Splenic vein thrombosis and pancreatic fistula after minimally invasive distal pancreatectomy (Br J Surg 2014; 101: 114–119)

Abstract

Postoperative pancreatic fistula (POPF) after open or minimally invasive distal pancreatic resection remains a clinically relevant problem with a reported incidence of approximately 30 per cent1. Despite the adoption of technical modifications, stapling devices and the identification of several risk factors, no progress has been made over the past two decades in lowering the rate of POPF after distal pancreatic resection. Kang and colleagues are to be congratulated for attempting to identify factors that lead to the development of a clinically relevant POPF after distal pancreatectomy. Initiated by the observation of a clinical case, this retrospective study coveringmore than 5 years found a strong correlation between splenic vein thrombosis (SVT) and clinically relevant POPF in patients undergoing distal pancreatosplenectomy. Considering these results, the authors advocate spleen preservation whenever possible. The main limitation of this study remains its retrospective design. The temporal relationship between SVT and POPF could not be demonstrated precisely during the postoperative clinical course. Thus, one could argue what the sequence of events actually was. On the one hand, it is possible that SVT is caused by an increased platelet count, blood flow turbulence and a ‘surgically activated’ endothelium, which all contribute to the development of POPF. On the other hand, local inflammation caused by POPF could result in the development of SVT. Importantly, this study showed that distal pancreatosplenectomy with a long splenic vein stump is associated with high rates of POPF (16 of 34; 47 per cent) and SVT (27 of 34; 79 per cent). Some favour parenchymal preservation in the treatment of benign lesions. This approach decreases the risk of postoperative endocrine insufficiency by using a limited distal pancreatic resection and leaving a splenic vein stump that drains a pancreatic body with ‘doubtful’ arterial vascularization. Others have found that transecting the pancreas at the neck reduces the rate of POPF2. A prospective comparative study between these two different methods of transection may provide an answer to this question. Spleen-preserving distal pancreatectomy should be the preferred technique when treating benign lesions of the distal pancreas. The surgical technique and postoperative care should be tailored to reduce rates of SVT and consequent clinically relevant POPF.