Spare the Splenic Vessels in Pancreatectomy

PALM BEACH, FLA. – When anatomy and pathology permit, patients reap the greatest benefits from a distal pancreatectomy that spares both the spleen and the splenic vessels.

Blood loss, fistula formation, length of hospital stay, and splenic infarct were all significantly lower in the spleen-sparing, vessel-sparing procedure than in a vessel-ligation procedure, Dr. Henry Pitt said at the annual meeting of the Southern Surgical Association.

"Splenic preservation with vessel ligation really offers no advantages over distal pancreatectomy with splenectomy, so vessel preservation is the preferred procedure for splenic-sparing distal pancreatectomy," said Dr. Pitt, a professor of surgery at Indiana University, Indianapolis.

Dr. Pitt presented a retrospective analysis of 86 spleen-sparing distal pancreatectomies, 45 with ligation and 41 with a vessel-sparing procedure. These were prospectively matched with another 86 patients who had distal pancreatectomy with splenectomy.

There were no significant differences in the patients' baseline characteristics. The average age was 55 years, with an average American Society of Anesthesiologists score of 3. "Pathology was also matched," Dr. Pitt said. The most common diagnosis was intraductal papular mucinous neoplasm, followed by cystic tumors. Other tumors included neuroendocrine and adenocarcinomas. None of the patients had invasive tumors.

Coauthor Dr. Attila Nakeeb described the process by which surgeons decide which path to pursue. Although the preoperative aim may be vessel sparing, "the ability to preserve the spleen is clearly a matter of anatomy and pathology," he said. "The ideal patient is one with a benign neoplasm, and any kind of inflammation is a major problem. The assessment usually depends on several factors, including the preoperative pathology."

The branching of the splenic vessels into the hilum is also important. "If you have a long pancreas with the hilum way up into the spleen and the vessels branching early, it’s much more difficult to do either of the techniques. Most of these patients get a splenectomy. In patients with inflammation, we don’t even make an attempt to preserve the vessels," said Dr. Nakeeb, a professor of surgery at Indiana University.

Intraoperative ultrasound is used in every case to identify the vasculature and trace the branching patterns, especially in patients with excess peripancreatic fat.

"If we make the preoperative decision to preserve the spleen, we also first attempt to preserve the vessels," Dr. Nakeeb said. "If we are unsuccessful in that, we convert to a ligation; if that does not go well, we convert to a splenectomy."

For the vessel-sparing, vessel-ligating, and splenectomy groups, there was no significant difference in operative time. The average time for the spleen-preserving procedures was 3.5 hours; for splenectomy, it was 4 hours.

Blood loss was significantly different. The average loss in the vessel-preserving group was 200 mL; in the ligation group, 500 mL; and in the splenectomy group, 600 mL.

In the spleen-preserving groups, splenic infarcts occurred in 2% (1) of the vessel-preservation group and in 39% (16) of the ligation group.

Pancreatic fistulas occurred in 2% (1) of the vessel-preservation group, 12% (5) of the vessel-ligation group, and 13% (11) of the splenectomy group. One patient in the vessel-preservation group required abscess drainage, compared with 15% of the vessel-ligation group and 16% of the splenectomy group – a significant difference.

The overall postoperative morbidity was 18% in the vessel-preservation group, 39% in the vessel-ligation group, and 38% in the splenectomy group, significantly favoring vessel preservation. The hospital length of stay was also significantly in favor of the vessel-preservation group – 4.5 days – compared with 6 days in the vessel-ligation group and 7 in the splenectomy group.

"Since the vessel-ligation outcomes were so similar to the outcomes in the splenectomy group, there is no real advantage over a distal pancreatectomy with splenectomy," Dr. Pitt said. "Vessel preservation was associated with less blood loss, a lower risk of requiring drainage, lower overall morbidity, shorter length of stay, and fewer infarcts."

Dr. Pitt attributed most of the research in the study to his colleague Dr. Joal Beane, an intern. "He really did all the work," Dr. Pitt said.

Dr. Pitt and Dr. Nakeeb reported no financial conflicts.

PALM BEACH, FLA. – When anatomy and pathology permit, patients reap the greatest benefits from a distal pancreatectomy that spares both the spleen and the splenic vessels.

Blood loss, fistula formation, length of hospital stay, and splenic infarct were all significantly lower in the spleen-sparing, vessel-sparing procedure than in a vessel-ligation procedure, Dr. Henry Pitt said at the annual meeting of the Southern Surgical Association.

"Splenic preservation with vessel ligation really offers no advantages over distal pancreatectomy with splenectomy, so vessel preservation is the preferred procedure for splenic-sparing distal pancreatectomy," said Dr. Pitt, a professor of surgery at Indiana University, Indianapolis.

Dr. Pitt presented a retrospective analysis of 86 spleen-sparing distal pancreatectomies, 45 with ligation and 41 with a vessel-sparing procedure. These were prospectively matched with another 86 patients who had distal pancreatectomy with splenectomy.

There were no significant differences in the patients' baseline characteristics. The average age was 55 years, with an average American Society of Anesthesiologists score of 3. "Pathology was also matched," Dr. Pitt said. The most common diagnosis was intraductal papular mucinous neoplasm, followed by cystic tumors. Other tumors included neuroendocrine and adenocarcinomas. None of the patients had invasive tumors.

Coauthor Dr. Attila Nakeeb described the process by which surgeons decide which path to pursue. Although the preoperative aim may be vessel sparing, "the ability to preserve the spleen is clearly a matter of anatomy and pathology," he said. "The ideal patient is one with a benign neoplasm, and any kind of inflammation is a major problem. The assessment usually depends on several factors, including the preoperative pathology."

The branching of the splenic vessels into the hilum is also important. "If you have a long pancreas with the hilum way up into the spleen and the vessels branching early, it’s much more difficult to do either of the techniques. Most of these patients get a splenectomy. In patients with inflammation, we don’t even make an attempt to preserve the vessels," said Dr. Nakeeb, a professor of surgery at Indiana University.

Intraoperative ultrasound is used in every case to identify the vasculature and trace the branching patterns, especially in patients with excess peripancreatic fat.

"If we make the preoperative decision to preserve the spleen, we also first attempt to preserve the vessels," Dr. Nakeeb said. "If we are unsuccessful in that, we convert to a ligation; if that does not go well, we convert to a splenectomy."

For the vessel-sparing, vessel-ligating, and splenectomy groups, there was no significant difference in operative time. The average time for the spleen-preserving procedures was 3.5 hours; for splenectomy, it was 4 hours.

Blood loss was significantly different. The average loss in the vessel-preserving group was 200 mL; in the ligation group, 500 mL; and in the splenectomy group, 600 mL.

In the spleen-preserving groups, splenic infarcts occurred in 2% (1) of the vessel-preservation group and in 39% (16) of the ligation group.

Pancreatic fistulas occurred in 2% (1) of the vessel-preservation group, 12% (5) of the vessel-ligation group, and 13% (11) of the splenectomy group. One patient in the vessel-preservation group required abscess drainage, compared with 15% of the vessel-ligation group and 16% of the splenectomy group – a significant difference.

The overall postoperative morbidity was 18% in the vessel-preservation group, 39% in the vessel-ligation group, and 38% in the splenectomy group, significantly favoring vessel preservation. The hospital length of stay was also significantly in favor of the vessel-preservation group – 4.5 days – compared with 6 days in the vessel-ligation group and 7 in the splenectomy group.

"Since the vessel-ligation outcomes were so similar to the outcomes in the splenectomy group, there is no real advantage over a distal pancreatectomy with splenectomy," Dr. Pitt said. "Vessel preservation was associated with less blood loss, a lower risk of requiring drainage, lower overall morbidity, shorter length of stay, and fewer infarcts."

Dr. Pitt attributed most of the research in the study to his colleague Dr. Joal Beane, an intern. "He really did all the work," Dr. Pitt said.

Dr. Pitt and Dr. Nakeeb reported no financial conflicts.

PALM BEACH, FLA. – When anatomy and pathology permit, patients reap the greatest benefits from a distal pancreatectomy that spares both the spleen and the splenic vessels.

Blood loss, fistula formation, length of hospital stay, and splenic infarct were all significantly lower in the spleen-sparing, vessel-sparing procedure than in a vessel-ligation procedure, Dr. Henry Pitt said at the annual meeting of the Southern Surgical Association.

"Splenic preservation with vessel ligation really offers no advantages over distal pancreatectomy with splenectomy, so vessel preservation is the preferred procedure for splenic-sparing distal pancreatectomy," said Dr. Pitt, a professor of surgery at Indiana University, Indianapolis.

Dr. Pitt presented a retrospective analysis of 86 spleen-sparing distal pancreatectomies, 45 with ligation and 41 with a vessel-sparing procedure. These were prospectively matched with another 86 patients who had distal pancreatectomy with splenectomy.

There were no significant differences in the patients' baseline characteristics. The average age was 55 years, with an average American Society of Anesthesiologists score of 3. "Pathology was also matched," Dr. Pitt said. The most common diagnosis was intraductal papular mucinous neoplasm, followed by cystic tumors. Other tumors included neuroendocrine and adenocarcinomas. None of the patients had invasive tumors.

Coauthor Dr. Attila Nakeeb described the process by which surgeons decide which path to pursue. Although the preoperative aim may be vessel sparing, "the ability to preserve the spleen is clearly a matter of anatomy and pathology," he said. "The ideal patient is one with a benign neoplasm, and any kind of inflammation is a major problem. The assessment usually depends on several factors, including the preoperative pathology."

The branching of the splenic vessels into the hilum is also important. "If you have a long pancreas with the hilum way up into the spleen and the vessels branching early, it’s much more difficult to do either of the techniques. Most of these patients get a splenectomy. In patients with inflammation, we don’t even make an attempt to preserve the vessels," said Dr. Nakeeb, a professor of surgery at Indiana University.

Intraoperative ultrasound is used in every case to identify the vasculature and trace the branching patterns, especially in patients with excess peripancreatic fat.

"If we make the preoperative decision to preserve the spleen, we also first attempt to preserve the vessels," Dr. Nakeeb said. "If we are unsuccessful in that, we convert to a ligation; if that does not go well, we convert to a splenectomy."

For the vessel-sparing, vessel-ligating, and splenectomy groups, there was no significant difference in operative time. The average time for the spleen-preserving procedures was 3.5 hours; for splenectomy, it was 4 hours.

Blood loss was significantly different. The average loss in the vessel-preserving group was 200 mL; in the ligation group, 500 mL; and in the splenectomy group, 600 mL.

In the spleen-preserving groups, splenic infarcts occurred in 2% (1) of the vessel-preservation group and in 39% (16) of the ligation group.

Pancreatic fistulas occurred in 2% (1) of the vessel-preservation group, 12% (5) of the vessel-ligation group, and 13% (11) of the splenectomy group. One patient in the vessel-preservation group required abscess drainage, compared with 15% of the vessel-ligation group and 16% of the splenectomy group – a significant difference.

The overall postoperative morbidity was 18% in the vessel-preservation group, 39% in the vessel-ligation group, and 38% in the splenectomy group, significantly favoring vessel preservation. The hospital length of stay was also significantly in favor of the vessel-preservation group – 4.5 days – compared with 6 days in the vessel-ligation group and 7 in the splenectomy group.

"Since the vessel-ligation outcomes were so similar to the outcomes in the splenectomy group, there is no real advantage over a distal pancreatectomy with splenectomy," Dr. Pitt said. "Vessel preservation was associated with less blood loss, a lower risk of requiring drainage, lower overall morbidity, shorter length of stay, and fewer infarcts."

Dr. Pitt attributed most of the research in the study to his colleague Dr. Joal Beane, an intern. "He really did all the work," Dr. Pitt said.

Dr. Pitt and Dr. Nakeeb reported no financial conflicts.