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UNUSUAL CASE
Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 249-252
 

Laparoscopic splenic vessels and spleen-preserving extended distal pancreatectomy for single metastatic renal cell carcinoma


Department of Surgery, Bankstown-Lidcombe Hospital, University of New South Wales, Bankstown, NSW, Australia

Date of Submission23-Jun-2018
Date of Acceptance17-Sep-2018
Date of Web Publication4-Jun-2019

Correspondence Address:
Christophe Roger Berney
Department of Surgery, Bankstown-Lidcombe Hospital, University of New South Wales, Eldridge Road, Bankstown NSW 2200
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_150_18

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 ¤ Abstract 

Laparoscopic splenic vessels and spleen-preserving (SVSP) distal pancreatectomy has been recommended to reduce long-term risk of developing infectious complications. Due to its technical challenge, most cases relate to <50% of the pancreatic gland being excised. We present our first case of a patient incidentally found to have a solitary pancreatic metastatic renal cell carcinoma (RCC), following left nephrectomy for kidney cancer 15 years ago. He underwent laparoscopic SVSP-extended distal pancreatectomy (EDP). Final histopathology confirmed the diagnosis and margins were clear. He made a good recovery and despite loosing >70% of his pancreas, hasn't developed new-onset diabetes. No adjuvant chemotherapy was necessary, but he will require long-term follow-up. This case suggests that even when the pancreatic lesion is located more proximally, near or at the pancreatic neck, laparoscopic SVSP-EDP may still be considered a safe and preferable option despite its greater complexity, increased intraoperative bleeding risk and longer operative time.


Keywords: Extended distal pancreatectomy, laparoscopic, metastatic renal cell carcinoma, splenic vessels spleen-preserving


How to cite this article:
Berney CR. Laparoscopic splenic vessels and spleen-preserving extended distal pancreatectomy for single metastatic renal cell carcinoma. J Min Access Surg 2019;15:249-52

How to cite this URL:
Berney CR. Laparoscopic splenic vessels and spleen-preserving extended distal pancreatectomy for single metastatic renal cell carcinoma. J Min Access Surg [serial online] 2019 [cited 2019 Jun 18];15:249-52. Available from: http://www.journalofmas.com/text.asp?2019/15/3/249/249436



 ¤ Introduction Top


Metastatic disease to the pancreas is uncommon and accounts for <5% of all pancreatic malignancies.[1] Most pancreatic metastases originate from renal cell carcinomas (RCCs) and seem to have higher survival rates compared to non-RCC surgically resected secondaries.[2],[3]

Laparoscopic distal pancreatectomy (DP), which is considered the preferred option for benign or low-grade primary malignant tumours located in the pancreatic tail traditionally includes 'en bloc' splenectomy that may significantly influence post-surgical outcome.[4] Consequently, and following the original spleen preservation DP technique described in 1998 by Warshaw,[5] laparoscopic upper gastrointestinal surgeons progressively started adopting this new approach[6] that essentially divides the splenic vessels, so the spleen only receives its blood supply from the short gastric and left gastroepiploic vessels. Unfortunately, Warshaw's technique also carries a considerable risk of secondary splenic infarction that may lead to splenectomy or long-term formation of perigastric varices.[7]

Following Kimura's innovative work that minimises these long-term complication risks,[8] this procedure has further evolved to a surgically more challenging yet physiologically superior splenic vessels and spleen-preserving (SVSP) approach, which is slowly gaining popularity worldwide. This trend is substantiated by several recent meta-analyses comparing these two spleen-preserving techniques (Warshaw's vs. SVSP) during laparoscopic DP.[9],[10],[11],[12],[13] However, due to its significantly higher degree of difficulty, most SVSP cases are only performed when <50% of the pancreatic gland needs to be excised.


 ¤ Case Report Top


This is our unit's first case of a 59-year-old man with medical history of left nephrectomy for kidney cancer 15 years ago who was incidentally found to have a pancreatic lesion during routine ultrasound (US). Subsequent abdominal/chest computed tomography and 68-Gallium DOTATATE positron emission tomography Scans, along with Endoscopic US, confirmed the diagnosis of solitary metastatic RCC. His case was discussed at our multidisciplinary oncology meeting, unanimously recommending curative surgical excision of the lesion. Due to its size (2.7 cm) and location (pancreatic neck), simple enucleation was not an option, and the patient was offered elective laparoscopic SVSP-extended DP (EDP).

The patient was positioned in the supine reverse Trendelenburg position with the primary operator standing between the legs and the first surgical-assistant standing on his right. A four trocars technique was used, with the camera device placed at the umbilicus through a 10-mm Hassan port. After retraction of the stomach superiorly, the gastrocolic ligament was divided, allowing free access to the lesser sac. The distal transverse colon and splenic flexure were then mobilised with spleen exposure. The inferior border of the pancreas was dissected off the retroperitoneum along the embryologic plane, with the division of small pancreatic vessels using clips and ultrasonic coagulating shears (Harmonic scalpel, Ethicon Endosurgery, Cincinnati, OH, USA). The Inferior Mesenteric Vein [IMV, [Figure 1]a] was exposed, followed by progressive dissection and blunt tunnelisation of the retropancreatic space to the right side of the IMV, with the identification of the splenic vein (SV) and splenic artery (SA) as shown in [Figure 1]b. The dorsal pancreatic artery [Figure 1]c was then exposed, clipped and divided. After complete mobilisation of the pancreatic neck and body almost to the level of the splenic-portal vein confluence, a powered articulated endomechanical vascular stapler device (Echelon Flex™, Ethicon Endosurgery) was inserted on the proximal right side of the lesion and gradually closed onto the pancreatic parenchyma for 3 min, before tissue transection at the neck of the pancreas [Figure 1]d. Fibrin sealant (Tisseel, Baxter, Deerfield, IL, USA) was applied at the resection margin to reduce the risk of pancreatic duct leak. Dissection was then carried out distally to the splenic hilum, with meticulous control of all the small feeding pancreatic tributaries being successively clipped [Figure 1]e and [Figure 1]f and divided (>15 in total), while simultaneously preserving the Short Gastric Vessels [SGV, [Figure 1]e and [Figure 1]f]. [Figure 2]a shows 75% of the pancreatic gland totally mobilised and [Figure 2]b demonstrates the final view of the pancreatic bed with complete preservation of the splenic vessels and spleen. The 15 cm long specimen was then removed from the abdominal cavity using an Endocatch bag through an extended 4 cm long left upper quadrant port site and sent off for analysis [Figure 2]c. The black circle [Figure 2]c shows the location of the metastatic RCC and the vertical white line corresponds to the edge of the surgical resection margin. The final histopathology report confirmed the diagnosis of metastatic RCC and margins was clear [Figure 2]d.
Figure 1: Laparoscopic views; (a) Exposed inferior mesenteric vein (IMV); (b) Retropancreatic tunnelisation, exposed splenic artery (SA) and splenic vein (SV); (c) Division dorsal pancreatic artery (DPA); (d) Stapling at pancreatic neck; (e and f) Distal dissection pancreatic gland (SGV: Short gastric vessels)

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Figure 2: (a) Laparoscopic view of fully mobilised and detached pancreatic specimen; (b) Final inspection of pancreatic bed with preserved splenic vessels (SA: Splenic artery, SV: Splenic vein, IMV: Inferior mesenteric vein, SH: Splenic hilum); (c) Macroscopic view of 15 cm long specimen (circle: metastatic RCC; line: resection margin; (d) Metastatic clear cell type renal cell carcinoma on the right (normal pancreatic tissue on the left) (×10)

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Perioperative blood loss was minimal and the patient made a very good recovery, only complicated by a minor chest infection that was successfully treated with antibiotics. Despite losing more than two-thirds of his pancreas he still has not developed new-onset diabetes. No adjuvant chemotherapy will be necessary, but the patient is currently on a long-term follow-up.


 ¤ Discussion Top


Overwhelming post-splenectomy infection syndrome is a devastating complication that may affect almost a third of splenectomy cases within the first 10 years' post-surgery.[14] Therefore, trying to preserve the spleen during pancreatic surgery – whenever oncologically acceptable – should be always considered and discussed with the patient. Warshaw's technique is an easier alternative to SVSP, where the spleen only relies on the short gastric and left gastroepiploic vessels following division of the splenic vessels, but it is also associated with increased risk of splenic infarction and delayed splenectomy.[15]

Laparoscopic SVSP DP is both time and labour intensive, as it requires meticulous division of all small pancreatic vascular branches that enter the pancreatic gland. This is particularly true with regards to the SV that is deeply embedded in the posterior side of the pancreatic parenchyma, making its preservation even more complicated and challenging.[16] Indeed, its small venous tributaries are fragile and may easily break (snap) when intending to divide them, potentially resulting in significant uncontrollable intraoperative bleeding and therefore conversion to open surgery. Unsurprisingly, Worhunsky et al. showed that splenic vessel ligation was favoured over SVSP laparoscopic DP if a greater length of the distal pancreas had to be removed (95 vs. 52 mm).[17] Likewise, most recent meta-analysis comparing preservation versus ligation (Warshaw's technique) of the splenic vessels during laparoscopic DP generally included cases of limited pancreatic tail resection.[9],[10],[11],[12],[13] In comparison, our specimen was 150 mm long.

Due to its technical difficulty, reports on laparoscopic SVSP-EDP or subtotal pancreatectomy still remain very scarce in medical literature since its initial case report of an 87-year-old woman successfully treated using this technique for a high-grade dysplastic cystic lesion of the body-tail of the pancreas.[18] A single series of 10 patients who underwent laparoscopic SVSP-EDP has been recently presented at the Society of American Gastrointestinal and Endoscopic Surgeons,[19] and to our knowledge, no other case report has been published using this technique for metastatic RCC.

Our case report suggests that even when the pancreatic lesion is located more proximally, near or at the pancreatic neck, laparoscopic SVSP-EDP may still be considered a safe and preferable option despite its amplified complexity, mainly due to the considerable increased numbers of short pancreatic venous tributaries that will need to be sequentially identified, clipped and carefully divided within the pancreatic parenchyma. This also means accepting a significantly higher risk of intraoperative bleeding and much longer operative time.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ¤ References Top

1.
Adsay NV, Andea A, Basturk O, Kilinc N, Nassar H, Cheng JD, et al. Secondary tumors of the pancreas: An analysis of a surgical and autopsy database and review of the literature. Virchows Arch 2004;444:527-35.  Back to cited text no. 1
    
2.
Karimi KM, McFadden DW. Pancreatic resection for metastatic renal cell carcinoma to the pancreas. Am Surg 2007;73:1158-60.  Back to cited text no. 2
    
3.
Lee SR, Gemenetzis G, Cooper M, Javed AA, Cameron JL, Wolfgang CL, et al. Long-term outcomes of 98 surgically resected metastatic tumors in the pancreas. Ann Surg Oncol 2017;24:801-7.  Back to cited text no. 3
    
4.
Venkat R, Edil BH, Schulick RD, Lidor AO, Makary MA, Wolfgang CL, et al. Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: A systematic review and meta-analysis. Ann Surg 2012;255:1048-59.  Back to cited text no. 4
    
5.
Warshaw AL. Conservation of the spleen with distal pancreatectomy. Arch Surg 1988;123:550-3.  Back to cited text no. 5
    
6.
Carrère N, Abid S, Julio CH, Bloom E, Pradère B. Spleen-preserving distal pancreatectomy with excision of splenic artery and vein: A case-matched comparison with conventional distal pancreatectomy with splenectomy. World J Surg 2007;31:375-82.  Back to cited text no. 6
    
7.
Butturini G, Inama M, Malleo G, Manfredi R, Melotti GL, Piccoli M, et al. Perioperative and long-term results of laparoscopic spleen-preserving distal pancreatectomy with or without splenic vessels conservation: A retrospective analysis. J Surg Oncol 2012;105:387-92.  Back to cited text no. 7
    
8.
Kimura W, Inoue T, Futakawa N, Shinkai H, Han I, Muto T, et al. Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. Surgery 1996;120:885-90.  Back to cited text no. 8
    
9.
Yongfei H, Javed AA, Burkhart R, Peters NA, Hasanain A, Weiss MJ, et al. Geographical variation and trends in outcomes of laparoscopic spleen-preserving distal pancreatectomy with or without splenic vessel preservation: A meta-analysis. Int J Surg 2017;45:47-55.  Back to cited text no. 9
    
10.
Hou B, Xiong D, Chen S, Ma T, Zhang C, Zhou Y, et al. Splenic vessel preservation versus splenic vessel resection in laparoscopic spleen-preserving distal pancreatectomy. ANZ J Surg 2018;88:E532-8.  Back to cited text no. 10
    
11.
Yu X, Li H, Jin C, Fu D, Di Y, Hao S, et al. Splenic vessel preservation versus Warshaw's technique during spleen-preserving distal pancreatectomy: A meta-analysis and systematic review. Langenbecks Arch Surg 2015;400:183-91.  Back to cited text no. 11
    
12.
Li BQ, Qiao YX, Li J, Yang WQ, Guo JC. Preservation or ligation of splenic vessels during spleen-preserving distal pancreatectomy: A meta-analysis. J Invest Surg 2018. doi: 10.1080/08941939.2018.1449918. [Epub ahead of print].  Back to cited text no. 12
    
13.
Nakata K, Shikata S, Ohtsuka T, Ukai T, Miyasaka Y, Mori Y, et al. Minimally invasive preservation versus splenectomy during distal pancreatectomy: A systematic review and meta-analysis. J Hepatobiliary Pancreat Sci 2018. doi: 10.1002/jhbp.569. [Epub ahead of print].   Back to cited text no. 13
    
14.
Sinwar PD. Overwhelming post splenectomy infection syndrome-review study. Int J Surg 2014;12:1314-6.  Back to cited text no. 14
    
15.
Jain G, Chakravartty S, Patel AG. Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: A systematic review. HPB (Oxford) 2013;15:403-10.  Back to cited text no. 15
    
16.
Suzuki O, Tanaka E, Hirano S, Suzuoki M, Hashida H, Ichimura T, et al. Efficacy of the electrothermal bipolar vessel sealer in laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. J Gastrointest Surg 2009;13:155-8.  Back to cited text no. 16
    
17.
Worhunsky DJ, Zak Y, Dua MM, Poultsides GA, Norton JA, Visser BC, et al. Laparoscopic spleen-preserving distal pancreatectomy: The technique must suit the lesion. J Gastrointest Surg 2014;18:1445-51.  Back to cited text no. 17
    
18.
Boutros C, Espat NJ, Somasundar P. Completely laparoscopic subtotal pancreatectomy with splenic artery preservation. J Gastrointest Surg 2010;14:171-4.  Back to cited text no. 18
    
19.
Kang CM, Im JH, Choi SH, Hwang HK, Lee WJ. Spleen-Preserving Laparoscopic Extended (Subtotal) Distal Pancreatectomy. Seattle, WA: SAGES Meeting; 2018. Available from: https://www.sages.org/meetings/annual-meeting/abstracts-archive/spleen-preserving-laparoscopic-extended-subtotal-distal-pancreatectomy/. [Last accessed on 2018 Oct 12].  Back to cited text no. 19
    


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