Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: a systematic review

Abstract

Background: Splenic preservation during a distal pancreatectomy (SPDP) may be performed with splenic vessel ligation, known as Warshaw's Technique (WT) or splenic vessel preservation (SVP). The consensus on which approach is best is divided. A systematic review of evidence in the literature was undertaken with the aim of analysing the merits and disadvantages of both WT and SVP.

Methods: A systematic search of medical literature from 1985-2011 was undertaken to identify all comparative studies and case series on SPDP. Non-English papers, series with < 5 patients, technical reports and reviews were excluded. The remaining articles were reviewed considering the study design, surgical technique, outcomes and complications.

Results: In 23 relevant studies, 356 patients underwent WT and 572 underwent SVP. In WT patients, the mean operating time (160 versus 215 min, P < 0.001), mean estimated blood loss (301 versus 390 ml, P < 0.001) and length of stay (8 versus 11 days, P < 0.001) was significantly less than the SVP patients, respectively. Considering complications, splenic infarction and splenectomy occurred more frequently in WT patients (P < 0.05).

Discussion: WT is technically easier to perform than SVP but has a higher incidence of subsequent splenectomies. Surgeons should be able to perform both procedures and tailor the technique according to the patient.

Figure 1

Laparoscopic splenic vessel preserving distal pancreatectomy in a patient with mucinous cystadenoma in the body of the pancreas

Figure 2

PRISMA flow diagram

Figure 3

Laparoscopic Warshaw technique in a patient showing (a) areas of ischaemia (straight arrows) intra-operatively and (b) on computerised tomography (CT) 10 days post-operatively. Serial CT scans show (c) a reduction in ischaemia (straight arrows) at 1 month and (d) regeneration and hypertrophy of the spleen at 6 months (curved arrow)