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distal pancreatectomy ( dp ) is the operation of choice for benign or malignant disease in the body or tail of the pancreas .
splenectomy in conjunction with distal pancreatectomy is clearly indicated in most patients with adenocarcinoma of the pancreas , as splenic preservation may compromise the oncologic resection .
however , for benign lesions or tumors with low - grade malignant potential , the issue of splenic preservation remained controversial . to reduce the risk of post - splenectomy sepsis and hematologic disorders ,
several authors have emphasized the benefits of spleen preservation ( 1 - 3 ) . on the other hand , some authors suggest that splenic preservation is more difficult , time - consuming , and is associated with increased blood loss from small venous tributaries ( 4 ) . thus , the aim of this study was to evaluate the clinical efficacy of spleen - preserving distal pancreatectomy ( spdp ) by comparing the perioperative factors and postoperative courses between dp and spdp for benign lesions or tumors with low - grade malignant potential of the body and tail of the pancreas .
from january 1995 to april 2006 , 143 patients underwent dp and the 37 patients underwent spdp for benign or low - grade malignant disease at seoul national university hospital , seoul , south korea . spleen preservation was achieved in which the pancreas was dissected off the splenic vessels .
the medical records were reviewed to evaluate the clinical outcomes such as surgical factors ( operation time , estimated blood loss , transfusion ) , postoperative complications , and postoperative long - term outcomes ( endocrine / exocrine function , and recurrence ) .
of these , laparoscopic dp was performed in 14 patients and laparoscopic spdp in one patient .
the pancreatic stump was oversewn with suture reinforcement using 4 - 0 black silk or 4 - 0 polypropylene ( prolene * , ethicon , somerville , nj , u.s.a . ) . for the laparoscopic dp ,
the pancreas was transected using the 48- or 35-mm vascular endoscopic linear stapler ( endo - gia stapler with vascular cartridge ; autosuture corp . ,
one closed suction drain was positioned in the splenic fossa close to the transected pancreas . in spdp , both the splenic artery and vein were preserved .
a pancreatic fistula was defined as drainage of more than 30 ml of fluid with an amylase level higher than 600 u / dl on or after postoperative week 1 ( 5 ) .
postoperative octreotide was given subcutaneously ( dose 100 mg every 8 hr ) for the patients considered high risk for pancreatic fistula based on the gland texture and duct size .
comparison of outcomes between the two groups was performed using the chi - square test and student 's t - test where appropriate .
clinical features of patients and indications for dp with or without splenectomy are shown in table 1 .
there were no significant differences in age , sex , preoperative diabetes mellitus , preoperative wbc count , platelet count , and indications .
four patients in the dp group and one patient in the spdp group underwent pancreaticojejunostomy due to the stricture of proximal pancreatic duct caused by chronic pancreatitis .
there were no significant differences in estimated blood loss , intraoperative transfusion and operative time between the two groups .
the white blood cells ( wbc ) and the platelet counts examined one week after operation were significantly higher in the dp group than the spdp group ( p<0.05 ) .
the incidence of complications was 27.3% ( 39/143 ) in the dp group comparing 21.6% ( 8/37 ) in the spdp group , and this was not statistically significant .
the incidence of pancreatic fistula in the dp group was 14.7% ( 21/143 ) and 8.1% ( 3/37 ) in the spdp group .
there was no significant difference between the two groups . for 85 patients in the dp group and 18 patients in the spdp group ,
pancreatic fistula occurred in 10 patients ( 11.8% , 10/85 ) of the dp group and in one patient ( 5.6% , 1/18 ) of the spdp group .
the mean duration of hospital stay was 159 days for patients in the dp group and 169 days for the spdp group .
they received no specific treatment , and spontaneous resolution of the thrombosis occurred as detected by radiologic imaging studies .
on the ct scan 4 yr after surgery , the appearance of volume loss with multifocal low attenuated lesions of the spleen with an intact splenic artery was detected without any overt symptoms .
there was one patient who was suspected of overwhelming postsplenectomy sepsis ( opsi ) and this was the only patient who experienced septic shock in our study .
a 65-yr - old male patient who was previously healthy underwent dp with splenectomy due to intraductal papillary mucinous neoplasm . on the 9th
postoperative day , fever developed and on ultrasonography , small fluid collection was observed near the dp site .
next day , he became suddenly hypotensive but no additional finding was detected on abdominal ct comparing ultrasonographic images received the previous day .
the mean follow - up period was 3633 months in the dp group and 4130 months in the spdp group ( table 3 ) .
the wbc and the platelet counts examined at 6 months after the operation were significantly higher in the dp group than the spdp group ( p<0.05 ) .
regarding endocrine function , 16 and 4 patients had diabetes mellitus in the dp group and spdp group , respectively .
diabetes did not get worse in any patient following dp or spdp . among the patients with preoperative normoglycemia , newly developed diabetes mellitus was noted in 16 patients in the dp group and 4 patients in the sppd group .
recurrence occurred in one patient 5 yr later after undergoing dp due to intraductal papillary mucinous neoplasm .
splenectomy during a dp is performed frequently because of its technical simplicity and clear indication in the majority of patients with adenocarcinoma of the pancreas , as splenic preservation may compromise the oncologic resection .
however spdp has been performed because of increasing interest in splenic salvage because of the increased risk of infection , changes in peripheral blood counts ( 6 - 8 ) and consideration of overwhelming postsplenectomy sepsis ( 6 - 8 ) .
there are currently four retrospective reviews comparing outcomes after dp with or without splenectomy ( 4 , 9 - 11 ) .
richardson and scott - conner ( 9 ) reported on 21 patients , who underwent surgery for trauma , and found no differences in complication rates between groups , concluding that splenectomy could be accomplished in selected cases .
aldridge and williamson ( 10 ) reported on 77 patients , who underwent surgery for chronic pancreatitis , and also concluded that the spleen can be preserved safely .
( 11 ) found in 40 patients with benign lesions other than pancreatitis that the complication rate was twice as high in the splenic preservation group as compared to the splenectomy patients .
they concluded that dp with splenectomy is the best procedure for benign disease of the tail and body of the pancreas . in the largest series in the literature , shoup et al .
( 4 )   evaluated 125 patients who underwent dp for benign or low - malignant potential tumors . in this series from memorial sloan - kettering cancer center , 79 patients underwent splenectomy and 46 underwent splenic preservation .
the overall complication rates were similar between the two groups ; however , patients undergoing splenectomy had a significantly higher rate of infectious complications ( 28% for splenectomy , 9% for splenic preservation , p=0.01 ) and severe complications (
their conclusion was that splenic preserving dp is safe and can be performed with decreased perioperative morbidity compared with conventional pancreatectomy with splenectomy and should be the operation of choice , when feasible , for distal pancreatic disease other than adenocarcinoma . in our study , splenic preservation has not increased the operative time , intraoperative bleeding , complication rate including pancreatic fistula , or length of hospital stay associated with dp .
however , there was only one patient who was suspected of overwhelming postsplenectomy sepsis ( opsi ) .
opsi had been defined as septicemia and/or meningitis , usually fulminant but not necessarily fatal , occurring at any time after removal of the spleen ( 12 ) .
although the incidence of infection after splenectomy in adults ranging from 0.28% to 1.9% with a 2.2% mortality rate ( 13 , 14 ) may be low , the infections are fatal
. therefore , distal pancreatectomy with splenectomy should be the operation of choice , when feasible . in the present study ,
there were 3 patients who experienced portal vein or splenic vein thrombosis after dp with splenectomy due to non - hematologic disease .
their platelet counts were less than 30010/l at the time of diagnosis of venous thrombosis .
fortunately , in all three patients , the extent of venous thrombosis was reduced without specific treatment .
unless the surgeon has a high index of suspicion , this complication may go undetected .
the progression of the thrombus to occlude the portal and mesenteric veins could cause acute hypertension in the splanchnic circulation resulting in intestinal infarction . although the reported incidence of this complication is low ( 15 , 16 ) , even vague symptoms must be considered seriously following splenectomy .
our results show that spdp with the preservation of the splenic vessels can be safely performed without increasing operative time , and length of postoperative hospitalization , or increasing the postoperative complication rate . additionally , spdp has the advantage of reducing the risk of overwhelming postsplenectomy infection and postoperative venous thrombosis .
therefore , spdp is worth considering for the treatment of benign or low - grade malignant potential lesions of the body or tail of the pancreas .
the spleen may be preserved during distal pancreatectomy ( dp ) for benign disease . 
 the aim of this study was to compare the perioperative and postoperative courses of patients with conventional dp and spleen - preserving distal pancreatectomy ( spdp ) for benign lesions or tumors with low - grade malignant potential occurred at the body or tail of the pancreas . 
 a retrospective analysis was performed for the hospital records of all the patients undergoing dp and spdp between january 1995 and april 2006 . 
 one - hundred forty - three patients underwent dp and 37 patients underwent spdp . 
 there were no significant differences in age , sex , indications of operation , estimated blood loss , operative time , and postoperative hospital stay between the two groups . 
 pancreatic fistula occurred in 21 ( 13.3% ) patients following dp and in 3 ( 8.1% ) following spdp without a significant difference ( p=0.081 ) . 
 portal vein thrombosis occurred in 4 patients after dp . 
 splenic infarction occurred in one patient after spdp . 
 overwhelming postosplenectomy infection was observed in one patient after dp . 
 spdp can be achieved with no increase in complication rate , operative time , or length of postoperative hospitalization as compared to conventional dp . 
 additionally , it has the advantage of reducing the risk of overwhelming postsplenectomy infection and postoperative venous thrombosis .