Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein: techniques and its significance

Background

Preservation of the spleen in distal pancreatectomy has recently attracted considerable attention. Since our first trial and success with spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis, this procedure (Kimura’s procedure) has been performed very frequently.

Methods

The techniques for spleen-preserving distal pancreatectomy (SpDP) with conservation of the splenic artery and vein are clarified. The splenic vein is identified behind the pancreas and within the thin connective tissue membrane (fusion fascia of Toldt). The connective tissue membrane is cut longitudinally above the splenic vein. It is important to remove the splenic vein from the pancreas by working from the body of the pancreas toward the spleen (median approach), because it is very difficult to remove it in the other direction. The pancreas is removed from the splenic artery by proceeding from the spleen toward the head of the pancreas.

Results

Preservation of the spleen offers various advantages. The maximum platelet levels in blood serum are significantly lower in postoperative patients with splenic preservation than in those with splenectomy. The platelet count was maximal on postoperative day 10 in the 16 patients with SpDP and the count was maximal on postoperative day 13 in the 16 patients with distal pancreatectomy with splenectomy (DPS), and there was a smaller increase in the patients with SpDP than in the patients with DPS. Postoperative bleeding from an ablated splenic artery and vein in SpDP has not been encountered. Either DPS or spleen preservation without preservation of the splenic artery and vein may reduce the blood supply to the residual proximal stomach after distal gastrectomy, which is different from the findings in the Kimura procedure.

Conclusion

In SpDP, a very slight elevation of the platelet count in serum may help to prevent infarction of the lungs and brain compared to DPS. Another advantage of SpDP performed according to our procedure is that the blood supply to the proximal stomach is conserved in patients with SpDP who undergo distal gastrectomy with resection of the left gastric artery. Benign lesions, as well as low-grade malignancy of the body and tail of the pancreas, may be indications for this procedure. Surgeons should know the techniques and significance of SpDP with conservation of the splenic artery and vein, which is a very safe and reliable method.     

Spleen-preserving distal pancreatectomy with preservation of the splenic artery and vein for intraductal papillary-mucinous tumor (IPMT): three interesting cases

Preservation of the spleen at distal pancreatectomy has recently attracted considerable attention. Since our first trial and success with spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis, this procedure has been performed more frequently. Three patients with intraductal papillary-mucinous tumor underwent spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. In this procedure, the splenic vein is identified behind the pancreas and the connective tissue membrane is cut longitudinally above the splenic vein. An important point is to remove the splenic vein from the pancreas from the body of the pancreas toward the spleen. In one patient with intraductal papillary-mucinous tumor in the body of the pancreas who had undergone distal gastrectomy for duodenal ulcer 32 years previously, residual proximal gastrectomy could be avoided with this procedure. In this case, the histological diagnosis was a pseudocyst, and epithelial dysplasia was found in other pancreatic ductuli. In another case, epithelia were borderline between hyperplasia and adenoma. In both of these cases, the histological diagnosis was different from the preoperative diagnosis. Even with advances in imaging techniques, diagnosis of a cystic lesion of the pancreas is still very difficult. Ordinary distal pancreatectomy with splenectomy would have been oversurgery in these two cases, which could be avoided using our procedure. Severe complications were not found in any of the three cases and the postoperative course was uneventful. The patients have been followed as outpatients without any recurrence. Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein is easy and safe, and should be performed for some patients with intraductal papillary mucinous tumor of the pancreas.     

Spleen-preserving distal pancreatectomy for intraductal papillary-mucinous tumor (IPMT)

BACKGROUND/AIMS: Recently, the significance of preserving the spleen has received a lot of attention. Since our first trial and success of spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for chronic pancreatitis, this procedure has been more frequently performed and reported. In this study, we introduce the technique and indications for the procedure for intraductal papillary mucinous tumor of the pancreas. METHODOLOGY: Nine patients underwent spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. We performed this procedure in two patients with intraductal papillary mucinous tumor. The splenic vein is identified behind the pancreas and within the thin connective tissue membrane. The connective tissue membrane is cut longitudinally above the splenic vein. An important technique is to remove the splenic vein from the pancreas from the body of the pancreas toward the spleen. There are many branches from the splenic vein on both sides, and these branches should be carefully ligated and cut. The pancreas is removed from the splenic artery from the spleen toward the head of the pancreas. This procedure is much easier than removing the pancreas from the vein. RESULTS: The postoperative course was uneventful in all nine cases, but one, in which pancreatic fistula continued for more than several weeks. The mean and standard deviation of the operative blood loss, the duration of the operation and the postoperative hospital stay in seven cases, excluding two cases, in which either Puestow's procedure or simultaneous subtotal esophagectomy was performed, were 413+/-385 mL, 298+/-55 min, and 39+/-15 days, respectively. Severe complications were not found in any of the nine cases. The two patients with intraductal papillary mucinous tumor have been followed as outpatients without any recurrence. CONCLUSIONS: Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein is easy and safe, and should be performed for some of the patients with intraductal papillary mucinous tumor of the pancreas.     

Distal pancreatectomy without splenectomy and with preservation of splenic vessels

BACKGROUND/AIMS: Conventional distal pancreatic resection routinely involves splenectomy. The awareness that spleen removal may lead to postoperative septic and hematological complications motivated the development of spleen-preserving procedures. Successful distal pancreatectomy with splenic conservation has been reported for treatment of benign pancreatic diseases of the distal pancreas. This report presents the results of spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. METHODOLOGY: Ten patients underwent distal pancreatectomy with splenic vessel preservation. In all cases, both splenic vessels were separated from the pancreas towards the spleen after transecting the body of the pancreas. RESULTS: The indications for the procedure were: neuroendocrine pancreatic tumors (n = 4), cystic neoplasm of the pancreas (n = 4) and cystic-papillary pancreatic tumors (n = 2). Four patients developed pancreatic fistulas with spontaneous healing and there was no mortality. CONCLUSIONS: Spleen-preserving distal pancreatectomy with splenic vessel conservation can be safely performed and should be indicated in the surgical management of benign pancreatic diseases of the distal pancreas.     

Laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein

Herein, we report the successful performance of a laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for a patient with pancreatic cystadenoma, as a minimally invasive procedure with the preservation of function. The laparoscopy-assisted distal pancreatectomy procedure involved detaching the spleen and the distal pancreas from the retroperitoneum by a hand-assisted procedure, removing them from the peritoneal cavity through a small incision, and detaching the distal pancreas by ligating and transecting the short gastric artery and vein and the branches of the splenic artery and vein, while the spleen and main splenic artery and vein were preserved under direct view. The pancreatic parenchyma was transected with a stapling device (TL-30), and continuous suturing was added to the resected margin. The patient’s postoperative course was uneventful; the patient started to eat and walk on postoperative day 2 and was discharged on day 8. It is considered that the combination of hand-assisted and laparoscopy-assisted distal pancreatectomy, with conservation of the splenic artery and vein, is a minimally invasive and clinically useful technique for treating tumors of cystic disease of the pancreas with low-grade malignant potential, or benign solitary neuroendocrine tumors.     

Distal pancreatectomy (with video)

Distal pancreatectomy is indicated for lesions in the pancreatic body and tail. Understanding of the anatomical structure of the pancreas and its surroundings is required in various situations in left upper abdominal surgery including the laparoscopic approach. Spleen-preserving distal pancreatectomy is indicated for lesions confined to the pancreas. Two major spleen-preserving procedures reported are the Warshaw procedure that conserves the spleen by blood flow from the short gastric vessels and the Kimura procedure that preserves the spleen with splenic vessels. Considering the laparoscopic approach, the surgeon may preserve splenic vessels from the median toward the splenic hilum without mobilization of the spleen. A standard distal pancreatectomy using the medial approach is presented on video. The intraoperative complications of distal pancreatectomy can be minimized by avoiding splenic capsule injury, by careful differentiation of the splenic artery from the common hepatic artery, and by secure closure of the splenic vein stump. The incidence of postoperative pancreatic fistula following distal pancreatectomy is reported to be 13% in a nationwide pancreatic cancer registry. Based on the results of an international randomized trial of hand-sewn and staple closure of the pancreatic stump, the closure method of the pancreatic stump can be the surgeon's choice.     

Distal pancreatectomy: en-bloc splenectomy vs spleen-preserving pancreatectomy

Distal pancreatectomy with en-bloc splenectomy has been considered the standard technique for management of benign and malignant pancreatic disorders. However, splenic preservation has recently been advocated. The aim of this study was to review the experiences of distal pancreatectomy using the open or the laparoscopic approach and to critically discuss the need to perform splenectomy. Original articles published in the English literature of peer-reviewed medical journals were selected for detailed analysis. In patients with malignant neoplasms in the body-tail of the pancreas, splenectomy has a negative influence on long-term survival after resection. The incidence of diabetes after spleen-preserving distal pancreatectomy for chronic pancreatitis is less than after en-bloc splenectomy. Spleen salvage eliminates the risk of overwhelming infections. Laparoscopic spleen-preserving distal pancreatectomy is feasible and safe. Laparoscopic spleen-preserving distal pancreatectomy may be preferable for the advantages of a minimally invasive approach.     

Endovascular treatment of post-laparoscopic pancreatectomy splenic arteriovenous fistula with splenic vein aneurysm

Splenic arteriovenous fistulas (SAVFs) with splenic vein aneurysms are extremely rare entities. There have been no prior reports of SAVFs developing after laparoscopic pancreatectomy. Here, we report the first case. A 40-year-old man underwent a laparoscopic, spleen-preserving, distal pancreatectomy for an endocrine neoplasm of the pancreatic tail. Three months after surgery, a computed tomography (CT) scan demonstrated an SAVF with a dilated splenic vein. The SAVF, together with the splenic vein aneurysm, was successfully treated using percutaneous transarterial coil embolization of the splenic artery, including the SAVF and drainage vein. After the endovascular treatment, the patient’s recovery was uneventful. He was discharged on postoperative day 6 and continues to be well 3 mo after discharge. An abdominal CT scan performed at his 3-mo follow-up demonstrated complete thrombosis of the splenic vein aneurysm, which had decreased to a 40 mm diameter. This is the first reported case of SAVF following a laparoscopic pancreatectomy and demonstrates the usefulness of endovascular treatment for this type of complication.     

Intra-operative color Doppler ultrasonography for assessing splenic blood supply during spleen-preserving distal pancreatectomy: a case report

A 67 year-old Japanese woman presented with a cystic tumorous lesion, measuring 5 cm in diameter, in the tail of the pancreas. She underwent a spleen-preserving distal pancreatectomy (SPDP), in which the splenic artery and vein were divided because they were involved in scar formation around the lesion. Intra-operative color Doppler ultrasonography (CDUS) confirmed that splenic circulation via collaterals (short gastric and left gastroepiploic vessels) was preserved throughout the salvaged spleen. Histology of the resected specimen showed localized pancreatitis with a pseudocyst without neoplastic tissue. The patient's post-operative course was uneventful with no evidence of splenic failure and she was discharged 20 days after the operation. A literature review suggests that SPDP without preserving the splenic artery and vein may result in failure of the preserved spleen due to inadvertent injury to the remaining collaterals. Based on the experience of our case, we think that intra-operative CDUS is useful for assessing splenic circulation after SPDP with division of the splenic artery and vein.     

Laparoscopic spleen-preserving distal pancreatectomy for pancreatic neoplasms: A retrospective study

AIM: To describe the clinical characteristics, technical procedures, and outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for benign and malignant pancreatic neoplasms.METHODS: The clinical data of 38 patients who underwent LSPDP in the Sir Run Run Shaw Hospital between January 2003 and August 2013 were analyzed retrospectively. Surgical techniques for LSPDP included preservation of the splenic artery and vein (Kimura’s technique) and ligation of the splenic pedicle with preservation of the short gastric vessels (Warshaw’s technique).RESULTS: There were no conversions to open surgery in the 38 patients. Splenic vessels were conserved during spleen-preserving pancreatectomy, except in two patients who underwent resection of the splenic vessels and preservation only of the short gastric vessels. The mean operation time was 123.2 ± 52.4 min, the mean intraoperative blood loss was 78.2 ± 39.5 mL, and the mean postoperative hospital stay was 7.6 ± 2.9 d. The overall rate of postoperative complications was 18.4% (7/38), and the rate of clinical pancreatic fistula was 13.2% (5/38). All postoperative complications were treated conservatively. The postoperative pathological diagnoses were 22 cases of benign pancreatic disease and 16 cases of borderline or low-grade malignant lesions. During a median follow-up of 38 mo (range: 5-133 mo), no recurrence was observed.CONCLUSION: LSPDP is a safe, feasible and effective procedure for the treatment of benign and low-grade malignant tumors of the distal pancreas.     

Spleen-preserving laparoscopic distal pancreatectomy for cystic adenoma

For borderline malignant diseases of the pancreas such as cystic adenoma, partial pancreatectomy or pancreatoduodenectomy including pylorus-preserving pancreaticoduodenectomy have been performed depending on tumor location under large median laparotomy. To investigate the feasibility of a technique with minimal skin incision, while retaining safety equivalent to conventional resection of the pancreatic tail, by making use of the advantages of laparoscopic procedure, we performed a minimally invasive laparoscopic resection of the pancreatic tail with preservation of the spleen. A 69-year-old woman underwent surgery for a diagnostic therapy for a cystic lesion of the pancreatic tail. The procedure was performed as follows: All procedures were performed completely laparoscopically under CO2 insufflation. After dissection of the omentum, laparoscopic ultrasound was performed to identify the location of the tumor and splenic vessels. The splenic hilus was dissected with preservation of the splenocolic ligament to maintain the lower blood supply to the spleen. The left gastroepiploic artery and the short gastric arteries and veins could be preserved. After division of the splenic hilus, the splenic artery and vein were identified from behind the pancreas by being held up and dissected individually by intracorporeal ligation by 3-0 Nylon. Then, pancreatic transection was performed 1 cm proximal to the tumor with the Endo-GIAII. The duration of operation was 4.5 hours. Intraoperative blood loss was under 50 mL. Histological examination revealed mucinous cytadenoma. She could walk the day after surgery and was discharged from the hospital uneventfully. CT prior to discharge from the hospital revealed sufficient blood flow in the spleen. Thus, it may be feasible to select laparoscopic spleen-preserving distal pancreatectomy as a first choice for diagnostic therapy for cystic lesions of the pancreatic tail.     

Procedure for lymph node dissection around splenic artery in proximal gastric cancer

BACKGROUND/AIMS: The effect of lymph node metastasis around the splenic artery on the prognosis of proximal gastric cancer patients is not confirmed. The aim of this study is to clarify the optimal procedure for lymph node dissection along the splenic artery in proximal gastric cancer. METHODOLOGY: Proximal gastric cancer patients who underwent total gastrectomy with pancreaticosplenectomy were examined. The anatomical location of lymph nodes and the metastases around the pancreas were also studied in pancreatic cancer patients who underwent total pancreatectomy. RESULTS: Multivariate analysis of lymph node metastasis around the splenic artery showed that No. 11 lymph node metastasis was affected by No.10 lymph node that was predicted by depth of invasion. Multivariate analysis of prognostic variables by Cox's proportional hazard regression revealed that No. 10 lymph node metastasis was the significant factor affecting prognosis. No lymph node metastasis infiltrating the pancreatic parenchyma was observed in the pancreatic body or the tail. CONCLUSIONS: Total gastrectomy preserving the pancreas and spleen is the optimal procedure in proximal T2 gastric cancer. Total gastrectomy with splenectomy is appropriate in T3 cases, and distal pancreatectomy should be additionally done only in cases of direct invasion by the lymph node and/or the tumor to the pancreas.     

Distal pancreatectomy with resection of the celiac axis and reconstruction of the hepatic artery for carcinoma of the body and tail of the pancreas

Distal pancreatectomy with resection of the celiac axis can increase resectability of carcinoma of the body and tail of the pancreas. We performed reconstruction of the hepatic artery to avoid complications caused by a decrease in hepatic arterial flow. We carried out distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas in four patients. When pulsation in the proper hepatic artery was weak after occlusion of the celiac axis, we performed reconstruction of the hepatic artery, using the splenic artery, which had been taken beforehand from the resected specimen. In two patients, we performed reconstruction of the hepatic artery. These two patients underwent reconstruction of the portal vein combined with prolonged clamping of the portal vein. Levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were elevated just after the operation, but recovered to normal levels within 10 days. No complications related to hepatic ischemia were observed. These results suggested that reconstruction of the hepatic artery allowed us to safely perform distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas.     

A drainage operation for injury to the pancreas preserved the distal pancreas, spleen and the residual stomach after distal gastrectomy: a case report

We experienced a case in which a drainage operation for injury of the pancreas preserved the distal pancreas, spleen and the residual stomach after distal gastrectomy for complete laceration of the stomach. A 23-year-old male was crushed by a large truck while driving a car without a seat belt. Abdominal computed tomography (CT) scan showed a low-density area in and around the body of the pancreas, which suggested contusion of the pancreatic parenchyma. An emergent operation was indicated due to free air and massive bleeding in the abdominal cavity and liver damage. At the operation, the antrum of the stomach was completely lacerated and distal gastrectomy was performed. Drains were set around the body of the pancreas. Distal pancreatectomy with splenectomy would have led to total gastrectomy because of lack of blood supply to the residual stomach after distal gastrectomy. We limited the drainage operation for pancreatic trauma. As a result, the pancreatic body and tail were preserved, which is thought to be a much better long-term result for this patient.     

Pancreatic Pseudocyst Involving the Spleen

A case of pseudocyst of the tail of the pancreas involving the spleen is presented. Diagnosis of splenic involvement by pseudocyst was made by angiography followed by immediate (elective) surgical intervention with distal pancreatectomy and splenectomy without pre- or postoperative complications.     

Distal pancreatectomy with preservation of the spleen

Distal pancreatectomy (resection of the pancreatic body and tail) can be performed with or without preservation of the spleen. Splenic preservation has the advantages of fewer postoperative complications such as abscesses in the resection bed, shorter length of hospitalization, and avoidance of the long-term risk of post-splenectomy sepsis related to encapsulated bacteria. Two techniques can be used to save the spleen: either by dissecting out the splenic artery and vein with division of the arterial and venous branches between the pancreas and the splenic artery and vein; or by resecting the splenic artery and vein along with the pancreas but with careful preservation of the vascular collaterals in the splenic hilum, which allows the spleen to survive on the short gastric vessels (Warshaw technique). The latter method has been shown to be associated with a shorter operation, less blood loss, and a shorter hospitalization. In general the Warshaw technique is easier, especially for laparoscopic pancreatectomy. The subsequent appearance of enlarged gastric veins (varices) is to be expected as a consequence of loss of the splenic vein but has not led to bleeding from these natural collaterals during long-term follow up.     

A case of using the remnant stomach as substitute after esophagectomy for esophageal cancer with history of distal gastrectomy

A 63-year-old man who had a distal subtotal gastrectomy and retrocolic end-to-side gastrojejunostomy was admitted because of a mid-thoracic esophageal cancer. He underwent a two-stage subtotal esophagectomy and reconstruction using the remnant stomach without microvascular anastomosis. We preserved the splenic artery, splenic vein, and the short gastric artery. The remnant stomach was pulled up together with the pancreas through the anterior sternal route. The superiority of this technique is that microvascular anastomosis is not needed because a sufficient blood supply from the splenic artery and only two anastomoses are needed, compared with three or four anastomoses when using the colon. This technique is also likely to be safer for patients requiring an esophagectomy after a distal gastrectomy.     

Spleen and gastrosplenic ligament preserving distal pancreatectomy under a minimum incision approach assisted by laparoscopy

Background

As a modification of hand-assisted laparoscopic pancreatectomy, we devised a method of spleen and gastrosplenic ligament preserving distal pancreatectomy, in which pancreatic resection is performed under direct vision extracorporeally.

Methods

The distal pancreas and spleen are pulled out of the peritoneal cavity through the minilaparotomy at the epigastrium following hand-assisted laparoscopic dissection of the distal pancreas. Spleen-preserving pancreatectomy is performed safely under direct vision. The gastrosplenic ligament is also preserved to prevent splenic volvulus after the operation. The transected main pancreatic duct is doubly ligated, and the transected pancreatic stump is sewn manually. The preserved spleen and splenic vessels are placed back in the peritoneal cavity after resection.

Results

In the current study (n = 3), overall morbidity rate, including splenic volvulus and pancreatic fistula, was 0%.

Conclusion

Preservation of the gastrosplenic ligament and extracorporeal preparation of the transected pancreatic stump under direct vision are useful measures in spleen-preserving distal pancreatectomy under a minimum incision approach assisted by laparoscopy.     

A Clinical Case of Insulinoma Presenting with Postprandial Hypoglycemia in a Patient with a History of Gastric Bypass Surgery

A 61-year-old man with a history of total gastrectomy for cancer with Roux-en-Y reconstruction showed severe postprandial hypoglycemia accompanied by endogenous hyperinsulinemia. Abdominal ultrasonography and contrast-enhanced computed tomography showed no abnormal findings in the pancreas. A selective arterial secretagogue injection test showed the marked induction of serum immunoreactive insulin when calcium was injected into the splenic artery. A pathological analysis following distal pancreatectomy with splenectomy revealed a pancreatic neuroendocrine microadenoma containing insulin-producing cells in the resected pancreas. This case highlights the importance of carefully evaluating refractory and severe hypoglycemia in patients with a history of gastric surgery to exclude insulinoma.     

Isolated splenic vein thrombosis secondary to splenic metastasis： A case report

INTRODUCTIONIsolated splenic vein thrombosis is a rare clinical syndrome that may lead to left-sided portal hypertension.Metastasis to the spleen from solid tumors is also considered rare.When identified it usually occurs in the setting of widely dissemin…