Vessels-Sparing Spleen-Preserving Distal Pancreatectomy.
Discussion of Management of a Benign Pancreatic Cyst
Mallikarjuna Uppara1*, Adam Esa1, Ashraf Rasheed1, Mark Robinson2, Majid Rashid3, Amir Kambal4
1Gwent Centre for Digestive Diseases, Division of Upper GI Surgery, Royal Gwent Hospital, Newport, UK
2Department of Radiology, Royal Gwent Hospital , Newport , UK
3Department of Pathology, Royal Gwent Hospital, Newport, Wales, UK
4Morriston Hospital, Swansea, UK
Mallikarjuna Uppara, Gwent Centre for Digestive Diseases, Division of Upper GI Surgery, Royal Gwent Hospital, Newport,
Wales, UK, E-mail:
Received: August 13, 2015; Accepted: November 30, 2015; Published: December 09, 2015
Citation: Uppara M, Esa A, Rasheed A, Robinson M, Rashid M, et al. (2015) Vessels-Sparing Spleen-Preserving Distal Pancreatectomy.
Discussion of Management of a Benign Pancreatic Cyst. SOJ Surgery 2(2): 1-4.
Context: The septic and haematological consequences of
splenectomy lead to the development of spleen-preserving
techniques during distal pancreatectomy.
Case Report: We report a case of a middle age woman
who underwent spleen-preserving distal pancreatectomy for a
symptomatic pancreatic cystic lesion. The diagnostic and therapeutic
challenges faced when caring for such patients are discussed. The
indications for SPDP are visited, different techniques for spleenpreserving
pancreatectomy are examined and the rationale behind
the chosen technique is explained.
Conclusion: Vessels-Sparing, Spleen-preserving distal
pancreatectomy is an optimum choice for benign Pancreatic Cystic
Keywords: Distal pancreatectomy; SPDP; PCL (Pancreatic Cystic
Spleen was thought to play no significant role in adult life and
was routinely removed during distal pancreatectomy (1). The
transient increase in T-suppressor cells following splenectomy
blunts the cellular response to antigens, the decreased IgM
production diminishes the anti-body response to antigens not
previously encountered, the decrease in properdin and tuftsin
levels impairs opsonisation and phagocytosis and increase the
risk of overwhelming infection from encapsulated organisms
following splenectomy (1,2). This lead to dispelling of the concept
of splenectomy as an innocuous procedure and the development
of Spleen Preserving Distal Pancreatectomy (SPDP).
We discuss the decision-making process in the case of a
middle age women who underwent SPDP examining the evidence
supporting these decisions.
A 50 year old female was referred with two months history
of severe un-remitting epigastric and back pain. The pain was alleviated but not relieved by opioids. An abdominal UltraSound
Study (USS) organised by the referring practitioner revealed a
left upper quadrant cystic mass.
Computed Tomography (CT) (Figure 1) confirmed it to be
of pancreatic origin measuring 44 mm in diameter. There were
no known risks for, or previous attacks of pancreatitis and all
haematological, biochemical, and tumour markers were within
The case was reviewed at the specialist Multi-Disciplinary
Meeting (MDM) and based on morphology, age and gender, a
provisional diagnosis of benign or low grade malignant cyst
was entertained. Resection was recommended, and spleenpreserving,
pancreatectomy (SPDP) sparing the spleenic artery
and vein was carried out (Figures 2).
The procedure lasted just over two hours and a 200 ml blood
loss was recorded. The patient had un-eventful recovery and was
discharged home on the fifth post postoperative day. Histological
examination of pancreatectomy specimen was confirmed to be a
pseudocyst (Figure 3).
At 4 weeks review, she had made a full recovery and was
back to normal activity. CT images at 1 and 6 months following
SPDP were compared with preoperative images to evaluate
postoperative changes in vascular patency and to determine
whether the analysed vessel was a native or collaterals that
developed after surgery following the possible occlusion of the
original spleenic artery or vein. The scans confirmed a normal
size spleen, patent spleenic vessels and without collateralisation
(Figure 3). The patient remained symptoms-free at 9 months and
was discharged from surgical follow
Pseudocysts are the most common pancreatic cystic lesions.
These benign cysts may appear similar to cystic neoplasms
and would need to be evaluated by CT, MRI +/- Endo-luminal
Figure 1: Computed Tomography (CT) of a solitary cystic lesion in the
tail of the pancreas. Pancreatic pseudocyst. Axial contrast-enhanced
CT images showing a well defined, encapsulated cystic lesion arising
from the pancreas.
Figure 2: Operative Photograph showing the preserved spleen and
the spared splenic vessels.
Figure 3: H & E stain illustrating benign cyst wall with organising
haemorrhage and no evidence of lining epithelium (Pseudocyst).
The Pre-Operative Evaluation of Pancreatic Cystic
Cross sectional imaging is limited in its ability to differentiate
benign from malignant pancreatic cystic lesions. Papillary
projections and peripheral calcification favours malignancy and avid contrast enhancement of the wall or any solid component
may point towards cystic endocrine malignancy. MRI is reliable
at evaluating the cyst's relationship to the pancreatic-biliary
tree and the improved spatial resolution of EUS and its Fine
Needle Aspiration (FNA) abilities increased its use especially for
small cysts ( < 2 cm in diameter). EUS is particularly helpful at
differentiating the internal architecture of the cyst and delineating
its relationship to the spleenic vessels. All image findings should
be integrated with demographics and clinical presentation when
planning the management strategies for these lesions (3).
Management of Pancreatic Cystic Lesions
Non-symptomatic, thin-walled, uni-locular cysts, less than 3
cm in size are commonly benign and a monitoring strategy can
be applied safely with 6 monthly imaging for the 1st year followed
by annual imaging for a period of 3 years then every 3 years in
patients < 70 years of age. If cyst stability is established and the
patient continues to be symptoms-free, no further evaluation
may be needed (3,4). We are proposing a flow chart (figure 4),
which reflects our experience and including our interpretation
of current knowledge in management of PCL but this should be
applied in the context of a specialist pancreatic MDM's (5).
Surgical resection is, however often indicated for symptomatic
and potentially malignant lesions provided the surgical risks
are acceptable for the individual patients. Pre-operative EUSguided
cyst aspiration for diagnostic and therapeutic purposes
was considered in this case. The severe symptoms, lesion's
resectability, and absence of extra pancreatic disease in this fit
lady, lead to the MDM's recommendation of pancreatic resection
without any further testing. This was perceived to be most
effective at relieving suffering and reaching a definitive diagnosis.
Pancreatic Resection- The Options
Distal pancreatic resection can be performed with or without
splenectomy and with or without vessels sparing (6,7). The
clinical features, preoperative imaging and normal tumour
markers in this case suggested the benign nature of the lesion
and hence the decision to preserve the spleen (8). This decision
starts pre-operatively but completed intra-operatively based on
the anatomic relationship of the tail of the pancreas to the splenic
hilum, the presence or absence of inflammatory adhesions around
the tail of the pancreas or splenic hilum, splenic vein involvement
and the extent of resection necessary as determined by the
underlying pathology (4,9) and the intra-operative findings.
Techniques for Spleen-Preserving Distal Pancreatectomy
There are two main variations in techniques of SPDP, with
or without preservation of splenic artery and vein. In Warshaw's
pioneering method, the splenic vessels are ligated at the splenic
hilum and spleen becomes dependent on the short gastric vessels
(10). This method is technically less demanding and can be
accomplished in a shorter operating time and is the preferred
technique when the splenic artery and vein are inflamed, fibrosed,
thrombosed or involved in the pathological process (9,10). The
disadvantages of this method is the association with a higher
Figure 4: Flow chart.
incidence of spleen vascular insufficiency, such as splenic infarct
or necrosis, and of gastric varices and gastrointestinal bleeding
possibly due to an increase of venous pressure in the area of the
left gastroepiploic and short gastric veins (8,11).
The other technique is the spleen-preserving, vessels-sparing
one (our preferred technique) is more demanding and requires
meticulous dissection of the pancreas from the splenic vessels.
In this technique, a narrow plane (wide enough to accommodate
the stapler) is carefully developed between the splenic vein,
superior mesenteric vein and the pancreas. The pancreas is then
transacted with endopath stapler Echelon 60 (Ethicon Endosurgery;
Johnson & Johnson, Cincinnati, OH, USA) close to but
not compromising the first branch of the splenic artery supplying
the tip of the pancreas on the remnant side, if the transaction of the pancreas is performed far from this branch, the remnant's tip
may become ischemic and lead to pancreatic leak. The cartridge
(staple size) is selected according to the thickness and texture of
the pancreas (mostly with vascular staples). Additional sutures
of 5/0 or 4/0 Prolene is applied as required.
The difficulty in discriminating the distal end of the pancreas
from the splenic hilum fat and branching of the splenic vessels
as they approach the hilum of the spleen make antegrade
pancreatectomy a safer procedure. This is completed by freeing
of the pancreatic body from the splenic vein starting at the point
of pancreatic transaction and progressing towards the spleen
(figure 5). The multiple short vessels connecting the body and tail
of the pancreas to the splenic artery and splenic vein are serially
isolated, Liga-clipped, oversewn with 5/0 Prolene or divided with an ultrasonic shears.
Both techniques of SPDP are achievable laparoscopically (9).
However, the degree of encountered retroperitoneal fibrosis
makes our selected conventional (open) surgical approach via
an upper midline incision with the added benefit of less trauma
or luminal compromise to the splenic vein the more appropriate
approach for this case. It is however important to remember that
while the open technique may give more space to operate and
immediate access to the surgical field, the laparoscopic optics
magnifies the field making it easier to see and secure the small
Possible Limitations of SPDP
Spleen serves as the junction between the mesenteric venous
circulation and the oesophagogastric venous plexus. Most of
the studies focused on the short-term outcomes of SPDP with
little information on the long-term consequences of splenic
vessels ligation. When splenic blood is unable to drain through
the splenic vein, it flows through the short gastric vessels in a
retrograde fashion into the sub-mucosal plexus in the gastric
fundus and cardia to drain into the coronary vein. Short term
follow up suggests adequacy of the supply by the short gastric
and the gastroepiploic arteries; however gastric and perigastric
varices were noted on subsequent imaging. In their study during
52 weeks observation, Miura et al concluded that gastric varices
located in short gastric veins frequently occurred in patients
who underwent SPDP with excision of the splenic vessels
leads to a localized venous hypertension called sinistral portal
hypertension. The cause of this condition was considered to be
the increase of blood flow of gastric veins, but the reason for
the increasing gastric venous blood flow despite the absence of
splenic arteries is unclear (11).
A single-centre retrospective study evaluated the short and
long term patency of preserved splenic vessels after laparoscopic
SPDP. A study which included 22 patients confirmed the short
term benefit of good perfusion to the spleen. Long term follow up
however revealed a risk for left-sided portal hypertension if the
splenic vein becomes occluded (12).
Figure 5: Ante grade pancreatectomy in SPDP (Spleen preserving distal
Further follow-up and additional investigations with larger
patient populations will be needed before definitive conclusions
can be drawn. In any event, we think that the splenic artery and
vein should be preserved as far as possible when performing
Our case report discussed the practical aspect of the procedure
without scrutinising the science supporting the practice. The
evidence seems to be limited to case series supporting the
feasibility and short term safety of SPDP. The procedure seems
to have entered the practice without standardisation or being
the subject of a trial to evaluate and provide the evidence to this
change. We caution against change in the practice based on logic
and without any robust scientific support. We would recommend
and despite the challenges due to the complexity and limited
indications to attempt RCT or as a bare minimum maintain all
such cases in a national robust database.
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