Spleen Preservation Research Articles

Predictors of surgical management of high grade blunt splenic injuries in adult trauma patients: a 5-year retrospective cohort study from an academic level I trauma center

BackgroundsSplenic injury accounts for 40% of all injuries after blunt abdominal trauma. Blunt splenic injury in hemodynamically unstable patients is preferably treated by splenectomy. Nowadays hemodynamically stable patients with low grade splenic injuries are mostly treated by non-operative management (NOM). However no consensus exists about the management of high grade splenic injuries in hemodynamically stable patients. Therefore the aim of this study was to analyze patients with high grade splenic injuries in our institution.MethodsWe retrospectively included all patients with a splenic injury presented to our level I trauma center during the 5-year period from January 1, 2012, until December 31, 2017. Baseline characteristics, data regarding complications and mortality were collected from the electronic patient registry. Patients were grouped based on splenic injury and the treatment they received.ResultsA total of 123 patients were included, of which 93 (75.6%) were male with a median age of 31 (24–52) and a median injury severity score of 27 (17–34). High grade injuries (n = 28) consisted of 20 Grade IV injuries and 8 grade V injuries. Splenectomy was required in 15/28 (53.6%) patients, of whom all remained hemodynamically unstable after resuscitation, including all grade V injuries. A total of 13 patients with high grade injuries were treated with spleen preserving therapy. Seven of these patients received angio-embolization. One patient went for laparotomy and the spleen was treated with a hemostatic agent. Secondary hemorrhage was present in 3 of these patients (initial treatment: 1 embolization/ 2 observational), resulting in a success rate of 76.9%. There is no mortality seen in patient with high grade splenic injuries.ConclusionNon-operative treatment in high grade splenic injuries is a safe treatment modality in hemodynamically stable patients. Hemodynamic status and peroperative bleeding, not injury severity or splenic injury grade were the drivers for surgical management by splenectomy. This selected cohort of patients must be closely monitored to prevent adverse outcomes from secondary delayed bleeding in case of non-operative management.

Postoperative risk of pancreatic fistula after distal pancreatectomy with or without spleen preservation.

Outcomes after distal pancreatectomy with or without splenectomy are controversial. The present study aims to investigate differences in short-term and long-term outcomes between spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). In this retrospective review of consecutive patients undergoing distal pancreatectomy with or without splenectomy from January 2011 until December 2017 for benign disease, the primary endpoint was to compare postoperative pancreatic fistula (POPF). The secondary endpoint was to compare duration of surgery, intraoperative blood loss, postoperative complications, length of hospital stay, and long-term outcomes. Patients undergoing SPDP had a lower rate of POPF (13.6% vs 46.1%; p = 0.02). Patients undergoing SPDP (n = 22) were discharged earlier than patients undergoing DPS (n = 26) (8 [4-29] vs 12 [6.48] days; p = 0.003). No differences in other intraoperative and postoperative outcomes were found between groups. Patients undergoing SPDP developed fewer POPF and were discharged earlier compared to patients undergoing DPS.

Comparison of clinical outcomes and quality of life between laparoscopic distal pancreatectomy with or without spleen preservation.

The studies comparing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and laparoscopic distal pancreatosplenectomy (LDPS) are limited. This study aimed to compare clinical outcomes and quality of life of patients undergoing LSPDP and LDPS. Between March 2004 and December 2014, patients who underwent laparoscopic distal pancreatectomy were reviewed. Patients were divided into 2 groups as LSPDP and LDPS. Data considered for comparison analysis were patient demographics, intraoperative variables, morbidity, postoperative hospital stay, mortality, pathologic findings, and quality of life (SF-36 questionnaire). A total of 110 patients (50 LSPDP and 60 LDPS) were included in the final analysis. Baseline characteristics were similar in the 2 groups. The LSPDP group had a significantly shorter operative time(153.3 ± 46.2 vs. 179.9 ± 54.1min, p = 0.015) than the LDPS group. Also in analysis of propensity-matched population(LSPDP:LDPS = 35:35, 1:1 matching), LSPDP group still had a significantly shorter operative time (159.3 ± 36.2 vs. 172.9 ± 44.1min, p = 0.045) than the LDPS group.There were no significant differences with respect to estimated blood loss, first flatus time, diet start time, and postoperative hospital stay. Postoperative outcomes, including morbidity, pancreatic fistula rates, and mortality, were similar in the LSPDP and LDPS group. On the follow-up survey, the total quality of life score (635.8 ± 50.7 vs. 596.1 ± 92.1)was higher in the LSPDP group compared with the LDPS group. However, the differences were not statistically significant(p > 0.05). The score in vitality (82.5 ± 14.4 vs. 68.9 ± 11.4, p = 0.046) was significantly higher in LSPDP group and not statistically significant in other areas (p > 0.05).Similar results of quality of life assessment were found in analysis of propensity-matched population. Compared to LDPS, LSPDP had shorter operating time and better quality of life with similar morbidity and recovery period.

Up-to-date comparison of robotic-assisted versus open distal pancreatectomy: A PRISMA-compliant meta-analysis.

Although robot-assisted distal pancreatectomy (RADP) has been successfully performed since 2003, its advantages over open distal pancreatectomy (ODP) are still uncertain. The objective of this meta-analysis is to compare the clinical and oncologic safety and efficacy of RADP vs ODP. Multiple databases (PubMed, Medline, EMBASE, Web of Science, and Cochrane Library) were searched to identify studies that compare the outcomes of RADP and ODP (up to February, 2020). Fixed and random effects models were applied according to different conditions. A total of 7 studies from high-volume robotic surgery centers comprising 2264 patients were included finally. Compared with ODP, RADP was associated with lower estimated blood loss, lower blood transfusion rate, lower postoperative mortality rate, and shorter length of hospital stay. No significant difference was observed in operating time, the number of lymph nodes harvested, positive margin rate, spleen preservation rate, rate of severe morbidity, incidence of postoperative pancreatic fistula, and severe postoperative pancreatic fistula (grade B and C) between the 2 groups. With regard to perioperative outcomes, RADP is a safe and feasible alternative to ODP in centers with expertise in robotic surgery. However, the evidence is limited and more randomized controlled trials are needed to further clearly define this role.

Laparoscopic Splenic Vessels and Spleen Preservation Distal Pancreatectomy Via Inferior-Posterior Splenic Vein Approach.

Preservation of splenic vessels can minimize the risks of splenic infarction and gastric varices in laparoscopic spleen preserving distal pancreatectomy. A well-established procedure would provide high splenic vessels and spleen preservation rate. This study evaluated the outcomes and depending factors of laparoscopic splenic vessels and spleen preservation distal pancreatectomy (LsvspDP) via inferior-posterior splenic vein approach. This retrospective study enrolled patients who underwent LsvspDP via inferior-posterior splenic vein approach in National Cheng-Kung University Hospital from February 2009 to June 2019. The clinic-pathologic data were collected and analyzed. The primary outcome of this study was the learning curve based on the cumulative sum analysis. The secondary outcomes were to evaluate the critical factors for the failure of splenic vessels and spleen preservation. During the study period, a total of 64 patients received LsvspDP attempt. Splenic vessels were successfully preserved in 49 patients and the overall spleen preservation rate was 76.6%. According to cumulative sum analysis, the learning curve of LsvspDP was the 33rd case and several plateaus were observed during the learning curve phase. Old age (P=0.001), tail location (P=0.038), and large tumor (P=0.01) were independent risk factors of failed splenic vessels preservation, whereas the cut-off point of tumor size for prediction of spleen preservation was 5.4 cm. The complication rates were 7.8%, 7.8%, and 12.5% for Clavien grade I, II, and III, respectively, and 0% for Clavien grade IV or V. The rate of postoperative pancreatic fistula-grade B was 14.8%, among which the tail location was lower than the nontail location (0% vs. 24.3%; P=0.008). The mean value of operative time, blood loss, and hospital stay were 198±67 minutes, 139±242 mL, and 8.5±5.6 days, respectively. In LsvspDP, the inferior-posterior splenic vein approach resulted in high splenic vessels and spleen preservation rate. Thirty-three patients were required to overcome the learning curve. Old age, tail location, and large tumor size were independent factors for the failure of splenic vessels preservation, whereas the cut-off value for tumor size was 5.4 cm to predict splenic vessels preservation.

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.

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.

Metastatic renal cell carcinoma to the pancreas and subcutaneous tissue 10\u2009years after radical nephrectomy: a case report

BackgroundSynchronous renal cell carcinoma metastasizing to the pancreas and subcutaneous tissue is very rare. Unusual metastatic sites require attention during follow-up of renal cell carcinoma. It is extremely rare for renal cell carcinoma to metastasize to the pancreas; it is also very rare for it to metastasize to the subcutaneous tissue and extremely rare for it to synchronously metastasize to the pancreas and subcutaneous tissue almost a decade after radical nephrectomy. It is well known that most pancreatic tumors are primary pancreatic adenocarcinoma. However, the pancreas can also be an uncommon site for metastasis. We present a rare case of synchronous metastasis of renal cell carcinoma to the pancreas and subcutaneous tissue; we believe it to be only the second such case reported to date.Case presentationWe describe a case of a 74-year-old Chinese man who was diagnosed with metastatic renal cell carcinoma to the pancreas and subcutaneous tissue at the same time, 10 years after left radical nephrectomy. He received distal pancreatectomy with spleen preservation plus resection of the subcutaneous tissue lesions on the left side of the anterior abdominal wall and right waist. Pathology showed that all resected metastatic tumors were of the clear cell type. The patient was seen in regular follow-up afterward.ConclusionSynchronous metastatic renal cell carcinoma to the pancreas and subcutaneous tissue is very rare, and it might occur after primary tumor resection. Patients must undergo lifelong monitoring and follow-up with regular examination so that any possible metastasis can be detected early. The optimal resection strategy should involve adequate resection margins and maximal tissue preservation of the pancreas, because renal cell carcinoma metastasizing to the pancreas and subcutaneous tissue has a good prognosis with long-term survival.

Meta-analysis of short-term outcomes comparing robot-assisted and laparoscopic distal pancreatectomy.

Aim: To evaluate and compare the short-term outcomes of robotic surgery and laparoscopic approach in distal pancreatectomy (DP). Materials& methods: EMBASE, PubMed, the Cochrane Library, CNKI and Wan Fang database were retrieved from the inception of electronic databases to June 2019. All analyses were performed using Stata/SE 15.1 version (StataCorp). Results: Twenty-two papers were included, four of which were prospective studies and the rest were retrospective studies. There was significant difference in spleen preservation rate (odds ratio: 2.020; 95% CI: 1.085-3.758; p =0.027), operation time (mean difference [MD]: 27.372; 95% CI: 8.236-47.210; p =0.000), the length of hospital stay (MD: -0.911; 95% CI: -1.287 to -0.535; p =0.000), conversion rate (rate difference: -0.090; 95% CI: -1.287 to -0.535; p =0.000), operation cost (MD: 2816.564; 95% CI: 1782.028-3851.064; p =0.000). However, no significant difference was detected in estimated blood loss, total complication, severe complication, lymph nodules harvest, blood transfusion rate, total pancreatic fistula, severe pancreatic fistula, R0 resection rate and mortality. Conclusion: Both robotic and laparoscopic DP are safe and feasible. Although robotic DP increases the operation cost, the spleen-preserving rate is much higher. Robotic surgery may be an alternative approach to DP.

Тотальная дуоденопанкреатэктомия с сохранением селезенки (клиническое наблюдение)

Тотальная дуоденопанкреатэктомия с сохранением селезенки (клиническое наблюдение)

Total pancreatectomy as an alternative to pancreaticojejunal anastomosis in very high risk patients for the development of a pancreatic fistula after pancreaticodudenectomy: our experience

Background: The Fistula Risk Score (FRS) for pancreaticoduodenectomy represent a validated tool to predict the onset of this treacherous complication. Although there is no agreement on the management of this peculiar subpopulation, total pancreatectomy is an option to be considered. Material & Methods: We considered 738 patients scheduled for a pancreaticoduodenectomy in our center between January 2010 and December 2018. Data were collected prospectively. 62 patients present a FRS ≥7. Major complication were considered as Clavien-Dindo ≥3. Continuous data are presented as median [IQR]. Islet autotrasplant after completion pancreatectomy is available in our institution as part of clinical studies for patients with preoperative normal glycemic control. Result(s): Of the 62 patients 35 where managed with pancreatico-jejunal anastomosis (GroupA); 18 with total pancreatectomy (GroupB1); 9 with total and islet autotransplant(GroupB2). In GroupB 70.4% underwent a spleen preserving procedure. 5.7% patients in GroupA,38.8% in GroupB1 were diabetic (p=0.038). Median age was 64.4[24.2] years GroupA; 73.1[10.1] GrupB1,67.5[12.2] GroupB2 (p=0,050). BMI was 24.85[6.6] GroupA 26.95[3.7] GroupB1 30.86[6.6] GroupB2 (p=0.014). 17,6% had an ASA score ≥3 in GroupA, 50% GroupB1, 33.3%, GroupB2 (p=0.079). 2 patients died 1 in GroupA an 1 in GroupB both to septic shock the second arising from a urinary tract infection. Major complication were 42.9% GroupA, 27.8% GroupB1, 22.2% GroupB2 (p=0.466). Reoperation rate was 17.1% GroupA, 11.1% GropB (p=0.090). Postoeprative length of stay was 15[9] GroupA 12[11] GroupB1 10[7] GroupB2 (p=0.501). Length of stay among total pancreatectomies was shorter in the spleen preserving 11[10] vs 14[9].In Group A Biochemical leak was 22.8%, pancreatic fistula B 40% C 8.5%. Readmission were observed only in Group A 25.7% (p:0.001). Conclusion(s): Completion pancreatectomy should be considered in high FRS patients, short term outcomes are good and islet autotrasplant offer promising scenarios for the long term. Patient’s characteristic and technical specific approaches had to be considered.

Robotic-assisted versus open left pancreatectomy for cystic tumours: A single-centre experience.

Background:Cystic pancreatic lesions (CPLs) are being identified increasingly, and some benefit from surgical treatment. With the increasing use of robotic-assisted surgery (RAS) for neoplasms of the pancreas, the aim of the present comparative study is to establish whether the RAS offered any advantages over conventional open surgery (OS) in the management of CPLs.Patients and Methods:Twenty-seven out of 37 robot-assisted left-sided pancreatectomy (LSP) performed between January 2010 and April 2017 were carried out for CPLs. The surgical outcome and histopathology were compared retrospectively with a control group of 27 patients who had undergone open LSP for CPLs, selected using a one-to-one case-matched methodology (OS-Group) from the prospectively collected institutional database.Results:The spleen was preserved in a significantly higher percentage of patients in the RAS-group (63% vs. 33.3%, P < 0.05). There was no difference in the post-operative course (pancreatic fistula and morbidity) between the two groups. The median post-operative hospital stay was significantly shorter in the RAS-group: 8 days (range 3–25) versus 12 days (range 7–26) in the OS-group (P < 0.01). No conversion to open approach was reported in the RAS-group.Conclusions:Robotically assisted LSP is a safe and effective procedure. It is accompanied by a significantly higher spleen preservation rate compared to the open approach. In addition, because of the reduced trauma, RAS incurred a shorter post-operative hospital stay and faster return to full recovery, particularly important in patients undergoing surgery for relative indications. However, these benefits of RAS for LSP require confirmation by prospective randomised controlled studies.

Primary Splenic Torsion Associated with Accessory Spleen in a Dog

Background: Primary splenic torsion occurs when there is a splenic vascular pedicle rotation without association of other diseases, as the Gastric Dilatation Volvulus (GDV). Accessory spleen consists in a splenic tissue fraction independent from main organ, caused by a spleen defect in the embryonic development, most remaining asymptomatic and discovered incidentally. They have their own blood supply, which is usually from a branch of the splenic artery. Present report represents a primary splenic torsion with the accessory spleen finding in a dog.Case: A 7-year-old female mongrel was referred to Veterinary Hospital of Universidade Federal do Rio Grande do Sul, showing pain and firm consistency in the left abdominal region, prostration and inappetence four days before the medical appointment. At the clinical examination, the patient was alert, 7% dehydration, hypocorous mucous membranes, without alteration in lymph nodes, left abdominal pain. Laboratory tests, chest radiographic and abdominal ultrasound was requested. Two images compatible with splenic image were visualized, one with a regular structure without vascularization suggesting splenic torsion and another with homogeneous parenchyma and echogenicity of the normal spleen, with vascularization signal. The animal was referred to the surgical procedure and the anesthetic induction protocol with propofol (6 mg.kg -1) and ketamine hydrochloride (2 mg.kg -1) and maintenance with total intravenous anesthesia with propofol (0.2-0.4 mg.kg -1 / min) and lidocaine (2 mg.kg -1), in a semi-closed loop and spontaneous ventilation. The pre-retro-umbilical incision in the ventral midline was performed, and the exploratory celiotomy was done. During the cavity exploring, a small amount of free fluid and a structure compatible with the spleen were observed. It was noted that the splenic vascular pedicle was twisted around its axis and the gastroesplenic and splenocolic ligaments were also involved. The stomach maintained its position, size and vascularization. Thus, an isolated or primary splenic torsion was characterized. The exploratory laparotomy was recommended, and the total splenectomy was the treatment of choice. The accessory spleen did not demonstrate vascular damage; therefore, was advocated the zeal in handling to preserve your integrity.Discussion: Isolated splenic torsion is a rare occurrence in dogs. A retrospective study was performed with 60 dogs presenting with non-traumatic hemoperitoneum, in which only three cases presented splenic torsion. Usually, twisting occurs in large or giant breed dogs with deep chest conformation. The etiology of splenic torsion is not well established. Primary splenic torsion is considered emergency surgery, and the prognosis is considered favorable. The literature shows no relation between the presence of the accessory spleen and the occurrence of primary splenic torsion, but both occur due to congenital defects, both of which may be correlated in this case. The accessory spleen is characterized by a defect in the embryonic formation of the splenic tissue and may be associated with other congenital malformations. It can be concluded that in the primary splenic torsion, early surgical treatment is the most indicated. Total splenectomy was considered adequate, and preservation of the accessory spleen was important due to the possibility of some organ functionality.

Total pancreatectomy with duodenal and spleen preservation on a multiple ipmn young patient

Total pancreatectomy with duodenal and spleen preservation on a multiple ipmn young patient

Robotic versus laparoscopic distal pancreatectomy for left-sided pancreatic tumors: a single surgeon's experience of 228 consecutive cases.

Laparoscopic distal pancreatectomy (LDP) has gained popularity for the treatment of left-sided pancreatic tumors. Robotic systems represent the most recent advancement in minimally invasive surgical treatment for such tumors. Theoretically, robotic systems are considered to have several advantages over laparoscopic systems. However, there have been few studies comparing both systems in the treatment of distal pancreatectomy. We compared perioperative and oncological outcomes between the two treatment modalities. A retrospective analysis was conducted of all consecutive minimally invasive distal pancreatectomy cases performed by a single surgeon at a high-volume center between January 2015 and December 2017. The analysis included 228 consecutive patients (LDP, n = 182; Robotic-assisted laparoscopic distal pancreatectomy [R-LDP], n = 46). Operative time was significantly longer in the R-LDP group than in the LDP group (166.4 vs. 140.7min; p = 0.001). In a subgroup analysis of patients who underwent the spleen-preserving approach, the spleen preservation rate associated with R-LDP was significantly higher than that associated with LDP (96.8% vs. 82.5%; p = 0.02). In another subgroup analysis of patients with pancreatic cancer, there were no significant differences in median overall and disease-free survival between the two groups. R-LDP is a safe and feasible approach with perioperative and oncological outcomes comparable to those of LDP. R-LDP offers an added technical advantage that enables the surgeon to perform a complex procedure with good ergonomic comfort.

Full Robotic Distal Pancreatectomy: Safety and Feasibility Analysis of a Multicenter Cohort of 236 Patients.

Introduction. Despite the widespread use of the robotic technology, only a few studies with small sample sizes report its application to pancreatic diseases treatment. Our aim is to present the results of a multicenter study on the safety and feasibility of robot-assisted distal pancreatectomy (RDP). Materials and Methods. All RDPs for benign, borderline, and malignant diseases performed in 5 referral centers from 2008 to 2016 were included. Perioperative outcomes were evaluated. Results. Two hundred thirty-six patients were included. Spleen preservation was performed in 114 cases (48.3%). Operative time was 277.8 ± 93.6 minutes. Progressive improvement in operative time was observed over the study period. Conversion rate was 6.3%. Morbidity occurred in 102 cases (43.2%), mainly due to grade A fistulas. Reoperation was required in 10 patients. Postoperatively, 2 patients died of sepsis due to a grade C fistula. Hospital readmission was necessary in 11 cases. A R0 resection was always achieved, with a mean number of 16.2 ± 15 harvested lymph nodes. Conclusion. To our knowledge, this is one of the largest RDP series. Safety and feasibility including the low conversion rate, the high spleen preservation rate, the adequate operative time, and the acceptable morbidity and mortality rates confirm the validity of this technique. Appropriate oncological outcomes have been also obtained.

Safety and Feasibility of Robotic Reduced-Port Distal Pancreatectomy: a Multicenter Experience of a Novel Technique

BackgroundA reduced-port approach including single-site surgery has been used for distal pancreatectomy. However, triangulation is difficult in reduced-port laparoscopic distal pancreatectomy, and instrument crowding, and collision may occur, so this approach has not been widely used. Recently, an innovative technique for distal pancreatectomy using a robotic single-site surgical system was introduced. Herein, we evaluate the safety and feasibility of this technique. MethodsTwenty-seven patients with a pancreatic tail mass underwent robotic single-site plus one-port distal pancreatectomy at six centers. We collected clinicopathologic data and evaluated the short-term perioperative outcomes of robotic single-site plus one-port distal pancreatectomy. ResultsWe evaluated 26 patients who underwent robotic single-site plus one-port distal pancreatectomy excluding one patient who needed more ports because of fatty abdomen. The mean age and body mass index were 47.3 years (range 21–74) and 22.6 kg/m2 (range 15.8–28.8), respectively. The most common pathologic diagnosis was solid papillary neoplasm followed by a neuroendocrine tumor. The mean operating time was 201 min. The mean length of hospital stay after surgery was 7 days (range 4–10). The rate of spleen preservation was 34.6% (9/26). Six patients had postoperative pancreatic fistula (POPF) grade A, and no patients had POPF grade B or C. Only one patient had class II morbidity. ConclusionRobotic single-site plus one-port distal pancreatectomy is safe and feasible in terms of short-term outcomes. This technique could be performed in select cases to expand the surgical boundaries of the robotic single-site platform. Further studies are needed with more cases to investigate long-term outcomes.

Robotic-Assisted versus Laparoscopic Distal Pancreatectomy: The Results of a Case-Matched Analysis from a Tertiary Care Center

Background: Laparoscopic distal pancreatectomy (LDP) has been adopted relatively slowly despite the benefits of minimally invasive approach. The robotic approach can overcome the limitations of LDP, thus increasing the acceptance of minimally invasive distal pancreatectomy. Methods: We performed a 1:1 retrospective case-matched comparison among 2 groups of 35 patients who underwent robotic-assisted distal pancreatectomy (RDP) or LDP from August 2014 to April 2017. Results: The operative time was similar in both groups (230 RDP vs. 205 LDP min, p = 0.382). The robotic group had a lower estimated blood loss (95 vs. 275 mL, p = 0.035). The spleen preservation rate was higher in the RDP group (100 vs. 66.7%, p = 0.027), while the conversion rate to open surgery was higher in the laparoscopic group (14.3 vs. 2.9%, p = 0.048). The overall complication rate was lower in the robotic group (25.7 vs. 37.1%, p = 0.044). There was no statistically significant difference in oncologic outcomes between the groups in terms of R0 resection rate (100% RDP vs. 85% LDP, p = 0.233) and number of harvested lymph nodes (14.4 RDP vs. 10.8 LDP, p = 0.678). Conclusions: The RDP showed a lower estimated blood loss, conversion, and morbidity rate. It offered a higher spleen preservation rate in comparison to LDP while maintaining comparable oncologic outcomes.

Twenty Years of Gut Transplantation for Chronic Intestinal Pseudo-obstruction: Technical Innovation, Long-term Outcome, Quality of Life, and Disease Recurrence.

To define long-term outcome, predictors of survival, and risk of disease recurrence after gut transplantation (GT) in patients with chronic intestinal pseudo-obstruction (CIPO). GT has been increasingly used to rescue patients with CIPO with end-stage disease and home parenteral nutrition (HPN)-associated complications. However, long-term outcome including quality of life and risk of disease recurrence has yet to be fully defined. Fifty-five patients with CIPO, 23 (42%) children and 32 (58%) adults, underwent GT and were prospectively studied. All patients suffered gut failure, received HPN, and experienced life-threatening complications. The 55 patients received 62 allografts; 43 (67%) liver-free and 19 (33%) liver-contained with 7 (13%) retransplants. Hindgut reconstruction was adopted in 1993 and preservation of native spleen was introduced in 1999. Immunosuppression was tacrolimus-based with antilymphocyte recipient pretreatment in 41 (75%). Patient survival was 89% at 1 year and 69% at 5 years with respective graft survival of 87% and 56%. Retransplantation was successful in 86%. Adults experienced better patient (P = 0.23) and graft (P = 0.08) survival with lower incidence of post-transplant lymphoproliferative disorder (P = 0.09) and graft versus host disease (P = 0.002). Antilymphocyte pretreatment improved overall patient (P = 0.005) and graft (P = 0.069) survival. The initially restored nutritional autonomy was sustainable in 23 (70%) of 33 long-term survivors with improved quality of life. The remaining 10 recipients required reinstitution of HPN due to allograft enterectomy (n = 3) or gut dysfunction (n = 7). Disease recurrence was highly suspected in 4 (7%) recipients. GT is life-saving for patients with end-stage CIPO and HPN-associated complications. Long-term survival is achievable with better quality of life and low risk of disease recurrence.

310.7: Spleen preservation attenuates GVHD in multivisceral transplant recipients.

Purpose: The immunological benefits of the spleen are well acknowledged, but splenectomy is often performed in recipients of multivisceral transplantation. Technical reason and the lack of room in the abdominal cavity are the key arguments to justify removal of the native spleen. We aimed to analyze the beneficial role of the spleen in MVTx recipients in a series of pediatric intestinal transplantation. Patients and methods: A total of 103 IT (55MV, 25SB, 22CLSB, 3MMV) were performed in 84 patients (male-60%-, mean age 5.3yrs) between 1999 and 2018. Mean time on the waiting list was 272days waiting list mortality was 25%. Main indications for the transplant on the first instance were short bowel syndrome (69%), motility disorders(12%) and epithelial diseases(9.5%). For the present study we included only pediatric (<18 years) cases that underwent multivisceral transplantation. Patients were divided patients in three groups, native spleen preservation, native spleen removal and spleen graft inclusion. We analyzed survival, GVHD, hemolytic disorders. Results: From the whole series, only 55 patients were included, all of them received a multivisceral graft. The spleen was included in the graft in 18.1% of patients, splenectomy was performed in 40%, in several of them after failed attempt of preservation; and native spleen was preserved in 41.8% Rejection in different forms was more frequent in patients who preserved the spleen, 4% presented humoral rejection, and acute cellular rejection was two times and chronic rejection four times more frequent compared with patients who underwent splenectomy. None of the patients with the spleen included in the graft presented humoral or chronic rejection, PTLD was also (1.8 times) more frequent in this group. The proportion of GVHD was significantly lower in the group of spleen preservation compared to splenectomy and graft spleen (RR 2.75, OR 3.33) (p<0.05). We also found a trend towards less hemolytic disorders in patients with spleen preservation. Conclusion: Native spleen preservation demonstrated to attenuate the occurrence and severity of GVHD in pediatric MVTx recipients. This technique should be considered in all patients, although technical difficulties, prolonged ischemia of the graft and other factors can preclude the success of the procedure.