The natural history and long-term follow-up of splenic artery aneurysms.

OBJECTIVE: Although splenic artery aneurysms (SAAs) are the most common visceral aneurysm, there is a paucity of literature on the behavior of these entities. The objective of this study was to review the natural history of patients with SAA. METHODS: This single-institution, retrospective analysis studied patients with SAA diagnosed by computed tomography imaging between 2015 and 2019, identified by our institutional radiology database. Imaging, demographic, and clinical data were obtained via the electronic medical record. The growth rate was calculated for patients with radiologic follow-up. RESULTS: The cohort consisted of 853 patients with 890 SAAs, of whom 692 were female (81.2%). There were 37 women (5.3%) of childbearing age (15-50 years). The mean age at diagnosis was 70.9 years (range: 28-100 years). Frequently observed medical comorbidities included hypertension (70.2%), hypercholesterolemia (54.7%), and prior smoking (32.2%). Imaging indications included abdominal pain (37.3%), unrelated follow-up (28.0%), and follow-up of a previously noted visceral artery aneurysm (8.6%). The mean diameter at diagnosis was 13.3 ± 6.3 mm. Anatomic locations included the splenic hilum (36.0%), distal splenic artery (30.3%), midsplenic artery (23.9%), and proximal splenic artery (9.7%). Radiographically, the majority were saccular aneurysms (72.4%) with calcifications (88.5%). One patient (38-year-old woman) was initially diagnosed at the time of rupture of a 25 mm aneurysm; this patient underwent immediate endovascular intervention with no complications. The mean clinical follow-up among 812 patients was 4.1 ± 4.0 years, and the mean radiological follow-up among 514 patients was 3.8 ± 6.8 years. Of the latter, 122 patients (23.7%) experienced growth. Aneurysm growth rates for initial sizes <10 mm (n = 123), 10 to 19 mm (n = 353), 20 to 29 mm (n = 34), and >30 mm (n = 4) were 0.166 mm/y, 0.172 mm/y, 0.383 mm/y, and 0.246 mm/y, respectively. Of the entire cohort, 27 patients (3.2%) eventually underwent intervention (81.5% endovascular), with the most common indications including size/growth criteria (70.4%) and symptom development (18.5%). On multivariate analysis, only prior tobacco use was significantly associated with aneurysm growth (P = .028). CONCLUSIONS: The majority of SAAs in this cohort remained stable in size, with few patients requiring intervention over a mean follow-up of 4 years. Current guidelines recommending treatment of asymptomatic aneurysms >30 mm appear appropriate given their slow progression. Despite societal recommendations for intervention for all SAAs among women of childbearing age, only a minority underwent vascular surgical consultation and intervention in this series, indicating that these recommendations are likely not well known in the general medical community.

Prognostic impact of the distance from the root of splenic artery to tumor in the patients with pancreatic body or tail cancer.

BACKGROUND: The impact of the distance from the root of splenic artery to tumor (DST) on the prognosis and optimal surgical procedures in the patients with pancreatic body/tail cancer has been unclear. METHODS: We retrospectively analyzed 94 patients who underwent distal pancreatectomy (DP) and 17 patients who underwent DP with celiac axis resection (DP-CAR) between 2008 and 2018. RESULTS: The 111 patients were assigned by DST length (in mm) as DST = 0: n = 14, 0

Clinical Outcomes of Splenic Artery Embolization Versus Splenectomy in the Management of Hemodynamically Stable High-Grade Blunt Splenic Injuries: A National Analysis.

INTRODUCTION: This study aims to compare the outcomes of splenic artery embolization (SAE) versus splenectomy in adult trauma patients with high-grade blunt splenic injuries. METHODS: This retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2021) compared SAE versus splenectomy in adults with blunt high-grade splenic injuries (grade ≥ IV). Patients were stratified first by hemodynamic status then splenic injury grade. Outcomes included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and transfusion requirements at four and 24 h from arrival. RESULTS: Three thousand one hundred nine hemodynamically stable patients were analyzed, with 2975 (95.7%) undergoing splenectomy and 134 (4.3%) with SAE. One thousand eight hundred sixty five patients had grade IV splenic injuries, and 1244 had grade V. Patients managed with SAE had 72% lower odds of in-hospital mortality (odds ratio [OR] 0.28; P = 0.002), significantly shorter ICU-LOS (7 versus 9 d, 95%, P = 0.028), and received a mean of 1606 mL less packed red blood cells at four h compared to those undergoing splenectomy. Patients with grade IV or V injuries both had significantly lower odds of mortality (IV: OR 0.153, P < 0.001; V: OR 0.365, P = 0.041) and were given less packed red blood cells within four h when treated with SAE (2056 mL versus 405 mL, P < 0.001). CONCLUSIONS: SAE may be a safer and more effective management approach for hemodynamically stable adult trauma patients with high-grade blunt splenic injuries, as demonstrated by its association with significantly lower rates of in-hospital mortality, shorter ICU-LOS, and lower transfusion requirements compared to splenectomy.

Scope transition and early arterial inflow control provide safe and comfortable dissection in robotic distal pancreatectomy.

PURPOSE: We describe details and outcomes of a novel technique for optimizing the surgical field during robotic distal pancreatectomy (RDP) for distal pancreatic lesions, which has become common with potential advantages over laparoscopic surgery. METHODS: For suprapancreatic lymph node dissection and splenic artery ligation, we used the basic center position with a scope through the midline port. During manipulation of the perisplenic area, the left position was used by moving the scope to the left medial side. The left lateral position is optionally used by moving the scope to the left lateral port when scope access to the perisplenic area is difficult. In addition, early splenic artery clipping and short gastric artery dissection for inflow block were performed to minimize bleeding around the spleen. We evaluated retrospectively the surgical outcomes of our method using a scoring system that allocated one point for blood inflow control and one point for optimizing the surgical view in the left position. RESULTS: We analyzed 34 patients who underwent RDP or R-radical antegrade modular pancreatosplenectomy (RAMPS). The left position was applied in 14 patients, and the left lateral position was applied in 6. Based on the scoring system, only the 0-point group (n = 8) had four bleeding cases (50%) with splenic injury or blood pooling; the other 1-point or 2-point groups (n = 13, respectively) had no bleeding cases (p = 0.0046). CONCLUSION: Optimization of the surgical field using scope transition and inflow control ensured safe dissection during RDP.

Anastomosis selection in liver transplantation for recipients with unusable recipient hepatic arteries: a bayesian network meta-analysis.

BACKGROUND: The anastomosis of donor and recipient hepatic arteries is standard in liver transplantations. For transplant recipients with unusable hepatic arteries, appropriate artery selection should be conducted using evidence-based considerations; therefore, this network meta-analysis (NMA) aimed to analyze the most suitable alternative recipient artery for anastomosis during liver transplantations. METHODS: Comprehensive searches of the Scopus, Cochrane Library, and MEDLINE databases were conducted to analyze observational studies containing non-standard anastomoses in liver transplantations that used the splenic artery, aorta, celiac, or branches of the gastric artery. The outcome parameters included intraoperative components, complications, and survival data. This NMA used the BUGSnet package in R studio and the results were presented in a Forest plot, league table, and SUCRA plot. RESULTS: Among the 13 studies included in this NMA, 5 arteries were used for the anastomoses. The splenic artery anastomosis showed a high risk of thrombosis and a low risk of stenosis (OR 1.12, 95% CI 0.13-3.14) and biliary tract abnormalities (OR 0.79, 95% CI 0.36-1.55). In addition, the graft survival (OR 1.08; 95% CI 0.96-1.23) and overall survival (1-year survival OR 1.09, 95% CI 0.94-1.26; 5-year survival OR 1.95% CI 0.83-1.22) showed favorable results using this artery. Constraints to the use of the splenic artery were longer operation and cold ischemic times. However, the duration of hospital stay (MD 1.36, 95% CI -7.47 to 10.8) was shorter than that when the other arteries were used, and the need for blood transfusions was minimal (MD -1.74, 95% CI -10.2 to 6.7). CONCLUSION: In recipients with unusable hepatic arteries, the splenic artery of the patient should be the first consideration for anastomosis selection in liver transplantations.

Perioperative proximal splenic artery embolization in cirrhotic patients with splenomegaly.

INTRODUCTION: The purpose of this study was to determine the effect of proximal splenic artery embolization (SAE) in cirrhotic patients with splenomegaly who underwent surgical laparotomy. MATERIAL AND METHODS: This retrospective observational study included 8 cirrhotic patients with splenomegaly. They underwent proximal SAE before- (n = 6) or after (n = 2) laparotomy. Vascular plugs or coils were placed in the proximal splenic artery. The diameter of the portal vein and the splenic volume were recorded. Clinical outcome assessments included platelet counts, the model for end-stage liver disease (MELD) score, and complications. RESULTS: After embolization, the portal venous diameter was significantly smaller (pre: 13.6 ± 2.7 mm, post: 12.5 ± 2.3 mm, p = 0.023), the splenic volume was significantly decreased (pre: 463.2 ± 145.7 ml, post: 373.3 ± 108.5 ml, p = 0.008) and the platelet count was significantly higher (pre: 69.6 ± 30.8 × 103/µl, post: 86.8 ± 27.7 × 103/µl, p = 0.035). Before embolization, the median MELD score was 12; after embolization, it was 11 (p = 0.026). No patient developed post-treatment complications after embolization. CONCLUSIONS: The reduction of hypersplenism by perioperative proximal SAE may be safe and reduce the surgical risk in cirrhotic patients with splenomegaly.

Splenic artery pathology presentation, operative interventions, and outcomes in 88 patients with vascular Ehlers-Danlos syndrome.

OBJECTIVE: Vascular Ehlers-Danlos syndrome (VEDS) is rare and associated with arteriopathies. The aim of this study is to investigate the presentation, operative interventions, and outcomes of splenic arterial pathology in a population of more than 1500 individuals with genetically confirmed VEDS due to pathogenic COL3A1 variants. METHODS: Cross-sectional analysis of 1547 individuals was performed. The data were assembled by harmonizing data from three overlapping cohorts with genetically confirmed VEDS: the VEDS Collaborative Natural History Study (N = 242), a single-center cohort (N = 75), and the University of Washington Collagen Diagnostic Lab cohort (N = 1231). Duplicates were identified and removed. Patients were selected for analysis if they had splenic artery aneurysm (SAA), pseudoaneurysm, dissection, thrombosis, or rupture. Demographics, COL3A1 variants, interventions, and outcomes were analyzed. Comparisons by splenic artery rupture were made. RESULTS: A total of 88 patients presented between 1992 and 2021 with splenic artery pathology (5.7% of the cohort; mean age at diagnosis, 37 ± 11.1 years; 50% male). One-third were diagnosed with VEDS prior to the splenic artery pathology diagnosis, and 17% were diagnosed post-mortem. Most had a positive family history (61%). Most had COL3A1 variants associated with minimal normal collagen production (71.6%). Median follow up was 8.5 years (interquartile range, 0.9-14.7 years). Initial presentation was rupture in 47% of the cases. Splenic artery rupture overall was 51% (n = 45), including four cases of splenic rupture. There were no major differences in VEDS-related manifestations or COL3A1 variant type by rupture status. SAA was noted in 39% of the cases. Only 12 patients had splenic artery diameter documented in 12 cases with a median diameter of 12 mm (interquartile range, 10.3-19.3 mm). A total of 34 patients (38.6%) underwent 40 splenic arterial interventions: 21 open surgical, 18 embolization, and one unknown procedure. More than one splenic artery intervention was performed in five cases (14.7%). Open repair complications included arteriovenous fistula (n = 1), intestinal or pancreatic injury (n = 1 each), and four intraoperative deaths. There were no deaths or access site complications related to splenic artery embolization. Four patients (23.5%) developed a new SAA in the remaining splenic artery post embolization. All-cause mortality was 35% (n = 31), including 22 related to a ruptured splenic artery. CONCLUSIONS: Splenic arteriopathy in VEDS is associated with variants that affect the structure and secretion of type III collagen and frequently present with rupture. Rupture and open repair are associated with high morbidity and mortality, whereas embolization is associated with favorable outcomes. Suggest repair considerations at SAA diameter of 15 mm. Long-term follow-up is indicated as secondary splenic arteriopathy can occur.

Surgical anatomy of the dorsal pancreatic artery: Considering embryonic development.

OBJECTIVES: The dorsal pancreatic artery (DPA) is a pancreatic branch with various anatomical variations. Previous studies mostly focused on the origin of the DPA, and its pathways and branching patterns have rarely been examined. The purpose of this study was to investigate the branching patterns and pathways of the DPA. METHODS: This study included 110 patients who underwent computed tomography scans. We examined the pathways and branching patterns of the DPA. RESULTS: The DPA was identified in 101 patients (92%), and originated from the splenic artery in 30 patients (31%), the common hepatic artery in 17 patients (17%), the celiac trunk in 10 patients (10%), the superior mesenteric artery in 27 patients (27%), the replaced right hepatic artery in 7 patients (7%), the inferior pancreaticoduodenal artery in 5 patients (5%), and other arteries in 3 patients (3%). Four distinct types of branches were identified as follows: the superior branch (32%), the inferior branch (86%), the right branch (80%), and the accessory middle colic artery (12%). Additionally, the arcs of Buhler and Riolan were observed in two patients each and their anastomotic vessels followed almost the same pathway as the DPA. CONCLUSION: A number of variations of the DPA were observed with regard to its origin and branching pattern; however, the DPA and its branches always ran along the same pathway, as summarized in Fig. 4. The anatomical information gained from this study may contribute to performing safe pancreatic resections.

Splenic Artery Steal Syndrome in Patients with Liver Cirrhosis: A Retrospective Clinical Study.

BACKGROUND Splenic artery steal syndrome (SASS) can aggravate liver damage in patients with cirrhosis. This study explored whether SASS could be an effective therapeutic target for improving hepatic artery perfusion and liver function in patients with decompensated cirrhosis. MATERIAL AND METHODS Based on inclusion and exclusion criteria, 87 patients with hepatitis B cirrhosis and portal hypertension hypersplenism admitted to our General Surgery Department for splenectomy and pericardial devascularization surgery were selected. A total of 35 cases met the diagnostic criteria of SASS and were assigned to the SASS group; the remaining 52 cases were assigned to the control group. The indicators before, during, and after surgery were compared between the 2 groups. RESULTS There were no significant differences in preoperative and intraoperative indicators between SASS group and control group (P>0.05). The MELD score 7 days after surgery and the hepatic artery diameter and hepatic artery velocity 14 days after surgery in both groups were significantly better than before surgery. The MELD score 7 days after surgery in the SASS group was significantly better than that in the control group, and the hepatic artery diameter and hepatic artery velocity 14 days after surgery in the SASS group were significantly better than those in the control group (P<0.05). CONCLUSIONS Splenectomy and pericardial devascularization surgery was an effective treatment to redirect blood flow to the hepatic artery for cirrhotic patients diagnosed with SASS. The introduction of cirrhotic SASS into clinical practice may benefit more patients with cirrhotic portal hypertension and hypersplenism.

"Parenchyma transection-first" strategy is superior to "tunnel-first" strategy in robotic spleen-preserving distal pancreatectomy with conservation of splenic vessels.

BACKGROUND: Creating a tunnel between the pancreas and splenic vessels followed by pancreatic parenchyma transection ("tunnel-first" strategy) has long been used in spleen-preserving distal pancreatectomy (SPDP) with splenic vessel preservation (Kimura's procedure). However, the operation space is limited in the tunnel, leading to the risks of bleeding and difficulties in suturing. We adopted the pancreatic "parenchyma transection-first" strategy to optimize Kimura's procedure. METHODS: The clinical data of consecutive patients who underwent robotic SPDP with Kimura's procedure between January 2017 and September 2022 at our center were retrieved. The cohort was classified into a "parenchyma transection-first" strategy (P-F) group and a "tunnel-first" strategy (T-F) group and analyzed. RESULTS: A total of 91 patients were enrolled in this cohort, with 49 in the T-F group and 42 in the P-F group. Compared with the T-F group, the P-F group had significantly shorter operative time (146.1 ± 39.2 min vs. 174.9 ± 46.6 min, P < 0.01) and lower estimated blood loss [40.0 (20.0-55.0) mL vs. 50.0 (20.0-100.0) mL, P = 0.03]. Failure of splenic vessel preservation occurred in 10.2% patients in the T-F group and 2.4% in the P-F group (P = 0.14). The grade 3/4 complications were similar between the two groups (P = 0.57). No differences in postoperative pancreatic fistula, abdominal infection or hemorrhage were observed between the two groups. CONCLUSIONS: The pancreatic "parenchyma transection-first" strategy is safe and feasible compared with traditional "tunnel-first strategy" in SPDP with Kimura's procedure.

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.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Anterocranial Splenic Artery-First Approach for Left-Sided Resectable Pancreatic Cancer (with Videos).

BACKGROUND: Laparoscopic radical antegrade modular pancreatosplenectomy (Lap-RAMPS) for left-sided pancreatic cancer remains a technically challenging procedure. How to approach the splenic artery in laparoscopic surgery has not been discussed in adequate detail, and the implications of an artery-first approach in left-sided pancreatic cancer remain unclear. PATIENTS AND METHODS: Forty-five consecutive patients with left-sided resectable pancreatic cancer underwent Lap-RAMPS between July 2018 and September 2020. They were divided according to whether Lap-RAMPS was performed using an anterocranial splenic artery-first (ASF) approach (ASF group, n = 23) or via another approach (non-ASF group, n = 22). Clinical, pathological, and short-term outcomes were reviewed and compared between the groups. RESULTS: The ASF approach was performed safely in all patients with resectable left-sided pancreatic cancer, and none required conversion to laparotomy. The ASF group had better outcomes in terms of conspicuous bleeding from the spleen during splenic mobilization (P = 0.016) and blood pooling during posterior dissection (P = 0.035). Consequently, blood loss was significantly less and operation time was significantly shorter in the ASF group than in the non-ASF group. There was no significant between-group difference in other short-term outcomes, including mortality, length of hospital stay, or Clavien-Dindo classification. CONCLUSIONS: The ASF approach was safe when performed for resectable left-sided pancreatic cancer and may help to prevent congestion of the pancreas and lessen intraoperative blood loss.

Preoperative splenic artery embolism followed by splenectomy is safe and effective in patients with sinistral portal hypertension.

BACKGROUND: Although preoperative splenic artery embolism (SAE) has been widely used for splenomegaly, the efficiency and safety of preoperative SAE in patients with sinistral portal hypertension (SPH) is unknown. METHODS: We designed a retrospective cohort of SPH patients who received preoperative SAE in our hospital (February 2018 to September 2020) and compared to those who received splenectomy only, in terms of intraoperative and postoperative outcomes. RESULTS: In all, 59 patients (18 patients received preoperative SAE) were analyzed. The median age was 44.7 years. Preoperative SAE reduced the intraoperative blood loss (637.0 vs. 420.3 ml, P = 0.041) and operation time (174.0 vs. 141.5 min, P = 0.012). The incidence of complications including postoperative pancreatic fistula (POPF), bleeding, and thromboembolism was comparable. Multivariate analysis showed that SAE was a protective factor for intraoperative blood loss and operation time, while prior pancreatic pseudocyst/abscess was a risk factor. CONCLUSIONS: Preoperative SAE could reduce intraoperative blood loss and operation time in SPH patients without increasing the incidence of complications compared to splenectomy only.

Successful Preoperative Partial Splenic Artery and Aneurysm Embolization for Thrombocytopenia Associated with Failed Fontan Circulation.

Long-term complications after the Fontan procedure are important concerns for patients with pediatric and adult congenital heart disease. Although thrombocytopenia due to portal hypertension and hypersplenism is a well-known complication of the Fontan circulation, few studies have reported on its management. Herein we describe a young adult Fontan patient with thrombocytopenia and a splenic artery aneurysm caused by conduit stenosis. The patient required conduit replacement due to high venous pressure. We performed partial splenic artery embolization (PSE) and embolization of the aneurysm preoperatively to reduce the risk of bleeding, resulting in successful subsequent cardiac surgery. Preoperative evaluation of the splenic artery aneurysm was informative, and PSE was a safe and effective treatment option for thrombocytopenia to avoid bleeding during open-heart surgery in this patient.

Laparoscopic splenic artery aneurysmectomy with ICG guided partial splenectomy: alternative approach.

We herein report the case of a voluminous splenic artery aneurysm (SAA) diagnosed in a 48 year-old Caucasian male patient. After endovascular treatment failure, considering the volumetric aneurysm increase and recurrent symptoms, a laparoscopic splenic artery aneurysmectomy with partial splenectomy guided by indocyanine green fluorescence (ICG) was performed. This conservative strategy leads to save a spleen volume of about 10 cm3 to avoid postsplenectomy thrombocytosis and infections, potential immunodeficiency and overwhelming postsplenectomy infection syndrome (OPSS) and to preserve pancreatic vascularization preventing distal pancreas injuries.

[Selecting the most appropriate surgical treatment of true splenic artery aneurysm]. / Vybor sposoba khirurgicheskogo lecheniya istinnykh anevrizm selezenochnoi arterii.

OBJECTIVE: To analyze the results of diagnosis and treatment of true splenic artery aneurysms. MATERIAL AND METHODS: We analyzed the results of diagnosis and treatment of 27 patients with true splenic artery aneurysm. All ones underwent surgical treatment at the Botkin Municipal Clinical Hospital between 2017 and 2021. Splenic artery aneurysm >1 cm was an indication for surgical treatment. Surgical option depended on aneurysm location. Laparoscopic splenectomy and aneurysmectomy were performed in 4 cases (14.8%), 5 (18.5%) patients underwent endovascular intervention, laparoscopic clipping was performed in 18 (66.7%) cases. Methods of surgical treatment, general and specific postoperative complications according to the Clavien-Dindo and ISGPS classifications were analyzed. RESULTS: Laparoscopic clipping was accompanied by fewer general and specific postoperative complications. Specific complications after laparoscopic splenectomy occurred in 2 patients (BL according to the ISGPS 2016 classification). There was one case of acute pancreatitis after endovascular interventions. In long-term postoperative period, aneurysm recanalization after endovascular intervention was observed in 1 case. CONCLUSION: Surgical treatment of splenic artery aneurysms requires a differentiated approach based on topographic and anatomical assessment of aneurysm relative to the arterial vessel.

Radiographic Splenic Artery Involvement Is a Poor Prognostic Factor in Upfront Surgery for Patients with Resectable Pancreatic Body and Tail Cancer.

PURPOSE: The prognostic impact of radiographic splenic vessel involvement in pancreatic cancer remains unclear. We evaluate its oncological significance in resectable pancreatic body/tail cancer. PATIENTS AND METHODS: We retrospectively review 102 cases of resectable pancreatic cancer and 51 of borderline resectable pancreatic cancer (BRPC) who underwent pancreatectomy for pancreatic body/tail cancer. Resectable pancreatic body/tail cancer was classified into one of three categories based on radiographic splenic vessel involvement. RESULTS: Among 102 cases of resectable pancreatic cancer, 37 (36.3%), 35 (34.3%), and 30 cases (29.4%) were classified as no splenic vessel involvement (Rnone), splenic vein involvement (RV), and splenic artery involvement (RA), respectively. Disease-free survival (DFS) among patients with Rnone, RV, RA, and BRPC was 58.5, 18.4, 10.8, and 9.2 months, respectively. Patients with RV and RA had significantly poorer DFS than patients with Rnone (P = 0.010, P < 0.001, respectively). Median survival among Rnone, RV, RA, and BRPC was 80.6, 23.4, 15.1, and 21.3 months, respectively. Patients with RV and RA had significantly poorer survival than patients with Rnone (P = 0.001, P < 0.001, respectively) and had short survival similar to that of those with BRPC. Multivariate Cox proportional hazard analysis detected preoperative CA19-9 ≥ 37 IU/L, radiologic splenic vein involvement, radiologic splenic artery involvement, intraoperative bleeding ≥ 500 ml, transfusion, positive washing cytology, and noncompletion of adjuvant therapy as independent prognostic factors. CONCLUSIONS: Radiographic splenic artery involvement is a poor prognostic factor in resectable pancreatic body/tail cancer and may have a role in stratification of treatment strategy.

Laparoscopic partial splenectomy with temporary occlusion of the trunk of the splenic artery in fifty-one cases: experience at a single center.

BACKGROUND: Laparoscopic partial splenectomy (LPS) for splenic benign space-occupying lesions has been reported by many researchers; however, few studies have described methods to control intraoperative bleeding. Trustworthy experience in LPS with a satisfactory intraoperative hemorrhage control technique is therefore necessary. The current study aims to present our experience in LPS with temporary occlusion of the trunk of the splenic artery for controlling intraoperative bleeding with a large sample of 51 cases and to evaluate the safety, feasibility, and reproducibility of this technique. METHODS: Fifty-one patients from August 2014 to April 2019 who underwent LPS in our institution were retrospectively analyzed. Surgical techniques were described in detail. RESULTS: All patients had successfully undergone LPS with temporary occlusion of the trunk of the splenic artery. Conversions to open surgery, hand-assisted laparoscopic splenectomies, or blood transfusions were not needed. The operative time was 94.75 ± 18.91 min, the estimated blood loss was 71.13 ± 53.87 ml, and the volume of resected spleen was 34.75 ± 12.19%. The range of postoperative stays was 4-14 days. One female patient (2%, 1/51) suffered from postoperative complications. No perioperative mortality, incision infections, postoperative pancreatic fistulas (POPFs), splenic infarctions, or portal/splenic vein thromboembolic events occurred. CONCLUSION: LPS is an effective spleen-preserving surgery. Although there are many other bleeding control methods, temporarily occluding the trunk of the splenic artery was found to be a safe, feasible, and reproducible technique in LPS. The outcomes of this technique and the efficacy of splenic parenchyma preservation are acceptable.

Retrograde artery first approach for "shoulder" pancreatic cancers in minimally invasive distal pancreatectomy.

BACKGROUND: "Shoulder" pancreatic cancer, defined as tumor located at the confluence where the splenic vein meets the portal vein, has specific adjacent anatomies. It's difficult to resect this type of tumor with adequate regional lymphadenectomy. METHODS: We described a new concept of "shoulder" pancreatic cancer, and retrospectively analyzed eleven consecutive cases from September 2019 to April 2020, to assess the safety and efficacy of the retrograde artery first approach in minimally invasive distal pancreatectomy. The primary outcome was set as radical (R0) resection rate. RESULTS: All of the 11 cases achieved R0 resection, with a median of 8 (range 5-32) lymph nodes harvested, given the ratio of embraced splenic vein in 72.7% of the cases, splenic artery embracement in 45.5%, and SMV-PV wall invasion in 27.3%. The maximum tumor size on pathology was 35 (range 20-65) mm. The median operative time was 260 (range 155-470) min, and the median estimated blood loss was 200 (range 50-1000) ml. One case needed intraoperative transfusion. One grade B postoperative pancreatic fistula occurred accompanied with abdominal infection, while the rest of cases recovered uneventful. The median postoperative length of stay was 9 (range 6-20) days. CONCLUSIONS: "Shoulder" pancreatic cancers are clinically significant. Retrograde artery first approach is a potentially safe and effective alternative to achieve a radical resection margin for shoulder pancreatic cancers in minimally invasive era. More evidences are needed in the future.