Pancreas: Distal Pancreatectomy

Basics

• Resection of the Pancreatic Body & Tail to the Left of the SMA/SMV
• Indications:
  • Chronic Pancreatitis with Small-Normal Ducts & Isolated to Tail
  • Distal Cyst Concerning for Malignancy
  • Distal Pancreatic Exocrine Cancer
  • Distal PNET
  • Metastases
  • Trauma
• Preform Staging Laparoscopy If Concerned for Malignancy

Technique

• Retrograde Pancreatectomy
  • Conventional Approach
  • Procedure:
    • Enter Lesser Sac – Divide Gastrocolic Ligament & Mobilize Omentum
    • Mobilize Stomach – Ligate Gastrosplenic Ligament & Retract Cranially
    • Mobilize Pancreatic Body/Tail – Spare Splenic Artery/Vein
    • Transect Pancreas
    • Consider Splenic Resection
    • If for Malignancy – Send Tissue from Transection Margin for Frozen Section
• Radical Antegrade Modular Pancreaticosplenectomy (RAMPS) Procedure
  • Provides More Extensive Lymph Node Dissection
  • Procedure:
    • Early Transection of Pancreas & Splenic Vessels
    • Celiac Node Dissection
    • Dissect Laterally
    • Resects Distal Pancreas & Spleen

Spleen Management

• Always Vaccinate Preoperatively (Splenectomy is Commonly Performed)
• Concurrent Splenectomy
  • Indications: High-Concern for Malignancy
    • Chronic Pancreatitis – Consider Preserving Although May Be Very Difficult with Inflammatory Adherence to Splenic Vein
  • Ligate: Splenic Artery (First), Then IMV & Finally Splenic Vein
    • May Preserve IMV if it is Proximal to Lesion or Enters SMV
• Spleen Preserving
  • Indications: Benign or Cystic Mass
  • Ligate: Individual Branches off Splenic Artery/Vein & IMV
    • May Preserve IMV if it is Proximal to Lesion or Enters SMV

Complications

• Pancreatic Fistula (Most Common) (30-40%)
  • Related More to Patient-Factors Than Operative-Technique
  • Risk Factors: Age ≥ 60, Obesity, Malnutrition, Absence of Epidural, Nonmalignant Pathology, Concomitant Splenectomy or Vascular Reconstruction
    • Not Impacted by Method of Resection, etc.
• Endocrine Insufficiency – New-Onset DM
  • Higher Risk if Preformed for Pancreatitis
• Splenic Vein Thrombosis
• Bleeding
• Infection/Abscess