Kimura's vs Warshaw's technique for spleen preserving distal pancreatectomy: a systematic review and meta-analysis of high-quality studies

Granieri, Stefano; Bonomi, Alessandro; Frassini, Simone; Gjoni, Elson; Germini, Alessandro; Kersik, Alessia; Bracchetti, Greta; Bruno, Federica; Paleino, Sissi; Lomaglio, Laura; Frontali, Alice; Cotsoglou, Christian

doi:10.1016/j.hpb.2023.02.009

Cited by 9 publications

(7 citation statements)

References 29 publications

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“…Regarding postoperative outcomes, no significant differences were observed between the two techniques of SP-DP regarding the rate of severe complications and complications specifically related to pancreatic surgery. These results are in accordance with the literature [ 15 , 20 ]. A peripancreatic collection on the transection margin appeared in more than half of the patients, without the need for drainage in three quarters of them.…”

Section: Discussionsupporting

confidence: 94%

Spleen-preserving pancreatectomy with removal of splenic vessels: impact on splenic parenchyma ?

Lete,

Brichard,

Rosa

et al. 2023

BMC Surg

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Background While outcomes after spleen-preserving distal pancreatectomy (SP-DP) have been widely reported, impacts on splenic parenchyma have not been well studied. This study aimed to compare postoperative outcomes, particularly spleen-related outcomes, by assessing splenic imaging after SP-DP with or without splenic vessels removal. Methods Data for all patients who underwent SP-DP with splenic vessels removal (Warshaw technique, WDP) or preservation (Kimura technique, KDP) between 2010 and 2022 in two tertiary centres were retrospectively analysed. Splenic ischemia and volume at early/late imaging and postoperative outcomes were reviewed. Results Eighty-seven patients were included, 51 in the WDP and 36 in the KDP groups. Median Charlson’s Comorbidity Index was significantly higher in the WDP group compared with the KDP group. Postoperative morbidity was similar between groups. There was more splenic ischemia at early imaging in the WDP group compared to the KDP group (55% vs. 14%, p = 0.018), especially severe ischemia (23% vs. 0%). Partial splenic atrophy was observed in 29% and 0% in the WDP and KDP groups, respectively (p = 0.002); no complete splenic atrophy was observed. Platelet levels at POD 1, 2 and 6 were significantly higher in the WDP group compared to KDP group. At univariate analysis, age, Charlson Comorbidity Index, platelet levels at POD 6, and early splenic infarction were prognostic factors for development of splenic atrophy. No episodes of overwhelming post-splenectomy infection or secondary splenectomy were recorded after a median follow-up of 9 and 11 months in the WDP and KDP groups, respectively. Conclusions Splenic ischemia appeared in one-half of patients undergoing SP-DP with splenic vessels removal at early imaging, and partial splenic atrophy in almost 30% at late imaging, without clinical impact or complete splenic atrophy. Age, Charlson Comorbidity Index, platelet levels at POD 6, and early splenic infarction could help to predict the occurrence of splenic atrophy.

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Section: Discussionsupporting

confidence: 94%

Spleen-preserving pancreatectomy with removal of splenic vessels: impact on splenic parenchyma ?

Lete,

Brichard,

Rosa

et al. 2023

BMC Surg

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“…A recent meta‐analysis published by Granieri et al . demonstrates an increased risk of splenic infarction ( P < 0.00001) and gastric varices ( P < 0.0001) for the Warshaw procedure when compared to Kimura 19 . While the rate of salvage splenectomy was relatively low at 1.6–2.6%, it is still a clinically relevant issue 19–21 .…”

Section: Discussionmentioning

confidence: 99%

“…10,11 A recent meta-analysis published by Granieri et al demonstrates an increased risk of splenic infarction (P < 0.00001) and gastric varices (P < 0.0001) for the Warshaw procedure when compared to Kimura. 19 While the rate of salvage splenectomy was relatively low at 1.6-2.6%, it is still a clinically relevant issue. [19][20][21] Warshaw proposed that the cases of complete splenic infarction were due to rare anatomical variants and the comparably large size of these spleens.…”

Section: Discussionmentioning

confidence: 99%

“…19 While the rate of salvage splenectomy was relatively low at 1.6-2.6%, it is still a clinically relevant issue. [19][20][21] Warshaw proposed that the cases of complete splenic infarction were due to rare anatomical variants and the comparably large size of these spleens. 7,22 We feel that laparoscopic distal pancreatectomy and partial splenectomy is the best option when involvement of the splenic hilum or splenic vessels preclude a Kimura procedure.…”

Section: Discussionmentioning

confidence: 99%

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Laparoscopic partial splenectomy in distal pancreatectomy may preserve splenic function

Bell‐Allen,

McNamara,

Bull

et al. 2024

ANZ Journal of Surgery

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IntroductionSplenectomy is known to carry a risk of infection with encapsulated organisms and associated sepsis. Current Australian guidelines recommend intensive vaccination schedules and long‐term antibiotic therapy. We postulate that in some clinical scenarios where distal pancreatectomy (DP) and splenectomy is being performed, a partial splenectomy is feasible. This may preserve splenic function and help retain immunocompetence.MethodsFive patients underwent laparoscopic distal pancreatectomy with partial splenectomy (LDPPS). The DP is performed with proximal division and resection of the splenic artery and vein. The inferior portion of the spleen is removed en bloc with the distal pancreas with ligasure and linear cutting staplers. The line of demarcation on the spleen after the division of the splenic artery identifies the portion supplied by the short gastric vessels. Temporary clamping of the short gastrics during splenic parenchymal transection reduces blood loss. All operations were completed laparoscopically and within 4 h.ResultsThe pathology of resected lesions includes a serous cystadenoma, a pseudocyst, an IPMN and two small medial pancreatic ductal adenocarcinomas. The benign lesions involved splenic vessels at the hilum, making Kimura or Warshaw procedures untenable. No patient required blood transfusion. One patient suffered a postoperative collection consistent with postoperative pancreatic fistula requiring a drain for 10 days. Follow‐up ranged from 6 to 24 months. Following surgery, all patients had a perfused splenic remnant on imaging and benign blood films, which suggests retained splenic function.ConclusionPreserving some spleen when performing distal pancreatectomy may provide long‐term benefits for patients.

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“…This method avoids disrupting the overall blood supply to the spleen. Numerous studies, including recent systematic reviews, have demonstrated the benefits of preserving the splenic artery and vein, including a reduction in the rates of spleen infarction and post-surgery gastric varices 4 , 5 . This theoretically lowers the risk of complications such as splenic atrophy and splenic abscess, as well as gastrointestinal bleeding, when compared to the approach requiring the ligation of both the splenic artery and vein.…”

Section: Introductionmentioning

confidence: 99%

Laparoscopic antegrade spleen-preserving distal pancreatectomy with conservation of the splenic vessels: A prospective multicenter case series (with Video)

Nguyen,

Luong,

Nguyen

et al. 2024

Annals of Medicine &Amp; Surgery

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Introduction: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with conservation of the splenic artery and vein (Kimura’ technique) is considered a technically challenging procedure that requires a high level of expertise in laparoscopic and pancreatic surgery. Methods: A prospective descriptive study on 18 patients with laparoscopic “antegrade” spleen-preserving distal pancreatectomy with Kimura’ technique from 2018 to 2023. The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated. Results: The mean age was 39.4±13.3. Only 2 male patients accounted for 11.1%. The average operating time is 171±23 minutes. The average blood loss is 65.7±43 ml. The average tumor size is 4.1cm. The average hospitalization is 9.4 days. The rate of pancreatic fistula is 66.7%. There is no case of transferring open surgery or blood transfusion during surgery. The results of pathological after surgery, there were 8 cases of solid pseudopapillary tumors, 4 cases of mucinous cystadenoma, 6 cases of neuroendocrine tumors. Conclusion: Kimura’s technique for laparoscopic spleen-preserving distal pancreatectomy is safe and feasible, which can be applied to benign tumors in the body and tail of pancreas. However, this is a difficult technique in laparoscopic surgery that requires surgeons to have a lot of experience and equipment need to be adequate.

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Kimura's vs Warshaw's technique for spleen preserving distal pancreatectomy: a systematic review and meta-analysis of high-quality studies

Cited by 9 publications

References 29 publications

Spleen-preserving pancreatectomy with removal of splenic vessels: impact on splenic parenchyma ?

Spleen-preserving pancreatectomy with removal of splenic vessels: impact on splenic parenchyma ?

Laparoscopic partial splenectomy in distal pancreatectomy may preserve splenic function

Laparoscopic antegrade spleen-preserving distal pancreatectomy with conservation of the splenic vessels: A prospective multicenter case series (with Video)

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