodal metastases was somewhat unpredictable based on tumor location. This data has potential implications for allocating patients to neoadjuvant treatment and supports the performance of routine splenectomy during DP for PDAC.

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.

Is Routine Splenectomy Justified for All Left-Sided Pancreatic Cancers? Histological Reappraisal of Splenic Hilar Lymphadenectomy

BACKGROUND

Although splenectomy is recommended during resection for left-sided resectable pancreatic ductal adenocarcinoma (PDAC) to perform lymphadenectomy of station 10 (splenic hilum), no level I evidence justifies this procedure. This study aims to evaluate the rate of lymph node (LN) and contiguous involvement of the splenic hilum in resectable distal PDAC.

METHODS

We retrospectively reviewed all patients who underwent splenopancreatectomy for PDAC in the past 10 years. Station 10 LN were routinely isolated, and all corresponding microscopic slides were reinterpreted by a pathologist. The computed tomography (CT) results of patients with tumoral involvement of the spleen or splenic hilum by contiguity (TISOSH) and ≤ 10 mm between the tumor and spleen on pathology were blindly reviewed by two radiologists to evaluate CT for diagnosis of TISOSH.

RESULTS

We included 110 consecutive patients, including 104 with analyzable station 10 LN. The tumor was N+ in 58 (53%) patients. The median number of LN identified at station 10 was 2.0 ± 3.0. No station 10 LNs were detected in 42 (40%) patients. No patients had tumor-positive LN at station 10. TISOSH was found in nine (8%) patients, and was significantly associated with tail location (p = 0.001), tumor size (p = 0.005), and multivisceral involvement (p = 0.015). For diagnosis of TISOSH, the sensitivity and specificity of CT were respectively 89% and 95% for radiologist 1 and 89% and 100% for radiologist 2.

CONCLUSIONS

Splenic preservation during resection of distal PDAC may be an option in selected patients with body tumors and no suspected splenic or splenic hilum involvement on preoperative CT.

Splenectomy is associated with an aggressive tumor growth pattern and altered host immunity in an orthotopic syngeneic murine pancreatic cancer model

The purpose of this study was to investigate whether splenectomy influences the tumor growth and metastatic pattern in an orthotopic syngeneic murine pancreatic cancer model. Murine pancreatic cancer cells (PAN02) were subcutaneously injected into the flanks of nude mice. A small tumor fragment (3 mm²), harvested from a subcutaneous tumor. was orthotopically implanted in the tail of the pancreas of C57/BL6 mice without splenectomy (control group, n=15) or with simultaneous splenectomy (splenectomy group, n=15). Tumor growth and metastatic patterns were analyzed by laparotomy at 21 days after surgery. No tumor growth was found in 5 mice (33.3%) of the control group and 1 mouse (6.7%) of the splenectomy group (p=0.169). Tumor volume was significantly larger in splenectomy group (p=0.013). Peritoneal seeding was more frequently observed in the splenectomy group (11 (73.3%) vs. 4 (26.7%), p=0.011). There were no differences in the number of liver and kidney metastasis between the two groups. The ratios of tumor-infiltrating CD4⁺ to FoxP3⁺ and CD8⁺ to FoxP3⁺ were significantly higher in the control group compared to the splenectomy group (8.2 ± 9.3 vs. 2.4 ± 1.5, p=0.046; 2.5 ± 1.4 vs. 1.5 ± 0.4, p=0.031, respectively). Splenectomy enhanced tumor growth and peritoneal seeding in an orthotopic syngeneic murine pancreatic cancer mouse model. The ramification of these results are discussed for pancreatic cancer treatment.

Radical antegrade modular pancreatosplenectomy versus standard procedure in the treatment of left-sided pancreatic cancer: A systemic review and meta-analysis

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS), first reported by Strasberg in 2003, has attracted increasing attention in the treatment of left-sided pancreatic cancer. The limited number of cases eligible for RAMPS makes it difficult to perform any prospective randomized trial of RAMPS versus the standard procedure. Therefore, we performed this systemic review and meta-analysis of the current data to clarify the role of the RAMPS procedure.

METHODS

A literature search was performed in electronic databases, including PubMed, Medline, Embase, CNKI and the Cochrane Library. Studies comparing RAMPS with the standard procedure were included in this meta-analysis. R0 resection rate, recurrence rate at the end of the follow-up, overall survival (OS) and disease-free survival (DFS) were measured as primary outcomes. Revman 5.3 was used to perform the analysis.

RESULTS

Six retrospective cohort studies with a total number of 378 patients were included in our analysis. Meta-analysis revealed that RAMPS was correlated with higher R0 resection rates [Odds Ratio (OR) 95% confidence interval (CI), 2.19 (1.16 ~ 4.13); P = 0.02] and successful harvest of more lymph nodes [weighted mean difference (WMD) 95% CI, 7.06 (4.52 ~ 9.60); P < 0.01] compared with the standard procedure. However, no statistically significant difference was found between the procedures with respect to recurrence rates [OR 95% CI, 0.66 (0.40 ~ 1.09); P = 0.10], OS [Hazard ratio (HR) 95% CI, 0.65 (0.42 ~ 1.00); P = 0.05] or DFS [HR 95% CI, 1.02 (0.62 ~ 1.68); P = 0.93].

CONCLUSIONS

RAMPS is safe and oncologically superior to the standard procedure for the treatment of left-sided pancreatic cancer. However, high-grade evidence will be necessary to confirm the potential survival benefits of RAMPS.

The detail of the en bloc technique and prognosis of spleen-preserving laparoscopic distal pancreatectomy for pancreatic cancer

BACKGROUND

Although laparoscopic spleen-preserving distal pancreatectomy surgery is more and more popular, the reports about the en bloc technique used for pancreatic cancer were still rare. The aim of our study was to illustrate the detail of the spleen-preserving en bloc technique as well as the short-term and long-term outcomes.

METHODS

The detail of the en bloc technique with pictures was described. The prognosis of the successive 23 cases that underwent the laparoscopic distal pancreatectomy (LDP) surgery was evaluated.

RESULTS

There were 17 cases that underwent spleen-preserving LDP while six cases underwent spleen-resecting LDP. The average surgery time was 203 ± 54 min, and the average blood loss volume was 208 ± 264 ml; one case transferred to open surgery because of severe adhesion. The complication rate was 47 % (n = 8) shortly after surgery. Pancreatic fistula rate was 41 % (n = 7). No lethal case occurred. The average diameter of the tumor was 32 ± 12 mm. The average number of the lymph nodes obtained was 19.8 ± 9.3. All the cutting edges were negative. Survival rates of the patient after 1, 3, and 5 years are 64.7, 52.9, and 41.2 %, respectively. These records showed no statistical significance compared with spleen-resecting LDP and open distal pancreatectomy (ODP) surgeries.

CONCLUSIONS

The en bloc spleen-preserving LDP can be performed by experienced surgeons. This surgery has good short-term and long-term outcomes.

A review of splenic pathology in distal pancreatectomies

OBJECTIVES

Splenectomy is often performed during distal pancreatectomy for malignancy, yet little data exist demonstrating splenic involvement in distal pancreatic pathology.

METHODS

We retrospectively reviewed 81 distal pancreatectomies performed for suspected or known pancreatic malignancies from 6/1/05 to 7/6/11. Exclusion criteria included metastatic disease, previous splenic preserving distal pancreatectomy, or planned en-bloc resection, leaving 47 cases. Data collected included spleen, hilar lymph node, or splenic vessel involvement by malignancy as confirmed by final pathology report. This was correlated with preoperative computed tomography (CT).

RESULTS

Final pathology showed adenocarcinoma in 10 (21%) patients. Three patients with adenocarcinoma had invasion of the spleen, splenic vessels or nodes on pathology. The first involved the splenic flexure, necessitating en-bloc colon resection. The second had splenic artery involvement as identified by CT, but no malignancy within the spleen. The third had direct extension to one of 11 peri-splenic nodes with significant inflammatory reaction noted intraoperatively.

CONCLUSIONS

Splenectomy is not mandated for all distal pancreatic tumors, and the spleen can be preserved in an overwhelming majority of cases. Pre- and intraoperative factors can adequately identify the necessity of splenectomy, and the approach should be tailored to individual patients.