Splenic Preserving Distal Pancreatectomy: Does Vessel Preservation Matter?

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<ul><li><p>Splenic Preserving Distal Pancreatectomy:D a</p><p>Jo keebC se,Th FAC</p><p>y (Sr, noas tonic vts unn (Vmilad mioing</p><p>d wi). Th</p><p>B or C pancreatic fistulas (2% vs 12% vs 14%; p NS) and splenic infarctions (5% vs 39%;</p><p>Dinigtaihafrebenosponthov</p><p>DisPreBea</p><p>RecFroIndCoanaIN</p><p> 2Pubp 0.01), less overall morbidity (18% vs 39% vs 38%, respectively; p 0.05) and need fordrainage procedure (2% vs 15% vs 16%; p 0.05), and shorter post-operative length of stay(4.5 vs 6.2 vs 6.6 days; p 0.05).</p><p>CONCLUSIONS: This analysis suggests that outcomes are (1) best for VP-SPDP and (2) VL-SPDP provides noshort-term advantage over distal pancreatectomy with splenectomy. We conclude that splenicVP is preferred when SPDP is performed. (J Am Coll Surg 2011;212:651657. 2011 by theAmerican College of Surgeons)</p><p>stal pancreatectomy is the procedure of choice for be-n, premalignant, and malignant disease of the body andl of the pancreas. In recent years distal pancreatectomys become a safe procedure that is being performed morequently because imaging studies are identifying morenign and premalignant lesions.1-4 For patients with ade-carcinoma of the pancreas, distal pancreatectomy withlenectomy is recommended to assure that an adequatecologic operation has been performed.5-7 However,e spleen has important immunologic functions, anderwhelming sepsis following splenectomy is a well-</p><p>described long-term complication.8,9 Thus, preservationof the spleen during distal pancreatectomy has been pro-posed to reduce the risk of post-splenectomy sepsis aswell as late malignancies.10</p><p>Distal pancreatectomy with splenic preservation wasfirst described by Mallet-Guy and Vachon in 1943.11 Thisclassic technique preserves the splenic artery and vein byidentification and ligation of the multiple small, short vas-cular connections to the body and tail of the pancreas. In1988 Warshaw12 published an alternative technique inwhich the splenic artery and vein(s) are ligated proximallyand distally, with retention of the short gastric and leftgastroepiploic vessels to preserve blood flow to and from thespleen. Splenic preserving distal pancreatectomy (SPDP) hasbeen recommended bymany surgeons because of fewer short-and long-term complications.13-18 In recent years splenicpreservation has received evenmore attention because lapa-roscopic distal pancreatectomy has been adopted by manygroups.2,4,19-25 To date, the relative merits of SPDP versusdistal pancreatectomy with splenectomy as well as open</p><p>closure Information: Nothing to disclose.sented at Southern Surgical Association 122nd Annual Meeting, Palmch, FL, December 2010.</p><p>eived December 6, 2010; Accepted December 14, 2010.m the Department of Surgery, Indiana University School of Medicine,ianapolis, IN.rrespondence address: Henry A. Pitt, MD, Department of Surgery, Indi-University School of Medicine, 535 Barnhill Dr RT 130D, Indianapolis,46202. email: hapitt@iupui.edu</p><p>651011 by the American College of Surgeons ISSN 1072-7515/11/$36.00lished by Elsevier Inc. doi:10.1016/j.jamcollsurg.2010.12.014oes Vessel Preservation M</p><p>al D Beane, MD, Henry A Pitt, MD, FACS, Attila NaMax Schmidt, MD, PhD, MBA, FACS, Michael G Houomas J Howard, MD, FACS, Keith D Lillemoe, MD,</p><p>BACKGROUND: Splenic preserving distal pancreatectomvein preservation or ligation. Howevetechniques. The aim of this analysis wpancreatectomy with and without sple</p><p>STUDY DESIGN: From 2002 through 2009, 434 patiensplenic preservation. Vessel preservatioperformed in 41. These patients were sisiologists class, pathology, surgeons, ana matched group of 86 patients undergwas analyzed.</p><p>RESULTS: The VP-SPDP procedure was associate508 vs 646 mL, respectively; p 0.05tter?</p><p>, MD, FACS,MD, Nicholas J Zyromski, MD, FACS,S</p><p>PDP) can be accomplished with splenic artery anddata are available on the relative merits of thesecompare the outcomes of splenic preserving distalessel preservation.derwent distal pancreatectomy and 86 (20%) hadP) was accomplished in 45 and ligation (VL) wasr with respect to age, American Society of Anesthe-nimally invasive approach (79%). For comparison,distal pancreatectomy with splenectomy (DPS)</p><p>th less blood loss than VL-SPDP or DPS (224 vse VP-SPDP procedure also resulted in fewer grade</p></li><li><p>vepomeshthpr</p><p>MPaPepaobIRfropaSppaaccpegroofmisontomchthetaloth</p><p>PaThwethesplpathemiscoforaccpeanma</p><p>tion versus splenectomy, and VP versus VL were left to thedistothema</p><p>PaAlDeofcofornomuanrou(2.enwetheogmarelad</p><p>SuOpProcreanCatiincsurreqtioquweofpuforfevopsioovreiveiagufecinof</p><p>652 Beane et al Splenic Preserving Distal Pancreatectomy J Am Coll Surgrsus laparoscopic distal pancreatectomy have been re-rted. However, no data are available on the relativerits of SPDP performed by the Mallet-Guy or War-aw technique. The aim of this analysis was to comparee outcomes of SPDP with and without splenic vesseleservation (VP).</p><p>ETHODStient populationrmission to review the outcomes of patients undergoingncreatic surgery at the Indiana University Hospital wastained from the Indiana University School of MedicineB. A search of operative, pathology, and billing recordsm January 2002 through August 2009 identified 434tients who had undergone distal pancreatectomy.lenic preservation (SPDP) was performed in 86 of thesetients (20%). Of the patients undergoing SPDP, VP wasomplished in 45 (52%) and vessel ligation (VL) wasrformed in 41 (48%). The VP-SPDP and VL-SPDPups were similar with respect to age, American SocietyAnesthesiologists (ASA) class, pathology, surgeons, andnimally invasive approach (79%). For further compari-, a group of 86 patients undergoing distal pancreatec-y with splenectomy (DPS) matched for the same 5</p><p>aracteristics also was analyzed. None of the patients inVP-SPDP, VL-SPDP, or DPS groups underwent dis-pancreatectomy for trauma or concomitantly with an-er major operation such as gastrectomy or colectomy.</p><p>ncreatic operationse VP-SPDP11 or VL-SPDP12 procedure and DPSre performed by standard techniques. Recent trends inrelative proportion of pancreatic operations includingenic preservation and laparoscopic and robotic distalncreatectomies have been reported elsewhere.4,26 In brief,percentage of minimally invasive distal pancreatecto-</p><p>es has increased so that 45% were performed laparo-pically or robotically in 2009. Seven surgeons per-med the 86 SPDP, whereas the 86 DPS wereomplished by 9 surgeons. However, the same 3 surgeonsrformed 95% of the VP-SPDP, 90% of the VL-SPDP,d 81% of the DPS. The decisions regarding a mini-lly invasive versus an open approach, splenic preserva-</p><p>Abbreviations and Acronyms</p><p>DPS distal pancreatectomy with splenectomySPDP splenic preserving distal pancreatectomyVL vessel ligationVP vessel preservationcretion of the surgeon. Similarly, the methods employedtransect the pancreas and close the pancreatic stump anddecisions regarding drain placement and removal werede by the individual surgeons.</p><p>ncreatic pathologyl pancreatic specimens were reviewed by members of thepartment of Pathology at the Indiana University SchoolMedicine. The length of the resected pancreas was re-rded for all specimens. The SPDP procedure was per-med most commonly for premalignant lesions such asninvasive intraductal papillary mucinous neoplasms,cinous cystic neoplasms, and neuroendocrine tumors,d benign pathology such as chronic pancreatitis and se-s cystadenomas. Only 2 patients undergoing SPDP3%) were determined at final pathology to have an ad-ocarcinoma of the pancreas. No significant differencesre observed in the relative pathologic diagnoses betweenVP-SPDP and the VL-SPDP groups.Thus, the pathol-y of these 2 groups was combined during the process oftching SPDP with DPS patients. In this process, theative frequency of the lesions wasmaintained, and only 3enocarcinomas were included in the DP-S group.</p><p>rgical outcomeserative data included blood loss and operative time.cedure-specific post-operative morbidity included pan-atic fistulas, surgical site infections, splenic infarctions,d hemorrhages. Pancreatic fistulas were graded A, B, oraccording to the International Study Group for Pancre-c Fistula.27 Only grade B and C pancreatic fistulas wereluded in the calculation of overall morbidity. Superficialgical site infections included those above the fascial leveluiring wound opening and drainage. Organ space infec-ns and uninfected peripancreatic fluid collections re-iring percutaneous, endoscopic, or operative drainagere recorded by themanagement procedure.The presencea splenic infarction was determined by review of com-terized tomography scans performed post-operativelyconcerns about undrained fluid collections, persistenters, and/or left upper abdominal or back pain. Post-erative hemorrhage was defined as the need for transfu-n and/or reoperation. Other complications included inerall morbidity were MI, respiratory failure requiringntubation, acute renal failure requiring dialysis, deepn thrombosis or pulmonary embolus requiring antico-lation, Clostridium difficile colitis, and urinary tract in-tions. Post-operative length of hospital stay was recordeddays. Post-operative survival was determined by reviewthe national Social Security database.</p></li><li><p>StCoCoDPt, cialniqtes</p><p>REPaDeDP</p><p>weenmomoillaneatiwegrowi8.7</p><p>OpTh(88maSPcalOpOpSPcanwiDP</p><p>PoGr3 p(2%wi(14(2%coan(Fi</p><p>Figpanprespl</p><p>Table 1. Patient Population</p><p>nAgSexMePat</p><p>*pASAwitneupanpan</p><p>Figcancreprespl</p><p>653Vol. 212, No. 4, April 2011 Beane et al Splenic Preserving Distal Pancreatectomyatistical analysesntinuous variables are presented as means SEM.mparison of the 3 groups, VP-SPDP, VL-SPDP, andS, was performed by ANOVA followed by Studentshi-square, or Fishers exact tests, as appropriate. Actuar-survival was determined by the Kaplan-Meier tech-ue, and survival differences were analyzed by log-rankting. Statistical significance was defined as p 0.05.</p><p>SULTStient populationmographic data regarding the VP-SPDP, VL-SPDP, andS groups are presented inTable 1. Because the groups</p><p>ure 2. Pancreatic fistulas, grades A, B, and C. DPS, distalcreatectomy with splenectomy; VL-SPDP, vessel ligationsplenicserving distal pancreatectomy; VP-SPDP, vessel preservationenic preserving distal pancreatectomy.</p><p>VP-SPDP VL-SPDP DPSn % n % n %</p><p>45 41 86e (y) 53.4 56.7 55.8(% female) 78* 54 56an ASA class 2.66 2.78 2.84hologyIPMN 14 31 11 27 22 26Cystic tumors 9 20 13 32 22 26Pancreatitis 11 24 9 22 22 26NET 5 11 5 12 11 13Adenocarcinoma 2 4 0 0 3 3Other 4 9 3 7 6 7</p><p> 0.03 versus VL-SPDP and DPS., American Society of Anesthesiologists; DPS, distal pancreatectomy</p><p>h splenectomy; IPMN, intraductal papillary mucinous neoplasm; NET,roendocrine tumor; VL-SPDP, vessel ligationsplenic preserving distalcreatectomy; VP-SPDP, vessel preservationsplenic preserving distalcreatectomy.re matched for age, ASA class, and pathology, no differ-ces were observed in these parameters. Significantlyre women (p 0.03) were in the VP-SPDP group. Thest frequent pathologic diagnoses were intraductal pap-ry mucinous neoplasms, cystic tumors (mucinous cysticoplasms and serous cystadenomas), and chronic pancre-tis (Table 1). Only 5 adenocarcinomas of the pancreasre included: 2 in the VP-SPDP and 3 in the DPSups. No differences were observed among the 3 groupsth respect to the mean length of pancreas resected (8.5 vsvs 8.6 cm; p NS).</p><p>erative outcomesirty-two of 45 VP-SPDP (71%), 36 of 41 VL-SPDP%), and 57 of 86 DPS (66%) were performed mini-lly invasively. Of these less invasive procedures, 11 VP-DP, 3 VL-SPDP, and 6 DPS were performed roboti-ly, with the remainder being completed laparoscopically.erative time and blood loss are presented in Figure 1.erative times were approximately 30minutes shorter forDP, but this difference did not reach statistical signifi-ce. Blood loss was 224 mL for VP-SPDP comparedth 507 mL for VL-SPDP (p 0.05) and 646 mL forS (p 0.05).</p><p>st-operative outcomesade A pancreatic fistulas were common after each of therocedures (Fig. 2). However, only 1 VP-SPDP patient) developed a grade B or C fistula (Fig. 3) compared</p><p>th 5 VL-SPDP patients (12%) and 12 DPS patients%) (Table 2). In addition, only 1 VP-SPDP patient) required drainage of an infected peripancreatic fluid</p><p>llection compared with 6 VL-SPDP (15%; p 0.05)d 14 DPS patients (16%; p 0.05). Splenic infarctsg. 4) also were significantly less common after VP-SPDP</p><p>ure 1. Operative time and blood loss. Blood loss was signifi-tly less (p 0.05) in the VP-SPDP patients. DPS, distal pan-atectomy with splenectomy; VL-SPDP, vessel ligationsplenicserving distal pancreatectomy; VP-SPDP, vessel preservationenic preserving distal pancreatectomy.</p></li><li><p>co2).paSPpaqureopawaco(38sigco(6.15SPDPno</p><p>DIDipe</p><p>gatcadTh41whcanopbidwepaDP</p><p>pamadissivtopaoringlittallisSPTa</p><p>Ou</p><p>PanSplDrReOvPo</p><p>*Grp DPsplesple</p><p>uiredligatiatien</p><p>654 Beane et al Splenic Preserving Distal Pancreatectomy J Am Coll Surgmpared with VL-SPDP (2% vs 39%; p 0.05) (TableReoperation was not required in any of the VP-SPDPtients, and all survived surgery. In comparison, 2 VL-DP patients (5%) required reoperation, and 1 of thesetients, who bled from the splenic artery stump, subse-ently died. Whereas 5 DPS patients (6%) requiredperations for infectious complications, all of the DPStients survived the second procedure. Overall morbiditys significantly less (p 0.05) in the VP-SPDP (18%)mpared with the VL-SPDP (39%) and DPS patients%). The mean length of post-operative stay also wasnificantly shorter (p 0.05) for VP-SPDP (4.5 days)mpared with that of VL-SPDP (6.3 days) and DPS6 days). Of the 167 patients without pancreatic cancer,7 (94%) were alive at 5 years after surgery. Only 1 VP-DP (2%) compared with 3 VL-SPDP (7%) and 6S patients (7%) have died, but these differences weret statistically significant.</p><p>SCUSSIONstal pancreatectomy with splenic preservation can berformed with splenic artery and vein preservation or li-</p><p>ble 2. Post-Operative Outcomes</p><p>tcomes</p><p>VP-SPDP</p><p>VL-SPDP DPS</p><p>n % n % n %</p><p>creatic fistula* 1 2 5 12 12 14enic infarction 1 2 16 39 NAainage procedure 1 2 6 15 14 16operation 0 0 2 5 5 6erall morbidity 8 18 16 39 33 38st-operative length of stay (d) 4.5 6.3 6.6</p><p>ades B and C.0.05 versus VL-SPDP and DPS.</p><p>S, distal pancreatectomy with splenectomy; VL-SPDP, vessel ligationnic preserving distal pancreatectomy; VP-SPDP, vessel preservationnic preserving distal pancreatectomy.</p><p>Figure 3. Infected pancreatic fistulas (*) that reqpreserving distal pancreatectomy and (B) vesselpatient. Note the small splenic infarctions in both pion. Although these 2 techniques were described de-es ago, no good comparative data have been available.is analysis evaluated 45 patients undergoing VP-SPDP,patients who had VL-SPDP, and 86 matched patientso underwent DPS. Operative blood loss was signifi-tly lower (p 0.05) in the VP-SPDP patients. Post-erative outcomes including splenic infarcts, overall mor-ity, the need for a drainage procedure, and length of stayre all significantly (p 0.05) better in the VP-SPDPtients. Outcomes for VL-SPDP were similar to those forS.With the proliferation of abdominal imaging in thest decade, more...</p></li></ul>

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