Superiority of Robotic Over Laparoscopic Spleen-Preserving Distal Pancreatectomy With Warshaw Procedure for Reducing the Incidence of Postoperative Splenic Infarction.

BACKGROUND: Minimally invasive spleen-preserving distal pancreatectomy with Warshaw procedure (MI-WP), has gained widespread recognition for the treatment of benign and low-grade malignant tumors of the pancreatic body and tail. However, the comparative advantages of the robotic Warshaw procedure (R-WP) over the laparoscopic Warshaw procedure (L-WP) remain uncertain. This study aimed to compare the surgical outcomes between R-WP and L-WP. MATERIALS AND METHODS: Among the 146 cases of MI-DP conducted between October 2020 and December 2023 (L-DP:115, R-DP:31), 33 cases of MI-WP were subjected to analysis, comprising the R-WP group (n=10) and the L-WP group (n=23). RESULTS: R-WP successfully completed all procedures under a purely laparoscopic approach, whereas L-WP necessitated conversion to open surgery in 2 cases (8.7%). Despite the significantly prolonged operative time in R-WP compared with L-WP (R-WP vs. L-WP: 421vs. 300 min), there was no significant difference in estimated blood loss between the 2 groups (R-WP vs. L-WP: 19 vs. 20 mL). Although the rate of major complications did not significantly differ between the 2 groups, 2 cases (8.7%) of L-WP required reoperation, including splenectomy in 1 instance. Furthermore, the incidence of postoperative splenic infarction was significantly higher in L-WP than in R-WP (R- vs. L-WP:0 vs. 43.5%, P =0.015). The length of hospital stay after surgery did not exhibit a significant difference between the 2 groups (R-WP vs. L-WP: 11 vs. 12 d). DISCUSSION: R-WP demonstrated superiority to L-WP for reducing the incidence of postoperative splenic infarction, potentially contributing to enhancing the spleen preservation rate.

Learning curve of robotic-assisted splenic vessel-preserving spleen-preserving distal pancreatectomy by one single surgeon: a retrospective cohort study.

AIM: Splenic vessel-preserving spleen-preserving distal pancreatectomy (SVP-SPDP) has a lower risk of splenic infarction than the splenicvessel-sacrificing SPDP, but it is more technically demanding. Learning curve of robotic-assisted SVP-SPDP (RSVP-SPDP) remains unreported. This study sought to analyze the perioperative outcomes and learning curve of RSVP-SPDP by one single surgeon. METHODS: Seventy-four patients who were intended to receive RSVP-SPDP at the First Affiliated Hospital of Sun Yat-sen University between May 2015 and January 2023 were included. The learning curve were retrospectively analyzed by using cumulative sum (CUSUM) analyses. RESULTS: Sixty-two patients underwent RSVP-SPDP (spleen preservation rate: 83.8%). According to CUSUM curve, the operation time (median, 318 vs. 220 min; P < 0.001) and intraoperative blood loss (median, 50 vs. 50 mL; P = 0.012) was improved significantly after 16 cases. Blood transfusion rate (12.5% vs. 3.4%; P = 0.202), postoperative major morbidity rate (6.3% vs. 3.4%; P = 0.524), and postoperative length-of-stay (median, 10 vs. 8 days; P = 0.120) improved after 16 cases but did not reach statistical difference. None of the patients had splenic infarction or abscess postoperatively. CONCLUSION: RSVP-SPDP was a safe and feasible approach for selected patients after learning curve. The improvement of operation time and intraoperative blood loss was achieved after 16 cases.

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

BACKGROUND: Spleen preserving distal pancreatectomy (SPDP) represents a widely adopted procedure in the presence of benign or low-grade malignant tumors. Splenic vessels preservation and resection (Kimura and Warshaw techniques respectively) represent the two main surgical modalities to avoid splenic resection. Each one is characterized by strengths and drawbacks. The aim of the present study is to systematically review the current high-quality evidence regarding these two techniques and analyze their short-term outcomes. METHODS: A systematic review was conducted according to PRISMA, AMSTAR II and MOOSE guidelines. The primary endpoint was to assess the incidence of splenic infarction and splenic infarction leading to splenectomy. As secondary endpoints, specific intraoperative variables and postoperative complications were explored. Metaregression analysis was conducted to evaluate the effect of general variables on specific outcomes. RESULTS: Seventeen high-quality studies were included in quantitative analysis. A significantly lower risk of splenic infarction for patients undergoing Kimura SPDP (OR = 0.14; p < 0.0001). Similarly, splenic vessel preservation was associated with a reduced risk of gastric varices (OR = 0.1; 95% p < 0.0001). Regarding all secondary outcome variables, no differences between the two techniques were noticed. Metaregression analysis failed to identify independent predictors of splenic infarction, blood loss, and operative time among general variables. CONCLUSIONS: Although Kimura and Warshaw SPDP have been demonstrated comparable for most of postoperative outcomes, the former resulted superior compared to the latter in reducing the risk of splenic infarction and gastric varices. For benign pancreatic tumors and low-grade malignancies Kimura SPDP may be preferred.

Splenic vessels preserving versus Warshaw technique in spleen preserving distal pancreatectomy: A systematic review and meta-analysis.

BACKGROUND: Spleen-preserving distal pancreatectomy is widely used to remove benign or low-grade malignant neoplasms located in the pancreatic body and tail. Both splenic vessels preserving (SVP-DP) and splenic vessels ligating (Warshaw technique [WT]) distal pancreatectomy are safe and effective methods but which technique is superior remains controversial. Thus, this study aimed to evaluate the clinical outcomes of patients who underwent both methods. MATERIAL AND METHODS: Major databases, including PubMed, Embase, Science Citation Index Expanded, and The Cochrane Library, were searched for studies comparing SVP-DP and the WT for spleen-preserving distal pancreatectomy up to December 2021. The perioperative and postoperative outcomes were compared between the SVP-DP and WT groups. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects models. RESULTS: Twenty retrospective studies with 2173 patients were analyzed. A total of 1467 (67.5%) patients underwent SVP-DP, while 706 (32.5%) patients underwent WT. Patients in the SVP-DP group had a significantly lower rate of splenic infarction (OR: 0.17; 95% CI, 0.11-0.25; P < 0.00001) and incidence of gastric varices (OR: 0.19; 95% CI, 0.11-0.32; P < 0.00001) compared to the patients in the WT group; furthermore, they had a shorter length of hospital stay (WMD: 0.71; 95% CI, -1.13 to -0.29; P = 0.0008). There were no significant differences between the two groups in terms of major complication, postoperative pancreatic fistula (B/C), reoperation, blood loss, or operation time. CONCLUSIONS: Compared to WT, SVP-DP should be preferred to reduce splenic infarction and gastric varices, and WT may be more suitable for large tumors. Moreover, considering the shortcomings of retrospective study, a multicenter randomized controlled study with a large sample size should be conducted to verify our results.

An infarcted wandering spleen leading to a sigmoid volvulus presenting with acute large bowel obstruction: a case report.

A wandering spleen is a very rare event characterised by the absence of the spleen in its anatomical position due to the hyperlaxity of its ligaments. We present a case of wandering spleen complicated by splenic vascular pedicle torsion, thrombosis and subsequent splenic infarction. Compression of the infarcted spleen on the rectosigmoid junction led to the development of a sigmoid volvulus, which presented as an acute large bowel obstruction. The patient underwent emergency laparotomy, splenectomy, sigmoid decompression and sigmoidopexy. After a follow-up period of two years, the volvulus had not recurred.

Clostridium tertium Peritonitis and Bacteremia in a Neonate With Congenital Intestinal Atresia: A Case Report.

We report a 1-day-old girl who was affected by peritonitis and bacteremia caused by Clostridium tertium following perforation of congenital intestinal atresia. Splenic infarction was also suspected during C. tertium bacteremia. C. tertium was identified by using mass spectrometry and 16S rRNA sequencing. This patient was successfully treated with emergency laparotomy and broad-spectrum antibiotics.

Infarto esplénico como complicación de gastrectomía vertical laparoscópica. Reporte de caso / Splenic infarction as a complication of laparoscopic vertical gastrectomy. Case report

La gastrectomía vertical laparoscópica es actualmente la cirugía bariátrica más empleada a nivel mundial. Aunque es un procedimiento seguro y efectivo pueden ocurrir complicaciones mayores. En el presente trabajo reportamos el caso de un infarto y absceso esplénico como una rara complicación de esta técnica, que requirió finalmente de esplenectomía como tratamiento definitivo. Caso clínico: Mujer de 22 años con obesidad grado I, a quien se le practicó gastrectomía vertical laparoscópica con buena evolución intrahospitalaria y egreso a las 48 horas. Al 4to día posoperatorio consultó por fiebre, dolor abdominal, taquipnea y taquicardia. Mediante tomografía computada de abdomen se diagnosticó infarto esplénico parcial. Recibió tratamiento médico con remisión inicial de los síntomas, los cuales reaparecieron a la 3era semana. Se reinició el tratamiento médico, esta vez sin respuesta, y con evolución al absceso esplénico. Se decidió esplenectomía como tratamiento definitivo logrando la recuperación completa de la paciente. Conclusión: El infarto esplénico es una complicación infrecuente de la gastrectomía vertical. Su tratamiento inicial es médico, reservando la esplenectomía para los casos que no responden(AU)

Laparoscopic sleeve gastrectomy is currently the most performed bariatric surgery worldwide. Although it is an effective and safe procedure major complications can occur. In the present manuscript we report a case of splenic infarct and abscess as a rare complication of laparoscopic sleeve gastrectomy, finally requiring a splenectomy as a definitive treatment. Case report: A 22 years old woman with grade I obesity underwent laparoscopic sleeve gastrectomy with good hospital evolution and 48 hours discharge. On the 4th postoperative day she return because fever, abdominal pain, tachypnea and tachycardia. By means of a computed tomography a splenic infarct was diagnosed. She received medical treatment with initial remission of symptoms, which reappear at the third week. Medical treatment was restarted, this time without success, and with progression to splenic abscess. We decided a splenectomy as definitive treatment achieving a complete patient recovery. Conclusion: Splenic infarction is a rare complication after sleeve gastrectomy. The treatment is non surgical, reserving the splenectomy for the non responded cases(AU)

Massive Splenic Infarction in a Child With Sickle Cell Disease on Chronic Transfusion Therapy.

Massive splenic infarction (MSI) is a rare complication of sickle cell disease, as the spleen generally atrophies within the first few years of life. We report a case of MSI in a 12-year-old boy with homozygous sickle cell anemia (Hb SS) whose chronic transfusion therapy resulted in hypersplenism. The occurrence of a complicated MSI in our patient should perhaps further encourage elective splenectomy in such patients, despite known potential perioperative complications and postsplenectomy risks of infection and thrombosis.

Infarcted accessory spleen masquerading as a mesenteric cyst.

An accessory spleen is a rare entity which is usually asymptomatic. When symptomatic, it presents as an acute abdomen, with either torsion, rupture or haemorrhage. We present the case of a 20-year-old man who presented with chronic lower abdominal pain since 3 months and a lump in the left lower quadrant. On clinical examination and investigations, the lump was diagnosed as a mesenteric cyst, and an uncomplicated laparoscopic excision was performed. The postoperative histopathological examination reported it as an infarcted accessory spleen.

Streptococcus agalactiae infective endocarditis complicated by multiple mycotic hepatic aneurysms and massive splenic infarction: a case report.

BACKGROUND: The burden of disease caused by Streptococcus agalactiae has increased significantly among older adults in the last decades. Group B streptococcus infection can be associated with invasive disease and severe clinical syndromes, such as meningitis and endocarditis. CASE PRESENTATION: We present the case of a 56-year-old man who developed multiple mycotic aneurysms of the right hepatic artery and massive splenic infarction as rare complications of Streptococcus agalactiae infective endocarditis. The patient underwent urgent right hepatic artery ligation and splenectomy. The postoperative course was complicated by an episode of hemobilia due to the rupture of a partially thrombosed mycotic aneurysm into the biliary tree. Thus, selective radiological embolization of the left hepatic artery branches was necessary. CONCLUSION: To our knowledge, this is the first case reported of infected aneurysms of visceral arteries caused by Group B streptococcus infection. Clinical and laboratory findings were non-specific, while imaging features with computed tomography scan and angiography were highly suggestive. In our case, early recognition, culture-specific intravenous antibiotics and urgent surgical treatment combined with interventional radiology played a decisive role in the final result.

Bilobate wandering spleen with doble torsion of the vascular pedicle. A case report.

INTRODUCTION: Wandering spleen is a rare clinical condition which is often an incidental finding. It is characterized by excessive mobility and displacement of the spleen within the abdomen; although the spleen is usually of normal size it has an elongated vascular pedicle . CASE STUDY: We present the case of an adult woman who complaining of abdominal pain who was brought to our institution for emergency treatment. She later developed an acute abdomen due to infarction of a wandering spleen caused by double torsion of the vascular pedicle. Emergency splenectomy was performed. RESULTS: Surgical treatment of a wandering spleen is generally conservative and consists in splenoplexy. In our case, complicated by ischemia leading to irreversible damage of the spleen, splenectomy was the solution. DISCUSSION: The long vascular pedicle of a migrant spleen is at risk of torsion which can cause irreversible acute ischemia of the spleen. Therefore a timely diagnosis with the use of modern imaging techniques is of primary importance. CONCLUSIONS: Early interpretation of the symptoms and computed tomography angiography can prevent the complications that result from torsion of the elongated pedicle. KEY WORDS: Acute abdomen, Bilobate wandering spleen, Splenectomy.

Surgical treatment for thoracoabdominal intra-aortic thrombus with multiple infarctions: a case report.

BACKGROUND: Mobile intra-aortic thrombus without atherosclerosis, aneurysm, or congenital coagulopathy is very rare, and there are few reports especially in young or middle-aged patients. Furthermore, there are presently no established guidelines or common strategies for the treatment of mobile intra-aortic thrombus. In this case report, we describe the first case of intra-aortic thrombus caused by secondary erythrocytosis and describe the recommended treatment strategy for intra-aortic thrombus. CASE PRESENTATION: We report a case of an independent 40-year-old Asian man with a current history of heavy cigarette smoking who had sudden onset of abdominal and lumbar pain. Contrast-enhanced computed tomography revealed partial renal and splenic infarction, and he was transferred to our hospital. He also had a large mural thrombus in his thoracoabdominal aorta. Blood analysis on admission showed a hemoglobin level of 19.4 g/dL and hematocrit of 54.3 %; his international normalized ratio of prothrombin time, fibrin degradation products, and activated partial thromboplastin time levels were 1.02, 2.8 µg/ml, and 26.9 seconds respectively. We could find no abnormalities in protein C and protein S activity levels. Lupus anticoagulant and anti-cardiolipin antibody were both negative. He had no past medical history of arrhythmia and we found no signs of an arrhythmic event during admission. We promptly started anticoagulant therapy, but as the thrombus seemed at high risk of causing further critical infarction, we performed emergency aortic thrombectomy using partial extracorporeal circulation. To prevent dissemination of the thrombus during extracorporeal circulation, we first clamped his proximal and distal aorta on either side of the thrombus just before initiating extracorporeal circulation. After the aortotomy we removed a 14-cm length of intra-aortic thrombus without residual lesion. He was discharged from our hospital 20 days after surgery. From the results of his blood analysis, we considered the only cause of this thrombus was secondary erythrocytosis, which was probably induced by his current heavy cigarette smoking. CONCLUSION: We are the first to report such a thrombosis caused by secondary erythrocytosis and conclude that once the diagnosis of intra-aortic thrombus with systemic embolism is clear, emergency surgical removal of such a thrombus must be considered to prevent further embolic complications.