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

Abstract

Background: 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. Materials and Methods: 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. Results: 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. Conclusions: 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.

The use of selective splenic vascular control in laparoscopic splenic vessels and spleen preservation distal pancreatectomy

“…In the case of tortuous expansion of the perisplenic blood vessels, pancreatitis, or a huge tumor in the tail of the pancreas, it will be difficult to separate the splenic blood vessels. In such cases, the Warshaw method or splenectomy may be appropriate (17,18).…”