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.

Indocyanine green fluorescence imaging for spleen preservation in laparoscopic splenic artery aneurysm resection: A case report

BACKGROUND

Splenic artery aneurysm (SAA) is a rare vascular lesion conventionally treated by resection or interventional therapy. The surgical procedure usually involves splenectomy, and interventional therapy may cause post-embolization syndromes. Preservation of the spleen and its function is rarely reported during the management of SAA.

CASE SUMMARY

We report a patient with an asymptomatic SAA (3.5 cm in diameter), which was en-bloc resected laparoscopically using indocyanine green (ICG) fluorescence imaging to preserve the spleen and its function.

CONCLUSION

ICG fluorescence imaging for spleen preservation in laparoscopic SAA resection is safe and may be beneficial in avoiding splenectomy and maintaining splenic function.

[Application of Early Splenic Artery Occlusion in Laparoscopic Spleen-preserving Distal Pancreatectomy using Kimura Technique]

Objective

To present our institutional experience in laparoscopic spleen-preserving distal pancreatectomy (Lap-SPDP) using Kimura technique with or without early occlusion of the root of the splenic artery. In addition, to explore the safety and feasibility of this occlusion technique, especially its advantages in intraoperative hemorrhage control and spleen preservation.

Methods

From February 2011 to May 2019, 54 consecutive patients who were diagnosed as benign or low-grade malignant space-occupying lesions at the body and the tail of pancreas underwent Lap-SPDP using Kimura technique in our institution. Twenty-five patients before 2015 were allocated into non-occlusion group and 29 patients after 2015 were allocated into occlusion group. The non-occlusion group underwent direct dissection of the distal pancreas with blood supply from the splenic artery as well as traditional traction of the splenic artery without occlusion. Whereas the occlusion group underwent temporary occlusion of the root of the splenic artery by Bulldog clip after transecting the neck of the pancreas and distal pancreas was excised under a relatively bloodless situation. Surgical techniques were described in detail. Data between groups were retrospectively collected and stratification analysis was performed based on the diameter of tumor (>3 cm or ≤3 cm).

Results

Before stratification, there was a statistical difference in age between the two groups ( P=0.033), but no difference in body mass index (BMI) ( P=0.069). The median lesion diameter of the two groups was 2.5 cm and 4 cm, respectively, with no statistical difference ( P=0.065). The success rates of spleen preservation in the two groups were 93.1% and 92% respectively, showing no significant difference ( P=1.000). The length of hospital stay was slightly longer in the non-occlusion group than that in the occlusion group ( P=0.020). Comparing with the non-occlusion group, the occlusion group had significantly shorter operation time (median, 165 min vs. 235 min) and less estimated blood loss (median, 100 mL vs. 200 mL) ( P<0.05). After stratification by the tumor diameter, there were 2 cases of failed spleen preservation both in occlusion and non-occlusion group with tumor diameter >3 cm (occlusion group: 2/8, 25% and non-occlusion group: 2/14,14.3%). However there was no statistical difference between the two groups ( P=0.602). When the tumor diameter ≤3 cm, the spleen preservation rate of both groups reached 100%. When the tumor diameter was >3 cm, the operation time of the occlusion group was shorter than that of the non-occlusion group ( P=0.005). In terms of intraoperative blood loss, regardless of tumor size, the occlusion group had less estimated blood loss than that of the non-occlusion group ( P<0.05). In the occlusion group, no conversion or blood transfusion was needed intraoperatively and/or postoperatively. After stratification, there was no difference in the length of hospital stay between two groups ( P>0.05). During the follow-up period (median (Min-Max), 13.5 (3-96) months), no perioperative death, disease recurrence, portal vein or splenic vein thrombosis, gastric varices or upper gastrointestinal bleeding was noted.

Conclusion

Lap-SPDP using Kimura technique with early occlusion of the root of splenic artery was safe and feasible and could be generally applied. By using this technique, we could reduce the operation time and blood loss, as well as sustain a high probability of spleen preservation.

Necessity of prophylactic splenic hilum lymph node clearance for middle and upper third gastric cancer: a network meta-analysis

Background

It remains controversial whether prophylactic No.10 lymph node clearance is necessary for gastric cancer. Thus, the present study aims to investigate the impact of prophylactic No.10 lymph node clearance on the perioperative complications and prognosis of upper and middle third gastric cancer.

Methods

A network meta-analysis to identify both direct and indirect evidence with respect to the comparison of gastrectomy alone (G-A), gastrectomy combination with splenectomy (G + S) and gastrectomy combination with spleen-preserving splenic hilar dissection (G + SPSHD) was conducted. We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies published before September 2018. Perioperative complications and overall survival were analyzed. Hazard ratios (HR) were extracted from the publications on the basis of reported values or were extracted from survival curves by established methods.

Results

Ten retrospective studies involving 2565 patients were included. In the direct comparison analyses, G-A showed comparable 5-year overall survival rate (HR: 1.1, 95%CI: 0.97–1.3) but lower total complication rate (OR: 0.37, 95%CI: 0.17–0.77) compared with G + S. Similarly, the 5-year overall survival rate between G + SPSHD and G + S was comparable (HR: 1.1, 95%CI: 0.92–1.4), while the total complication rate of G + SPSHD was lower than that of G + S (OR: 0.50, 95%CI: 0.28–0.88). In the indirect comparison analyses, both the 5-year overall survival rate (HR: 1.0, 95%CI: 0.78–1.3) and total complication rate (OR: 0.75, 95%CI: 0.29–1.9) were comparable between G-A and G + SPSHD.

Conclusions

Prophylactic No.10 lymph node clearance was not recommended for treatment of upper and middle third gastric cancer.

[Importance of splenectomy in the operative treatment of gastric cancer]

BACKGROUND

The value of simultaneous splenectomy as part of an oncologically adequate resection for gastric cancer has been controversially discussed over the last decades.

METHODS

As part of a prospective multicenter observational study data were obtained from patients admitted to hospital with histologically diagnosed primary gastric cancer or adenocarcinoma of the esophagogastric junction (AEG). The profiles of care of patients who had undergone surgical treatment in 141 surgical departments from 1 January 2007 to 31 December 2009 were collated. Overall, 2897 patients were enrolled in the study (tumor resection, n = 2545).

RESULTS

The overall splenectomy rate was 11.1% (n = 283) and the highest proportion was found in AEG tumor lesions (19.4%). In the whole group of patients as well as depending on the tumor site, there was a higher preoperative comorbidity in splenectomized patients. While the rate of general postoperative complications after splenectomy was significantly increased in all patients and also depending on various tumor sites, there were no differences in the rate of specific postoperative complications. A significantly higher hospital mortality comparing the splenectomy group of patients with those in whom the spleen could be preserved, was only observed in AEG-associated tumor lesions (15.2% vs. 5.0%). All splenectomized patients showed a shorter long-term survival (p < 0.001) compared to resections with a preserved spleen (18 months vs. 36 months).

CONCLUSION

In the surgical treatment of gastric cancer, splenectomy can be considered a negative predictor for a worse perioperative outcome and a worse long-term survival.

The Liverpool duodenum-and spleen-preserving near-total pancreatectomy can provide long-term pain relief in patients with end-stage chronic pancreatitis

PURPOSE

Total pancreatectomy may improve symptoms in patients with severe end-stage chronic pancreatitis. This might be achieved whilst preserving both the duodenum- and spleen-(DPSPTP). Mature clinical outcomes of this approach are presented.

METHODS

Single-centre prospective cohort study performed between September 1996 and May 2016. Demographic, clinical details, pain scores and employment status were prospectively recorded during clinic attendance.

RESULTS

Fifty-one patients (33 men, 18 women) with a median (interquartile range) age of 40.8 (35.3-49.4) years, a median weight of 69.8 (61.0-81.5) Kg and a median body mass index of 23.8 (21.5-27.8), underwent intended duodenum-and spleen-preserving near-total pancreatectomy for end-stage chronic pancreatitis. Aetiology was excess alcohol in 25, idiopathic (no mutation) in 15, idiopathic (SPINK-1/CFTR mutations) in two, hereditary (PRSS1 mutation) in seven and one each post-necrotising pancreatitis and obstructive pancreatic duct divisum in 1. The main indication for surgery was severe pain. Findings included parenchymal calcification in 79% and ductal calculi in 24%, a dilated main pancreatic duct in 57% and a dilated main bile duct in 17%, major vascular involvement in 27% and pancreato-peritoneal fistula in 2%. Postoperative complications occurred in 20 patients with two deaths. Median pain scores were 8 (7-8) preoperatively and 3 (0.25-5.75) at 5 years (p = 0.013). Opiate analgesic use was significantly reduced postoperatively (p = 0.048). Following surgery, 22 (63%) of 38 patients of working age re-entered employment compared with 12 (33%) working preoperatively (p = 0.016).

CONCLUSION

Duodenum-and spleen-preserving near-total pancreatectomy provided long-term relief in adult patients with intractable chronic pancreatitis pain, with improved employment prospects.

Dual-Incision Laparoscopic Spleen-Preserving Distal Pancreatectomy: Merits Compared to the Conventional Method

BACKGROUND

Herein, we assess the safety and feasibility of dual-incision laparoscopic spleen-preserving distal pancreatectomy (DILSPDP) through lateral approach with reduced trocars for benign and low-grade malignancy in pancreas tail. We compare DILSPDP with surgical outcomes of conventional laparoscopic spleen-preserving distal pancreatectomy (LSPDP).

METHODS

Patients with benign pancreas tail mass that had been scheduled for LSPDP were selected to undergo DILSPDP. These patients had spleen-preserving distal pancreatectomy with the dissection in lateral-to-medial fashion using a multichannel trocar in the right lateral decubitus position of patient. We compared the demographics and operative outcomes of DILSPDP with those of conventional LSPDP which was performed with dissection in medial-to-lateral fashion using four or five trocars in supine position.

RESULTS

Twenty two cases of DILSPDP and 26 cases of conventional LSPDP were reviewed. There was no difference in terms of demographic features including diagnosis or tumor size, although the location of the tumor was fundamentally different between the two groups. Significantly shorter operative times and reduced blood loss were observed in DILSPDP group (p = 0.004 and 0.011, respectively) and the preservation of splenic vessels was more successful with DILSPDP than conventional surgery (95.5% vs. 65.4%, p = 0.013).

CONCLUSIONS

DILSPDP appears to be a feasible method of spleen-preserving distal pancreatectomy for benign or low-malignancy of pancreas tail and is accompanied by advantages in terms of splenic vessel preservation and reduced parietal trauma.

A systematic review and meta-analysis of spleen-preserving distal pancreatectomy with preservation or ligation of the splenic artery and vein

INTRODUCTION

Spleen-preserving distal pancreatectomy (SPDP) can be performed either by ligating (SPDP-VL) or preserving (SPDP-VP) the splenic vessels.

METHODS

A systematic review was performed, and standard PRISMA guidelines were followed. A literature search was conducted using Medline, PubMed and the Cochrane Central Register of Controlled Trials between January 1988 and May 2014. The article titles and abstracts were examined by two independent reviewers.

RESULTS

Thirteen non-randomized control trials were included in the meta-analysis. The pooled data included 667 patients who underwent SPDP. There were 209 patients in the SPDP-VL group and 458 patients in the SPDP-VP group. The risk of splenic infarction was significantly higher in the SPDP-VL group [20.88 vs. 2.09%; OR 11.89 (95% CI 4.33 to 32.70); p < 0.00001]. The rate of splenectomy as a result of splenic infarction was also statistically associated with SPDP-VL [7.69% vs. 1.36%; OR 3.87 (95% CI 1.05 to 14.26); p = 0.05)]. The surgical operative time was shorter in the SPDP-VL group than in the SPDP-VP group (mean difference 21.2 min), but this result was not statistically significant (95% CI -47.01 to -4.48; p = 0.11). The two procedures were comparable with respect to mean intraoperative blood loss and rate of pancreatic fistula. SPDP-VL did not influence the risk of developing perigastric collateral vessels and submucosal varices.

CONCLUSIONS

SPDP-VL may result in a higher rate of splenic infarction and splenectomy than SPDP-VP. However, the low quality of the included studies does not lead to clear conclusions.

Totally laparoscopic spleen-preserving splenic hilum lymph nodes dissection in radical total gastrectomy: an omnibearing method

OBJECTIVE

To investigate the feasibility and safety of laparoscopic spleen-preserving splenic hilum lymph nodes (LNs) dissection for advanced proximal gastric cancer using an omnibearing method.

METHODS

Between August 2013 and December 2014, 16 patients with advanced proximal gastric cancer treated in Guangdong Province Hospital of Chinese Medicine, were enrolled and subsequently underwent laparoscopic radical total gastrectomy (TG) with spleen-preserving splenic hilum LNs dissection. During dissecting Nos. 10 and 11 LNs, we divided them into two parts, namely LNs anterosuperior and posterior to the splenic vessel. The clinicopathological characteristics, intraoperative outcomes and postoperative courses were retrospectively collected and analyzed in the study.

RESULTS

Laparoscopic surgery was successfully completed in all 16 patients without conversion to open surgery, and no perioperative death occurred. The mean operating time was 328.75 ± 46.96 min, and the mean estimated blood loss was 135.63 ± 62.07 ml. One patient experienced intraoperative bleeding due to the splenic vein injury which was successfully handled with laparoscopic vessel suturing, and one postoperative pulmonary infection was recorded. The mean time to first flatus was 3.56 ± 1.03 days with a mean 9.63 ± 1.50 days of postoperative hospital stay. The mean number of retrieved LNs was 28.31 ± 5.99, in which LNs anterosuperior to splenic artery was 2.88 ± 2.66 and LNs posterior was 1.38 ± 1.75.

CONCLUSION

Laparoscopic TG with spleen-preserving splenic hilum LNs dissection using an omnibearing method for advanced proximal gastric cancer was safe and technically feasible in experienced hands. Further studies in terms of its clinical significance are needed.

Laparoscopic spleen-preserving resection of the pancreatic body and tail via the left anterior pararenal approach

AIM: To investigate the safety and efficacy of laparoscopic spleen preserving pancreatic resection via the left anterior pararenal approach.

METHODS: Clinical data for 40 patients who underwent spleen-preserving resection of the pancreatic body and tail from January 2012 to December 2013 at Nanyang Central Hospital were analyzed retrospectively.

RESULTS: The surgery was successful in all the 40 patients, and there was no conversion to open surgery. The operative time was 57.1 min ± 14.6 min. Intraoperative blood loss was 82.4 mL ± 23.5 mL. Hospital stay was 7.1 d ± 0.4 d. After surgery, no bleeding, splenic infarction, pancreatic leakage, intra-abdominal infections or other complications occurred. Blood sugar returned to normal after surgery. Follow-up time was 8.4 mo ± 2.1 mo, and blood and kidney function, blood sugar and abdominal B ultrasound findings were all normal during the follow-up period. No recurrence occurred.

CONCLUSION: Laparoscopic spleen-preserving resection of the pancreatic body and tail via the left anterior pararenal approach is feasible and associated with fast postoperative recovery and few complications.

Laparoscopic spleen-preserving distal pancreatectomy for insulinoma: experience of a single center. Int J Surg. 2014;12 Suppl 1:S152-S155. [PMID: 24862672 DOI: 10.1016/j.ijsu.2014.05.023]

BACKGROUND

Laparoscopic spleen-preserving distal pancreatectomy is gaining acceptance for the treatment of insulinomas of the pancreatic body and tail. The aim of this report is to evaluate the feasibility, safety and outcomes of this procedure in a retrospective series.

METHODS

From May 2004 to November 2013, 9 patients underwent laparoscopic spleen-preserving distal pancreatectomy for benign insulinomas in our department. Tumors were single and sporadic in eight patients, while the remaining patient had insulinomas in the setting of multiple endocrine neoplasia type 1. Tumors were located by preoperative imaging in all cases. Laparoscopic ultrasound was always performed to guide the surgical procedure.

RESULTS

All the operations were carried out laparoscopically with a mean operative time of 110 min (range 90-210 min) and a mean blood loss of 50 ml (range 30-120 ml). One patient (11.1%) died on the 22nd post-operative day for massive intra-abdominal bleeding associated with pancreatitis of the stump. Two patients (22.2%) developed pancreatic fistula that healed conservatively. Mean postoperative hospital stay was 7.1 days (range 5-18 days). All alive patients were free from recurrence after a mean follow-up of 45 months (range 11-72 months).

CONCLUSION

Laparoscopic spleen-preserving distal pancreatectomy is safe and feasible for the management of benign insulinomas. Definition of the tumor with preoperative imaging and laparoscopic ultrasound is essential to achieve high cure rate with minimal conversion.

Spleen-preserving operation for the treatment of traumatic splenic rupture: An analysis of 36 cases

AIM: To discuss our experience in managing traumatic splenic rupture by spleen-preserving operation.

METHODS: Eighty-five cases of splenic traumatic rupture were selected, and 36 of them were retrospectively analyzed.

RESULTS: Twelve patients was treated by hot compress, application of biological glue to injury tissue surface, and coverage using the greater omentum flap. Nineteen patients were treated by irregular splenectomy and splenic wound repair. Five patients underwent subtotal splenectomy. Complications occurred in 8 patients and were cured after proper treatments. The median length of hospital stay was 22.6 d ± 19.0 d. All patients were satisfactory for the treatment.

CONCLUSION: For patients with traumatic splenic rupture, saving life is more important than preserving the spleen. For children patients, spleen-preserving operation is preferred. An appropriate treatment should be selected based on the patient's condition.

Laparoscopic distal pancreatectomy is as safe and feasible as open procedure: A meta-analysis

AIM: To evaluate the feasibility and safety of laparoscopic distal pancreatectomy (LDP) compared with open distal pancreatectomy (ODP).

METHODS: Meta-analysis was performed using the databases, including PubMed, the Cochrane Central Register of Controlled Trials, Web of Science and BIOSIS Previews. Articles should contain quantitative data of the comparison of LDP and ODP. Each article was reviewed by two authors. Indices of operative time, spleen-preserving rate, time to fluid intake, ratio of malignant tumors, postoperative hospital stay, incidence rate of pancreatic fistula and overall morbidity rate were analyzed.

RESULTS: Nine articles with 1341 patients who underwent pancreatectomy met the inclusion criteria. LDP was performed in 501 (37.4%) patients, while ODP was performed in 840 (62.6%) patients. There were significant differences in the operative time, time to fluid intake, postoperative hospital stay and spleen-preserving rate between LDP and ODP. There was no difference between the two groups in pancreatic fistula rate [random effects model, risk ratio (RR) 0.996 (0.663, 1.494), P = 0.983, I² = 28.4%] and overall morbidity rate [random effects model, RR 0.81 (0.596, 1.101), P = 0.178, I² = 55.6%].

CONCLUSION: LDP has the advantages of shorter hospital stay and operative time, more rapid recovery and higher spleen-preserving rate as compared with ODP.