Kimura Technique Research Articles

Robotic Spleen-Preserving Distal Pancreatectomy: The Warshaw and Kimura Techniques.

Spleen-preserving distal pancreatectomy offers an alternative surgical approach to the traditional distal pancreatectomy combined with splenectomy for removing benign and low-grade malignant lesions in the distal pancreas, avoiding complications associated with splenectomy. This procedure can be accomplished either by resecting and ligating the splenic vessels (Warshaw technique) or by preserving them (Kimura technique). Currently, the widespread use of minimally invasive surgery has established laparoscopic and robotic approaches for spleen-preserving distal pancreatectomy as valid and safe options for treating such conditions. Our protocol aims to describe how the Warshaw and Kimura techniques of spleen-preserving distal pancreatectomy can be performed robotically. The first patient is a 36-year-old female with a neuroendocrine tumor (NET) in the pancreatic body who underwent a spleen-preserving distal pancreatectomy with the ligation of the splenic vessels (WT). The second patient is a 76-year-old male with chronic pancreatitis presenting with a dilated main pancreatic duct in the tail of the pancreas who underwent a spleen-preserving distal pancreatectomy with a vessel-preserving approach (KT).

Interim analysis of short-term outcomes after laparoscopic spleen-preserving distal pancreatectomy with or without preservation of splenic vessels: a randomised controlled trial.

Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) is a widely adopted surgical approach for benign and low-grade malignant neoplasms of the distal pancreas. The Kimura and Warshaw techniques represent two principal strategies, yet it still needs to be determined which one is superior. Our investigation aimed to evaluate the clinical outcomes associated with each technique. This single-center, parallel-group, patient-blinded randomized controlled trial (RCT) was conducted at the XXXXX University. Stratified block randomization was utilized to enroll 114 patients starting in March 2022, with an interim analysis of short-term outcomes scheduled after 45%-50% of participant enrollment. Patients were randomized to receive LSPDP via either the Kimura or Warshaw technique. The primary endpoint was intraoperative blood loss, while secondary endpoints included a range of outcomes from composite outcome to quality of life, as quantified by the EQ-5D-5L. From March 2022 to November 2023, 53 patients were randomly allocated to the Kimura (n=25) or Warshaw (n=28) groups for LSPDP. Baseline characteristics and postoperative outcomes were similar between the groups, such as pancreatic fistula incidence, EQ-5D-5L index scores, and delayed gastric emptying rates. Per-protocol (PP) analysis revealed that the Kimura group experienced significantly less blood loss (52.5±51.6mL vs. 91.7±113.5mL, P=0.007) and a reduced rate of composite outcome (23.8% vs. 56.7%, P=0.019), but incurred higher costs in the Warshaw group (¥56,227.4±¥7,027.0 vs. ¥63,513.8±¥12,944.5, P=0.013). Splenic infarction rates were higher in the Warshaw group, though not statistically significant (ITT: 39.3% vs. 12.5%, P=0.058; PP: 36.7% vs. 14.3%, P=0.113), without necessitating intervention. Neither group experienced postpancreatectomy haemorrhage, 90-day mortality, or ICU admissions, and all postoperative complications were mild (Clavien-Dindo Grade <III). The 90-day interim analysis postoperatively indicates that both Kimura and Warshaw techniques for LSPDP are safe and viable. The Kimura technique, however, confers superior in terms of reduced intraoperative blood loss and fewer complications, alongside lower costs.

Laparoscopic spleen-preserving distal pancreatectomy: A novel technique with splenic artery resection and splenic vein preservation.

Laparoscopic spleen-preserving distal pancreatectomy (LSDP) is widely performed to treat benign and low-grade malignant diseases. Although preservation of splenic vessels may be desirable considering the risk of postoperative complications, it is sometimes difficult due to tumor size, inflammation, and proximity of the tumor and splenic vessels. Herein, we present the first case of LSDP with splenic artery resection and splenic vein preservation. A 40-year-old woman with a pancreatic tumor was referred to our hospital. Contrast-enhanced computed tomography (CT) revealed a tumor in the pancreatic tail that was in contact with the splenic artery and distant from the splenic vein. The splenic artery and vein were separated from the pancreas near the dissection line. The splenic artery was resected after pancreatic dissection using a linear stapler. After the pancreatic tail was separated from the splenic hilum while preserving the splenic vein, the distal side of the splenic artery was resected, and the specimen was removed. The postoperative course was uneventful and the patient was discharged on postoperative Day 9. Four months after surgery, postoperative follow-up CT findings showed neither splenic infarction nor gastric varices. This technique is an alternative method of splenic preservation when there is no attachment of the tumor to the splenic vein or uncontrolled expected bleeding of the splenic artery using the Kimura technique.

Distal pancreatectomy with partial preservation of the spleen: a new surgical technique.

Presently, spleen-preserving distal pancreatectomy is predominantly utilized for benign or low-grade malignant tumors of the pancreatic body and tail. The splenic blood vessel-preserving Kimura technique and non-splenic blood vessel-preserving Warshaw technique represent the two primary procedures. In prior reports, total splenectomy was most frequently performed when splenic blood vessels could not be preserved, and severe splenic congestion and ischemia were identified following the dissection of splenic blood vessels. This paper introduces a new method of spleen-preserving distal pancreatectomy, entailing a distal pancreatectomy with partial spleen preservation, illustrated through the presentation of two surgical cases. During physical examination, two patients were identified to have benign or low-grade malignant masses in the pancreatic tail. Preoperative examination indicated that the lesion was closely associated with the splenic blood vessels or splenic hilum. During surgery, neither the Kimura technique nor the Warshaw technique could be executed. After resecting the pancreatic body and tail, and a portion of the spleen, the superior pole of the spleen was successfully preserved by maintaining the short gastric blood vessels therein. This technical report demonstrates the viability of this novel spleen-preserving distal pancreatectomy, a distal pancreatectomy with partial spleen preservation, for benign and low-grade malignant pancreatic body and tail lesions. The innovative technique achieves partial spleen preservation by effectively preserving the short gastric blood vessels in the superior pole of the spleen.

Analysis of long-term outcomes after minimally invasive spleen-preserving distal pancreatectomy under the 'Kimura-first' strategy.

Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation. The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up. A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group ( P = 0.02). We also found less blood loss for patients who underwent KT ( P = 0.02). The occurrence of gastric varices was significantly higher in the WT group ( P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group ( P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire. The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.

Spleen-preserving pancreatectomy with removal of splenic vessels: impact on splenic parenchyma ?

BackgroundWhile outcomes after spleen-preserving distal pancreatectomy (SP-DP) have been widely reported, impacts on splenic parenchyma have not been well studied. This study aimed to compare postoperative outcomes, particularly spleen-related outcomes, by assessing splenic imaging after SP-DP with or without splenic vessels removal.MethodsData for all patients who underwent SP-DP with splenic vessels removal (Warshaw technique, WDP) or preservation (Kimura technique, KDP) between 2010 and 2022 in two tertiary centres were retrospectively analysed. Splenic ischemia and volume at early/late imaging and postoperative outcomes were reviewed.ResultsEighty-seven patients were included, 51 in the WDP and 36 in the KDP groups. Median Charlson’s Comorbidity Index was significantly higher in the WDP group compared with the KDP group. Postoperative morbidity was similar between groups. There was more splenic ischemia at early imaging in the WDP group compared to the KDP group (55% vs. 14%, p = 0.018), especially severe ischemia (23% vs. 0%). Partial splenic atrophy was observed in 29% and 0% in the WDP and KDP groups, respectively (p = 0.002); no complete splenic atrophy was observed. Platelet levels at POD 1, 2 and 6 were significantly higher in the WDP group compared to KDP group. At univariate analysis, age, Charlson Comorbidity Index, platelet levels at POD 6, and early splenic infarction were prognostic factors for development of splenic atrophy. No episodes of overwhelming post-splenectomy infection or secondary splenectomy were recorded after a median follow-up of 9 and 11 months in the WDP and KDP groups, respectively.ConclusionsSplenic ischemia appeared in one-half of patients undergoing SP-DP with splenic vessels removal at early imaging, and partial splenic atrophy in almost 30% at late imaging, without clinical impact or complete splenic atrophy. Age, Charlson Comorbidity Index, platelet levels at POD 6, and early splenic infarction could help to predict the occurrence of splenic atrophy.

Utility of the Kimura technique for the definitive management of high jejunal atresia

BackgroundOperative management of high jejunal atresia may be challenging due to significant size discrepancy between the dilated proximal jejunum and distal atretic bowel.Case presentationWe report a female newborn infant with a high type 1 proximal jejunal atresia located precariously at the duodenojejunal flexure which was successfully corrected with the Kimura operation, i.e., jejunojejunostomy as originally first described for duodenal atresia. The patient was weaned onto full enteral feeds by the end of the first postoperative week and promptly discharged without complication(s).ConclusionsThe utility and versatility of Kimura’s diamond-shaped anastomosis are highlighted in this unique case report.

Spleen-Preserving Retrograde Distal Pancreatectomy for Malignant Insulinoma

Introduction: Distal pancreatectomy is performed primarily for malignant and premalignant diseases of the pancreas. Neuroendocrine tumors within the body and tail of the pancreas can be resected or enucleated depending upon the size and relationship of the tumor with the pancreatic duct.1,2 This video presents the technical details of a spleen-preserving laparoscopic distal pancreatectomy using a retrograde dissection (Kimura technique) for malignant pancreatic neuroendocrine tumor treatment. Operative Technique: A 47-year-old woman with medical history of hypertension and hypothyroidism comes to endocrinology presenting 3 months history of lumbar pain and 6 months history of neuroglycopenic symptoms. The work-up demonstrated hyperinsulinemic hypoglycemia produced by a 2.7 cm insulin-producing tumor of the body of the pancreas. A 1 cm cyst of the tail of the pancreas, a 5 mm sellar mass, and an adenoma of one parathyroid gland with elevated parathyroid hormone and calcium are seen as well, indicatory of a multiple endocrine neoplasia type 1.3–5 A five-trocar laparoscopic distal pancreatectomy was performed with one surgeon between the legs and two more surgeons on each side of the patient. The liver was retracted for better visibility and started with the section of splenocolic ligament to release the splenic angle of the colon and move it to the midline. Short gastric vessels of the gastrosplenic ligament are sectioned to address the posterior face of the stomach, through the lesser sac. The stomach was retracted cephalad, allowing for a better exposure of the pancreas. The insulinoma became visible on the anteroinferior margin and was well delimited with intraoperative manipulation. Pancreas is accessed through the retroperitoneum. Splenic vessels are dissected. The splenic artery and vein are identified and referred to be able to dissect along the upper edge of the pancreas, in a retrograde approach to preserve vascular structures. Ligaclips are placed on the branches of the splenic vessels. Transection is performed at the level of the junction of the head and neck of the pancreas, leaving enough space between the mass using a linear stapler capable of 60 mm long cuts and with 3.5 mm open staple height. The integrity of the piece is verified and is extracted with a laparoscopic specimen retrieval bag. In the case of this patient with previous surgery, an existing Pfannenstiel-type scar is used to avoid extension of the laparoscopic scars. Blake-type drain is placed in situ. Results: The postoperative course was uneventful. No postoperative diabetes was observed and no treatment for hypoglycemia was necessary. Early oral feeding postoperatively was well tolerated. The patient was discharged home 3 days after surgery with a placed drain. Histology analysis confirmed the full resection of the intrapancreatic neuroendocrine tumor. No competing financial interests exist. Runtime of video: 9 mins 24 secs

Total Pancreatectomy with Spleen Preservation for Degenerated IPMN: A Hybrid Fusion between the Kimura Technique and the Whipple Procedure

Total Pancreatectomy with Spleen Preservation for Degenerated IPMN: A Hybrid Fusion between the Kimura Technique and the Whipple Procedure

TREATMENT OF CONGENITAL DUODENAL OBSTRUCTION: FROM OPEN TO LAPAROSCOPIC APPROACH FOR DUODENO-DUODENAL ANASTOMOSIS.

Conginental duodenal obstruction is a relatively rare malformation. Laparoscopic operation for this condition was described for the first time in 2001, but more than 20 years later, there is still debate over the preferred method of surgical correction. We believe that laparoscopic correction of conginental duodenal obstruction is a safe and feasible method and can be used in premature infants with low body weight. Materials and Methods: From September 2017 to December 2021, 27 children with conginental duodenal obstruction were treated in our department. We were able to identify the diagnosis in 17 children during the antenatal period, while plain X-ray confirmed postnatal diagnosis. In doubtful cases the contrast fluoroscopy was performed. Four children underwent open correction of the defect via a circumbilical approach, while laparoscopic duodeno-duodenal anastomosis using the Kimura technique was performed in the remaining 23 children. Results: Intraoperative complication in the form of duct injury was observed in 1 patient with an atypically located Wirsung duct. In the postoperative period, anastomotic failure was noted in 2 children, and perforation of the duodenum was detected in 2 patients. The mortality rate comprised 26%, which was partly attributed to severe concomitant pathologies. The use of prolonged epidural analgesia in combination with laparoscopic surgery provided early weaning from mechanical ventilation and transfer from the intensive care unit. Enteral feeding was initiated on postoperative day 5, and the average length of hospital stay was 29±10.5 days. Conclusion: There are no limitations to performing laparoscopic correction of congenital duodenal obstruction. When there are accompanying congenital defects, minimally invasive technology allows to perform combined operations on organs of the thoracic and abdominal cavity, which reduces the overall surgical time. In combination with prolonged epidural analgesia, laparoscopic technique reduces the length of stay in the intensive care unit and the need for parenteral nutrition, which ultimately lowers the risk of inflammatory complications and treatment costs.

Robot Assisted Spleen Preserving Distal Pancreatectomy - Demonstration of the Kimura Technique

Robot Assisted Spleen Preserving Distal Pancreatectomy - Demonstration of the Kimura Technique

Robotic Spleen-Preserving Distal Pancreatectomy with Preservation of Splenic Vessels Using the Gastrohepatic Ligament Approach: The Superior Window Approach in the Kimura Technique

Minimally invasive spleen-preserving distal pancreatectomy (SPDP) is technically challenging, and only a few reports have described surgical approaches for minimally invasive SPDP. This report demonstrates our novel gastrohepatic ligament approach in robotic SPDP with preservation of the splenic vessels (the superior window approach in the Kimura technique). Our gastrohepatic ligament approach for robotic SPDP included four steps. First, the gastrohepatic ligament was divided extensively, and the pancreas was confirmed (step 1). In this step, we did not lift the stomach, nor did we divide the gastrocolic ligament. Next, the superior and inferior borders of the pancreas were dissected, and the tunneling of the pancreas on the superior mesenteric vein was performed (step 2). Following the division of the pancreas (step 3), the pancreatic body and tail were dissected from the medial to the lateral side with preservation of the splenic vessels (step 4). Using this approach, the pancreas can be directly accessed via the gastrohepatic ligament route and dissected without division of the gastrocolic ligament or retraction of the stomach. The present approach for robotic SPDP preserves splenic vessels, facilitating easy access to the pancreas with minimal dissection, and may be optional in selected patients, including those with low body mass index.

Splenic vessels first approach laparoscopic spleen-preserving distal pancreatectomy with kimura technique (with short video clip)

Aim: In order to improve the success rate of spleen preservation in laparoscopic distal pancreatectomy with Kimura technique, we use a new splenic vessels control procedure which we call splenic vessels first approach. Method: We begin the operation with dividing the gastrosplenic ligament in order to expose the body and tail of the pancreas. We are now dissecting out the splenic artery first. With opening the capsule of the superior border of the pancreas, here the splenic artery comes into view. The proximal splenic artery is blocked with a bulldog. The next step wiil be distal splenic vein mobilization and blockage. We dissect at left side of the inferior border of the pancreas tail near the splenic hilus and block the distal splenic vein with another bulldog. After fully blocking the proximal splenic artery and distal splenic vein, we perform laparoscopic spleen-preserving distal pancreatectomy with standard Kimura technique. Result: With fully controlling the inflow of splenic artery and outflow of distal splenic vein , the distal pancrease is easy dissected with the splenic vessels presevation. We have successfully fulfilled all 10 cases of laparoscopic spleen-preserving distal pancreatectomy with Kimura technique. No postoperative splenic complications such as splenic infarction and abscess have been founded by far. Conclusions: Splenic vessels first approach laparoscopic spleen-preserving distal pancreatectomy is a safe procedure and offers technique advantages of lesser blood loss, operation time spare and higher success rate of spleen preservation over the conventional Kimura technique, while no extra postoperative morbidity founded.

"Kimura-first" strategy for robotic spleen-preserving distal pancreatectomy: experiences from 61 consecutive cases in a single institution.

Robotic spleen-preserving distal pancreatectomy (RSPDP) is an ideal procedure for benign and low-grade malignant tumors in the distal pancreas, and two splenic preservation techniques (the Kimura and Warshaw techniques) can be used for RSPDP. This study aimed to evaluate the feasibility and safety of the "Kimura-first" strategy for RSPDP and to investigate the risk factors affecting the preservation of the spleen and splenic vessels. The electronic medical records of patients who underwent robotic distal pancreatectomy (RDP) between October 2016 and December 2019 at our institution were retrospectively reviewed. Univariate and multivariate analyses were conducted to identify the risk factors influencing preservation of the spleen and splenic vessels during RDP. Sixty-one patients scheduled for RSPDP who received RDP were included in this study [Kimura technique, 41 patients; Warshaw technique, 11 patients; and robotic distal pancreatectomy with splenectomy (RDPS), 9 patients]. The overall splenic preservation rate with RDP was 85.2% (52/61). The preservation rate of splenic vessels with the Kimura technique with RSPDP was 78.8% (41/52). The RSPDP group had remarkably less estimated blood loss (EBL; median 50 vs. 300 mL, P=0.000) and a lower morbidity rate (13.5% vs. 44.4%, P=0.047) than the RDPS group. The logistic regression models showed that obvious splenic vessel compression by the tumor was an independent risk factor for splenic vessel preservation with RSPDP (OR 0.021, 95% CI: 0.002-0.271, P=0.003) and RDP (OR 0.019, 95% CI: 0.002-0.176, P=0.000). The "Kimura-first" strategy is feasible and safe for RSPDP, with high rates of splenic and splenic vessel preservation. Obvious splenic vessel compression by the tumor can be used as a predictor of splenic vessel preservation with planned RDP.

Splenic Vascular Patency after Spleen and Vessel Preserving Distal Pancreatectomy: Is the Kimura Technique Worth the Effort?

Purpose: Spleen-preserving surgical techniques combined with a minimally invasive approach have become increasingly common for benign or borderline malignant lesions of the pancreas. These more challenging procedures have immunologic advantages due to the maintenance of a functional spleen. The aim of this study was to evaluate the patency of the splenic vessels and splenic perfusion after spleen and splenic vessel-preserving distal pancreatectomy. Method: This retrospective single-centre study included all patients who underwent a spleen and splenic vessel-preserving distal pancreatectomy between April 2009 and October 2018. Patency of the vessels and splenic perfusion were assessed and classified based on computed tomography or magnetic resonance imaging. Results: Twenty-five patients underwent a spleen-preserving distal pancreatectomy of which 20 patients also had a splenic vessel-preserving surgery. The majority of the patients was operated with a minimal invasive technique (17 via laparoscopy or robot-assisted surgery and 3 via laparotomy). Five patients had no postoperative imaging. Normal patency of the splenic artery and vein was observed in 14 and 9 patients, respectively. Partial occlusion of the splenic vein was observed in 5 patients and total occlusion of the artery and vein was observed in 1 patient. Only 2 of these last 6 patients showed a limited infarction (< 50%) of the total splenic volume although without functional consequences. Conclusion: Spleen and splenic vessel-preserving distal pancreatectomy is safe and feasible. The patency of the splenic vessel is preserved in the majority of the patients and the perfusion of the spleen is also maintained, even when the splenic vessels are compromised.

Robotic-assisted versus open distal pancreatectomy for benign and low-grade malignant pancreatic tumors: a propensity score-matched study

BackgroundThis study aimed to compare the short-term outcomes of open and robotic-assisted distal pancreatectomy (ODP and RDP) for benign and low-grade malignant tumors.MethodsThe patients who underwent RDP and ODP for benign or low-grade malignant pancreatic tumors at our center were included. After PSM at a 1:1 ratio, the perioperative variations in the two cohorts were compared.ResultsAfter 1:1 PSM, 219 cases of RDP and ODP were recorded. The RDP cohort showed advantages in the operative duration [120 (90–150) min vs 175 (130–210) min, P < 0.001], estimated blood loss [50 (30–175) ml vs 200 (100–300) ml, P < 0.001], spleen preservation rate (63.5% vs 26.5%, P < 0.001), infection rate (4.6% vs 12.3%, P = 0.006), and gastrointestinal function recovery [3 (2–4) vs. 3 (3–5), P = 0.019]. There were no significant differences in postoperative pancreatic fistula, postoperative hemorrhage, and delayed gastric emptying. Multivariate analysis showed that RDP (HR 0.24; 95% CI 0.16–0.36, P < 0.001), age (HR 1.02; 95% CI 1.00–1.03, P = 0.033), tumor size (HR 1.28; 95% CI 1.17–1.40, P < 0.001), pathological inflammatory neoplasm type (HR 5.12; 95% CI 2.22–11.81, P < 0.001), and estimated blood loss (HR 1.003; 95% CI 1.001–1.004, P < 0.001) were independent predictors of spleen preservation; RDP (HR 0.27; 95% CI 0.17–0.43, P < 0.001), age (HR 1.02; 95% CI 1.00–1.03, P = 0.022), elevated CA 19–9 level (HR 2.55; 95% CI 1.02–6.39, P = 0.046), tumor size (HR 1.44; 95% CI 1.29–1.61, P < 0.001), pathological inflammatory neoplasm type (HR 4.48; 95% CI 1.69–11.85, P = 0.003), and estimated blood loss (HR 1.003; 95% CI 1.001–1.004, P < 0.001) were independent predictors of spleen preservation with the Kimura technique.ConclusionRDP has advantages in the operative time, blood loss, spleen preservation, infection rate, and gastrointestinal function recovery over ODP in treating benign and low-grade malignant pancreatic tumors. The robotic-assisted approach was an independent predictor of spleen preservation and use of the Kimura technique.

Short- and Long-Term Outcomes of Laparoscopic Organ-Sparing Resection for Pancreatic Neuroendocrine Neoplasms.

Pancreatic neuroendocrine neoplasms (PNENs) are rare neoplasms associated with a long life expectancy after resection. In this setting, patients may benefit from laparoscopic organ-sparing resection. Studies of laparoscopic organ-sparing resection for PNENs are limited. The aim of this study was to evaluate the short- and long-term outcomes of laparoscopic organ-sparing resection for PNENs. A retrospective study was performed for patients with PNENs who underwent laparoscopic organ-sparing pancreatectomy between March 2005 and May 2018. The patients' demographic data, operative results, pathological reports, hospital courses and morbidity, mortality, and follow-up data (until August 2018) were analysed. Thirty-five patients were included in the final analysis. There were 9 male and 26 female patients, with a median age of 46years (range 25-75years). The mean BMI was 24.6 ± 3.3kg/m2. Nine patients received laparoscopic enucleation (LE), 20 received laparoscopic spleen-preserving distal pancreatectomy (LSPDP), and 6 received laparoscopic central pancreatectomy. The operative time, intraoperative blood loss, transfusion rate, and postoperative hospital stay were 186.4 ± 60.2min, 165 ± 73.0ml, 0days, and 9days (range 5-23days), respectively. The morbidity rate, grade ≥ III complication rate, and grade ≥ B pancreatic fistula rate were 34.2%, 11.4%, and 8.7%, respectively, with no mortality. The rate of follow-up was 94.3%, and the median follow-up time was 55months (range 3-158months). One patient developed recurrence 36months after LE and was managed with surgical resection. The other patients survived without metastases or recurrence during the follow-up. One patient had diabetes after LSPDP, and no patients had symptoms of pancreatic exocrine insufficiency. Nineteen patients who underwent LSPDP (16 with the Kimura technique and 3 with the Warshaw technique) were followed. Normal patency of the splenic artery and vein was observed in 14 and 14 patients within 1month of surgery and in 15 and 14 patients 6months or more after the operation, respectively. Partial splenic infarction was observed in 3 patients within 1month of surgery and in no patients 6months or more after the operation. Three patients eventually developed collateral venous vessels around the gastric fundus and reserved spleen, with one case of variceal bleeding. Laparoscopic organ-sparing resection for selected cases of PNENs is safe and feasible and has favourable short- and long-term outcomes.

The short-term result of distal pancreatectomy with splenic preservation

The tumor of pancreatic body and tail are relatively rare compared to those of head of pancreas. Splenic preservation in pancreatic carcinoma’s surgery should be decided on every case. This study to determine the feasibility of distal pancreatectomy with splenic preservation, the rate of early complications of splenectomy surgery to preserve the spleen and the factors: tumor size, tumor location, tumor characteristic to help assess the possibility of preserving the splenic vessels in distal pancreatectomy with splenic preservation. retrospective study, case series description for all patients aged 16 years and older with distal pancreatectomy and splenic preservation from 01/01/2012 to 31/12/2017. We had 47 case of distal pancreatectomy with splenic preservation. There were 26 cases of splenic preservation with preserving the splenic vessels (Kimura technique), 13 cases of splenectomy but not preserving the splenic vessels (Warshaw technique). There were 16 cases of laparoscopic surgery, 31 cases open surgery, general complication in surgery 11 cases. The mean age was 41.13 (17-76 years old). The mean hospital stay was 7.7 days (3 days - 21 days). General complication after surgery in 7 cases, pancreatic fistula in 5 cases, no cases need re-operation, no mortality. The rate of intraopertative incidence was 23.4%; complications after surgery 14.9%. No case of re-operation or mortality in the study. Factors such as tumor size, tumor location, tumor characteristic did not help assess the possibility of preserving the splenic vessels in of distal pancreatectomy with splenic preservation.

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

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. 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). 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. 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.

A new manoeuvre of vascular control in laparoscopic spleen-preserving distal pancreatectomy: Retrospective review for a modified Kimura's method.

Background:The aim of this study is to explore a new manoeuvre of vascular control technique in laparoscopic spleen-preserving distal pancreatectomy (LSPDP).Materials and Methods:A total of 63 patients were diagnosed with pancreatic tumour in our hospital from January 2013 to December 2018. In these cases, Kimura technique was utilised in 33 patients and total blood flow blocked technique was used in 30 patients. The clinical data of these 63 patients of were retrospectively analysed.Results:Four groups of patients were operated smoothly. In Kimura group, 33 patients were carried out using Kimura technique. Four patients' spleens were resected because the spleen artery was damaged. Three patients among them were converted to open surgery. In the other group, one patient was converted to open and resected the spleen. When comparing the Kimura group with the last series group, the mean surgical time decreased by 27 min, the estimated blood loss decreased by 108 ml, which had a significant statistical difference, whereas postoperative haemorrhage and postoperative pancreatic fistula had no statistical difference.Conclusion:After ten patient's practice, application of new manoeuvre of vascular control technique in LSPDP is feasible and safe, with advantages of less blood loss and shorter operation time.