Splenic Preservation Research Articles

Robotic versus open total pancreatectomy: a retrospective cohort study.

Robotic total pancreatectomy (RTP), although considered safe and feasible, has rarely been reported. This study aimed to evaluate whether RTP has advantages over open TP (OTP). Demographics and perioperative outcomes among patients who underwent RTP (n=14) versus OTP (n=15) between May 2015 and September 2020 were retrospectively analyzed. RTP reduced the operative time (307.2 vs. 382.0 min, p=0.01) and estimated blood loss (EBL) (200 vs. 700 ml, p=0.002) compared to those of OTP. The patients in the RTP group got out of their beds and stood, received their first liquid, and took oral diets earlier (2.0 vs. 3.0 days, p=0.002; 2.0 vs. 4.0 days, p=0.009; 3.0 vs. 5.0 days, p=0.006) and experienced a shorter postoperative hospital stay (PHS) (9.0 vs. 12.0 days, p=0.03). There were no significant differences in the rates of spleen preservation, splenic vessel preservation, bile leakage, delayed gastric emptying, morbidity, or the number of lymph nodes harvest between the two groups. This study demonstrates that RTP is safe and feasible in selected patients with different indications in experienced robotic center. RTP was associated with a shorter operative time, lower EBL, and shorter PHS than OTP.

Comparative analysis of open, laparoscopic and robotic distal pancreatic resection: The United Kingdom's first single-centre experience.

Introduction:Laparoscopic distal pancreatectomy (LDP) has potential advantages over its open equivalent open distal pancreatectomy (ODP) for pancreatic disease in the neck, body and tail. Within the United Kingdom (UK), there has been no previous experience describing the role of robotic distal pancreatectomy (RDP). This study evaluated differences between ODP, LDP and RDP.Methods:Patients undergoing distal pancreatectomy performed in the Department of Hepatobiliary and Pancreatic Surgery at the Freeman Hospital between September 2007 and December 2018 were included from a prospectively maintained database. The primary outcome measure was length of hospital stay, and the secondary outcome measures were complication rates graded according to the Clavien–Dindo classification.Results:Of the 125 patients, the median age was 61 years and 46% were male. Patients undergoing RDP (n = 40) had higher American Society of Anesthesiologists grading III compared to ODP (n = 38) and LDP (n = 47) (57% vs. 37% vs. 38%, P = 0.02). RDP had a slightly lower but not significant conversion rate (10% vs. 13%, P = 0.084), less blood loss (median: 0 vs. 250 ml, P < 0.001) and a higher rate of splenic preservation (30% vs. 2%, P < 0.001) and shorter operative time, once docking time excluded (284 vs. 300 min, P < 0.001) compared to LDP. RDP had a higher R0 resection rate than ODP and LDP (79% vs. 47% vs. 71%, P = 0.078) for neoplasms. RDP was associated with significantly shorter hospital stay than LDP and ODP (8 vs. 9 vs. 10 days, P = 0.001). While there was no significant different in overall complications across the groups, RDP was associated with lower rates of Grade C pancreatic fistula than ODP and LDP (2% vs. 5% vs. 6%, P = 0.194).Conclusion:Minimally invasive pancreatic resection offers potential advantages over ODP, with a trend showing RDP to be marginally superior when compared to conventional LDP, but it is accepted that that this is likely to be at greater expense compared to the other current techniques.

Splenic Artery Angioembolization is Associated With Increased Venous Thromboembolism

Angioembolization has become an increasingly utilized adjunct for splenic preservation after trauma. Embolization of the splenic artery may produce a transient systemic hypercoagulable state. This study was designed to determine the risk of venous thromboembolism (VTE) in blunt trauma patients managed nonoperatively with splenic angioembolization, relative to those managed without. Retrospective review of the American College of Surgeons Trauma Quality Improvement Performance (TQIP) Database from 2013 to 2016. Adult (>16 years) patients with isolated, severe (Grades III–V) blunt splenic injuries managed nonoperatively who received pharmacological VTE prophylaxis formed the study population. Outcomes included deep venous thrombosis (DVT), pulmonary embolism (PE), or any VTE. A total of 2643 patients met inclusion criteria (69.1% Grade III, 26.5% Grade IV, 4.5% Grade V). The incidence of DVT was 4.5% in patients who underwent angioembolization, compared to 1.4% in patients who did not (p<0.001). Multivariable analysis showed that angioembolization was an independent risk factor for both DVT (OR 2.65, p = 0.006) and any VTE (OR 2.04, p = 0.01). Analysis according to splenic injury Grades showed that angioembolization remained an independent risk factor for DVT (p = 0.004) in the Grade IV-V injury group, and for VTE (p<0.01) in the Grade III injury group. Initiation of pharmacological VTE prophylaxis 48 h after admission was associated with increased VTE rates in comparison to early initiation (OR 1.75, p = 0.02) Splenic artery angioembolization may be an independent risk factor for VTE events in isolated, severe blunt splenic trauma managed nonoperatively. Early prophylaxis with LMWH after intervention should be strongly considered.

The Robotic Spleen Preserving Distal Pancreatectomy Under Temporary Splenic Artery Occlusion: the Royal North Shore Technique

There are numerous advantages of splenic vessel preservation in performing the minimally invasive spleen preserving distal pancreatectomy. Dissection along the splenic artery, and a medial to lateral dissection of the splenic vein, is associated with high risk of injury and bleeding. Proximal control of the splenic artery with vessel loops, which require tightening or adjustment with the advent of distal bleeding, is inefficient. Instead, a modified technique (the Royal North Shore Technique), whereby a vascular clamp is placed on the splenic artery, reduces splenic artery inflow and indirectly, splenic vein returns. This allows for more accurate and injury-free dissection of the now non-distended splenic vein and the associated tributaries, and maintains a relatively bloodless field in the event of arterial injury.

A retrospective comparative study of robotic distal pancreatectomy with or without splenic vessel and spleen preservation

BackgroundRobotic distal pancreatectomy has been accepted to be safe and effective for pancreatic tail lesion. Whether spleen preservation by preserving the splenic vessels with robot assistance is feasible and beneficial remains controversial. Here we would like to compare the operative outcomes of robotic distal pancreatectomy and splenectomy (DPS) with robotic spleen preserving distal pancreatectomy by means of splenic vessel preservation (SVP). MethodsBetween March 2011 and September 2019, 56 consecutive patients undergoing robotic distal pancreatectomy were identified, with 28 patients in each group. Patient demographics, histopathology findings and operative outcomes were prospectively collected and compared between the two groups. A subgroup analysis was made after excluding malignant and pancreatic lesions >6 cm in the DPS group. ResultsThe two groups had similar conversion rate, blood loss, morbidity and pancreatic fistula rate. There was no operative mortality. The SVP group had shorter median operative time (245 vs 303.5 min, P = 0.019) and shorter median hospital stay (5 vs 6 days, P = 0.019) than the DPS group. However, all malignant lesions occurred in the DPS group and lesion size in DPS group was significantly larger. After matching, there were 28 SVP and 15 DPS. The histopathology findings and lesion size became comparable. The SVP group still had shorter operative time (245 vs 290 min, P = 0.022) and shorter hospital stay (5 vs 7 days, P = 0.014) than the DPS group. ConclusionApart from avoiding risk of overwhelming postsplenectomy sepsis, robotic SVP had additional advantage of shorter operative time and shorter hospital stay than robotic DPS.

Managing Ruptured Splenic Ectopic Pregnancy Without Splenectomy: Case Report and Literature Review

Splenic ectopic pregnancy is extremely rare but carries a high risk of uncontrollable life-threatening bleeding. Our aim is to try to diagnose those cases earlier and to include splenic preservation as good alternative for selected cases. Extensive review of the literature has been performed. Thirty-one case reports were identified, of which 4 have been excluded because they were not written in English. A 36-year-old woman presented to the Emergency Department with haemorrhagic shock. Despite the levonorgestrel intrauterine system (LNG-IUS) being in situ for 4 months, urinary and serum tests were both positive for pregnancy, and an ultrasound scan revealed haemoperitoneum suggestive of a ruptured ectopic pregnancy. An emergency Pfannenstiel laparotomy was performed and a diagnosis of spontaneous tubal abortion was made and the abdomen was subsequently closed. Following a period of cardiovascular instability on the Intensive Care Unit postoperatively, an urgent CT scan was performed which revealed bleeding from the spleen. A midline laparotomy was performed by the general surgeon, which involved resection of the gestational sac and splenorrhaphy. Twenty-seven cases were reviewed, and 73% of them presented as an emergency and 21 cases (81%) had been managed with splenectomy. CT scan had been used in eight of the previous case reports of splenic ectopic pregnancy with 100% diagnostic accuracy rate. Non-tubal ectopic pregnancies are very rare. Splenorrhaphy is a safe alternative to splenectomy in cases of splenic ectopic pregnancy. CT abdomen and pelvis with intravenous contrast can be very helpful in relatively stable patients with a vaginal ultrasound demonstrating an empty uterus, no clear adnexal masses or free fluid.

Splenic preservation after isolated splenic blunt trauma: The angioembolization paradox

BackgroundThe spleen is the most commonly injured organ in blunt abdominal trauma. The management for splenic trauma includes nonoperative management, splenectomy, and splenic artery angioembolization. The aim of this study is to investigate recent trends in the usage of splenic artery angioembolization in patients with isolated blunt splenic trauma. MethodsAdult patients (age >15) with isolated blunt splenic trauma were identified from the National Trauma Databank (2007–2015) using International Classification of Diseases, Ninth Revision, codes. The defined groups included nonoperative management, splenectomy, and splenic artery angioembolization. Patient variables collected included year of traumatic injury, age, sex, race, insurance status, and geographic region. Clinical variables collected included vital signs (systolic blood pressure, pulse, respiratory rate) recorded upon arrival to the emergency room, injury severity score, abbreviated injury severity scores, diagnoses, procedures, and mechanism. Outcome measures included mortality, hospital duration of stay, and complications. We performed 2 independent Poisson logistic regression models to assess relative risk for both splenectomy and angioembolization. ResultsA total of 10,812 patients were included in the analysis (nonoperative management: 7,920; splenectomy: 2,083; angioembolization: 809). Angioembolization proportion increased from 2007 (4.6%) to 2015 (10%), while splenectomy proportion remained unchanged (19.2% to 18.3%). Poisson logistic regression suggests the adjusted probability of receiving angioembolization for a splenic injury increased year-to-year, while the adjusted probability of receiving a splenectomy remained unchanged. ConclusionThe use of angioembolization for isolated blunt splenic injuries has increased over the past decade without a reciprocal change in splenectomy. Based on this study, angioembolization may be an overused resource without a significant benefit.

Solid pseudopapilar neoplasm of the pancreas.

Solid pseudopapillary tumor of the pancreas is a rare entity, more frequent in women between the 2nd and 4th decades. The diagnosis is usually incidental and it can be reached by computed tomography or magnetic resonance imaging. Subsequent pathological confirmation is necessary for an adequate treatment. A retrospective study of six cases was carried out. All the patients were female, between 14 and 56 years of age, in which 50% the tumor were an incidental finding. We had three cases located in the head and three in the body of the pancreas. We performed three pancreaticoduodenectomies and three distal pancreatectomies with splenic preservation, without disease recurrence.

"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.

Laparoscopic spleen-preserving distal pancreatectomy with splenic vessels preservation for pNET in a young patient

Introduction: The frequency of incidentally discovered nonfunctioning pancreatic neuroendocrine tumors (pNET) is increasing due of the modern imaging techniques. Mostly discovered in patients with a small size, surgical treatment by a minimally invasive (MI) approach is worldwide accepted reducing perioperative morbidity. Spleen preserving distal pancreatectomy (SPDP) with splenic preservation, according to Kimura procedure decreases the risk of post-splenectomy sepsis, perigastric varices and splenic infarctions. Method: A 28 year old man (ASA I) referred because a highly suspect non functioning pNET (Ø 3.6 cm). This video highlights the key steps required for performing a SPDP. The video also focused how the pre-operative planning by CT scan, magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) is mandatory. It shows clearly patient and trocar positioning, as well as operative tactics. The dissection strategy along the splenic vessels using novel energy devises to control direct splenic venous branches into the pancreas as well as the transection of the pancreatic tissue by a stapler is showed. Results: Estimated intraoperative blood loss was 100 ml. Operative time: 210 minutes. No major morbidity (Clavien-Dindo ≥III) occured. Discharged on 6th postoperative day. Final pathology: cystic pNET pT1N0, G1, mitotic count/50 HPF < 2, Ki67< 3%. Conclusion: Improvements in imaging and MI approach have enabled surgeons to preserve the major splenic vessels reducing the risk of splenic infarcts, abscesses and re-operations, and minimize the risk of left-sided portal hypertension.

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

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

Robotic central pancreatectomy for a solid pseudopapillary neoplasm

Introduction: Solid pseudopapillary neoplasms (SPN) are a rare entity that mostly occurs in young women. For its malignant potential, the standard treatment is surgery. Robotic surgery offers more accuracy and range of movement, facilitates the dissection the pancreas and increases the rate of splenic vessels preservation. Methods and Results: We present the case of a 30-year-old women diagnosed of an incidental pancreatic cystic neoplasm in a Computed Tomography scan. A Magnetic Resonance and an Endoscopic Ultrasound confirmed the diagnosis. The intervention was performed with the DaVinci Xi. Three 8mm and one 12mm robotic ports and one 12mm laparoscopic port were placed. The gastrocolic ligament was dissected with access to the lesser sac. An intraoperative ultrasonography was performed with visualization of the lesion limited to the pancreatic body. The pancreatic neck was divided with an endostapler, the body was dissected reaching the distal margin of the SPN and also divided at that level. Intraoperative pathology report confirmed negative margins. The splenic vessels were identified and preserved. Reconstruction was performed with a pancreato-gastric anastomosis. During the postoperative course, the patient presented upper gastrointestinal bleeding exteriorized as melena. Blood transfusion and an upper gastrointestinal endoscopy with electrocauterization of an arteriolar bleeding of the pancreas were required. The patient remained hemodynamically stable. No pancreatic fistula occurred. The patient was discharged on postoperative day 14. Conclusion: Central pancreatectomy is a parenchyma-sparing procedure that can be used in pancreatic lesions limited to the neck/body. Robotic surgery offers major precision in order to dissect and preserve splenic vessels and helps in a more accurate and tight anastomosis.

Laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein (Kimura's procedure)

Authors present the case of a laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein (Kimura's procedure). A 26-year old female patient was admitted with a neoplasm of the tail of the pancreas detected by abdominal ultrasound. Pancreatic protocol CT-scan revealed a 7 cm round-shaped tumor in the tail of the pancreas. The CT features of the lesion were suggestive for mucinous cystadenoma. Spleen-preserving laparoscopic distal pancreatectomy is considered as the first choice procedure for benign lesions located at the body or tail of the pancreas and is performed very frequently worldwide. The advantages of preservation of the spleen are related to the preserved immune function of the organ. The two main surgical techniques that have been proposed and widely adopted for spleen preserving laparoscopic distal pancreatectomy are the Warshaw (splenic vessel ligation) and Kimura (splenic vessel preservation) techniques. The procedure was complicated due to the large size of the lesion and firm adhesions between the vessels and the tumor. Nevertheless the splenic vessels were successfully preserved after clipping all the branches of the splenic vein and artery. No significant bleeding occurred. The estimated blood loss was 50 ml. The operation time was 210 minutes. The postoperative course was complicated by a postoperative pancreatic fistula (POPF) grade B (according to the ISGPF classification), which was managed successfully using interventional percutaneous drainage. Final histopathological examination confirmed mucinous cystadenoma of the tail of the pancreas. The patient was discharged on postoperative day 14 with external drainage tube, which was removed in three weeks after amylase level control in an outpatient clinic. The purpose of the video is to demonstrate our experience in performing Kimura's procedure.

Laparoscopic distal pancreatectomy for benign and malignant disease: a review of techniques and results.

Diagnosis of pancreatic cancer is challenging in the initial phases because its progression is rapid. The pancreatic tail and body roughly accounts for 20–30% of all cancerous cases. The standard treatment for symptomatic benign, malignant, and premalignant diseases of the pancreatic tail and body is distal pancreatectomy. This technique has been modified over the years to fit certain indications, with the goal of enhancing post-operative results as well as reducing patient trauma. In cases of a premalignant and symptomatic benign condition, the spleen must be preserved either using Kimura’s splenic vessel preservation technique or Warshaw’s splenic vessel resection technique. A better long-term prognosis is ensured by regional lymph node dissection and radical R0 resection. Radical antegrade modular pancreatosplenectomy was proposed to tackle the shortcomings of traditional surgery for pancreatic tail and body cancer. In this review, study techniques and results of laparoscopic distal pancreatectomy for malignant and benign pancreatic ailments were described with the intention of providing knowledge on various suitable techniques reported for pancreatic cancer treatment. Furthermore, this study will serve as a ready reckoner for surgeons and could serve to boost their confidence levels during surgery by avoiding confusion on the selection of suitable for the pancreatic diseases diagnosed.

Distal Pancreatectomy Using Clockwise Technique: Laparoscopic vs Robotic Approach

Purpose: The 2020 Miami Guidelines for Minimally Invasive Pancreas Resection postulate that both laparoscopic and robotic distal pancreatectomy are safe approeaches. Studies carried out so far suggest comparable results in terms of general morbidity, postsurgical complications, and oncological outcomes. Method: In this video we intend to compare the laparoscopic versus robotic approach of distal pancreatectomy, performed in two similar clinical cases using the “clockwise” technique described in 2002 by HJ Asbun. We are able to visualize the feasibility of this technique in both approaches and the differences found in its five standardized steps. Results: Twenty-four procedures were performed in our centre according to the clockwise technique, ten robotic and fourteen laparoscopic. Two of them needed conversion to open surgery, one from each approach. Median operative time was 194 min (lap: 167 min; robotic: 233 min) and median hospital stay was of 6.6 days. Major morbidity and pancreatic fistula rates were 4% (Clavien Dindo> III) and 20% (including from grade A to C) respectively. Margins were negative in all 24 patients. Conclusion: Robotic left pancreatectomy can offer greater comfort in terms of surgeon ergonomy, better vision, and precision. Larger randomized studies are required to assess the possible differences between these two approaches, paying special attention to the rate of intraoperative complications, splenic preservation rate, oncological results, and cost analysis.

Quantitative analysis of three-dimensional reconstruction data to guide the selection of methods for laparoscopic distal pancreatectomy.

To explore the risk factors of splenic vessel preservation in laparoscopic distal pancreatectomy (LDP) and to guide with the appropriate selection of surgical methods through three-dimensional (3D) reconstruction. Patients suffering from benign or low-grade malignant tumors of pancreatic body and tail having undergone LDP in Ningbo Medical Center Lihuili Hospital from January 2014 to September 2019 were selected for quantitative analysis of the anatomical data of patients' pancreas, tumors, splenic vessels and spleens by 3D reconstruction. According to the final surgical methods, the patients were divided into the laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation (lap-SVP) group and the non-lap-SVP group. Clinical data of the two groups were compared to assess the risk factors for surgical failure of lap-SVP and logistic regression model was applied to predict the choice of surgical methods. A total of 218 patients were included in the study, including 144 in the lap-SVP group and 74 in the non-lap-SVP group. Multivariate analysis confirms that large tumor volume, large contact area between the pancreas to be resected and the splenic vein, and large maximum ratio of the circumference of the splenic vessel embedded in the pancreas to be resected to the circumference of the splenic vessel are independent risk factors for surgical failure of lap-SVP (OR>1, P<.05). The prediction accuracy of lap-SVP operation by the logistic regression reaches up to 80.9%. 3D reconstruction can provide essential basis for the surgical method selection of laparoscopic distal pancreatectomy.

Dynamic hematological changes in patients undergoing distal pancreatectomy with or without splenectomy: a population-based cohort study

BackgroundThe clinical outcomes of patients who received distal pancreatectomy with splenectomy (DPS) and spleen-preserving distal pancreatectomy (SPDP) have been generally investigated. However, postoperative hematological changes after distal pancreatectomy with or without splenectomy are poorly understood.MethodsInformation from patients undergoing distal pancreatectomy (DP) between January 2014 and June 2019 at a single institution was reviewed. A linear mixed-effects model was used to compare dynamic hematological changes between different groups.ResultsA total of 302 patients who underwent DP were enrolled. In the long term, most postoperative hematological parameters remained significantly higher than preoperative levels in the DPS group, while postoperative lymphocyte, monocyte, basophil, and platelet levels returned to preoperative levels in the SPDP group. All postoperative hematological parameters except for red blood cell count and serum hemoglobulin level were significantly higher in the DPS group than in the SPDP group. There were no significant differences in hematological changes between the splenic vessel preservation (SVP) and Warshaw technique (WT) groups.ConclusionsPostoperative hematological changes were significantly different between the DPS and SPDP groups. Compared to DPS, SPDP reduced abnormal hematological changes caused by splenectomy. SVP and WT were comparable in terms of postoperative hematological changes.

Splenic Artery Angioembolization is Associated with Increased Venous Thromboembolism.

Angioembolization has become an increasingly utilized adjunct for splenic preservation after trauma. Embolization of the splenic artery may produce a transient systemic hypercoagulable state. This study was designed to determine the risk of venous thromboembolism (VTE) in blunt trauma patients managed nonoperatively with splenic angioembolization, relative to those managed without. Retrospective review of the American College of Surgeons Trauma Quality Improvement Performance (TQIP) Database from 2013 to 2016. Adult (>16years) patients with isolated, severe (Grades III-V) blunt splenic injuries managed nonoperatively who received pharmacological VTE prophylaxis formed the study population. Outcomes included deep venous thrombosis (DVT), pulmonary embolism (PE), or any VTE. A total of 2643 patients met inclusion criteria (69.1% Grade III, 26.5% Grade IV, 4.5% Grade V). The incidence of DVT was 4.5% in patients who underwent angioembolization, compared to 1.4% in patients who did not (p<0.001). Multivariable analysis showed that angioembolization was an independent risk factor for both DVT (OR 2.65, p = 0.006) and any VTE (OR 2.04, p = 0.01). Analysis according to splenic injury Grades showed that angioembolization remained an independent risk factor for DVT (p = 0.004) in the Grade IV-V injury group, and for VTE (p<0.01) in the Grade III injury group. Initiation of pharmacological VTE prophylaxis 48h after admission was associated with increased VTE rates in comparison to early initiation (OR 1.75, p = 0.02) CONCLUSIONS: Splenic artery angioembolization may be an independent risk factor for VTE events in isolated, severe blunt splenic trauma managed nonoperatively. Early prophylaxis with LMWH after intervention should be strongly considered.

S3434 Gastric Compression Due to Splenic Cyst

INTRODUCTION: Splenic cyst have a very low overall incidence of 0.07% out of which 0.5% across the splenectomy patient population and a further 0.08% diagnosed at autopsy. The primary epithelial cysts account for 10% of all splenic cysts. CASE DESCRIPTION/METHODS: 25 year old Caucasian female no past medical history complains of epigastric and left upper abdominal pain associated with nausea, multiple episodes of post-prandial vomiting and diarrhea for 3 weeks. CT abdomen suggested cystic splenic mass 10.1 cm in the anterior portion most likely a splenic epithelial cyst or splenic pseudocyst that was compressing the stomach. Further studies of Echinococcosis IgG, CMB/ EBV, stool ova & parasite, AFB serologies were negative, Interventional radiology performed fine needle aspiration with pig tail catheter placement. Cultures of the aspirate was positive for Enterococcus Casseliflavus, Staph. Xylosus and Enterobaccter cloacae and was treated with antibiotics. Upon resolution of the size of the cyst, stomach was distended and patient was able to tolerate PO diet. Due to persistent drainage, patient underwent cyst sclerotherapy without complication with good outcome. DISCUSSION: Splenic Cysts are asymptomatic in 30% to 60% of patients and most are diagnosed incidentally. Small (8 cm) are more likely to produce symptoms.They are Type I primary or “true” cysts and Type II secondary splenic cysts or pseudocysts. Type I splenic cysts re defined by the presence of an epithelial lining. They include both parasitic and nonparasitic etiologies.Up to 80% of nonparasitic cysts are found in patients younger than age 20 years, suggesting a congenital origin. Parasitic cysts of the spleen are caused by Taenia echinococcus, most often E. granulosus. Earlier, total splenectomy was the treatment of choice; now, splenic preservation, including partial splenectomy, cystectomy, and cyst decapsulation is becoming more commonly used. Other treatment options include (1) drainage via radiologic guidance and (2) total splenectomy. Due to the complex presentation of the splenic cyst there is only few evidence-based management and treatment regimens. Most cysts can be treated via partial and total splenectomy however splenic conservation procedures should be the focus for the future treatment.Figure 1

A single institution experience with robotic and laparoscopic distal pancreatectomies.

Backgrounds/AimsThis study aims to describe our experience with minimally-invasive distal pancreatectomies, with emphasis on the comparison between robotic distal pancreatectomy (RDP) and laparoscopic distal pancreatectomy (LDP).MethodsRetrospective review of 102 consecutive RDP and LDP from 2006 to 2019 was performed.ResultsThere were 27 and 75 patients who underwent RDP and LDP, respectively. There were 12 (11.8%) open conversions and 16 (15.7%) patients had major (>grade 2) morbidities. Patients who underwent RDP had significantly higher rates of splenic preservation (44.4% vs. 13.3%, p=0.002), higher rates of splenic-vessel preservation (40.7% vs. 9.3%, p=0.001), higher median difficulty score (5 vs. 3, p=0.002) but longer operation time (385 vs. 245 minutes, p<0.001). The rate of open conversion tended to be lower with RDP (3.7% vs. 14.7%, p=0.175).ConclusionsIn our institution practice, both RDP and LDP were safe and effective. The use of RDP appeared to be complementary to LDP, allowing us to perform more difficult procedures with comparable postoperative outcomes.