Combined division of the splenic vein a safe method for distal pancreatectomy

Safety of combined division vs separate division of the splenic vein in patients undergoing distal pancreatectomy

1. In distal pancreatectomy procedures, combined division of the splenic vein with the pancreatic parenchyma had no difference in safety compared to the conventional, separated division method.

Evidence Rating Level: 1 (Excellent)

In a distal pancreatectomy (DP) procedure, apart from dissecting the pancreas, surgeons conventionally dissect the splenic artery and vein after isolating them from the pancreas parenchyma. The logic of this isolation was to prevent potential pancreatic fistulas (PFs) and intra-abdominal hemorrhage, which is reported in 1-8% of DP patients. However, a simpler method is dissecting the splenic vein and pancreatic parenchyma together, although the safety of this technique has not previously been investigated. Therefore, the aim of this multicentre, phase 3 randomized controlled trial, was to establish the non-inferiority of the combined resection versus separated resection of the splenic vein in DP procedures. There were 316 patients overall (159 in the intent-to-treat separate division, 157 in the intent-to-treat combined division), with procedures done in 45 institutions in Japan between 2016 and 2019. The primary outcome measured was the incidence of grade B/C PF. In the separate division group, the incidence was 27.1% (42 patients), compared to 28.6% (44 patients) in the combined division (odds ratio 1.108, 95% CI 0.847-1.225, p = 0.047). Additionally, there were no differences in operative time, blood loss, or incidence of postoperative intra-abdominal hemorrhage (only 2 patients in each group experienced this). Although there was a higher incidence of pancreatic injury, such as laceration, in the combined group, the difference was not statistically significant (5.9% versus 2.0%, p = 0.14). Overall, the study demonstrated non-inferiority of the technique involving dissection of the pancreatic parenchyma combined with the splenic vein, compared to the technique involving separate dissection, for distal pancreatectomy procedures.

Image: PD

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