Comparison of Spleen-Preservation vs Splenectomy in Minimally Invasive Distal Pancreatectomy: A Propensity-Matched Analysis

Abstract

Introduction: Spleen-preservation during minimally invasive distal pancreatectomy (MIDP) can be technically challenging and remains controversial. Our primary aim was to compare minimally invasive distal pancreatectomy and splenectomy (MDPS) with minimally invasive spleen-preserving distal pancreatectomy (MSPDP). Secondary, we compared 2 spleen-preserving techniques. Methods: Adults undergoing MSPDP or MDPS (2001-2021) were retrospectively included in this single-center study. Patients were optimally matched using age, gender, American Society of Anesthesiologists score, BMI, and tumor size using MatchIt. Intraoperative and postoperative outcomes were compared using the Mann-Whitney U test for continuous data, and Fisher’s exact test for categorical data. Results: Of the 296 patients who underwent MIDP, 173 (58%) had spleen-preservation via the Warshaw technique (129;75%) or vessel-preservation (44;25%). All MDPSs were matched 1:1 to a spleen-preserving case with absolute standardized mean differences for all matching covariates below 0.20. The MSPDP group had shorter length of stay (3 vs 4 days, p = 0.01), fewer conversions to open (1 vs 13, p < 0.01) and less blood loss (p < 0.01) compared with MDPS. Operative times were comparable (245 vs 214 minutes, p = 0.16). No differences were found between the two spleen-preserving techniques. At a median follow-up of 42 (interquartile range 18-19) months, only 2 (1.2%) patients after MSPDP had required splenectomy (1 Warshaw for abscess, 1 vessel-preserving for variceal bleeding). Conclusion: Spleen-preservation does not carry the price of greater risk of blood loss, longer hospital stay, conversion, nor lengthy operating room times. Late splenectomy is very rarely required. Given the immune consequences of splenectomy, spleen-preservation should be preferred in MIDP when oncologically appropriate.