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

Spleen Preservation in Solid Pseudopapillary Neoplasms of the Distal Pancreas: A Single-Center Experience

INTRODUCTION

Solid pseudopapillary neoplasms (SPNs) are rare tumors of the pancreas that are typically low-grade but may carry malignant potential. While concurrent splenectomy is recommended for oncologic resection of malignant distal pancreas tumors, this is not well-described for SPN. This study evaluates the outcomes of spleen preservation for distal pancreas SPN.

METHODS

A retrospective review was conducted for adult patients with SPN who underwent surgical resection at a single tertiary center (2010-2023). Distal tumors were located within the pancreatic body or tail. Patient factors and outcomes were compared between those who underwent spleen-preserving (SP) versus nonspleen-preserving (NSP) distal pancreatectomy.

RESULTS

In total, 52 patients underwent surgery for SPN. Thirty six had localized distal pancreatic tumors and underwent distal/subtotal pancreatectomy: 25 (69%) were SP and 11 (31%) were NSP. Overall, median age was 31 y, 86% were female, and 61% were symptomatic at diagnosis. Median tumor size (4.9 cm SP versus 6.0 cm NSP, P = 0.469) and number of lymph nodes examined (6 SP versus 11 NSP, P = 0.241) were similar. The majority of SP operations were completed minimally invasively via laparoscopic or robotic approaches (84% SP versus 36% NSP, P = 0.008). There was no difference in operative time, complications, length of stay, or readmission between groups. Neither cohort had recurrence of SPN at median follow-up of 3 y.

CONCLUSIONS

SP pancreatectomy can be performed safely for distal SPN with excellent long-term oncologic outcomes. This technique may be achieved minimally invasively and should be considered for localized SPN in the body or tail of the pancreas.

Interim analysis of short-term outcomes after laparoscopic spleen-preserving distal pancreatectomy with or without preservation of splenic vessels: a randomised controlled trial

BACKGROUND

Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) is a widely adopted surgical approach for benign and low-grade malignant neoplasms of the distal pancreas. The Kimura and Warshaw techniques represent two principal strategies, yet it still needs to be determined which one is superior. Our investigation aimed to evaluate the clinical outcomes associated with each technique.

MATERIALS AND METHODS

This single-center, parallel-group, patient-blinded randomized controlled trial was conducted at the West China Hospital of Sichuan University. Stratified block randomization was utilized to enroll 114 patients starting in March 2022, with an interim analysis of short-term outcomes scheduled after 45-50% of participant enrollment. Patients were randomized to receive LSPDP via either the Kimura or Warshaw technique. The primary endpoint was intraoperative blood loss, while secondary endpoints included a range of outcomes from composite outcome to quality of life, as quantified by the EQ-5D-5L.

RESULTS

From March 2022 to November 2023, 53 patients were randomly allocated to the Kimura ( n =25) or Warshaw ( n =28) groups for LSPDP. Baseline characteristics and postoperative outcomes were similar between the groups, such as pancreatic fistula incidence, EQ-5D-5L index scores, and delayed gastric emptying rates. Per-protocol (PP) analysis revealed that the Kimura group experienced significantly less blood loss (52.5±51.6 ml vs. 91.7±113.5 ml, P =0.007) and a reduced rate of composite outcome (23.8 vs. 56.7%, P =0.019), but incurred higher costs in the Warshaw group (¥56 227.4±¥7027.0 vs. ¥63 513.8±¥12 944.5, P =0.013). Splenic infarction rates were higher in the Warshaw group, though not statistically significant (ITT: 39.3 vs. 12.5%, P =0.058; PP: 36.7 vs. 14.3%, P =0.113), without necessitating intervention. Neither group experienced postpancreatectomy hemorrhage, 90-day mortality, or ICU admissions, and all postoperative complications were mild (Clavien-Dindo Grade

CONCLUSIONS

The 90-day interim analysis postoperatively indicates that both Kimura and Warshaw techniques for LSPDP are safe and viable. The Kimura technique, however, confers superior in terms of reduced intraoperative blood loss and fewer complications, alongside lower costs.

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Key Words

• kimura technique
• laparoscopic spleen-preserving distal pancreatectomy
• warshaw technique

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MESH Headings

• Humans
• Pancreatectomy/methods
• Pancreatectomy/adverse effects
• Laparoscopy/methods
• Female
• Male
• Middle Aged
• Pancreatic Neoplasms/surgery
• Spleen/blood supply
• Spleen/surgery
• Treatment Outcome
• Organ Sparing Treatments/methods
• Aged
• Adult
• Blood Loss, Surgical/statistics & numerical data
• Quality of Life
• Postoperative Complications/epidemiology
• Splenic Artery/surgery
• China

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Affiliation(s)

Qiangxing Chen Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University West China School of Medicine, West China Hospital, Sichuan University Department of Pancreatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
Yangzhi Fu Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University West China School of Medicine, West China Hospital, Sichuan University
Yongbin Li Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University Department of Hepatopancreatobiliary Minimal Invasive Surgery, Shangjin Nanfu Hospital
He Cai Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
Xin Wang Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
Zhong Wu Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
Lingwei Meng Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University West China School of Medicine, West China Hospital, Sichuan University
Man Zhang Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
Zixin Chen Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University West China School of Medicine, West China Hospital, Sichuan University
Jingwen Jiang Division of Pancreatic Surgery and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China; and Med-X Center for Informatics, Sichuan University
Ke Cheng Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University Division of Liver Surgery, Department of General Surgery, West China Hospital of Sichuan University
Jun Li Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University West China School of Medicine, West China Hospital, Sichuan University
Dian Zhang Department of Radiology, West China Hospital, Sichuan University, Chengdu, People’s Republic of China, Guangzhou, China
Yu Cai Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
Jiaying You Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
Yunqiang Cai Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
Bing Peng Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University

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Risk factors and predictive model development for high blood loss in minimally invasive distal pancreatectomy: a retrospective cohort study

BACKGROUND

High blood loss is an adverse event related to increased morbidity and poorer outcomes in pancreatic surgery patients. The aim of this study was to identify risk factors and establish a predictive model for high perioperative blood loss (HPBL) in minimally invasive distal pancreatectomy (MIDP).

METHODS

We collected data from 353 patients who underwent MIDP at a university affiliated tertiary hospital between January 2016 and October 2023. Perioperative blood loss was calculated based on pre- and postoperative hemoglobin concentrations according to a combination of the formulas provided by Nadler and Gross. Multivariate logistic regression analyses were performed for the training cohort to identify the clinical factors independently associated with perioperative blood loss (PBL). A predictive nomogram based on these factors was established and validated.

RESULTS

Weight, imaging findings, serum albumin concentration, MIDP experience, spleen treatment, and operation time were independent predictors for HPBL. The established model for predicting HPBL showed that the area under the curve (AUC) was 0.799 (95% CI = 0.746-0.853) and 0.852 (95% CI = 0.760-0.943) for the training cohort and validation cohort, respectively. When utilized to predict blood transfusion, the AUC was 0.778 (95% CI = 0.691-0.865) in the training cohort and 0.818 (95% CI = 0.681-0.955) in the validation cohort. Patients with a high predicted risk had significantly higher incidences of postoperative pancreatic fistula, intra-abdominal infection, and longer hospital stays than patients with a low risk.

CONCLUSIONS

We established and validated a model for predicting HPBL in MIDP patients. This novel model may have future utility when generating surgical strategies.

Laparoscopic partial splenectomy in distal pancreatectomy may preserve splenic function

INTRODUCTION

Splenectomy is known to carry a risk of infection with encapsulated organisms and associated sepsis. Current Australian guidelines recommend intensive vaccination schedules and long-term antibiotic therapy. We postulate that in some clinical scenarios where distal pancreatectomy (DP) and splenectomy is being performed, a partial splenectomy is feasible. This may preserve splenic function and help retain immunocompetence.

METHODS

Five patients underwent laparoscopic distal pancreatectomy with partial splenectomy (LDPPS). The DP is performed with proximal division and resection of the splenic artery and vein. The inferior portion of the spleen is removed en bloc with the distal pancreas with ligasure and linear cutting staplers. The line of demarcation on the spleen after the division of the splenic artery identifies the portion supplied by the short gastric vessels. Temporary clamping of the short gastrics during splenic parenchymal transection reduces blood loss. All operations were completed laparoscopically and within 4 h.

RESULTS

The pathology of resected lesions includes a serous cystadenoma, a pseudocyst, an IPMN and two small medial pancreatic ductal adenocarcinomas. The benign lesions involved splenic vessels at the hilum, making Kimura or Warshaw procedures untenable. No patient required blood transfusion. One patient suffered a postoperative collection consistent with postoperative pancreatic fistula requiring a drain for 10 days. Follow-up ranged from 6 to 24 months. Following surgery, all patients had a perfused splenic remnant on imaging and benign blood films, which suggests retained splenic function.

CONCLUSION

Preserving some spleen when performing distal pancreatectomy may provide long-term benefits for patients.

Fate of small remnant pancreatic tail in splenic hilum after laparoscopic spleen preserving distal pancreatectomy: a retrospective study

Purpose

When performing laparoscopic spleen-preserving distal pancreatectomy (LSPDP), sometimes, anatomically challenging patients are encountered, where the pancreatic tail is deep in the splenic hilum. The purpose of this study was to discuss the experience with the surgical technique of leaving the deep pancreatic tail of the splenic hilum in these patients.

Methods

Eleven patients who underwent LSPDP with remnant pancreatic tails between November 2019 and August 2021 at Samsung Medical Center in Seoul, Korea were included in the study. Their short-term postoperative outcomes were analyzed retrospectively.

Results

The mean operative time was 168.6 ± 26.0 minutes, the estimated blood loss was 172.7 ± 95.8 mL, and the postoperative length of stay was 6.1 ± 1.0 days. All 11 lesions were in the body or tail of the pancreas and included 2 intraductal papillary mucinous neoplasms, 6 neuroendocrine tumors, 2 cystic neoplasms, and 1 patient with chronic pancreatitis. In 10 of the 11 patients, only the pancreatic tail was left inside the distal portion of the splenic hilum of the branching splenic vessel, and there was a collection of intraabdominal fluid, which was naturally resolved. One patient with a remnant pancreatic tail above the hilar vessels was readmitted due to a postoperative pancreatic fistula with fever and underwent internal drainage.

Conclusion

In spleen preservation, leaving a small pancreatic tail inside the splenic hilum is feasible and more beneficial to the patient than performing splenectomy in anatomically challenging patients.

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.

Kimura's vs Warshaw's technique for spleen preserving distal pancreatectomy: a systematic review and meta-analysis of high-quality studies

BACKGROUND

Spleen preserving distal pancreatectomy (SPDP) represents a widely adopted procedure in the presence of benign or low-grade malignant tumors. Splenic vessels preservation and resection (Kimura and Warshaw techniques respectively) represent the two main surgical modalities to avoid splenic resection. Each one is characterized by strengths and drawbacks. The aim of the present study is to systematically review the current high-quality evidence regarding these two techniques and analyze their short-term outcomes.

METHODS

A systematic review was conducted according to PRISMA, AMSTAR II and MOOSE guidelines. The primary endpoint was to assess the incidence of splenic infarction and splenic infarction leading to splenectomy. As secondary endpoints, specific intraoperative variables and postoperative complications were explored. Metaregression analysis was conducted to evaluate the effect of general variables on specific outcomes.

RESULTS

Seventeen high-quality studies were included in quantitative analysis. A significantly lower risk of splenic infarction for patients undergoing Kimura SPDP (OR = 0.14; p < 0.0001). Similarly, splenic vessel preservation was associated with a reduced risk of gastric varices (OR = 0.1; 95% p < 0.0001). Regarding all secondary outcome variables, no differences between the two techniques were noticed. Metaregression analysis failed to identify independent predictors of splenic infarction, blood loss, and operative time among general variables.

CONCLUSIONS

Although Kimura and Warshaw SPDP have been demonstrated comparable for most of postoperative outcomes, the former resulted superior compared to the latter in reducing the risk of splenic infarction and gastric varices. For benign pancreatic tumors and low-grade malignancies Kimura SPDP may be preferred.

Values of spleen-preserving distal pancreatectomy in well-differentiated non-functioning pancreatic neuroendocrine tumors: a comparative study

Background

The feasibility of spleen-preserving distal pancreatectomy (SPDP) to treat well-differentiated non-functioning pancreatic neuroendocrine tumors (NF-pNETs) located at the body and/or tail of the pancreas remains controversial. Distal pancreatectomy with splenectomy (DPS) has been widely applied in the treatment of NF-pNETs; however, it may increase the post-operative morbidities. This study aimed to evaluate whether SPDP is inferior to DPS in post-operative outcomes and survivals when being used to treat patients with NF-pNETs in our institute.

Methods

Clinicopathological features of patients with NF-pNETs who underwent curative SPDP or DPS at the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between January 2010 and January 2022 were collected. Short-term outcomes and 5-year survivals were compared between patients undergoing SPDP and those undergoing DPS.

Results

Sixty-three patients (SPDP, 27; DPS, 36) with well-differentiated NF-pNETs were enrolled. All patients had grade 1/2 tumors. After identifying patients with T1-T2 NF-pNETs (SPDP, 27; DPS, 15), there was no disparity between the SPDP and DPS groups except for tumor size (median, 1.4 vs 2.6 cm, P = 0.001). There were no differences in operation time (median, 250 vs 295 min, P = 0.478), intraoperative blood loss (median, 50 vs 100 mL, P = 0.145), post-operative major complications (3.7% vs 13.3%, P = 0.287), clinically relevant post-operative pancreatic fistula (22.2% vs 6.7%, P = 0.390), or post-operative hospital stays (median, 9 vs 9 days, P = 0.750) between the SPDP and DPS groups. Kaplan-Meier curve showed no significant differences in the 5-year overall survival rate (100% vs 100%, log-rank P > 0.999) or recurrence-free survival (100% vs 100%, log-rank P > 0.999) between patients with T1-T2 NF-pNETs undergoing SPDP and those undergoing DPS.

Conclusions

In patients with T1-T2 well-differentiated NF-pNETs, SPDP could achieve comparable post-operative outcomes and prognosis compared with DPS.