Spleen-preserving distal pancreatectomy from multi-port to reducedport surgery approach

BACKGROUND Minimally invasive pancreatic surgery via the multi-port approach has become a primary surgical method for distal pancreatectomy(DP)due to its advantages of lower wound pain and superior cosmetic results.Some studies have applied reduced-port techniques for DP in an attempt to enhance cosmetic outcomes due to the minimally invasive effects.Numerous recent review studies have compared multi-port laparoscopic DP(LDP)and multi-port robotic DP(RDP);most of these studies concluded multi-port RDP is more beneficial than multi-port LDP for spleen preservation.However,there have been no comprehensive reviews of the value of reduced-port LDP and reduced-port RDP.AIM To search for and review the studies on spleen preservation and the clinical outcomes of minimally invasive DP that compared reduced-port DP surgery with multi-port DP surgery.METHODS The PubMed medical database was searched for articles published between 2013 and 2022.The search terms were implemented using the following Boolean search algorithm:(“distal pancreatectomy”OR“left pancreatectomy”OR“peripheral pancreatic resection”)AND(“reduced-port”OR“single-site”OR“single-port”OR“dual-incision”OR“single-incision”)AND(“spleen-preserving”OR“spleen preservation”OR“splenic preservation”).A literature review was conducted to identify studies that compared the perioperative outcomes of reduced-port LDP and reduced-port RDP.RESULTS Fifteen articles published in the period from 2013 to 2022 were retrieved using three groups of search terms.Two studies were added after manually searching the related papers.Finally,10 papers were selected after removing case reports(n=3),non-English language papers(n=1),technique papers(n=1),reviews(n=1),and animal studies(n=1).The common items were defined as items reported in more than five papers,and data on these common items were extracted from all papers.The ten studies included a total of 337 patients(females/males:231/106)who underwent DP.In total,166 patients(females/males,106/60)received multi-port LDP,126(females/males,90/36)received reduced-port LDP,and 45(females/males,35/10)received reduced-port RDP.CONCLUSION Reduced-port RDP leads to a lower intraoperative blood loss,a lower postoperative pancreatic fistula rate,and shorter hospital stay and follow-up duration,but has a lower spleen preservation rate.

Minimally invasive spleen-preserving distal pancreatectomy: Does splenic vessel preservation have better postoperative outcomes? A systematic review and meta-analysis

BACKGROUND： Minimally invasive spleen-preserving distal pancreatectomy （SPDP） can be performed with either splenic vessel preservation （SVP） or resection [Warshaw procedure （WP）]. The aim of this study was to evaluate the postoperative clinical outcomes of patients undergoing both methods. DATA SOURCES： Database search of PubMed, Embase, Scopus, Cochrane, and Google Scholar was performed （2000-2014）; key bibliographies were reviewed. Qualified studies compar- ing patients undergoing SPDP with either SVP or WP, and as- sessing postoperative complications were included. Calculated pooled risk ratio （RR） with the corresponding 95% confidence interval （CI） by random effects methods were used in the meta-analyses. RESULTS： The search yielded 215 studies, of which only 14 observational studies met our selection criteria. The studies included 943 patients in total; 652 （69%） underwent SVP and 291 （31%） underwent WP. Overall, there was a lower incidence of splenic infarction （RR=0.17; 95% Ch 0.09-0.33; P〈0.001）, gastric varices （RR=0.16; 95% Ch 0.05-0.51; P=0.002）, and intra/postoperative splenectomy （RR=0.20; 95% Ch 0.08-0.49; P〈0.001） in the SVP group. There was no difference in in- cidence of pancreatic fistula （WP vs SVP, 23.6% vs 22.9%;P=0.37）, length of hospital stay, operative time or blood loss. There was moderate cross-study heterogeneity. CONCLUSIONS： SVP is a safe, efficient and feasible technique that may be used to preserve the spleen. WP may be more suit- able for large tumors dose to the splenic hilum or those associ- ated with splenomegaly. Randomized clinical trials are justified to examine the long-term benefits of SVP-SPDP.

Laparoscopic spleen-preserving distal pancreatectomy for pancreatic neoplasms:A retrospective study

AIM:To describe the clinical characteristics,technical procedures,and outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy(LSPDP)for benign and malignant pancreatic neoplasms.METHODS:The clinical data of 38 patients who underwent LSPDP in the Sir Run Run Shaw Hospital between January 2003 and August 2013 were analyzed retrospectively.Surgical techniques for LSPDP included preservation of the splenic artery and vein(Kimura’s technique)and ligation of the splenic pedicle with preservation of the short gastric vessels(Warshaw’s technique).RESULTS:There were no conversions to open surgery in the 38 patients.Splenic vessels were conserved during spleen-preserving pancreatectomy,except in two patients who underwent resection of the splenic vessels and preservation only of the short gastric vessels.The mean operation time was 123.2±52.4 min,the mean intraoperative blood loss was 78.2±39.5 mL,and the mean postoperative hospital stay was 7.6±2.9 d.The overall rate of postoperative complications was 18.4%(7/38),and the rate of clinical pancreatic fistula was13.2%(5/38).All postoperative complications were treated conservatively.The postoperative pathological diagnoses were 22 cases of benign pancreatic disease and 16 cases of borderline or low-grade malignant lesions.During a median follow-up of 38 mo(range:5-133mo),no recurrence was observed.CONCLUSION:LSPDP is a safe,feasible and effective procedure for the treatment of benign and low-grade malignant tumors of the distal pancreas.

Successful treatment of a pancreatic schwannoma by spleen-preserving distal pancreatectomy

Schwannomas are neurogenic tumors that arise from the neural sheaths of peripheral nerves.These tumors can be located in any area of the human body;the most common locations are the head,neck,trunk and extremities.Pancreatic schwannomas are very rare.Over the past 40 years,only 67 cases of pancreatic schwannomas have been reported in the English literature.Here we present a case of pancreatic schwannoma in a 62-year-old male.The tumor was revealed by ultrasound and computed tomography in the neck and body of the pancreas.An accurate diagnosis was difficult to obtain preoperatively.The patient consented to the performance of a laparotomy,and the mass was found in the neck and body of the pancreas and successfully treated using a spleenpreserving distal pancreatectomy with splenic artery and vein preservation.The procedure has only been reported in one other case of pancreatic schwannoma;here we present the second reported case.Macroscopically,the tumor was well circumscribed,gray-white in color and3.3 cm×2.8 cm in size.Microscopically,the tumor cells were spindle-shaped and had a palisading arrangement with no atypia,which are results compatible with a benign tumor.Both hypercellular and hypocellular areas were visible.Immunohistochemically,the tumor cells were strongly positive for S-100 protein.The tumor was definitively diagnosed as a schwannoma of the pancreatic neck and body.The patient was followed for 72 mo and has been doing well without any complications.

Successful treatment of pancreatic accessory splenic hamartoma by laparoscopic spleen-preserving distal pancreatectomy:A case report

BACKGROUND Pancreatic accessory spleen(PAS)is an uncommon congenital abnormality of the spleen.Spleen hamartoma(SH)is also rare.Moreover,hamartoma in the PAS has not been reported thus far.We report the first case here.CASE SUMMARY A 26-year-old male presented with a one-month history of left upper quadrant abdominal pain,and computerized tomography(CT)examination suggested a mass in the pancreas tail.The patient then attended our hospital for diagnosis and treatment.Ultrasonography,CT,and magnetic resonance imaging revealed a solid mass with cystic degeneration growing from the tail of the pancreas.The tumor marker carbohydrate antigen 19-9(CA19-9)increased to 96.7 U/mL(normal range 0-37 U/mL).An epidermoid cyst in a PAS was considered preoperatively.However,a malignant tumor cannot be ruled out.We performed laparoscopic surgery,and two pancreatic masses were found growing from the pancreatic tail.The two masses were so closely connected that preoperative imaging examinations suggested only one mass.We carefully isolated the masses from the splenic artery and vein.A laparoscopic spleen-preserving distal pancreatectomy was successfully performed.On pathological examination,the masses were well-defined,homogeneous red-tan,4×3,and 4.5×1.5 in size,respectively.One of them was cystically degenerated.On microscopical examination,the mass contained unorganized small slit-like vascular channels enclosing red blood cells and lined with plump endothelial cells.No area of cytologic atypia was identified.Focal lymphoid aggregates were found in the intravascular areas.White pulp or fibrosis was not observed.The final diagnosis was pancreatic accessory SH with cystic degeneration.After the operation,CA19-9 was reduced to normal.The patient recovered well,and the 34-mo follow-up period was uneventful.CONCLUSION Here,we report the first case of pancreatic accessory SH.A laparoscopic spleen-preserving distal pancreatectomy was successfully performed.The patient recovered well and had a good prognosis.

Male gender and increased body mass index independently predicts clinically relevant morbidity after spleen-preserving distal pancreatectomy

AIM To identify risk factors for clinically relevant complications after spleen-preserving distal pancreatectomy(SPDP). No previous studies explored potential predictors of morbidity after SPDP.METHODS The data of 41 patients who underwent a SPDP in a single surgical center between 2000 and 2015 were retrospectively reviewed from a prospectively maintained electronic database established in our Department of Surgery. The database included demographic, clinical, bioumoral, pathological, intraoperative and postoperative parameters. Uni-and multivariate ana-lyses were performed to assess potential predictors of clinically relevant morbidity. Postoperative morbidity was defined as in-hospital complications and mortality was assessed at 90 d. Clinically relevant morbidity was defined as complication ≥ grade 2 Dindo.RESULTS Overall morbidity rate was 34.1%(14 patients): grade Ⅰ(6 patients, 14.6%), grade Ⅱ(2 patients, 4.8%), grade Ⅲa(1 patient, 2.4%), and grade Ⅲb(5 patients, 12.2%). A number of 5 patients(12.2%) required re-laparotomy for postoperative complications. There was no postoperative mortality. Thus, at least one clinically relevant complication occurred in 8 patients(19.5%). Univariate analysis identified male gender(P = 0.034), increased body mass index(P = 0.002) and neuroendocrine pathology(P = 0.013) as statistically significant risk factors. Multivariate analysis identified male gender [odds ratio(OR): 1.29, 95%CI: 1.07-1.55, P = 0.005] and increased body mass index(OR: 23.18, 95%CI: 1.72-310.96, P = 0.018) as the only independent risk factors of clinically relevant morbidity after SPDP.CONCLUSION Male gender and increased body mass index are independently associated with increased risk of clinically relevant morbidity after SPDP. These findings may assist a surgeon in clinical decision-making to better select patients suitable for SPDP.

Laparoscopic spleen-preserving total pancreatectomy for the treatment of low-grade malignant pancreatic tumors:Two case reports and review of literature

BACKGROUND Function-preserving pancreatectomy can improve the long-term quality of life of patients with benign or low-grade malignant tumors,such as intraductal papillary mucinous neoplasms(IPMNs)and mucinous cystic neoplasms.However,there is limited literature on laparoscopic spleen-preserving total pancreatectomy(LSpTP)due to technical difficulties.CASE SUMMARY Patient 1 was a 51-year-old male diagnosed with IPMN based on preoperative imaging,showing solid nodules in the pancreatic head and diffuse dilation of the main pancreatic duct with atrophy of the distal pancreas.We performed L-SpTP with preservation of the splenic vessels,and the postoperative pathology report revealed IPMN with invasive carcinoma.Patient 2 was a 60-year-old male with multiple cystic lesions in the pancreatic head and body.L-SpTP was performed,and intraoperatively,the splenic vein was injured and required ligation.Postoperative pathology revealed a mucinous cystic tumor of the pancreas with low-grade dysplasia.Both patients were discharged on postoperative day 7,and there were no major complications during the perioperative period.CONCLUSION We believe that L-SpTP is a safe and feasible treatment for low-grade malignant pancreatic tumors,but more case studies are needed to evaluate its safety,efficacy,and long-term outcomes.

Spleen-preserving distal pancreatectomy with conservation of the spleen vessels

Background Distal pancreatectomy traditionally included splenectomy; the spleen, however, is an important organ in the immunologic defense of the host and is worthy of preservation. The aim of this research was to study the feasibility,safety and clinical effects of spleen and splenic vessel-preserving distal pancreatectomy.Methods A retrospective review was performed for 26 patients undergoing distal pancreatectomy for benign or low grade malignant disease with splenectomy （n=13） or splenic preservation （n=13） at the First Hospital of Sun Yat-sen University and Guangdong General Hospital in Southern China from May 2002 to April 2009.Results All 26 pancreatectomies with splenectomy or splenic preservation were performed successfully. There was no statistically significant difference between two groups in mean operative time （（172±47） minutes vs. （157±52） minutes, P ＞0.05）, intraoperative estimated blood loss （（183±68） ml vs. （160±51） ml, P ＞0.05）, incidence of noninfectious and infection complication and mean length of postoperative hospital stay （（10.1±2.2） days vs. （12.1 ±4.6） days, P ＞0.05）. The platelet counts examined one week after operation were significantly higher in the distal pancreatectomy with splenectomy group than the other group （（37.3±12.8）×109/L vs. （54.7±13.2）×109/L, P ＜0.05）.Conclusions Spleen-preserving distal pancreatectomy appears to be a feasible and safe procedure. In selected cases of benign or low-grade malignant disease, spleen-preserving distal pancreatectomy is recommended.

Values of spleen-preserving distal pancreatectomy in well-differentiated non-functioning pancreatic neuroendocrine tumors:a comparative study

Background The feasibility of spleen-preserving distal pancreatectomy(SPDP)to treat well-differentiated non-functioning pancreatic neuroendocrine tumors(NF-pNETs)located at the body and/or tail of the pancreas remains controversial.Distal pancreatectomy with splenectomy(DPS)has been widely applied in the treatment of NF-pNETs;however,it may increase the post-operative morbidities.This study aimed to evaluate whether SPDP is inferior to DPS in post-operative outcomes and survivals when being used to treat patients with NF-pNETs in our institute.Methods Clinicopathological features of patients with NF-pNETs who underwent curative SPDP or DPS at the First Affiliated Hospital of Sun Yat-sen University(Guangzhou,China)between January 2010 and January 2022 were collected.Short-term outcomes and 5-year survivals were compared between patients undergoing SPDP and those undergoing DPS.Results Sixty-three patients(SPDP,27;DPS,36)with well-differentiated NF-pNETs were enrolled.All patients had grade 1/2 tumors.After identifying patients with T1–T2 NF-pNETs(SPDP,27;DPS,15),there was no disparity between the SPDP and DPS groups except for tumor size(median,1.4 vs 2.6 cm,P=0.001).There were no differences in operation time(median,250 vs 295 min,P=0.478),intraoperative blood loss(median,50 vs 100 mL,P=0.145),post-operative major complications(3.7%vs 13.3%,P=0.287),clinically relevant post-operative pancreatic fistula(22.2%vs 6.7%,P=0.390),or post-operative hospital stays(median,9 vs 9 days,P=0.750)between the SPDP and DPS groups.Kaplan–Meier curve showed no significant differences in the 5-year overall survival rate(100%vs 100%,log-rank P>0.999)or recurrence-free survival(100%vs 100%,log-rank P>0.999)between patients with T1–T2 NF-pNETs undergoing SPDP and those undergoing DPS.Conclusions In patients with T1–T2 well-differentiated NF-pNETs,SPDP could achieve comparable post-operative outcomes and prognosis compared with DPS.

Robotic versus laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: A propensity score-matched analysis

Background: Minimally invasive surgery is becoming increasingly popular in the field of pancreatic surgery. However, there are few studies of robotic distal pancreatectomy(RDP) for pancreatic ductal adenocarcinoma(PDAC). This study aimed to investigate the efficacy and feasibility of RDP for PDAC. Methods: Patients who underwent RDP or laparoscopic distal pancreatectomy(LDP) for PDAC between January 2015 and September 2020 were reviewed. Propensity score matching analyses were performed. Results: Of the 335 patients included in the study, 24 underwent RDP and 311 underwent LDP. A total of 21 RDP patients were matched 1:1 with LDP patients. RDP was associated with longer operative time(209.7 vs. 163.2 min;P = 0.003), lower open conversion rate(0% vs. 4.8%;P < 0.001), higher cost(15 722 vs. 12 699 dollars;P = 0.003), and a higher rate of achievement of an R0 resection margin(90.5% vs. 61.9%;P = 0.042). However, postoperative pancreatic fistula grade B or C showed no significant intergroup difference(9.5% vs. 9.5%). The median disease-free survival(34.5 vs. 17.3 months;P = 0.588) and overall survival(37.7 vs. 21.9 months;P = 0.171) were comparable between the groups. Conclusions: RDP is associated with longer operative time, a higher cost of surgery, and a higher likelihood of achieving R0 margins than LDP.

Laparoscopic distal pancreatectomy with or without splenectomy: spleen-preservation does not increase morbidity

BACKGROUND: The indications for laparoscopic spleen- preserving distal pancreatectomy (LSPDP) and its morbidity compared with laparoscopic distal pancreatectomy with splenectomy (LDPS) are ill-defined. This study aimed to share the indications for spleen-preservation and investigate the safety and outcome of LSPDP at our institution. METHODS: A retrospective review of patients who were scheduled to receive laparoscopic surgery for distal pancreatic lesions was conducted. The indications, surgical procedures, intra-operative data, and outcomes of the two procedures were collected and compared by statistical analysis. RESULTS: LDPS and LSPDP were successfully performed in 16 and 21 patients respectively, whereas they were converted to open surgery in 9 patients. There were no significant differences in age, gender, operation time, blood loss, and conversion rate between the LDPS and LSPDP groups. The mean tumor size showed an inter-group difference (5.05 vs 2.53 cm, P<0.001). There were no significant differences in complication and morbidity rates between the two groups. All patients remained alive without recurrence during a follow-up of 9 to 67 months (median 35).CONCLUSION: LSPDP has a morbidity and outcome comparable to LDPS.

Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy

Because distal pancreatectomy(DP)has no reconstructive steps and less frequent vascular involvement,it is thought to be the easier counterpart of pancreaticoduodenectomy.This procedure has a high surgical risk and the overall incidences of perioperative morbidity(mainly pancreatic fistula),and mortality are still high,in addition to the challenges that accompany delayed access to adjuvant therapies(if any)and prolonged impairment of daily activities.Moreover,surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes.From this perspective,new surgical approaches,and aggressive techniques,such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection,could lead to improved survival in those affected by more locally advanced tumors.Conversely,minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress.The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications,length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy.Because a dedicated multidisciplinary team is crucial to pancreatic surgery,hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign,borderline,and malignant diseases of the pancreas.The purpose of this review is to examine the state of the art in distal pancreatectomies,with a special focus on minimally invasive approaches and oncological-directed techniques.The widespread reproducibility,cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.

Optimizing prediction models for pancreatic fistula after pancreatectomy:Current status and future perspectives

Postoperative pancreatic fistula(POPF)is a frequent complication after pancre-atectomy,leading to increased morbidity and mortality.Optimizing prediction models for POPF has emerged as a critical focus in surgical research.Although over sixty models following pancreaticoduodenectomy,predominantly reliant on a variety of clinical,surgical,and radiological parameters,have been documented,their predictive accuracy remains suboptimal in external validation and across diverse populations.As models after distal pancreatectomy continue to be pro-gressively reported,their external validation is eagerly anticipated.Conversely,POPF prediction after central pancreatectomy is in its nascent stage,warranting urgent need for further development and validation.The potential of machine learning and big data analytics offers promising prospects for enhancing the accuracy of prediction models by incorporating an extensive array of variables and optimizing algorithm performance.Moreover,there is potential for the development of personalized prediction models based on patient-or pancreas-specific factors and postoperative serum or drain fluid biomarkers to improve accuracy in identifying individuals at risk of POPF.In the future,prospective multicenter studies and the integration of novel imaging technologies,such as artificial intelligence-based radiomics,may further refine predictive models.Addressing these issues is anticipated to revolutionize risk stratification,clinical decision-making,and postoperative management in patients undergoing pancre-atectomy.

Laparoscopic vs open distal pancreatectomy for solid pseudopapillary tumor of the pancreas

AIM:To compare short-and long-term outcomes of laparoscopic vs open distal pancreatectomy for solid pseudopapillary tumor(SPT)of the pancreas.METHODS:This retrospective study included 28 patients who underwent distal pancreatectomy for SPT of the pancreas between 1998 and 2012.The patients were divided into two groups based on the surgical approach:the laparoscopic surgery group and the open surgery group.The patients’demographic data,operative results,pathological reports,hospital courses,morbidity and mortality,and follow-up data were compared between the two groups.RESULTS:Fifteen patients with SPT of the pancreas underwent laparoscopic distal pancreatectomy(LDP),and 13 underwent open distal pancreatectomy(ODP).Baseline characteristics were similar between the two groups except for a female predominance in the LDP group(100.0%vs 69.2%,P=0.035).Mortality,morbidity(33.3%vs 38.5%,P=1.000),pancreatic fistula rates(26.7%vs 30.8%,P=0.728),and reoperation rates(0.0%vs 7.7%,P=0.464)were similar in the two groups.There were no significant differences in the operating time(171 min vs 178 min,P=0.755)between the two groups.The intraoperative blood loss(149 mL vs 580 mL,P=0.002),transfusion requirement(6.7%vs 46.2%,P=0.029),first flatus time(1.9d vs 3.5 d,P=0.000),diet start time(2.3 d vs 4.9 d,P=0.000),and postoperative hospital stay(8.1 d vs 12.8d,P=0.029)were significantly less in the LDP group than in the ODP group.All patients had negative surgical margins at final pathology.There were no significant differences in number of lymph nodes harvested(4.6 vs6.4,P=0.549)between the two groups.The median follow-up was 33(3-100)mo for the LDP group and 45(17-127)mo for the ODP group.All patients were alive with one recurrence.CONCLUSION:LDP for SPT has short-term benefits compared with ODP.Long-term outcomes of LDP are similar to those of ODP.

Perioperative management of distal pancreatectomy

Recent advances in surgical techniques and perioperative management have markedly reduced operative morbidity after distal pancreatectomy(DP).However,some questions remain regarding the protocol for the perioperative management of DP,in particular,with regard to the development of pancreatic fistula(PF).A review of DP was therefore conducted in order to standardize the management of patients for a favorable outcome.Overall,operative technique and perioperative management emerged as two critical factors contributing to favorable outcome in DP patients.As for the operative method,surgical and closure techniques exhibited differences in outcome.Laparoscopic DP generally yields more favorable perioperative outcomes compared to open DP,and is applicable for benign tumors and some ductal carcinomas of the pancreas.Robotic DP is also available for safe pancreatic surgery.En bloc celiac axis resection offers a high R0 resection rate and potentially allows for some local control in the case of advanced pancreatic cancer.Following resection,staple closure was not found to reduce the rate of PF when compared to hand-sewn closure.In addition,ultrasonic dissection devices,fibrin glue sealing,and staple closure with mesh reinforcement were shown to significantly reduce PF,although there was some bias in these studies.In perioperative management,both preoperative and postoperative treatment affected outcome.First,preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against fistula development following DP in selected patients.Second,in postoperative management,a multifactorial approach including prophylactic antibiotics improved high surgical site infection rates following complex hepato-pancreatobiliary surgery.Furthermore,although conflicting results have been reported,somatostatin analogues should be administered selectively to patients considered to have a high risk for PF.Finally,careful drain management also facilitates a favorable outcome in patients with PF after DP.The results of the review indicate that laparoscopic DP coupled with perioperative management influences outcome in DP patients.

Pancreatic Castleman disease treated with laparoscopic distal pancreatectomy

BACKGROUND: Castleman disease is an uncommon lympho-proliferative disorder most frequently occurring in the mediastinum. Abdominal forms are less frequent, with pancreatic localization of the disease in particular being extremely rare. Only seventeen cases have been described in the world literature. METHOD: This report describes an interesting and unusual case of pancreatic Castleman disease treated with laparoscopic resection. RESULTS: A 48-year-old woman presented with epigastric pain. CT scan showed a well-encapsulated mass on the ventral border of the pancreas. Endosonography with fine needle aspiration biopsy was performed. Biopsy showed lymphoid elements and structures of a normal lymph node. The patient was treated with laparoscopic distal pancreatectomy. The pancreas was transected with a Ligasure device and the pancreatic stump was secured with a manual suture. One year after surgery the patient was complaint-free and showed no signs of recurrence of the disease. CONCLUSIONS: Laparoscopic distal pancreatectomy is a feasible and safe method for the treatment of lesions in the body and tail of the pancreas. Transection of the pancreas with a Ligasure device offers the advantages of low bleeding and low risk of pancreatic fistula.

Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial?

AIM: To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy (DP) and to determine the effectiveness of using a stapled and a sutured closed of pancreatic stump. METHODS: Sixty-four patients underwent DP during a 10-year period. Information regarding diagnosis, operative details, and perioperative morbidity or mortality was collected. Eight risk factors were examined. RESULTS: Indications for DP included primary pancreatic disease (n = 38, 59%) and non-pancreatic malignancy (n = 26, 41%). Postoperative mortality and morbidity rates were 1.5% and 37% respectively; one patient died due to sepsis and two patients required a reoperation due to postoperative bleeding. Pancreatic fistula was developed in 14 patients (22%); 4 of fistulas were classified as Grade A, 9 as Grade B and only 1 as Grade C. Incidence of pancreatic fistula rate was significantly associated with four risk factors: pathology, use of prophylactic octreotide therapy, concomitant splenectomy, and texture of pancreatic parenchyma. The role that technique (either stapler or suture) of pancreatic stump closure plays in the development of pancreatic leak remains unclear. CONCLUSION: The pancreatic fistula rate after DP is 22%. This is reduced for patients with non-pancreatic malignancy, fibrotic pancreatic tissue, postoperative prophylactic octreotide therapy and concomitant splenectomy.

Laparoscopic distal pancreatectomy is as safe and feasible as open procedure:A meta-analysis

AIM:To evaluate the feasibility and safety of laparoscopic distal pancreatectomy(LDP) compared with open distal pancreatectomy(ODP).METHODS:Meta-analysis was performed using the databases,including PubMed,the Cochrane Central Register of Controlled Trials,Web of Science and BIOSIS Previews.Articles should contain quantitative data of the comparison of LDP and ODP.Each article was reviewed by two authors.Indices of operative time,spleen-preserving rate,time to fluid intake,ratio of malignant tumors,postoperative hospital stay,incidence rate of pancreatic fistula and overall morbidity rate were analyzed.RESULTS:Nine articles with 1341 patients who underwent pancreatectomy met the inclusion criteria.LDP was performed in 501(37.4%) patients,while ODP was performed in 840(62.6%) patients.There were significant differences in the operative time,time to fluid intake,postoperative hospital stay and spleen-preserving rate between LDP and ODP.There was no difference between the two groups in pancreatic fistula rate [random effects model,risk ratio(RR) 0.996(0.663,1.494),P = 0.983,I2 = 28.4%] and overall morbidity rate [random effects model,RR 0.81(0.596,1.101),P = 0.178,I2 = 55.6%].CONCLUSION:LDP has the advantages of shorter hospital stay and operative time,more rapid recovery and higher spleen-preserving rate as compared with ODP.

Spleen preserving distal pancreatectomy in an isolated blunt pancreatic trauma

Blunt isolated pancreatic trauma is uncommon,accounting for 1%-4% of high impact abdominal injuries.In addition,its diagnosis can be difficult;physical signs may be poor and laboratory findings nonspecific,resulting in delayed treatment.Preserving the spleen during distal pancreatectomy (DP) is controversial.One of the spleen's functions regards immunity;complications following splenectomy include leukocytosis,thrombocytosis,overwhelming post splenectomy sepsis and some degree of immunodeficiency.This is why many authors favor its preservation.We describe a case of a young man with an isolated pancreatic trauma due to a blunt abdominal trauma with a delayed presentation who was treated with spleen-preserving DP and we discuss the value of this procedure with reference to the literature.

Laparoscopic distal pancreatectomy: Up-to-date and literature review

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffu- sion. Additional researches are necessary to determine the best technique to improve the procedure results.