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
  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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).