Overview
Definition:
Spleen-preserving distal pancreatectomy (DP) is a surgical procedure to remove the distal portion of the pancreas, from the neck of the pancreas to the spleen, while preserving the spleen and its vascular supply
The Warshaw technique specifically refers to one method of achieving this, often involving careful dissection and management of the splenic vessels to maintain splenic viability.
Epidemiology:
Distal pancreatectomy is performed for various benign and malignant lesions of the pancreatic body and tail, including adenocarcinoma, neuroendocrine tumors, cystic neoplasms, and chronic pancreatitis
The incidence of spleen preservation varies by institution and surgeon preference, but it is increasingly favored when oncologically safe.
Clinical Significance:
Preserving the spleen is crucial to maintain immunocompetence, reducing the risk of overwhelming post-splenectomy infection (OPSI)
This significantly improves long-term patient outcomes and quality of life
For surgical residents preparing for DNB and NEET SS, understanding the indications, techniques, and potential complications is vital for managing patients with pancreatic pathologies.
Indications
Surgical Indications:
Malignant lesions of the pancreatic body and tail (e.g., adenocarcinoma, neuroendocrine tumors, metastases)
Benign cystic neoplasms (e.g., mucinous cystic neoplasms, intraductal papillary mucinous neoplasms)
Symptomatic chronic pancreatitis involving the pancreatic tail
Incidentalomas requiring resection.
Contraindications:
Extensive local invasion by tumor that would necessitate splenectomy for clear margins
Major vascular involvement of the splenic vessels or portal vein that cannot be safely managed with spleen preservation
Severe coagulopathy
Unresectable distant metastases.
Oncological Considerations:
Tumor size, grade, and extent of invasion are critical
For malignant lesions, achieving negative surgical margins (R0 resection) is paramount
The spleen-preserving approach must not compromise oncological safety
Multidisciplinary team discussion is essential.
Preoperative Preparation
Patient Assessment:
Thorough medical evaluation including comorbidities
Nutritional assessment and optimization
Preoperative imaging (CT, MRI) to assess tumor extent and vascular anatomy
Blood group and cross-matching.
Imaging Guidance:
Contrast-enhanced CT is the standard for staging and surgical planning, evaluating the relationship of the tumor to the splenic vein and artery
MRI may be used for better soft tissue characterization or vascular assessment.
Anesthesia Considerations:
General anesthesia
Careful fluid management
Monitoring of vital signs
Potential for intraoperative blood loss requiring transfusion.
Perioperative Management:
Prophylactic antibiotics
Deep vein thrombosis prophylaxis
Bowel preparation if indicated
Discussing the procedure and potential for splenectomy with the patient.
Procedure Steps
Surgical Approach:
Laparoscopic or open approach
Laparoscopic approach is favored in many centers for its minimally invasive benefits, provided the surgeon has adequate experience
A left subcostal or midline incision is typically used for open surgery.
Dissection And Mobilization:
Mobilization of the left colon and splenic flexure
Identification and dissection of the pancreatic neck
Careful identification and preservation of the splenic artery and vein
The key is to dissect along the anterior surface of the splenic vein, preserving it and its branches to the pancreas tail.
Pancreatic Neck Division:
Division of the pancreas at the neck using energy devices (e.g., harmonic scalpel, electrocautery) or staplers
Careful control of pancreatic ductal and vascular bleeding.
Specimen Removal:
En bloc removal of the distal pancreas and any involved surrounding lymph nodes or organs.
Splenic Preservation Technique:
The splenic vessels (artery and vein) are carefully skeletonized and preserved
In the Warshaw technique, the pancreas is divided at its neck, and the splenic vessels are carefully dissected away from the pancreatic tissue
Ensuring adequate length of the splenic artery and vein is critical for their patency after pancreatic division
Some techniques involve ligating short gastric arteries if they are too short or injured.
Anastomosis And Drainage:
No pancreaticojejunal anastomosis is performed as the remaining pancreas is the head or uncinums, which are typically not resected in distal pancreatectomy
Placement of surgical drains near the pancreatic remnant and in the operative bed.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and abdominal distension
Pain management
Monitoring of drain output for signs of pancreatic fistula (serosanguinous, increasing volume).
Nutritional Support:
Initial NPO status, followed by gradual advancement of diet as tolerated
Enteral nutrition may be initiated via nasojejunal tube if prolonged ileus is anticipated.
Pancreatic Fistula Management:
Pancreatic fistulas are a major concern
Management involves optimizing drain management, nutritional support, and somatostatin analogs
High output fistulas may require re-exploration or percutaneous drainage.
Splenic Function Monitoring:
While the spleen is preserved, patients are still at risk for impaired splenic function and should receive vaccinations (pneumococcal, meningococcal, Haemophilus influenzae type b) postoperatively and education on OPSI risks.
Complications
Early Complications:
Pancreatic fistula (most common, incidence 10-30% depending on definition and risk factors)
Intra-abdominal abscess
Bleeding
Delayed gastric emptying
Splenic vein thrombosis (rare with careful dissection).
Late Complications:
Overwhelming post-splenectomy infection (OPSI) (though reduced by spleen preservation, risk remains if splenic function is compromised)
Incisional hernia
Recurrence of pancreatic disease (e.g., chronic pancreatitis).
Prevention Strategies:
Meticulous surgical technique to preserve vascular supply
Careful handling of pancreatic tissue
Effective drain management
Judicious use of prophylactic somatostatin analogs in high-risk patients
Patient education on OPSI
Careful patient selection for spleen preservation.
Prognosis
Factors Affecting Prognosis:
Histological type and stage of tumor (for malignant lesions)
Presence and severity of postoperative complications (especially pancreatic fistula)
Overall patient health status
Technical success of the surgery and achievement of negative margins.
Outcomes:
For benign conditions, prognosis is generally excellent after successful resection
For malignant conditions, survival depends on the tumor type, stage, and resectability
Spleen preservation generally improves long-term quality of life without compromising survival for oncologically appropriate cases.
Follow Up:
Regular clinical follow-up
Imaging as per oncological guidelines for malignant lesions
Monitoring for long-term complications of splenectomy if function is compromised
Patients should be educated about lifelong OPSI risk and immediate medical attention if fever develops.
Key Points
Exam Focus:
Indications for spleen preservation in DP
Warshaw technique as a method to preserve the spleen
Management of pancreatic fistula
Risk of OPSI and its prevention
Indications for splenectomy vs
spleen preservation in distal pancreatic lesions.
Clinical Pearls:
Always assess oncological safety first
spleen preservation should not compromise radical resection
Meticulous dissection of the splenic vessels is key
Recognize high-risk factors for pancreatic fistula (e.g., soft pancreas, duct size < 5mm, overweight BMI)
Educate patients about OPSI risks and symptoms.
Common Mistakes:
Compromising oncological margins for spleen preservation
Inadequate dissection or injury to splenic vessels leading to splenic infarction
Poor management of pancreatic stump or drain
Failure to adequately counsel patients on OPSI risks.