Spleen-Preserving Distal Pancreatectomy
For benign or low-grade malignant tumors in the distal pancreas, spleen-preserving distal pancreatectomy (SPDP) is the recommended approach when technically feasible, particularly for smaller tumors not involving the splenic vessels. 1
Indications for Spleen Preservation
Spleen preservation should be attempted for:
- Insulinomas - smaller tumors not involving splenic vessels are ideal candidates for SPDP 1
- Small peripheral tumors (<2 cm) - can undergo distal pancreatectomy with or without splenectomy 1
- Benign or low-grade malignant lesions - SPDP is safe and effective for these pathologies 2, 3
Technical Approaches
Two main techniques exist for spleen preservation:
Kimura Technique (Splenic Vessel Preservation)
- Preserves both splenic artery and vein 2
- Preferred for lesions requiring less extensive pancreatic resection (typically <52 mm) 4
- Associated with shorter operative times (201 min vs 256 min) 4
Warshaw Technique (Splenic Vessel Ligation)
- Ligates splenic vessels while preserving short gastric vessels 1
- Achieves lymph node retrieval comparable to en bloc splenectomy 1
- Better suited for lesions requiring more extensive pancreatic resection (typically >95 mm) 4
- No difference in splenic viability or complication rates compared to vessel preservation 4
Clinical Outcomes
SPDP demonstrates superior outcomes compared to conventional distal pancreatectomy with splenectomy:
- Reduced infectious complications - 3% vs 18% intra-abdominal infections 3
- Lower overall complication rates - 13% vs 34% 3
- Eliminates risk of overwhelming post-splenectomy infection (OPSI) 5, 3
- Reduces postoperative venous thrombosis risk 5
- No increase in operative time, blood loss, or hospital stay 5, 3
- Pancreatic fistula rates remain comparable - 8.1% vs 13.3% 5
Laparoscopic Approach
Laparoscopic SPDP is safe and feasible with:
- High success rate of spleen preservation - 91% 4
- Mean operative time - 123 minutes 2
- Low blood loss - 78 mL 2
- Short hospital stay - 7.6 days 2
- Clinical pancreatic fistula rate - 13.2% 2
- No recurrence during median 38-month follow-up for benign and low-grade malignant lesions 2
Critical Caveats
Splenectomy is mandatory for:
- Glucagonomas - typically malignant with regional node involvement requiring distal pancreatectomy with splenectomy 1, 6
- VIPomas - require splenectomy with peripancreatic lymph node resection 1
- Larger tumors (>2 cm) or malignant-appearing lesions - when adequate lymph node dissection is needed 1
- Tumors with splenic vessel involvement - when vessels cannot be preserved 1
For glucagonomas specifically, perioperative anticoagulation should be considered due to hypercoagulable state and increased risk of pulmonary emboli. 1, 6