1. Distal Pancreatectomy
Spleen-Preserving
Distal Pancreatectomy
Traian Dumitrascu
Dan Setlacec Center of General Surgery and Liver Transplant
Fundeni Clinical Institute
Bucharest

2. Introduction Spleen-preserving distal pancreatectomy (SPDP):
an alternative procedure to distal pancreatectomy with splenectomy
for benign/ low-grade malignant tumors of the pancreatic body
removal of the spleen during distal pancreatectomy was associated with increased postoperative morbidity
the role of the spleen in immunity was clearly demonstrated by experimental and clinical studies
Shoup, Arch Surg, 2002; Ionescu, Chirurgia, 2003; Fernandez-Cruz, HPB (Oxford), 2005; Tiron & Vasilescu, Chirurgia, 2008; Dumitrascu, Dig Surg, 2012; Lacatus, Chirurgia, 2013

3. Introduction WHY Spleen-preservation? Spleen play a key role in:
mechanical filtration, which removes senescent erythrocytes
maintenance of normal immune function and host defenses against certain types of infectious agents
prevention of infection in children
avoid overwhelming postsplenectomy infection (OPSI): S. pneumoniae, H. influenze, N. meningitidis
major site of production for the opsonins: properdin and tuftsin (bactericide and anti tumor activity)
Removal of the spleen results in loss of
both the immunologic and filtering
functions
Ionescu, Chirurgia, 2003; Tiron & Vasilescu, Chirurgia, 2008;Lacatus, Chirurgia, 2013
Vasilescu, Splina. De la laparoscopie la chirurgia robotica si inapoi, Ed. Medicala, 2016

4. Introduction What are the risks following splenectomy?
Infectious risks- OPSI
The highest risk in the first 2 years
Mortality – up to 46%
Non-infectious risks :
Arterial events
Thromboembolic events
Pulmonary hypertension
Developing cancer
Dragomir, Chirurgia, 2016

5. SPDP PRO: CONS: the role of the spleen in immunity
better endocrine function preservation
removal of the spleen during distal pancreatectomy was associated with increased postoperative morbidity
the major concern after splenectomy is overwhelming postsplenectomy infection (OPSI)
CONS:
more technically challenging
increased morbidity
Shoup, Arch Surg, 2002; Ionescu, Chirurgia, 2003; Fernandez-Cruz, HPB (Oxford), 2005; Tiron & Vasilescu, Chirurgia, 2008; Dumitrascu, Dig Surg, 2012; Lacatus, Chirurgia, 2013

6. Anatomy - arteries
Mikami, Diseases of the Pancreas, Springer-Verlag, 2008

7. Anatomy - veins
Mikami, Diseases of the Pancreas, Springer-Verlag, 2008 7

8. Technique
Warshaw, Arch Surg, 1988; Warshaw, J Hepatobiliary Pancreat Sci, 2010 8

9. Technique
Fernandez-Cruz, Atlas of Advanced Operative Surgery, Elsevier, 2013 9

10. Technique
Fernandez-Cruz, Atlas of Advanced Operative Surgery, Elsevier, 2013 10

11. Technique
Kimura, Surgery, 1996

12. Technique
Fernandez-Cruz, Atlas of Advanced Operative Surgery, Elsevier, 2013 12

13. Technique
Spleen SA PV SV
Pancreas Head
VMS
SPDP – final aspect

14. Technique Fundeni Clinical Institute: 41 SPDP
– 6 minimally-invasive (2 laparoscopic; 4 robotic)

15. Indications T
Ferrone & Warshaw, Ann Surg, 2011

17. Indications
Serous cystadenoma

18. Indications
Neuroendocrine neoplasm G1

19. Indications
Solid pseudopapillary tumor

20. Indications
Grawitz metastasis

21. 21

22. Tol, Surgery, 2014 22

23. Indications
2012 23

24. 24

25. Morbidity Early morbidity 22 - 46% Splenectomy rate (1.9 – 5.2%)
Ferrone & Warshaw, Ann Surg, 2011; Tien, Ann Surg Oncol, 2010; Shoup, Arch Surg, 2002

26. Splenic vein/ artery thrombosis26

27. Splenic vein/ artery thrombosis27

28. Splenic vein/ artery thrombosis28

29. Perigastric varices – up to 30%
Long-term Outcome
Perigastric varices – up to 30% 29

30. Discussion Estimated blood loss higher for:
SPDP (Ma JP, Chinese Med J, 2011)
DPS (Shoup M, Arch Surg, 2002)
No difference (Nau P, Gastroenterology Research and Practice, 2009; Lee SE, J Korean Med Sci, 2008; Tezuka K, Dig Surg, 2012; Tsiouris A, HPB, 2011; Kimura W, J Hepatobiliary Pancreat Sci, 2010; Choi SH, Surg Endosc, 2012)
Overall complications rate higher for:
DPS (Carrere N, World J Surg, 2006; Choi SH, Surg Endosc, 2012)
No difference (Nau P, Gastroenterology Research and Practice, 2009; Lee SE, J Korean Med Sci, 2008; Tezuka K, Dig Surg, 2012; Tsiouris A, HPB, 2011; Kimura W, J Hepatobiliary Pancreat Sci, 2010)
Infectious complications higher for
DPS (Shoup M, Arch Surg, 2002; Benoist S, JACS, 1999; Choi SH, Surg Endosc, 2012)
Diabetes rate is lower for
SPDP (Fernandez-Cruz L, HPB, 2005; Govil S, Br J Surg, 1999)
no differences (Carrere N, World J Surg, 2006; Lee SE, J Korean Med Sci, 2008; Kimura W, J Hepatobiliary Pancreat Sci, 2010) T
IVC Mp
SMV PV
SMV
SMA CT
SMA

31. T
IVC Mp
SMV PV
SMV
SMA CT
SMA

32. T
IVC Mp
SMV PV
SMV
SMA CT
SMA

33. Discussion Ma JP, Chinese Med J, 2011 MpT
Ma JP, Chinese Med J, 2011
IVC Mp
Lee SE, J Korean Med Sci, 2008
SMV PV
SMV
SMA CT
Tsiouris A, HPB, 2011
SMA
Kimura W, J Hepatobiliary Pancreat Sci, 2010

34. Fundeni Clinical Institute Experience
Indications
Postoperative morbidity - infectious
Long-term results

35. Fundeni Clinical Institute
Patients & Methods
Fundeni Clinical Institute
2000 – 2015
41 patients with SPDP

36. Results Median age: 41 years (18 – 76) Sex ratio F/M = 2.4/1 (29/12)
Median BMI: 25 kg/m2 (19 – 42)
Symptoms:
Present – 37 pts (90%)
Epigastric pain – 27 pts
Hypoglycemia – 9 pts
Absent – 4 pts

37. Results Pancreas texture: soft – 35 pts (85%) Median operative time:
150 min (70 – 330)

38. Results
Blood loss:
Median intraoperative blood loss: 150 ml (50 – 300 ml)
1 pts with intraoperative transfusions
Postoperative transfusions – 6 pts (14%)

39. Results Morbidity – 14 pts (34%) Mortality – 0 pts
POPF – 13 pts (32%):
Grade A – 6 pts
Grade B – 5 pts
Grade C – 2 pts
Postoperative hemorrhage – 5 pts (12%)
Delayed gastric empting – 5 pts (12%)

40. Results Re-laparotomy for complications – 5 pts (12%):
POPF grade C – 2 pts (2 pts with POH)
PO Hemorrhage alone – 2 pts
Abdominal abscess – 1 pt
Cave: 1 pt – splenectomy

41. Results Median tumor diameter: 3.5 cm (0.4 – 14) Pathology:
Benign/ low-grade malignant – 37 pts
Malignant – 4 pts

42. Results Serous cystadenoma – 6 pts Mucinous cystadenoma – 3 pts
NET G1/ G2 – 15 pts
Non-functional: 5 pts
Insulinoma: 9 pts
Gastrinoma: 1 pt
Solid pseudopapillary tumor – 6 pt
Focal chronic pancreatitis – 5 pt
Malignant – 3 pt
Metastases of other neoplasia – 1 pts

43. Results Median follow-up: 65 months (1 – 177)
Functional results (34 pts):
Diabetes mellitus – 6 pts (17%)
Exocrine pancreatic insufficiency – 2 pts (6%)

44. T
IVC Mp
SMV PV
SMV
SMA CT
SMA
Dumitrascu, Dig Surg, 2012

45. T
IVC Mp
SMV PV
SMV
SMA CT
SMA

46. Dumitrascu, J Hepatobiliary Pancreat Sci, 2014
IVC Mp
SMV PV
SMV
SMA CT
SMA
Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

47. Dumitrascu, J Hepatobiliary Pancreat Sci, 2014
IVC Mp
SMV PV
SMV
SMA CT
SMA
Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

48. Dumitrascu, J Hepatobiliary Pancreat Sci, 2014
IVC Mp
SMV PV
SMV
SMA CT
SMA
Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

49. Dumitrascu, J Hepatobiliary Pancreat Sci, 2014
IVC Mp
SMV PV
SMV
SMA CT
SMA
Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

50. Dumitrascu, J Hepatobiliary Pancreat Sci, 2014
IVC Mp
SMV PV
SMV
SMA CT
SMA
Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

51. Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

52. T
IVC Mp
SMV PV
SMV
SMA CT
SMA

53. Take Home Messages
SPDP can be safely performed with low rates of severe morbidity
Preservation of the spleen should be the first option during distal pancreatectomy for benign and low-grade malignant tumors of the distal pancreas. T
IVC Mp
SMV
SMV
SMA CT
SMA

54. T
IVC Mp
SMV
SMV
SMA CT
SMA
Vă multumesc !