Spleen Preservation Research Articles

Immediate and Long-Term Results of Portacaval Shunt Surgeries in Portal Hypertension: 10-Year Clinical Experience of a Regional Vascular Surgery Department

INTRODUCTION: The number of patients with liver cirrhosis (LC) makes 20–40 cases per 100 thousand populations and rises steadily. A five-year survival rate of patients with LC in the compensation stage is 50%–62%, in the decompensation stage — 11%–40%. In the overwhelming majority of patients (80%–90%), LC leads to the compensatory formation of esophageal and gastric varices (EV and GV, respectively), which is further complicated with a life-threatening bleeding in 30% of patients. AIM: To evaluate 5-year results of partial portacaval shunt surgeries. MATERIALS AND METHODS: The paper describes a 10-year clinical experience of the vascular surgery department of Yaroslavl Regional Clinical Hospital in surgical treatment of patients with LC with a clinical presentation of portal hypertension, with recorded esophageal and gastric variceal bleeding. The study included 26 patients (of them 11 men; the mean age 48 ± 7.3 years) with LC (A and B classes on Child-Pugh scale), who underwent planned reconstructive surgery on the portal system. By the type of anastomosis, the patients were divided into 3 groups: group 1 — mesocaval anastomosis (n = 6); group 2 — distal splenorenal anastomosis with preservation of spleen (n = 10); group 3 — splenorenal H-shaped shunt. The primary end points of the study were survival of the patients, rebleeding from EV, shunt patency. Secondary end points were dynamics of EV size, changes in the spleen size, dynamics of the portal and splenic veins size, blood flow directions in the portal system, the presence of hepatic encephalopathy. Postoperative mortality was 3.8%. RESULTS: Survival at 1, 3 and 5 years was 96%, 90% and 58, respectively, and patency of anastomoses was 96%, 96% and 91%, respectively. Rebleeding at 1 year made 4% (n = 1), at 3 years — 0, at 5 years — 17% (n = 2). Changes in the hemodynamics of the portal system were recorded after formation of all types of anastomoses: reduction of the diameter of the portal vein by on average 5 mm, of the splenic vein by 3 mm, of the spleen size by 210 cm3. Shunt thrombosis occurred in two of 26 patients (7.7%) at 1 year (splenorenal H-shaped shunt with use of prosthesis) and 4 years (splenorenal autovenous shunt), respectively. CONCLUSION: The formation of partial portacaval anastomoses in patients with portal hypertension and episodes of bleeding from esophageal varices is a reliable prevention of rebleeding. The first bleeding episode is an indication for an open surgery in case the transjugular intrahepatic stenting is impossible. Survival rate of patients after portacaval shunt surgeries is determined by the initial degree of hepatic failure and patency of the formed anastomoses.

Impact of splenectomy on long-term outcomes after gastrectomy for gastric cancer: a population-based study

BackgroundNo national studies comparing long-term survival after total or partial gastrectomy with splenectomy due to injury or oncologic reasons or spleen preservation exist. This study aimed to examine the 5-year overall survival (OS) of patients with gastric adenocarcinoma who underwent total or partial gastrectomy with splenectomy due to injury or oncologic reasons or spleen preservation in a population-based nationwide setting. MethodsThis study included all patients undergoing total or partial gastrectomy with splenectomy or spleen preservation for gastric adenocarcinoma in Finland from 2005 to 2016, with follow-up until December 31, 2019. A total of 2196 patients with gastric cancer diagnosis and total or partial gastrectomy were identified in the registries. Of these patients, 2118 were applicable for this study. Cox proportional hazard models provided hazard ratios (HRs) with 95% CIs of 5-year OS. The results were adjusted for age, sex, year of operation, comorbidities, tumor location, pathologic stage, and neoadjuvant therapy. ResultsThe observed 5-year OS rates were 38.7% in patients with no or minor spleen injury, 39.7% in patients with splenectomy due to injury, and 30.8% in patients with splenectomy due to oncologic reasons (P = .032). Patients who underwent R0 gastrectomy with splenectomy due to oncologic reasons had higher 5-year mortality (the adjusted model HR, 1.26; 95% CI, 1.01–1.56) than patients who underwent spleen preservation. ConclusionThe OS was worst in patients who underwent gastrectomy with splenectomy due to oncologic reasons, highlighting the poor prognosis in patients with advanced gastric cancer. Splenectomy due to injury does not compromise the prognosis.

Analysis of Factors Determining Spleen Preservation during Laparoscopic Distal Pancreatectomy - A Cohort Study.

Spleen preservation during laparoscopic distal pancreatectomy (LSPDP) should be pursued if safe and oncologically justified. The aim of the presented study was to compare surgical outcomes and identify risk factors for unplanned splenectomy during laparoscopic distal pancreatectomy and evaluate short and long-terms outcomes. The following study is a retrospective cohort study of consecutive patients who underwent laparoscopic distal pancreatectomy, with the intention of preserving the spleen, for benign tumors of the body and tail of the pancreas between August 2012 and December 2022. Follow-up for patients' survival was completed in January 2023. In all, 106 patients were in total included in this study. Median age was 58 (41 to 67) years. The study population included 29 males (27.4%) and 77 females (72.6%). Spleen preservation was possible in 67 (63.2%) patients. The tumor size was larger in the splenectomy group (respectively, 30 (16.5 to 49) vs. 15 (11 to 25); P <0.001). Overall, serious postoperative morbidity was 13.4% in the LSPDP group and 20.5% in the second group ( P =0.494). There were no perioperative deaths. The postoperative pancreatic fistula rate was 18% in the splenectomy group and 14.9% in the LSPDP group, while B and C fistulas were diagnosed in 15.4% and 10.5% of patients, respectively. In the multivariate logistic regression model, tumor size >3 cm was found to independently increase odds for unplanned splenectomy (OR 8.41, 95%CI 2.89-24.46; standardized for BMI). Unplanned splenectomy during the attempt of LSPDP does not increase the risk for postoperative morbidity and postoperative pancreatic fistula. The independent risk factor for unplanned splenectomy during LSPDP is tumor size above 3cm.

Superiority of Robotic Over Laparoscopic Spleen-Preserving Distal Pancreatectomy With Warshaw Procedure for Reducing the Incidence of Postoperative Splenic Infarction.

Minimally invasive spleen-preserving distal pancreatectomy with Warshaw procedure (MI-WP), has gained widespread recognition for the treatment of benign and low-grade malignant tumors of the pancreatic body and tail. However, the comparative advantages of the robotic Warshaw procedure (R-WP) over the laparoscopic Warshaw procedure (L-WP) remain uncertain. This study aimed to compare the surgical outcomes between R-WP and L-WP. Among the 146 cases of MI-DP conducted between October 2020 and December 2023 (L-DP:115, R-DP:31), 33 cases of MI-WP were subjected to analysis, comprising the R-WP group (n=10) and the L-WP group (n=23). R-WP successfully completed all procedures under a purely laparoscopic approach, whereas L-WP necessitated conversion to open surgery in 2 cases (8.7%). Despite the significantly prolonged operative time in R-WP compared with L-WP (R-WP vs. L-WP: 421vs. 300 min), there was no significant difference in estimated blood loss between the 2 groups (R-WP vs. L-WP: 19 vs. 20mL). Although the rate of major complications did not significantly differ between the 2 groups, 2 cases (8.7%) of L-WP required reoperation, including splenectomy in 1 instance. Furthermore, the incidence of postoperative splenic infarction was significantly higher in L-WP than in R-WP (R- vs. L-WP:0 vs. 43.5%, P =0.015). The length of hospital stay after surgery did not exhibit a significant difference between the 2 groups (R-WP vs. L-WP: 11 vs. 12d). R-WP demonstrated superiority to L-WP for reducing the incidence of postoperative splenic infarction, potentially contributing to enhancing the spleen preservation rate.

Potential of endovideosurgery in the treatment of children with focal pancreatic lesions

Aim. To evaluate the effectiveness of laparoscopic surgeries for diseases and malformations of the pancreas in children. Materials and methods. 53 laparoscopies were performed from 2005 to 2023. Enucleation was performed in 16 children, distal resection of the pancreas with spleen preservation – in 16, corpo-caudal resection of the pancreas – in 4, subtotal resection of the pancreas – in 9, central resection of the pancreas – in 5, head resection with duodenal preservation – in 1, pancreaticoduodenal resection with pyloric preservation – in 2 children. The age of the children ranged from 2 months to 17 years. Results. All surgeries have achieved the intended clinical effect. The average time of enucleation accounted for 88.1 ± 47.7 min., distal resection with spleen preservation – 100.3 ± 21 min., corpo-caudal resection – 113.3 ± 28.9min., subtotal resection – 101 ± 21.7 min., central resection – 243.3 ± 81.1 min., head resection with duodenal preservation – 235 min., pancreaticoduodenal resection with pyloric preservation – laparoscopic and laparoscopically assisted – 435 and 415 min. Intraoperative bleeding was noted in 6 cases (11.3 %), in 2 (3.8 %) conversion was performed in 2 cases (3.8 %). The postoperative period revealed 6 (13.2 %) early and 8 (15.1 %) late complications. No fatal outcomes reported. The follow-up ranged from 1 to 10 years, no recurrences reported. Conclusion. Focal pancreatic lesions in children refer to heterogeneous diseases and malformations requiring various resection interventions. Laparoscopic enucleation and distal resection of the pancreas are considered as the most effective. Further clinical experience is required to explore the feasibility of using laparoscopy in children to perform central resection of the pancreas and pancreaticoduodenectomy.

Anatomic and Surgical Aspects of Total Pancreatectomy in Swine

IntroductionThe swine is valuable model for preclinical research and surgical technique training. From the induction of Diabetes through total pancreatectomy, these animals can be used in many research studies, such as islet transplantation. In view of the lack of elucidation in literature, the purpose of this work is to describe anatomical aspects, surgical technique of total pancreatectomy, intra- and postoperative complications and autopsy results Material and MethodFive male pigs, hybrids (Large White/Landrace), 20-35 kg, submitted to total pancreatectomy with duodenum, bile duct and spleen preservation. Postoperatively, daily clinical assessment and capillary blood glucose collection were performed. At the end of the 30-day limit or in the occurrence of serious clinical complications, euthanasia and autopsy were performed ResultsThe average duration of surgery was 128 minutes, without intraoperative deaths or anesthesia induction failures. Median survival was 6.6 days. Postoperative complications were weight loss (3), emesis (2), constipation (2), abdominal distension (2), diarrhea (1) and loss of appetite (1). All animals were euthanized due to serious complications. Two animals presented surgical complications (duodenal necrosis with gastroparesis and internal hernia with intestinal necrosis). The other three animals presented serious clinical complications related to exocrine pancreatic insufficiency due to deficiency of pancreatic enzymes. Glycemic values above 200 mg/dL were found on the first postoperative day and above 300 mg/dL on the seventh day in all animals Discussion and ConclusionsIn this experiment, a model of total pancreatectomy with duodenum, spleen and bile duct preservation in pigs was established. All animals had diabetes, however animals without postoperative complications were euthanized due to serious complications related to pancreas exocrine insufficiency.

Most total pancreatectomies for ductal adenocarcinoma potentially can Be replaced by whipple over the splenic artery: a before and after study.

Recently, more and more total pancreatectomy (TP) has been performed for central-located pancreatic ductal cell adenocarcinoma (PDCA) which abuts or involves both gastroduodenal and splenic arteries and demands transaction of both of them for a complete resection. Spiked by Warshaw's procedure (spleen-preserving distal pancreatectomy with excision of splenic vessels), we developed a new procedure "Whipple over the splenic artery (WOTSA)" to replace TP by leftward extension of pancreatic parenchyma transaction line and preservation of pancreatic tail and spleen after excision of splenic artery. This uncontrolled before and after study assesses the safety and efficacy of a new technique "Whipple over the splenic artery (WOTSA)" as a treatment for PDAC which traditionally requires total pancreatectomy (TP) for a complete excision. The study group comprised 40 consecutive patients who underwent WOTSA for PDAC between August 2019 and September 2022. Their clinicopathological characteristics and survival were compared with those of a historical control group comprising 30 consecutive patients who underwent TP between January 2016 and July 2019. None of the 40 patients in the WOTSA group required reoperation due to infarction of the pancreas and/or spleen remnant. DM medication after WOTSA were none in 19, oral hypoglycemic agents in 19, and insulin preparations in 2 patients. Compared with TP, patients who underwent WOTSA exhibited similar rates of major operative complications, clear pancreatic parenchyma transaction margin, and number of harvested positive lymph nodes, but higher rate of adjuvant chemotherapy completion and a trend toward better median disease free survival (14 vs. 7.5mo, P=0.023). Compared to TP, WOTSA can be safely performed and have much better postoperative glycemic status without cost of higher operative risk or impaired surgical radicality. These findings indicate that most TPs for PDAC potentially can be replaced by WOTSAs.

Evaluating the economic efficiency of open, laparoscopic, and robotic distal pancreatectomy: an updated systematic review and network meta-analysis.

This study compared the cost-effectiveness of open (ODP), laparoscopic (LDP), and robotic (RDP) distal pancreatectomy (DP). Studies reporting the costs of DP were included in a literature search until August 2023. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area (SUCRA) values, mean difference (MD), odds ratio (OR), and 95% credible intervals (CrIs) were calculated for outcomes of interest. Cluster analysis was performed to examine the similarity and classification of DP approaches into homogeneous clusters. A decision model-based cost-utility analysis was conducted for the cost-effectiveness analysis of DP strategies. Twenty-six studies with 29,164 patients were included in the analysis. Among the three groups, LDP had the lowest overall costs, while ODP had the highest overall costs (LDP vs. ODP: MD - 3521.36, 95% CrI - 6172.91 to - 1228.59). RDP had the highest procedural costs (ODP vs. RDP: MD - 4311.15, 95% CrI - 6005.40 to - 2599.16; LDP vs. RDP: MD - 3772.25, 95% CrI - 4989.50 to - 2535.16), but incurred the lowest hospitalization costs. Both LDP (MD - 3663.82, 95% CrI - 6906.52 to - 747.69) and RDP (MD - 6678.42, 95% CrI - 11,434.30 to - 2972.89) had significantly reduced hospitalization costs compared to ODP. LDP and RDP demonstrated a superior profile regarding costs-morbidity, costs-mortality, costs-efficacy, and costs-utility compared to ODP. Compared to ODP, LDP and RDP cost $3110 and $817 less per patient, resulting in 0.03 and 0.05 additional quality-adjusted life years (QALYs), respectively, with positive incremental net monetary benefit (NMB). RDP costs $2293 more than LDP with a negative incremental NMB but generates 0.02 additional QALYs with improved postoperative morbidity and spleen preservation. Probabilistic sensitivity analysis suggests that LDP and RDP are more cost-effective options compared to ODP at various willingness-to-pay thresholds. LDP and RDP are more cost-effective than ODP, with LDP exhibiting better cost savings and RDP demonstrating superior surgical outcomes and improved QALYs.

Pancreatic Neuroendocrine Tumors: What Is the Best Surgical Option?

Background: Pancreatic neuroendocrine tumors (pNETs) represent a rare subset of pancreatic cancer. Functional tumors cause hormonal changes and clinical syndromes, while non-functional ones are often diagnosed late. Surgical management needs multidisciplinary planning, involving enucleation, distal pancreatectomy with or without spleen preservation, central pancreatectomy, pancreaticoduodenectomy or total pancreatectomy. Minimally invasive approaches have increased in the last decade compared to the open technique. The aim of this study was to analyze the current diagnostic and surgical trends for pNETs, to identify better interventions and their outcomes. Methods: The study adhered to the PRISMA guidelines, conducting a systematic review of the literature from May 2008 to March 2022 across multiple databases. Several combinations of keywords were used (“NET”, “pancreatic”, “surgery”, “laparoscopic”, “minimally invasive”, “robotic”, “enucleation”, “parenchyma sparing”) and relevant article references were manually checked. The manuscript quality was evaluated. Results: The study screened 3867 manuscripts and twelve studies were selected, primarily from Italy, the United States, and China. A total of 7767 surgically treated patients were collected from 160 included centers. The mean age was 56.3 y.o. Enucleation (EN) and distal pancreatectomy (DP) were the most commonly performed surgeries and represented 43.4% and 38.6% of the total interventions, respectively. Pancreatic fistulae, postoperative bleeding, re-operation, and follow-up were recorded and analyzed. Conclusions: Enucleation shows better postoperative outcomes and lower mortality rates compared to pancreaticoduodenectomy (PD) or distal pancreatectomy (DP), despite the similar risks of postoperative pancreatic fistulae (POPF). DP is preferred over enucleation for the pancreas body–tail, while laparoscopic enucleation is better for head pNETs.

Laparotomy for Traumatic Splenic Injury: Should we Increase our Efforts to Preserve the Spleen?

Abstract Background In trauma laparotomy the spleen is removed very liberally, and often little effort is made for splenic preservation. Aims The aim of this study was to assess the effect of surgical management (splenic repair vs. splenectomy) on outcomes in patients undergoing trauma laparotomy. Methods This is a trauma registry (TQIP) study (2013–2019), including adult patients with severe splenic injuries (grades III-V) undergoing trauma laparotomy. Characteristics and outcomes of patients who underwent splenic repair vs. splenectomy within 6 hours of admission were compared using different statistical approaches, i.e. 1:1 exact matching with consecutive conditional logistic regression analysis as primary analysis, multivariable logistic regression, propensity score matching and inverse-probability weighting as sensitivity analyses. The primary outcome was in-hospital mortality. Results A total of 11,247 patients with a severe splenic injury undergoing trauma laparotomy within 6 hours of admission were identified. Of these, 10,820 (96.2%) patients underwent splenectomy and 427 (3.8%) patients splenic repair within 6 hours of admission. Among patients who underwent an initial splenic salvage procedure, 23 (5.3%) patients underwent a splenectomy during the subsequent hospital stay. 400 patients with splenic preservation, were matched with 400 patients who underwent splenectomy (matched for age, sex, hypotension, trauma mechanism as well as AIS spleen grades 3,4,5 and AIS groups (AIS 0-2, AIS 3, AIS 4-5) for head, face, neck, thorax, spine, and lower &amp; upper extremity). The mortality was significantly lower in the group of patients with splenic repair (6.5% vs 12.8%, p=0.002). The mortality benefit was subsequently verified by conditional regression analysis (aOR 0.4, CI 95% 0.2; 0.9). Multivariable logistic regression, propensity score matching, and inverse-probability weighting confirmed the lower mortality in the splenic repair group. Conclusion In trauma laparotomy splenic repair was independently associated with lower mortality compared with splenectomy. Splenectomy was required in approximately 5% of the patients after initial splenic repair. The findings provide evidence that efforts for spleen preservation in trauma laparotomy should be considered in selected cases.

ASO Author Reflections: Rethinking Spleen Preservation in Patients with Body Pancreatic Ductal Adenocarcinoma.

ASO Author Reflections: Rethinking Spleen Preservation in Patients with Body Pancreatic Ductal Adenocarcinoma.

Robot-assisted distal pancreatectomy with spleen preservation in the treatment of a child with a solid pseudopapillary tumor

The use of robots in pancreatic surgery offers several advantages as an adjunct to laparoscopic surgery, including increased maneuverability of robotic instruments and three-dimensional (3D) visualization. To our knowledge, only two cases of robot-assisted distal pancreatectomy with spleen preservation in children have been reported worldwide. In this study, the patient was an 11-year-old boy who was admitted to a children’s hospital with complaints of recurrent upper abdominal pain. He was diagnosed with pancreatic tumor based on ultrasound findings. It was confirmed by magnetic resonance imaging, which revealed a well-defined heterogeneous formation at the border of the body and tail of the pancreas, measuring 2.28 × 2.73 × 2.62 cm with compression of the Wirsung duct. The surgical intervention was performed using a surgical robot VERSIUS (CMR, (UK). Splenic vessels were mobilized carefully, a tourniquet was placed around the body of the pancreas, and it was intersected using a stapler at the border of healthy tissue. The surgical intervention took 340 min, including robot installation time (docking time) of 15 min and a main console time of 325 min. No serious intraoperative complications, such as bleeding or damage to the vascular structures adjacent to the pancreas (branches of the celiac trunk and portal vein), were noted. Histological examination of the tumor confirmed the diagnosis of a solid pseudopapillary tumor. After surgery, the patient’s condition was stable. Recovery proceeded without complications. Magnetic resonance imaging of the abdominal cavity, which was performed 6 months after surgery, revealed no signs of disease recurrence. Robot-assisted surgery is an acceptable alternative to laparoscopic and open surgery for patients with solid pseudopapillary pancreatic tumors because robots offer additional connections, enable closure in improved 3D imaging, increase dexterity when handling instruments, and eliminate of hand tremors.

Splenectomy is Associated With More Complications Than Spleen Preservation in Patients With Blunt Abdominal Trauma

Splenectomy is Associated With More Complications Than Spleen Preservation in Patients With Blunt Abdominal Trauma

Autogenic splenic implantation versus splenectomy in patients undergoing distal pancreatectomy for benign or low-grade malignant lesions of the distal pancreas: study protocol for a multicentre, open-label, randomized controlled trial (RESTORE)

BackgroundThe spleen plays a significant role in the clearance of circulating microorganisms. Sequelae of splenectomy, especially immunodeficiency, can have a deleterious effect on a patient’s health and even lead to death. Hence, splenectomy should be avoided and spleen preservation during elective surgery has become a treatment goal. However, this cannot be achieved in every patient due to intraoperative technical difficulties or oncological reasons. Autogenic splenic implantation (ASI) is currently the only possible way to preserve splenic function when a splenectomy is necessary. Experience largely stems from trauma patients with a splenic rupture. Splenic immune function can be measured by the body’s clearing capacity of encapsulated bacteria. The aim of this study is to assess the splenic immune function after ASI was performed during minimally invasive (laparoscopic or robotic) distal pancreatectomy with splenectomy.MethodsThis is the protocol for a multicentre, randomized, open-labelled trial. Thirty participants with benign or low-grade malignant lesions of the distal pancreas requiring minimally invasive distal pancreatectomy and splenectomy will be allocated to either additional intraoperative ASI (intervention) or no further intervention (control). An additional 15 patients who will undergo spleen-preserving distal pancreatectomy serve as the control group with normal splenic function. Six months postoperatively, after assumed restoration of splenic function, patients will be given a Salmonella typhi (Typhim Vi™) vaccine. The Salmonella typhi vaccine is a polysaccharide vaccine. The specific antibody titres immediately before and 4 to 6 weeks after vaccination will be measured. The ratio between pre- and post-vaccination antibody count is the primary outcome measure and secondary outcome measures include intraoperative details, length of hospital stay, 30-day mortality and morbidity.DiscussionThis study will investigate the splenic immune function of patients who undergo ASI during minimally invasive distal pancreatectomy with splenectomy. The splenic immune function will be measured using the surrogate outcome of specific antibody titre after vaccination with a Salmonella typhi vaccine. The results will reveal details about splenic function after ASI and guide further treatment options for patients when a splenectomy cannot be avoided. It might eventually lead to a new standard of care making sometimes more demanding and time-consuming spleen-preserving procedures redundant.Trial registrationInternational Standard Randomized Controlled Trials Number (ISRCTN) ISRCTN10171587. Prospectively registered on 18 February 2019.

Portal thrombosis after surgical treatment of schistosomatic portal hypertension.

Several studies have investigated the correlation between the effects of different surgical treatments and laboratory exams for schistosomal portal hypertension, especially concerning portal system thrombosis. The etiopathogenic factors of this thrombosis are not fully understood. In this study, the correlation between surgical treatment for schistosomal portal hypertension and the occurrence of postoperative portal system thrombosis was investigated. A total of 61 patients who underwent surgical treatment for schistosomal portal hypertension were distributed into four groups: Patients in Group 1 (n=12) underwent portal variceal disconnection associated with splenic artery ligation and spleen preservation. Patients in Group 2 (n=20) underwent portal variceal disconnection and total splenectomy. Patients in Group 3 (n=20) underwent portal variceal disconnection with subtotal splenectomy, preserving the upper splenic pole supplied by the splenogastric vessels. Patients in Group 4 (n=9) underwent portal variceal disconnection with total splenectomy and autogenous splenic implants on the greater omentum. Late postoperative portal vein thrombosis was diagnosed using Doppler ultrasound. Over the 10-year follow-up, portal vein thrombosis occurred in 26 operated patients (42.6%), with no significant difference observed among the four surgical groups (p=0.217). Most of the thrombi only partially occluded the portal system veins. All the patients presented with a thrombus inside the portal vein. There was no difference in hematological and biochemical tests between groups with or without portal vein thrombosis. Portal vein thrombosis is often observed in the late postoperative period, irrespective of the surgical treatment employed, and is not associated with patient characteristics or any hematological and biochemical tests.

Ex-situ Open Approach Spleen Preserving Splenic Hilum Lymphadenectomy.

Background: multiple studies showed important benefices arising from splenic preservation in patients with digestive cancer in general and gastric cancer in particular. The minimally invasive approach remains controversial in locally advanced gastric cancer cases whilst the open approach still has an important role. This paper's aim is to describe and present the feasibility of an open surgical technique that allows removing stations 10 together with 11p and 11d with spleen and splenic vessels preservation in pacients operated upon by open surgery. Material and Methods: We present an open "Ex-situ" spleen and pancreas preserving surgical technique that removes the anterior and posterior ganglia from the splenic hilum, the splenic vessels and the distal pancreas in locally advanced gastric cancer cases of the upper two thirds of the stomach. Forty-three consecutive patients since 2003 were operated upon by the author in multiple centers. during upper two thirds gastric cancer resections requiring no. 10 lymphadenectomy. Results: no splenectomy was needed . All the spleens were viable at postoperative Doppler echography and CT scans. No spleen migrated nor caused mechanical complications. No clinically significant pancreatic leaks were noticed. Two patients died during hospital stay, one of miocardial infarction and one of massive stroke. Pertinent follow up data and survival were not available. Conclusions: The method enables the surgeon to remove the lymph nodes no. 10 along with 11p and 11d without needing to sacrifice the spleen. All spleens were reattached sucessfully using the preserved spleno-renal ligament fold, no wandering spleen was noticed.

Solid Pseudopapillary Neoplasm of the Pancreas: Unraveling Insights from a Single Institutional Study Emphasizing Preoperative Diagnosis of a Rare Tumor.

Solid pseudopapillary neoplasm (SPN), a slow-growing pancreatic tumor with a vague clinical presentation and non-specific radiological features, is rather uncommon. We share our experience emphasizing on preoperative diagnosis and the correlation with final histopathological examination. This is a retrospective analysis of the 468 patients who underwent pancreas-related surgery at our institution between January 2013 and July 2022. Demographic characteristics, symptoms at presentation, preoperative serum calcium carbohydrate antigen (CA 19-9), lesion characteristics on cross-sectional diagnostic imaging, surgical technique, complications in postoperative period, length of stay, histopathological features, and 3-year follow-up findings of the patients with SPN of pancreas were evaluated. The male-to-female ratio was 1:11 and the mean age at presentation was 33.3 ± 9.5 years. Upper abdomen discomfort was the most common presenting complaint (91%). And five patients had findings suggestive of SPN on preoperative CECT abdomen, and the remaining six individuals were diagnosed solely based on final histological examination. The tumor's median diameter was 5.6 cm (range, 4.1-7.9). The distal body and tail of pancreas was the most common location (63%), followed by the head (36%), and was managed with distal pancreatectomy with or without spleen preservation and Whipple's procedure, respectively. One patient developed grade III Clavien-Dindo complication. The average length of in-hospital stay was 8.27±2.72 days. None of the patients had recurrence on follow-up. Solid pseudopapillary neoplasm of the pancreas is often misdiagnosed preoperatively. Endoscopic ultrasound-guided FNA with IHC will be beneficial to diagnose it preoperatively especially in small-sized tumors with atypical features. Complete surgical resection with adequate margins without routine lymphadenectomy is curative in resectable tumors. Jayapal L, Kumar SR, Jebakumar GS, et al. Solid Pseudopapillary Neoplasm of the Pancreas: Unraveling Insights from a Single Institutional Study Emphasizing Preoperative Diagnosis of a Rare Tumor. Euroasian J Hepato-Gastroenterol 2023;13(2):50-54.

Learning curve of robotic-assisted splenic vessel-preserving spleen-preserving distal pancreatectomy by one single surgeon: a retrospective cohort study

AimSplenic vessel-preserving spleen-preserving distal pancreatectomy (SVP-SPDP) has a lower risk of splenic infarction than the splenicvessel-sacrificing SPDP, but it is more technically demanding. Learning curve of robotic-assisted SVP-SPDP (RSVP-SPDP) remains unreported. This study sought to analyze the perioperative outcomes and learning curve of RSVP-SPDP by one single surgeon.MethodsSeventy-four patients who were intended to receive RSVP-SPDP at the First Affiliated Hospital of Sun Yat-sen University between May 2015 and January 2023 were included. The learning curve were retrospectively analyzed by using cumulative sum (CUSUM) analyses.ResultsSixty-two patients underwent RSVP-SPDP (spleen preservation rate: 83.8%). According to CUSUM curve, the operation time (median, 318 vs. 220 min; P < 0.001) and intraoperative blood loss (median, 50 vs. 50 mL; P = 0.012) was improved significantly after 16 cases. Blood transfusion rate (12.5% vs. 3.4%; P = 0.202), postoperative major morbidity rate (6.3% vs. 3.4%; P = 0.524), and postoperative length-of-stay (median, 10 vs. 8 days; P = 0.120) improved after 16 cases but did not reach statistical difference. None of the patients had splenic infarction or abscess postoperatively.ConclusionRSVP-SPDP was a safe and feasible approach for selected patients after learning curve. The improvement of operation time and intraoperative blood loss was achieved after 16 cases.

Which Factors Are Associated with Distal Pancreatectomy Outcomes' Optimization with the Application of an Enhanced Recovery After Surgery Program?

Background: Distal pancreatectomy (DP) represents the best therapeutic option for patients with body-tail pancreatic neoplasms (PNs). The enhanced recovery after surgery protocol is widely used for treating patients with PN to speed up postoperative recovery. This study aims to describe our institute's experience in the application of fast recovery protocol in a cohort of patients treated with DP, identifying predictors facilitating a decrease in the length of hospital stay. Patient and Methods: Were retrospectively enrolled 60 consecutive cases of DP performed from January 2016 to June 2022 in patients treated with enhanced recovery protocol, 25% of them were treated with spleen preserving procedure. Single-variable logistic regression models were used to evaluate the potential association between patient characteristics and the probability of postoperative complications. Standard linear regression models were used for length of stay, number of postoperative days (PODs) from surgery to full bowel function recovery, and PODs to the interruption of intravenous analgesia administration. Results: Thirty-four (57%) patients underwent open surgery and 26 (43%) laparoscopic surgery. Patients who underwent laparoscopic surgery and spleen-preserving procedures experienced a lower complication rate (P = .037), shorter length of stay, and time of analgesic requirements. With single-variable logistic regression models patients treated with laparoscopic surgery had statistically significant higher recovery times in terms of nasogastric tube removal (P = .004) and early enteral nutrition (P = .001). Conclusion: Continual refinement with enhanced recovery protocol for treating PN patients based on perioperative counseling and surgical decision-making is crucial to reduce patient morbidity and time for recovery.

Robotic Distal Pancreatectomy Yields Superior Outcomes Compared to Laparoscopic Technique: A Single Surgeon Experience of 123 Consecutive Cases.

Technical limitations of laparoscopic distal pancreatectomy (LDP), in comparison to robotic distal pancreatectomy (RDP), may translate to high conversion rates and morbidity. LDP and RDP procedures performed between December 2008 and January 2023 in our tertiary referral hepatobiliary and pancreatic centres were analysed and compared with regard to short-term outcomes. A total of 62 consecutive LDP cases and 61 RDP cases were performed. There was more conversion to open surgeries in the laparoscopic group compared with the robotic group (21.0% vs. 1.6%, p = 0.001). The LDP group also had a higher rate of postoperative complications (43.5% vs. 23.0%, p = 0.005). However, there was no significant difference between the two groups in terms of major complication or pancreatic fistular after operations (p = 0.20 and p = 0.71, respectively). For planned spleen-preserving operations, the RDP group had a shorter mean operative time (147 min vs. 194 min, p = 0.015) and a reduced total length of hospital stay compared with the LDP group (4 days vs. 7 days, p = 0.0002). The failure rate for spleen preservation was 0% in RDP and 20% (n = 5/25) in the LDP group (p = 0.009). RDP offered a better method for splenic preservation with Kimura's technique compared with LDP to avoid the risk of splenic infarction and gastric varices related to ligation and division of splenic pedicles. RDP should be the standard operation for the resection of pancreatic tumours at the body and tail of the pancreas without involving the celiac axis or common hepatic artery.