Conventional Distal Pancreatectomy Research Articles

Beyond Laparoscopy for Pancreatic Surgery in the Caribbean: Robot Assisted Pancreatico-Splenectomy

Patients with left-sided pancreatic carcinomas are likely to present with advanced disease. Fewer than 10% of these patients are candidates for operative resection at the time of presentation [1]. Due to the advanced disease stage, there has been a recent shift from the conventional distal pancreatectomy (DP) toward radical antegrade modular pancreatico-splenectomy (RAMPS) for better disease clearance [2]. In the past two decades, we also witnessed a trend toward the use of laparoscopic techniques for left sided pancreatic resections [3-7]. A major limitation, however, is limited maneuverability of straight instruments deep in the retroperitoneum. Robotic systems can overcome this limitation with full articulating wrist movements, thereby facilitating dissections with greater dexterity [8-11]. Full robotic platforms, however, are expensive and are not available in low and middle-income Caribbean nations [12]. In the Anglophone Caribbean, there have been few reports of laparoscopic DP at low volumes [3], but we have encountered no reports of laparoscopic RAMPS in our literature review. We report our initial experience using the FreeHand® robotic camera holder (Freehand 2010 Ltd., Guildford, Surrey, UK) to assist in the completion of laparoscopic RAMPS in Trinidad & Tobago.

Radical antegrade modular pancreatosplenectomy enhances local control of the disease in patients with left-sided pancreatic cancer

BackgroundRadical antegrade modular pancreatosplenectomy (RAMPS) was developed to enhance curability in patients with left-sided pancreatic cancer. However, no evidence is available regarding the prognostic superiority of RAMPS compared with conventional distal pancreatectomy (cDP). Here, we aimed to assess the oncological benefit of RAMPS by comparing surgical outcomes between patients who underwent cDP and RAMPS with propensity score (PS) adjustment. MethodsClinical data of 174 patients undergoing cDP and RAMPS between 2009 and 2016 at two high-volume centers were analyzed with PS matching. Recurrence-free survival (RFS), overall survival (OS), and local recurrence rates were compared between patients who underwent cDP and RAMPS. ResultsThe cDP and RAMPS groups were successfully matched with baseline characteristics. No differences were found in the 3-year RFS and OS rates between the two groups (3-year RFS: cDP 46% vs RAMPS 40%, p = 0.451, 3-year OS: cDP 57% vs RAMPS 53%, p = 0.692). However, the 3-year local recurrence rate was lower in the RAMPS (10%) than that in the cDP group (34%) (hazard ratio 0.275, 95% confidence interval 0.090–0.842, p = 0.02). ConclusionRAMPS is oncologically superior to conventional procedure in achieving local control of the disease in patients with left-sided pancreatic cancer.

Extensive (subtotal) distal pancreatectomy for pancreatic ductal adenocarcinoma: a propensity score matched cohort study of short- and long-term outcomes compared with those of conventional distal pancreatectomy.

Extensive distal pancreatectomy (ExDP) can transect the pancreatic parenchyma more from the right side than conventional distal pancreatectomy (CDP) can. This study aimed to evaluate the short- and long-term outcomes of ExDP for pancreatic ductal adenocarcinoma (PDAC) of the pancreatic body, located adjacent to the portal vein (PV). Medical records of 98 patients who underwent ExDP (n = 15) or CDP (n = 83) for PDAC were retrospectively reviewed. Short- and long-term outcomes of the two groups were compared. Propensity score matched analysis was additionally performed to minimize the impact of treatment allocation bias. In the total cohort, the CDP group had a significantly higher proportion of pancreatic tail lesions (P < 0.01), higher proportion of males, and larger tumor size. Of the 15 patients who underwent ExDP, 11 could be matched. These differences of patients' characteristics were not observed after matching. Before and after matching, the duration of surgery, blood loss, rate of morbidity including pancreatic fistula, and postoperative course were comparable between the groups. The rate of recurrence and recurrence pattern were also not significantly different between the groups. ExDP for PDAC of the pancreatic body near the PV did not increase local or lymph node recurrence. The disease-free and overall survival did not differ between the groups. Surgical and oncological outcomes after ExDP for PDAC were acceptable and comparable to those after CDP. ExDP is a feasible procedure, and could be an option for the treatment of PDAC of the pancreatic body near PV.

Effect of Spleen Preservation on the Occurrence of Sepsis in Patients Who Underwent Distal Pancreatectomy: A Population-Based, Propensity Score Matching Study

Background: To investigate the long-term effects of splenectomy on sepsis occurrence in patients undergoing distal pancreatectomy. Splenectomy is associated with sepsis and other severe infections. Splenic preservation has been advocated during distal pancreatectomy for benign or borderline pancreatic diseases. To date, no population-based study has investigated the risk of sepsis occurrence with regard to splenectomy in patients undergoing distal pancreatectomy. Methods: In this population-based study, the Health Insurance Review & Assessment Service (HIRA) database was used to identify patients who underwent distal pancreatectomy between 2010 and 2014. After propensity score matching, the variables that affect sepsis occurrence were analysed between the spleen-preserving distal pancreatectomy (SPDP) and the conventional distal pancreatectomy (CDP) groups. Findings: A total of 5,613 patients undergoing distal pancreatectomy were included in the HIRA database (2,560 splenectomised patients and 3,053 spleen-preserved patients). We matched 2,262 splenectomised patients to 2,262 spleen-preserved patients. No significant difference was observed in the rate of sepsis occurrence between the SPDP and CDP groups. Interpretation: Compared to spleen-preservation, splenectomy during distal pancreatectomy is not related to an increased likelihood of long-term sepsis. Thus, preservation of the spleen during distal pancreatectomy may not be mandatory in patients with benign pancreatic disease. However, further population-based studies are warranted to analyse the role of spleen-preserving distal pancreatectomy in other outcomes. Funding Information: This study received no financial support. Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: This study was approved by institutional review board of Kangnam Sacred Heart Hospital (HKS 2018-11-013), and the need for informed consent from each patient was waived because the authors did not have access to identifiable information.

Comparison of conventional distal pancreatectomy and splenectomy with radical antegrade modular pancreatosplenectomy, multicenter, retrospective study

Comparison of conventional distal pancreatectomy and splenectomy with radical antegrade modular pancreatosplenectomy, multicenter, retrospective study

Evaluating the relationships between splenic artery and pancreatic parenchyma using three dimensional CT for laparoscopic distal pancreatectomy

Background: Isolating the root of splenic artery (SPA) is essential for conventional distal pancreatectomy, while remains challenging in laparoscopic procedure due to the complexity in anatomical variation around SPA. This study aimed to investigate the usefulness of preoperative evaluation of the relationships between SPA and pancreatic parenchyma using 3D-CT. Methods: A total of 104 patients who underwent distal pancreatectomy (74 with laparoscopic procedure and 30 with open procedure) were evaluated. The relationship between SPA and pancreatic parenchyma was classified into two types with preoperative 3D-CT, namely “Buried type” and “Non-buried type”. Video clips of 50 patients were reviewed to investigate whether this classification would be related with the difficulty of isolating the SPA. In addition, the distribution of dorsal pancreatic artery (DPA) was also evaluated. Results: DPA from SPA was identified in 94 (91.3%) patients and the number was four in one patient, three in 8, two in 29, and one in 56. Fifty-eight (55.8%) patients had DPA within 30mm of the root of the SPA. Of the 50 assessed patients who underwent LDP, there were “Buried-type” in 30 (60.0%) and “Non-buried” type in 20 (40.0%). The median time for isolating SPA in “Buried-type” (25.8 min; range, 4.0 to 101) was significantly longer than that in “Non-buried type” (7.0 min, range, 1.0 to 27.0) (P< 0.001). Conclusion: Preoperative 3D anatomical image analysis around pancreas is practical to predict the difficulty of isolating the root of SPA and to provide the safety of the procedure.

Oncological Superiority of RAMPS to Conventional Distal Pancreatectomy

Background: To improve local radicality of surgical treatment for left-sided pancreatic cancer, radical antegrade modular pancreatosplenectomy (RAMPS) was developed. However, no evidences are available regarding the superiority of RAMPS to conventional distal pancreatectomy (cDP) in terms of long-term outcomes.

Minimally Invasive Distal Pancreatectomy for the Management of Left-Sided Pancreatic Cancer

Curative surgical resection is considered the most effective treatment option to achieve long–term survival in patients with pancreatic cancer. In performing a Distal Pancreatectomy (DP) for left–sided pancreatic cancer, there are two main approaches to dissection: proceeding from left to right and from right to left. The conventional DP procedure was the Standard Retrograde Pancreatosplenectomy (SRPS), with a left–to–right dissection, and then the radical antegrade Modular Pancreatosplenectomy (RAMPS), with a right–to–left dissection, was developed. A greater number of harvested lymph nodes and an increase in R0 resection have been achieved in RAMPS as compared to SRPS; however, oncological outcomes, including patient survival, are comparable in these procedures. Recently, Minimally Invasive Distal Pancreatectomy (MIDP) using laparoscopy for pancreatic cancer has been advanced. The MIDP also has not been enough to show oncological benefits as compared with an open DP. Additional randomized controlled trials should be conducted to clarify the impacts and benefits of each surgical approach in performing DP for cancer of the body or tail of the pancreas

Revisiting the potential advantage of robotic surgical system in spleen-preserving distal pancreatectomy over conventional laparoscopic approach.

BackgroundThis study aimed to compare success rate of spleen preservation between robotic and laparoscopic distal pancreatectomy (DP).MethodsBetween November 2007 and March 2018, forty-one patients underwent the conventional laparoscopic DP (Lap group) and the other 37 patients underwent robotic DP (Robot group). The perioperative clinicopathologic variables were compared.ResultsThe robotic procedure was chosen by younger patients compared to conventional laparoscopic surgery (42.9±14.0 vs. 51.3±14.6 years, P=0.016). The mean operation time was longer (313 vs. 246 min, P=0.000), but the mean tumor size was smaller in Robot group (2.7±1.2 vs. 4.2±3.3 cm, P=0.018). The overall spleen-preserving rate was higher in the Robot group (91.9% vs. 68.3%, P=0.012). However, with accumulating laparoscopic experiences (after 16th case), the statistical differences in spleen preservation rate between the Robot and Lap groups had diminished (P=0.428).ConclusionsThe present results suggest a robot can be helpful to save the spleen during DP for benign and borderline malignancy. However, a surgeon highly experienced in the laparoscopic approach can also produce a high success rate of spleen preservation, similar to that shown with the robotic approach.

Is distal pancreatectomy with en-bloc celiac axis resection effective for patients with locally advanced pancreatic ductal adenocarcinoma? -Multicenter surgical group study

ObjectivesWe retrospectively investigated the operative outcomes of patients who underwent distal pancreatectomy (DP) for invasive pancreatic ductal adenocarcinoma (PDAC) located at the body and tail. MethodsData from 395 patients with PDAC who underwent DP with margin-negative resection (R0 or R1) were collected from seven high-volume centers in Japan from 2001 to 2012. Among them, 72 patients underwent DP with en-bloc celiac axis resection (DP-CAR). The remaining 323 patients underwent conventional DP with splenectomy (DP-S). To determine the efficacy of DP-CAR, clinicopathological data were compared between the DP-CAR and the DP-S groups. ResultsThe DP-S group consisted mainly of patients with resectable disease (93%), and conversely, all patients in the DP-CAR group had borderline resectable or unresectable disease. The overall morbidity was significantly higher in the DP-CAR group than in the DP-S group (63% vs 47%, respectively; P = 0.017). The median survival time (MST) of the DP-CAR group was significantly shorter than that of the DP-S group (17.5 vs 28.6 months, respectively; P = 0.004). However, the MST of patients in the DP-CAR group (n = 61, 85%) who received adjuvant therapy was significantly longer than that of patients in the DP-S group (n = 65, 20%) who underwent R1 resection (21.9 vs 16.7 months, respectively; P = 0.024). ConclusionDP-CAR followed by adjuvant chemotherapy provided an acceptable overall survival rate in patients with highly advanced PDAC, but should be performed with great caution because of high morbidity. Patients with a high risk of positive surgical margins with DP-S may be candidates for DP-CAR.

Initial experience with radical antegrade modular pancreatosplenectomy in a single institution.

PurposeRadical antegrade modular pancreatosplenectomy (RAMPS) is expected to be favorable for obtaining the negative tangential margin with oncologic feasibility through the horizontal dissection in a right-to-left fashion for radical lymph node dissections.MethodsFrom January 2007 to February 2015, a total of 30 RAMPS and 19 conventional distal pancreatectomy (DP) cases were enrolled. The demographics, perioperative and survival outcomes were compared according to the type of surgery.ResultsThe mean operative time, blood loss and length of hospital stay were similar between 2 groups. Morbidities were reported in 14 cases of RAMPS (46.7%) and 8 cases of DP (42.1%) (P = 0.777). The rate of negative tangential margin (96.2%) and the number of harvested lymph nodes (mean ± standard deviation, 21.5 ± 8.3) were significantly higher in RAMPS group (P = 0.011, P = 0.003, respectively). In terms of survival outcomes, there was no significant difference in regard to the overall 3-year disease-free survival (DFS; 30.4% in RAMPS vs. 35.0% in DP, P = 0.354) or overall survival (OS; 29.9% vs. 29.4%, P = 0.429) between the 2 groups. After exclusion of cases with nodal invasion, however, the RAMPS group had a longer DFS than the DP group (55.6% vs. 27.3%, P = 0.048) although OS was similar without significant difference (42.4% vs. 27.3%, P = 0.197).ConclusionRAMPS is a safe and oncologically feasible procedure in left-sided pancreatic cancer by obtaining a successful negative tangential margin and radical lymph node dissection. The authors suggest it could also be useful for local control, especially for the limited left-sided pancreatic cancer without nodal invasion.

Robotic distal pancreatectomy with or without preservation of spleen: a technical note.

BackgroundDistal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy.MethodsIn this article, we describe a standardized operative technique for fully robotic distal pancreatectomy.ResultsIn the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years).ConclusionsRDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills.

Short-term perioperative outcomes after robot-assisted and laparoscopic distal pancreatectomy.

Robotic surgery offers potential technical advantages that may facilitate pancreatic resection. The aim of this study was to evaluate the learning curve and short-term perioperative outcomes in patients who underwent laparoscopic and robot-assisted distal pancreatectomy. All perioperative variables were evaluated and compared retrospectively between laparoscopic (LDP) (n=23) and robot-assisted (RDP) (n=11) distal pancreatectomy. The mean total operative time was shorter in LDP (194 vs. 225min; p=0.017). All other perioperative criteria were similar between LDP and RDP patients (blood loss, transfusion rate, conversion, pancreatic fistula, postoperative morbidity, and duration of hospitalization). Non-adjusted CUSUM curve for composite events including operative time, conversion, postoperative morbidity and reoperation rates showed that the RDP learning curve corresponded to the first seven consecutive patients. During early experience, RDP was associated with longer operative time but similar short-term perioperative outcomes compared to conventional distal pancreatectomy.

Reduced Port Surgery for Laparoscopic Distal Pancreatectomy Using the Transumbilical Approach with Zigzag Incision

Introduction: Laparoscopic surgery in distal pancreatectomy (DP) is as an effective approach for patients with pancreatic disease because of the reduction in the blood loss, length of hospital stay, and risks of overall postoperative complications and wound infection, without a substantial increase in the operating time.1 Moreover, single-port laparoscopic surgery has become increasingly popular with a widened indication in more types of surgery. However, compared with the conventional laparoscopy, this approach may take longer to complete and requires advanced skills and dedicated instrumentations to compensate for the lack of triangulation.2 In particular, the Gelport laparoscopic system provides a flexible, airtight fulcrum to facilitate the triangulation of standard instrumentation while maintaining the pneumoperitoneum for a minimally invasive surgery. As it is easy to perform hand-assisted operation at the same time, the surgeon can cope with unexpected bleeding with safe quickly. The device has been used for various organ laparoscopic surgeries.3–5 The combination of the umbilical zigzag skin incision technique and the Gelport laparoscopic system was introduced as an effective procedure for laparoscopic surgery to various organs, reconciling the reduction of technical difficulties with the cosmetic outcomes in laparoscopic surgery.6 In this video (410 seconds), we demonstrate the technique as a safe procedure for reduced port surgery performed in laparoscopic DP, without adverse cosmetic effects. Materials and Methods: A 64-year-old woman underwent laparoscopic DP for pancreatic nonfunctional endocrine tumor. The procedure is described as follows: After marking the umbilical region for a zigzag skin incision, the skin was incised along the line. Then, a Gelport double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The Gelport was latched to the wound retractor ring, and the pneumoperitoneum was then inflated using CO2. Two additional 5-mm trocars were inserted into the upper middle and lower left hypochondria. If the operation field is not enough for continuing the procedure, the 5-mm flexible retractor is useful for lifting the organ through another 5-mm trocar. The pancreatic body and spleen were resected using the standard procedures. After dissection of the splenic artery and vein, the pancreatic parenchyma was dissected using the stapler technique. The dissected specimen was extracted smoothly through the umbilical incision, without any additional incision and destruction of the spleen. The operating time was 385 minutes, and the blood loss was 20 mL. During the postoperative period, the wound in the umbilical region shrank to the bottom of the umbilicus. Results and Conclusions: We introduced a transumbilical approach using the Gelport system with an umbilical zigzag incision for reduced port surgery in laparoscopic DP. Although this procedure took a longer operating time compared to the conventional method, this patient was still a second case for us after experiences of 15 conventional laparoscopic DP cases in our department. We consider that it is not difficult to shorten the operating time by repeating experience. Thus, we suggest that the creation of an umbilical incision using the zigzag technique allows for an easy and safe laparoscopic surgery for pancreatic diseases. The authors have no conflicts of interest or financial ties to disclose. Runtime of video: 6 mins 50 secs

Distal Pancreatectomy Combined with Celiac Axis Resection in Treatment of Carcinoma of the Body/Tail of the Pancreas: A Single-Center Experience

Few comparison studies have been carried out on patients with distal pancreatectomy (DP) combined with celiac axis (CA) resection. The aim of this study was to assess the safety and efficacy of this extended procedure in treatment of advanced carcinoma of the body/tail of the pancreas. This was a retrospective analysis of 206 patients with carcinoma of the body/tail of the pancreas from January 2003 through June 2008. Patients were divided into three groups based on the relationship of tumor and CA/common hepatic artery (CHA) as well as different treatment strategies. Data for operation time, blood loss, complications, and survival time were collected and statistically analyzed. Sixty-five patients (31.6%) received radical distal pancreatectomy (DP), including 11 patients who underwent DP combined with celiac axis resection (group A) and 54 patients who received conventional DP (group B). Twenty patients did not undergo DP because of CA and/or CHA invasion only (group C). Group A had longer mean operative time than group B (323 versus 225 min, P = 0.000); there was no difference in mean estimated blood loss, percentage of pancreatic fistula or median survival time (14 versus 15 months, P = 0.197). However, group A had significantly prolonged median survival time compared with the 20 patients in group C (14 versus 5 months, P = 0.013), and quality of life was also dramatically improved. DP combined with CA resection can be safely performed in certain patients with carcinoma of body/tail of the pancreas and significantly improves patient survival and quality of life.

Ten years of experience with resection of left-sided pancreatic ductal adenocarcinoma: evolution and initial experience to a laparoscopic approach

With increasing laparoscopic experience, laparoscopic distal pancreatectomy with or without splenectomy is being regarded as a safe and effective treatment for benign and borderline malignant lesions of the pancreas; however, its application for left-sided pancreatic ductal adenocarcinoma (PDAC) is still debatable. We analyzed patients who underwent conventional distal pancreatectomy with splenectomy (DPS) for distal pancreatic cancer at our institution. We have performed laparoscopic DPS partly based on radical antegrade modular pancreatosplenectomy (RAMPS) for well-selected left-sided PDAC since 2007. We compared laparoscopic DPS to conventional DPS according to various clinicopathologic factors. From January 1999 to December 2008, 45 patients underwent conventional DPS for resectable left-sided PDAC, and 18 needed combined adjacent organ resection for potential margin negative (R0) resection. The median survival of resected left-sided PDAC was 27.9 months with a 5-year survival of 28.9%. A small amount of intraoperative bleeding [< or =760 ml Exp(beta) = 6.312, p = 0.001] and R0 resection [Exp(beta) = 4.349, p = 0.090] were the most significant prognostic factors. To achieve bloodless and R0 resection, the potential indication for laparoscopic DPS was suspicious pancreatic cancer confined to the pancreas that could be removed by DPS without resection of the adjacent organs. Five patients underwent laparoscopic/robot-assisted DPS for left-sided PDAC. Compared to conventional DPS, only the operation time (p = 0.011) and tumor size (p = 0.031) were significantly different, but other clinicopathologic variables were comparable. All patients still are alive. Four patients have lived without tumor recurrence (follow-up = 4-22 months), and only one experienced multiple liver metastasis and subsequent retroperitoneal local recurrence. Laparoscopic/robot-assisted modified anterior RAMPS may be technically feasible for well-selected PDAC. The oncologic feasibility still remains to be determined due to limited experience.

Spleen‐preserving Distal Pancreatectomy with Excision of Splenic Artery and Vein: A Case‐matched Comparison with Conventional Distal Pancreatectomy with Splenectomy

The value of spleen preservation during distal pancreatectomy (DP) still remains controversial. Spleen-preserving DP with excision of the splenic artery and vein is a simplified technique for spleen preservation. The aim of this study was to compare the postoperative course of DP with or without splenectomy. From 1990 to 2005, 38 consecutive patients with benign or low-grade malignant disease underwent a spleen-preserving DP operation with excision of the splenic artery and vein (Conservative Group). They were compared with 38 patients who underwent conventional DP with splenectomy over the same time period (Splenectomy Group) and who had been matched for age, American Society of Anesthesiologists (ASA) score, and pathological diagnosis. Postoperative courses were analyzed and compared between the Conservative Group and Splenectomy Group. Spleen preservation was effective in 36 of the 38 attempts (95%). Postoperative complications - in particular, infectious intra-abdominal complications - were significantly higher in the Splenectomy Group (34 and 18%, respectively) than in the Conservative Group (13 and 3%, respectively) (P = 0.03 and P = 0.02, respectively). The length of the surgery, perioperative blood loss or transfusions, perioperative mortality and length of hospital stay did not differ between the two groups. Univariate analysis showed that splenectomy was the only risk factor for postoperative complication. Spleen-preserving DP with excision of the splenic artery and vein is a fast, safe and effective procedure associated, in this series, with a reduction of postoperative complications relative to conventional DP with splenectomy. This technique should be considered in patients with benign or low-grade malignant disease of the pancreas.

Middle segment pancreatectomy for the treatment of benign and low malignant potential pancreatic tumours

Background: Conventional distal pancreatectomy is used for the removal of lesions located at the body and tail of the pancreas. Generally, the spleen is sacrificed. But for benign and low malignant potential tumours in the pancreatic neck and body, this incurs notable loss of normal pancreatic tissue and the unnecessary risk of diabetes mellitus as well as splenic loss.Methods: We report three cases of middle segment pancreatectomy in an effort to avoid the unnecessary loss of normal pancreatic tissue and the spleen. Two patients were males with a mucinous cystadenoma and non‐cystic mucinous cystadenocarcinoma. The other was a female with a serous cystadenoma. Middle segment pancreatectomy was performed. Two patients were reconstructed with double pancreaticojejunostomy and the third with a pancreaticogastrostomy.Results: No major complications were observed.Comnclusions: Middle segment pancreatectomy is a safe and effective procedure for the resection of benign and low malignant potential tumours in the pancreatic neck and body with preservation of normal pancreatic tissue and the spleen in selected patients. This is the first report of middle segment pancreatectomy for pancreatic tumour in China.

Distal pancreatectomy with and without splenectomy

Splenectomy is performed routinely during distal pancreatectomy, yet the spleen has an important role in host defence and can often be preserved. A personal series of 100 distal pancreatectomies undertaken for pancreatic disease between 1978 and 1990 included 23 patients undergoing total pancreatic resection. The remaining 77 patients, who form the basis of the present report, underwent primary distal pancreatectomy and comprised 34 women and 43 men with a median age of 41 years (range 17-78 years). Conventional distal pancreatectomy including splenectomy was performed in 42 patients (55 per cent) for chronic pancreatitis (34 patients), pancreatic neoplasia (six patients), suspected pancreatitis (one patient) or pancreatitic trauma (one patient). Conservative resection with splenic preservation was performed in 35 patients (45 per cent) for chronic pancreatitis (12 patients), suspected pancreatitis (13 patients, including eight patients with pancreas divisum), pancreatic neoplasia (six patients), recurrent acute pancreatitis (two patients) and pancreatic trauma (two patients). There were no postoperative deaths in either group. Early complications followed conventional resection in 10 patients (24 per cent) and conservative resection in seven patients (20 per cent). In five patients the splenic vessels were ligated away from the splenic hilum and the spleen was left in situ, but subsequent isotope scans and haematological indices showed no hyposplenism. The spleen can safely be preserved in many distal pancreatic resections, including those for inflammatory disease, and we now prefer a retrograde technique for dissecting the pancreas off the splenic vessels.

The value of splenic preservation with distal pancreatectomy.

Splenic-preserving distal pancreatectomy for benign or low-grade malignant disease is associated with decreased perioperative morbidity compared with conventional distal pancreatectomy with splenectomy. A retrospective review of a prospective database of patients. Memorial Sloan-Kettering Cancer Center, New York, NY. All patients (N = 211) undergoing distal pancreatectomy. Perioperative complications, length of postoperative stay, and overall survival times were analyzed. After excluding patients with adenocarcinoma and those who had other major organ resection, 125 patients underwent distal pancreatectomy for benign or low-grade malignant disease with splenectomy (n = 79) or splenic preservation (n = 46). Perioperative complications occurred in 39 (49%) of the 79 patients following splenectomy and 18 (39%) of the 46 patients following splenic preservation (P =.21). Perioperative infectious complications and severe complications were significantly higher in the splenectomy group (28% and 11%) compared with the splenic preservation group (9% and 2%) (P =.01 and.05), respectively. Length of hospital stay was 9 days (range, 5-41 days) following splenectomy and 7 days (range, 5-26 days) following splenic preservation (P<.01). No difference in length of surgery, units of blood transfused, or perioperative mortality was noted between groups. Splenic preservation following distal pancreatectomy for benign or low-grade malignant disease is safe and is associated with a reduction in perioperative infectious complications, severe complications, and length of hospital stay compared with conventional distal pancreatectomy with splenectomy. Therefore, splenic preservation should be considered in this group of patients.