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Traian Dumitrascu Dan Setlacec Center of General Surgery and Liver Transplant

Spleen-Preserving Distal Pancreatectomy. Traian Dumitrascu Dan Setlacec Center of General Surgery and Liver Transplant Fundeni Clinical Institute Bucharest. Introduction. Spleen-preserving distal pancreatectomy (SPDP): an alternative procedure to distal pancreatectomy with splenectomy

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Traian Dumitrascu Dan Setlacec Center of General Surgery and Liver Transplant

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  1. Spleen-Preserving Distal Pancreatectomy Traian Dumitrascu Dan Setlacec Center of General Surgery and Liver Transplant Fundeni Clinical Institute Bucharest

  2. Introduction • Spleen-preserving distal pancreatectomy (SPDP): • an alternative procedure to distal pancreatectomy with splenectomy • for benign/ low-grade malignant tumors of the pancreatic body • removal of the spleen during distal pancreatectomy was associated with increased postoperative morbidity • the role of the spleen in immunity was clearly demonstrated by experimental and clinical studies Shoup, Arch Surg, 2002; Ionescu, Chirurgia, 2003; Fernandez-Cruz, HPB (Oxford), 2005; Tiron & Vasilescu, Chirurgia, 2008; Dumitrascu, Dig Surg, 2012; Lacatus, Chirurgia, 2013

  3. Introduction • WHY Spleen-preservation? • Spleen play a key role in: • mechanical filtration, which removes senescent erythrocytes • maintenance of normal immune function and host defenses against certain types of infectious agents • prevention of infection in children • avoid overwhelming postsplenectomy infection (OPSI): S. pneumoniae, H. influenze, N. meningitidis • major site of production for the opsonins: properdin and tuftsin (bactericide and anti tumor activity) Removal of the spleen results in loss of both the immunologic and filtering functions Ionescu, Chirurgia, 2003; Tiron & Vasilescu, Chirurgia, 2008;Lacatus, Chirurgia, 2013 Vasilescu, Splina. De la laparoscopie la chirurgia robotica si inapoi, Ed. Medicala, 2016

  4. Introduction • What are the risks following splenectomy? • Infectious risks- OPSI • The highest risk in the first 2 years • Mortality – up to 46% • Non-infectious risks : • Arterial events • Thromboembolic events • Pulmonary hypertension • Developing cancer Dragomir, Chirurgia, 2016

  5. SPDP • PRO: • the role of the spleen in immunity • better endocrine function preservation • removal of the spleen during distal pancreatectomy was associated with increased postoperative morbidity • the major concern after splenectomy is overwhelming postsplenectomy infection (OPSI) • CONS: • more technically challenging • increased morbidity Shoup, Arch Surg, 2002; Ionescu, Chirurgia, 2003; Fernandez-Cruz, HPB (Oxford), 2005; Tiron & Vasilescu, Chirurgia, 2008; Dumitrascu, Dig Surg, 2012; Lacatus, Chirurgia, 2013

  6. Anatomy - arteries Mikami, Diseases of the Pancreas, Springer-Verlag, 2008

  7. Anatomy - veins Mikami, Diseases of the Pancreas, Springer-Verlag, 2008 7

  8. Technique Warshaw, Arch Surg, 1988; Warshaw, J Hepatobiliary Pancreat Sci, 2010 8

  9. Technique Fernandez-Cruz, Atlas of Advanced Operative Surgery, Elsevier, 2013 9

  10. Technique Fernandez-Cruz, Atlas of Advanced Operative Surgery, Elsevier, 2013 10

  11. Technique Kimura, Surgery, 1996

  12. Technique Fernandez-Cruz, Atlas of Advanced Operative Surgery, Elsevier, 2013 12

  13. Technique Spleen SA PV SV Pancreas Head VMS SPDP – final aspect

  14. Technique Fundeni Clinical Institute: 41 SPDP – 6 minimally-invasive (2 laparoscopic; 4 robotic)

  15. Indications T Ferrone & Warshaw, Ann Surg, 2011

  16. Indications Serous cystadenoma

  17. Indications Neuroendocrine neoplasm G1

  18. Indications Solid pseudopapillary tumor

  19. Indications Grawitz metastasis

  20. 21

  21. Tol, Surgery, 2014 22

  22. Indications 2012 23

  23. 24

  24. Morbidity • Early morbidity • 22 - 46% • Splenectomy rate (1.9 – 5.2%) Ferrone & Warshaw, Ann Surg, 2011; Tien, Ann Surg Oncol, 2010; Shoup, Arch Surg, 2002

  25. Splenic vein/ artery thrombosis 26

  26. Splenic vein/ artery thrombosis 27

  27. Splenic vein/ artery thrombosis 28

  28. Long-term Outcome • Perigastric varices – up to 30% 29

  29. Discussion • Estimated blood loss higher for: • SPDP (Ma JP, Chinese Med J, 2011) • DPS (Shoup M, Arch Surg, 2002) • No difference (Nau P, Gastroenterology Research and Practice, 2009; Lee SE, J Korean Med Sci, 2008; Tezuka K, Dig Surg, 2012; Tsiouris A, HPB, 2011; Kimura W, J Hepatobiliary Pancreat Sci, 2010; Choi SH, Surg Endosc, 2012) • Overall complications rate higher for: • DPS (Carrere N, World J Surg, 2006; Choi SH, Surg Endosc, 2012) • No difference (Nau P, Gastroenterology Research and Practice, 2009; Lee SE, J Korean Med Sci, 2008; Tezuka K, Dig Surg, 2012; Tsiouris A, HPB, 2011; Kimura W, J Hepatobiliary Pancreat Sci, 2010) • Infectious complications higher for • DPS (Shoup M, Arch Surg, 2002; Benoist S, JACS, 1999; Choi SH, Surg Endosc, 2012) • No difference (Nau P, Gastroenterology Research and Practice, 2009; Lee SE, J Korean Med Sci, 2008; Tezuka K, Dig Surg, 2012; Tsiouris A, HPB, 2011; Kimura W, J Hepatobiliary Pancreat Sci, 2010) • Diabetes rate is lower for • SPDP (Fernandez-Cruz L, HPB, 2005; Govil S, Br J Surg, 1999) • no differences (Carrere N, World J Surg, 2006; Lee SE, J Korean Med Sci, 2008; Kimura W, J Hepatobiliary Pancreat Sci, 2010) T IVC Mp SMV PV SMV SMA CT SMA

  30. T IVC Mp SMV PV SMV SMA CT SMA

  31. T IVC Mp SMV PV SMV SMA CT SMA

  32. Discussion T Ma JP, Chinese Med J, 2011 IVC Mp Lee SE, J Korean Med Sci, 2008 SMV PV SMV SMA Tsiouris A, HPB, 2011 CT SMA Kimura W, J Hepatobiliary Pancreat Sci, 2010

  33. Fundeni Clinical Institute Experience • Indications • Postoperative morbidity - infectious • Long-term results

  34. Patients & Methods Fundeni Clinical Institute 2000 – 2015 41 patients with SPDP

  35. Results • Median age: 41 years (18 – 76) • Sex ratio F/M = 2.4/1 (29/12) • Median BMI: 25 kg/m2 (19 – 42) • Symptoms: • Present – 37 pts (90%) • Epigastric pain – 27 pts • Hypoglycemia – 9 pts • Absent – 4 pts

  36. Results • Pancreas texture: soft – 35 pts (85%) • Median operative time: • 150 min (70 – 330)

  37. Results • Blood loss: • Median intraoperative blood loss: 150 ml (50 – 300 ml) • 1 pts with intraoperative transfusions • Postoperative transfusions – 6 pts (14%)

  38. Results • Morbidity – 14 pts (34%) • Mortality – 0 pts • POPF – 13 pts (32%): • Grade A – 6 pts • Grade B – 5 pts • Grade C – 2 pts • Postoperative hemorrhage – 5 pts (12%) • Delayed gastric empting – 5 pts (12%)

  39. Results • Re-laparotomy for complications – 5 pts (12%): • POPF grade C – 2 pts (2 pts with POH) • PO Hemorrhage alone – 2 pts • Abdominal abscess – 1 pt • Cave: 1 pt – splenectomy

  40. Results • Median tumor diameter: 3.5 cm (0.4 – 14) • Pathology: • Benign/ low-grade malignant – 37 pts • Malignant – 4 pts

  41. Results • Serous cystadenoma – 6 pts • Mucinous cystadenoma – 3 pts • NET G1/ G2 – 15 pts • Non-functional: 5 pts • Insulinoma: 9 pts • Gastrinoma: 1 pt • Solid pseudopapillary tumor – 6 pt • Focal chronic pancreatitis – 5 pt • Malignant – 3 pt • Metastases of other neoplasia – 1 pts

  42. Results • Median follow-up: 65 months (1 – 177) • Functional results (34 pts): • Diabetes mellitus – 6 pts (17%) • Exocrine pancreatic insufficiency – 2 pts (6%)

  43. T IVC Mp SMV PV SMV SMA CT SMA Dumitrascu, Dig Surg, 2012

  44. T IVC Mp SMV PV SMV SMA CT SMA

  45. T IVC Mp SMV PV SMV SMA CT SMA Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

  46. T IVC Mp SMV PV SMV SMA CT SMA Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

  47. T IVC Mp SMV PV SMV SMA CT SMA Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

  48. T IVC Mp SMV PV SMV SMA CT SMA Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

  49. T IVC Mp SMV PV SMV SMA CT SMA Dumitrascu, J Hepatobiliary Pancreat Sci, 2014

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