Splenic Vessel-preserving Distal Pancreatectomy Research Articles

Inferior-Medial Approach to Laparoscopic Splenic Vessel-Preserving Distal Pancreatectomy.

Complete preservation of the splenic vessels is ideal during laparoscopic spleen-preserving distal pancreatectomy (LSPDP). However, this remains challenging and time-consuming because the vessels are often deeply embedded in the pancreatic parenchyma. Herein, we introduce our inferior-medial approach to laparoscopic splenic vessel-preserving distal pancreatectomy (lap-SVPDP) and evaluate its safety and feasibility. Forty-three patients underwent LSPDP performed by a single surgeon at our institution: 26 (60.5%) lap-SVPDPs with an inferior-medial approach and 17 with the laparoscopic Warshaw technique (lap-WT). We compared the outcomes of the 2 groups. No patient undergoing lap-SVPDP required conversion to laparotomy or lap-WT. Most preoperative characteristics and postoperative outcomes did not differ between the 2 groups; neither the operation time nor the intraoperative blood loss differed despite the greater technical complexity of lap-SVPDP. The mean tumor size was greater in the lap-WT than the lap-SVPDP group (P = .001). The splenic vein patency rate of the lap-SVPDP group was not inferior to that of the open SVPDP group treated by the same surgeon. Inferior-medial approach lap-SVPDP could be a safe and feasible technique for lap-SVPDP; neither blood loss nor operation time is increased.

Inferior-medial approach for laparoscopic splenic vessel-preserving distal pancreatectomy: A single surgeon’s experience

Inferior-medial approach for laparoscopic splenic vessel-preserving distal pancreatectomy: A single surgeon’s experience

A Pragmatic Approach to Pancreatic Trauma: A Single-Center Experience From a Tertiary Care Center.

IntroductionPancreatic trauma is rare and is usually associated with adjacent organ and vascular injuries, which adds to the high morbidity and mortality. In the American Association for the Surgery of Trauma (AAST) pancreatic trauma (PT) grading system, the higher grades are a composite of less and more severe extents of injuries. We hereby present an observational study of PT with management based on an indigenous algorithmic approach. Our protocol incorporating both the extent of disruption of the main pancreatic duct (MPD) and its amenability to interventions (endoscopic, radiological, or surgical) is pragmatic.MethodsOurs is a retrospective observational study of 28 consecutive cases of PT, done over a three-year period in an academic institution, by an expert Surgical Gastroenterology unit. All patients diagnosed with PT on a contrast abdominal CT scan were included. After stabilization, they were stratified and managed according to an indigenous protocol. The primary outcome measure was treatment success in terms of recovery. The secondary outcome measure was morbidity of any form.ResultsOne patient with Grade 1 PT was operated on for associated hollow viscus injury. Two patients with AAST Grade 2 and two patients with AAST Grade 3 injury were managed successfully without surgery. Twelve of 21 patients with Grade 3 PT underwent Kimura’s splenic vessel preserving distal pancreatectomy. Distal pancreatectomy with splenectomy and central pancreatectomy with Roux-en-Y pancreaticojejunostomy (PJ) was done for 7/21 and 2/21 patients, respectively, with Grade 3 PT. Two with Grade 5 injury underwent trauma Whipple. The overall mortality and morbidity rates in our series were 15.7% and 64%, respectively.ConclusionThe pathogenesis in PT is a dynamic process and shows temporal evolution. These patients require serial and periodical clinical and radiological monitoring, especially in those managed conservatively initially. PT can be low or high grade. Patients with isolated low-grade PT can be managed according to the standard step-up approach for acute pancreatitis. A carefully selected subgroup of patients with partial MPD disruption either in the head or body of the pancreas can be managed by endotherapy. Complete distal parenchymal transections require early surgery tailored to individual patients in the form of either splenic vessel preserving distal pancreatectomy (SPDP) or distal pancreatectomy with splenectomy (DP+S). Damage control surgery is the dictum in unstable patients with Grades 4 and 5 injuries not responding to resuscitative measures. A trauma Whipple can be done in a carefully selected subgroup of stable patients with proximal massive disruptions in an experienced hepato-pancreatico-biliary (HPB) unit.

A New Robotic Technique to Facilitate Distal Pancreatectomy with Preservation of Splenic Vessels: Left Lateral Approach in Right Lateral Decubitus Position

Introduction: Spleen-preserving distal pancreatectomy (SPDP), with or without splenic vessel preservation, is the technique of choice for patients with benign or small low-grade malignant tumours of the body or tail of the pancreas, as it avoids the potential side effects of splenectomy. Furthermore, splenic vessel-preserving distal pancreatectomy (SVPDP) is the ideal procedure although it is technically demanding, even when performed by open surgery. In order to simplify the preservation of the splenic vessels, different open and laparoscopic approaches have been described in the literature. Methods: In this article, we describe a new variation in surgical technique performed at our centre: robotic left-lateral approach SVPDP in right lateral decubitus position, in a patient with a solid and pseudopapillary neoplasm (SPN) of the pancreatic tail. Results: Recent publications have shown a higher splenic preservation rate in robotic distal pancreatectomy when compared to the laparoscopic approach. Our experience shows that the robotic approach might facilitate this procedure and shorten hospital stay. Conclusions: The robotic left lateral approach-SVPDP in the right lateral decubitus position is a feasible and safe approach for distal benign or small low-grade malignant tumours of the pancreatic tail. The right lateral decubitus position associated with robotic assistance can facilitate this complex procedure with a lower risk of conversion and shorten the learning curve.

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

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

Splenic vessel patency: is it real menace to perform laparoscopic splenic vessel-preserving distal pancreatectomy.

PurposeThis study compared the patency of the splenic vessels between laparoscopic and open spleen and splenic vessel-preserving distal pancreatectomy.MethodsWe retrospectively reviewed a database of 137 patients who underwent laparoscopic (n = 91) or open (n = 46) spleen and splenic vessel-preserving distal pancreatectomy at a single institute from 2001 through 2015. Splenic vessel patency was assessed by abdominal computed tomography and classified into three grades according to the degree of stenosis.ResultsThe splenic artery patency rate was similar in both groups (97.8 vs. 95.7%, P = 0.779). Also, the splenic vein patency rate was not significantly different between the 2 groups (74.7% vs. 82.6%, P = 0.521). Postoperative wound complication was significantly lower in the laparoscopic group (19.8% vs. 28.3%, P = 0.006), and hospital stay was significantly shorter in the laparoscopic group (7 days vs. 9 days, P = 0.001) than in the open group. Median follow-up periods were 22 months (3.7–96.2 months) and 31.7 months (4–104 months) in the laparoscopic and open groups, respectively.ConclusionLaparoscopic distal pancreatectomy showed good splenic vessel patency as well as open distal pancreatectomy. For this reason, splenic vessel patency is not an obstacle in performing laparoscopic splenic vessel-preserving distal pancreatectomy.

The video shows laparoscopic spleen and splenic vessel-preserving distal pancreatectomy and laparoscopic distal pancreatectomy with splenectomy in two patients with PNETs

The video shows laparoscopic spleen and splenic vessel-preserving distal pancreatectomy and laparoscopic distal pancreatectomy with splenectomy in two patients with PNETs

Effects of laparoscopic versus open surgery on splenic vessel patency after spleen and splenic vessel-preserving distal pancreatectomy: a retrospective multicenter study.

The aims of this study were to compare splenic vessel patency between laparoscopic and open spleen and splenic vessel-preserving distal pancreatectomy (SSVpDP), and to identify possible risk factors for poor splenic vessel patency. This retrospective multicenter study included 116 patients who underwent laparoscopic (n = 70) or open (n = 46) SSVpDP at seven Korean tertiary medical institutions between 2004 and 2011. Clinical parameters and the splenic vessel patency assessed by abdominal computed tomography were compared between the two surgical procedures. The clinical parameters were not significantly different between both groups, except for postoperative hospital stay, which was significantly shorter in the laparoscopic group (10.4 vs. 13.5 days, P = 0.024). The splenic artery patency rate was similar in both groups (90.0 vs. 97.8 %), but the splenic vein patency rate was significantly lower in the laparoscopic group (64.3 vs. 87.0 %, P = 0.022). Univariate and multivariate analyses revealed surgical procedure [odds ratio (OR) 3.085, P = 0.043] and intraoperative blood loss (OR 4.624, P = 0.002) as independent risk factors for compromised splenic vein patency (partial or total occlusion). The splenic vein patency rate was significantly better in the late group (n = 34) than in the early period (n = 35) (79.4 vs. 48.6 %, P = 0.008). Although laparoscopic SSVpDP had an advantage of shorter hospital stay compared with open surgery, it was associated with greater risk of poor splenic vein patency. However, this risk could decrease with increasing surgical experience and with efforts to minimize blood loss.

Modified Laparoscopic Splenic Vessel‐Preserving Distal Pancreatectomy: Matador Assistance and Peel‐Away Technique

Laparoscopic splenic vessel-preserving distal pancreatectomy (lap-SVPDP) is a popular procedure in pancreatic surgery. However, postoperative complications include false aneurysms of the splenic artery, splenic vein stenosis and thrombosis, pancreatic fistulas, abscess, and perigastric varices. Eight patients (three men, five women, average age 66.1 years) with benign tumors underwent lap-SVPDP. Lap-SVPDP was performed in the lithotomy position with the head slightly elevated. The splenic vein was peeled longitudinally toward the pancreatic tail. A vessel-sealing system was used to detach the pancreatic body from the greater omentum, and the pancreas was transected using a surgical stapler. Mean operation time was 254 min; mean blood loss was 163 ml; and mean post-surgical hospitalization time was 13 days. No postoperative bleeding from the preserved splenic vessels occurred, and there were no splenic infarcts or splenic abscesses. For safe performance of lap-SVPDP, the posterior surface of the pancreas should be completely exposed. The splenic vein should be 'peeled away', starting from its central rear, enabling easy detection of its course to avoid inadvertent sealing. With improved operational techniques, lap-SVPDP can be adopted as a standard procedure in pancreatic surgery.

Laparoscopic spleen-preserving distal pancreatectomy: Comparative study of spleen preservation with splenic vessel resection and splenic vessel preservation

We sought to evaluate the feasibility of the lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy (LA-SVPDP).Complete preservation of the splenic vessels is an ideal outcome in spleen-preserving distal pancreatectomy (SPDP). However, the preservation of the vessels is challenging in laparoscopic surgery because the splenic vein is often embedded in the pancreatic parenchyma. Herein we have described LA-SVPDP, the most feasible method for laparoscopic SPDP, and the outcome of our initial experience.Twenty-three patients underwent laparoscopic SPDP. Before we adopted LA-SVPDP, 8 patients underwent the Warshaw method and 6 underwent SVPDP. After the adoption of LA-SVPDP, 8 patients underwent LA-SVPDP and 1 donor underwent the Warshaw method.None of patients undergoing LA-SVPDP required conversion to an open operation, whereas 2 patients undergoing the other procedures were converted to open operations. Five out of 8 patients who underwent the Warshaw method showed engorgement of the gastric veins, revealed by computed tomography. However, only 1 of the 5 patients showed mild gastric varices on endoscopy.Although the Warshaw method is acceptable with a low incidence of gastric varices in our analysis, SVPDP is a feasible approach for SPDP. Our LA-SVPDP technique may contribute to safer and easier SVPDP in laparoscopic surgery.

The effect of operative approach on splenic vessel patency after spleen and splenic vessel-preserving distal pancreatectomy in multi-institutional study: Laparoscopic versus open approach

The effect of operative approach on splenic vessel patency after spleen and splenic vessel-preserving distal pancreatectomy in multi-institutional study: Laparoscopic versus open approach

Lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy

We sought to evaluate the feasibility of the lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy (LA-SVPDP). Complete preservation of the splenic vessels is an ideal outcome in spleen-preserving distal pancreatectomy (SPDP). However, the preservation of the vessels is challenging in laparoscopic surgery because the splenic vein is often embedded in the pancreatic parenchyma. Herein we have described LA-SVPDP, the most feasible method for laparoscopic SPDP, and the outcome of our initial experience. Twenty-three patients underwent laparoscopic SPDP. Before we adopted LA-SVPDP, 8 patients underwent the Warshaw method and 6 underwent SVPDP. After the adoption of LA-SVPDP, 8 patients underwent LA-SVPDP and 1 donor underwent the Warshaw method. None of patients undergoing LA-SVPDP required conversion to an open operation, whereas 2 patients undergoing the other procedures were converted to open operations. Five out of 8 patients who underwent the Warshaw method showed engorgement of the gastric veins, revealed by computed tomography. However, only 1 of the 5 patients showed mild gastric varices on endoscopy. Although the Warshaw method is acceptable with a low incidence of gastric varices in our analysis, SVPDP is a feasible approach for SPDP. Our LA-SVPDP technique may contribute to safer and easier SVPDP in laparoscopic surgery.

Patency of splenic vessels after laparoscopic spleen and splenic vessel-preserving distal pancreatectomy

This study evaluated the short- and long-term patency of preserved splenic vessels after laparoscopic spleen-preserving distal pancreatectomy (SPDP) with preservation of the splenic vessels. This single-centre retrospective study included all patients who had undergone splenic vessel-preserving laparoscopic SPDP between 2004 and 2007. The patency of the splenic vessels was assessed by abdominal computed tomography and classified into three grades according to the degree of stenosis. Twenty-two patients were included. The preoperative patency of the splenic artery and vein was normal in 20 and 19 patients respectively. Normal patency of the splenic artery and vein was observed in 16 and five patients respectively within 1 month of surgery, and in 19 and nine patients 6 months or more after operation. Nine of ten patients with complete splenic vein occlusion developed a collateral circulation in the late postoperative phase. Splenic perfusion was well preserved in all patients. Splenic vessel-preserving laparoscopic SPDP has the short-term benefit of good perfusion to the spleen. In the long term, there is a risk of left-sided portal hypertension if the splenic vein becomes occluded after surgery. (c) 2009 British Journal of Surgery Society Ltd.

Open and Laparoscopic Spleen-preserving, Splenic Vessel-preserving Distal Pancreatectomy: Indications and Outcomes

BackgroundSpleen-preserving distal pancreatectomy has been described lately in order to reduce the risks associated with splenectomy. The aim of this study is to report a series of open and laparoscopic distal pancreatectomies with splenic vessel preservation. MethodsFrom June 2001 to April 2007, 11 spleen-preserving distal pancreatectomies were performed, utilizing open and laparoscopic techniques. The main variables recorded were demographics, intra- and postoperative complications, and final pathology results. ResultsAll 11 spleen-preserving distal pancreatectomies were performed successfully. Laparoscopic resection was possible in seven patients. Postoperative morbidity consisted of one pancreatic fluid collection. The overall incidence of pancreatic leak was 18%. The final pathology revealed serous cystadenoma in 36% of the cases, neuroendocrine tumor in two cases, three mucinous cystadenomas, one carcinoid tumor, and one intrapancreatic spleen. With a median follow-up of 26 months, no splenic vein thrombosis was detected. ConclusionsOpen or laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation is a feasible and safe procedure. In selected cases of cystic lesions and low grade neoplasms, distal pancreatectomy with splenic preservation is possible.