Discussion
In adults, MIDP has become the preferred approach for the treatment of
the pancreatic tumor located in the body or tail and an international
consensus on precision anatomy for MIDP was recently established.
Laparoscopic spleen preserving distal pancreatectomy (LSPDP) has the
advantage of eliminating the risk of overwhelming post-splenectomy
sepsis and has been proposed for benign or low-grade malignant tumor in
adults. Theoretically speaking, LSPDP should be the treatment of choice
in the pediatric population as well. However, the data on the safety and
efficiency of MIDP in children remains scarce. The present case is the
first report of LSPDS for a child under the concept of precision
anatomy.
To the best of our knowledge, only a total of 34 pediatric patients
(less than 18 years old) who have undergone MIDP for SPN of the
pancreatic body or tail has been reported in English literature
(Table1). Of 34 MIDPs, spleen preservation was attempted in 26 cases;
however, splenectomy was required for a tumor in the close vicinity of
the splenic hilum and for another tumor in which the splenic vessels
were embedded. In the remaining 24 cases with spleen preservation,
splenic vessels were preserved (Kimura’s technique) in 20 and in the
other 2 cases, spleen vessels were dissected (Warshaw’ s technique). In
Warshaw’ s technique, the blood flow to the spleen is compensated by
collateral circulation [4].
The aforementioned international consensus underscores the importance of
understanding the pros and cons of Kimura’s and Warshaw’s techniques.
Although Kimura’s technique leads to fewer postoperative complications
related to infection and pancreatic fistula compared to Warshaw’s, it is
technically more demanding. In the present case, Kimura’s technique was
successfully performed and resulted in an uneventful recovery. In
addition, the recognition of celiac trunk variation, origin and course
of the splenic and dorsal pancreatic arteries, and drainage pattern of
left gastric and inferior veins is paramount to perform MIDP safely
under the concept of precision anatomy. The preservation of the left
gastric/gastroepiploic veins and splenic hilum veins is crucial to
prevent symptomatic gastric varices [1]. In the present case, we
intentionally did not expose the celiac trunk and left
gastric/gastroepiploic veins because the tumor was located in the very
end of the pancreatic tail, but we precisely checked the courses of
these vessels preoperatively to ensure preservation. It is also
important to identify the anatomical layer when dissecting the posterior
aspect of the pancreas. We first identified the Gerota’s fascia and kept
the dissection line above so as not to injure other structures. There
are two approaches to dissect the splenic artery in relation to the
pancreatic parenchyma; anterior and posterior. A comparative study
revealed that the anterior approach resulted in shorter operative time
and lower estimated blood loss than the posterior approach.
In conclusion, the implementation of precision anatomy for MIDP in the
pediatric population is urgently needed to establish LSPDP as a
standardized procedure for SPN and other benign or low-grade malignant
tumors in the pancreatic body or tail in children. Randomized controlled
trial is unlikely to take place considering the low incidence rate of
SPN and global collaborations are warranted for safe diffusion of this
procedure.
References
- Ban D, Nishino H, Ohtsuka T, et al. International Expert Consensus on
Precision Anatomy for minimally invasive distal pancreatectomy:
PAM-HBP Surgery Project. J Hepatobiliary Pancreat Sci.2022;29(1):161-173.
- Namgoong JM, Kim DY, Kim SC, et al. Laparoscopic distal pancreatectomy
to treat solid pseudopapillary tumors in children: transition from
open to laparoscopic approaches in suitable cases. Pediatr Surg
Int. 2014 Mar;30(3):259-66.
- Nishino H, Zimmitti G, Ohtsuka T, et al. Precision vascular anatomy
for minimally invasive distal pancreatectomy: A systematic review.J Hepatobiliary Pancreat Sci. 2022;29(1):136-150.
- Ban D, Garbarino GM, Ishikawa Y, et al. Surgical approaches for
minimally invasive distal pancreatectomy: A systematic review. J
Hepatobiliary Pancreat Sci. 2022;29(1):151-160.
- Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the
International Study Group (ISGPS) definition and grading of
postoperative pancreatic fistula: 11 Years After. Surgery.2017;161(3):584-591.
Figure Legends
Figure 1.
(A) Preoperative dynamic computed tomography revealed that the splenic
artery originated from the celiac artery (Type I, Adachi’s
classification), running along the superior edge of the pancreas (SpA
type B, Inoko’s classification)
(B) After switching from posterior to anterior approach, the splenic
artery was encircled for traction because they were firmly embedded in
the pancreatic parenchyma (a). The posterior dissection line was kept
above the renal fascia (b). After compression of the pancreatic
parenchyma with two intestinal clips (c), the pancreas was divided with
an automatic stapling device (d).