Surgical resection of lesions of the body and tail of the pancreas

INTRODUCTION — 

A variety of pancreatic pathologies, malignant and benign, may indicate the need to remove the pancreatic tissue to the left of the superior mesenteric artery and vein (ie, distal pancreas). Distal pancreatectomy, which removes the body and tail of the pancreas, accounts for approximately 25 percent of all pancreatic resections. Less extensive resections can also be performed in the form of central pancreatectomy, which removes part of the body of the pancreas, or enucleation, which limits the resection to the lesion and immediately adjacent parenchyma.

The indications, preoperative evaluation and preparation, and techniques for resecting lesions of the body and tail of the pancreas will be reviewed here. Resection of the head of the pancreas requires concomitant resection of the duodenum (ie, pancreaticoduodenectomy) and is discussed in detail elsewhere. (See "Surgical resection of lesions of the head of the pancreas".)

PANCREATIC ANATOMY — 

The pancreas is a compound exocrine and endocrine gland located in the retroperitoneum at the level of the second lumbar vertebrae. Exocrine pancreatic secretion is composed of enzymes, water, electrolytes, and bicarbonate, which are delivered to the duodenum via the pancreatic duct of Wirsung and aid with digestion. Endocrine secretions include insulin, glucagon, and somatostatin from the islets of Langerhans, A cells, and D cells, respectively. Removal of up to 90 percent of the mass of the pancreas can be performed without resulting in diabetes.

The pancreas is divided into five parts, including the head, uncinate process, neck, body, and tail (figure 1). The head of the pancreas lies to the right of the superior mesenteric artery. The uncinate process is a variable posterolateral extension of the head that passes behind the retropancreatic vessels and anterior to the inferior vena cava and aorta. The neck is defined as the portion of the gland overlying the superior mesenteric vessels. The body and tail lie to the left of the mesenteric vessels; there is no meaningful anatomic division between the body and tail.

Ductal anatomy — The pancreatic duct, located at the posterior (dorsal) aspect of the gland, joins the common bile duct to drain into the duodenum via the major papilla (ampulla of Vater) (figure 2 and picture 1). The anatomy of these ducts can vary. In 85 percent of individuals, the pancreatic duct and the common bile duct enter the duodenum through a common channel. In 5 percent of patients, both ducts enter the duodenum through the same ampulla but via separate channels. In the remaining 10 percent of patients, each duct enters the duodenum through a separate ampulla [1]. The entry of the common bile duct into the pancreatic tissue posteriorly can also vary (figure 3).

Neurovascular supply — The arterial supply to the duodenum and pancreas is derived from the celiac artery (figure 4), providing the superior pancreaticoduodenal arteries (anterior and posterior branches), and the superior mesenteric artery, providing the inferior pancreaticoduodenal arteries (anterior and posterior branches) (figure 5). The splenic artery supplies primarily the body and tail of the pancreas. The venous drainage (figure 6) follows the arteries to provide tributaries to the splenic vein and superior mesenteric vein, which drain into the portal vein.

The pancreas is innervated by sympathetic fibers from the splanchnic nerves (figure 7) and parasympathetic fibers from the vagus, both of which give rise to intrapancreatic periacinar nerve plexuses. The parasympathetic fibers stimulate exocrine and endocrine function, whereas the sympathetic fibers have an inhibitory effect.

INDICATIONS FOR DISTAL PANCREATECTOMY — 

Distal pancreatectomy is performed primarily for malignant and premalignant diseases of the pancreas, including:

●Pancreatic adenocarcinoma. (See "Overview of surgery in the treatment of exocrine pancreatic cancer and prognosis", section on 'Tumors in the body or tail'.)

●Pancreatic neuroendocrine tumors. (See "Surgical resection of sporadic pancreatic neuroendocrine neoplasms".)

●Premalignant and cystic pancreatic neoplasms including mucinous cystic neoplasms, serous cystadenoma, solid pseudopapillary epithelial neoplasms (also called papillary cystic neoplasms), and intraductal papillary mucinous neoplasms. (See "Intraductal papillary mucinous neoplasm of the pancreas (IPMN): Evaluation and management", section on 'High-grade dysplasia or invasive cancer' and "Pancreatic cystic neoplasms: Clinical manifestations, diagnosis, and management", section on 'Management'.)

●Isolated metastasis to the pancreatic gland (usually renal cell cancer). (See "Role of surgery in patients with metastatic renal cell carcinoma", section on 'Metastasectomy'.)

Benign indications for distal pancreatectomy include:

●Chronic pancreatitis. (See "Overview of the complications of chronic pancreatitis" and "Chronic pancreatitis: Management".)

●Pancreatic pseudocysts. (See "Approach to walled-off pancreatic fluid collections in adults", section on 'Surgery'.)

●Trauma associated with pancreatic ductal disruption. (See "Management of pancreatic trauma in adults", section on 'Pancreatic ductal injuries'.)

PREOPERATIVE EVALUATION AND PREPARATION — 

Patients with indications for resecting the distal pancreas frequently have significant medical comorbidities. Most pancreatic resections are performed under elective circumstances for which adequate time is available to assess risk factors and optimize the patient's medical status. Preoperative medical assessment is discussed elsewhere. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation of perioperative pulmonary risk".)

Preoperative imaging — For all indications of distal pancreatic resection, the preoperative evaluation usually starts with a high-resolution abdominal imaging to determine the size, location, and relation of any masses or cysts to surrounding structures and, for patients with disruption of the pancreatic duct, to assess the location and amount of peripancreatic fluid, including potential fluid in the lesser sac.

●A high-resolution pancreatic protocol computed tomography scan is most commonly used. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'CT abdomen and pelvis'.)

●A variety of other imaging modalities, including endoscopic ultrasound, magnetic resonance cholangiopancreatography, and positron emission tomography, may be required to assess resectability in some circumstances. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Other studies'.)

Bowel preparation — The approach to bowel preparation varies across different institutions, with a trend toward fewer using bowel preparation before surgery. We do not perform a bowel preparation except when a concomitant colon resection may be required (eg, for pancreatic lesions involving the colon). In a survey of perioperative practices among centers participating in the DISPACT (DIStal PAnCreaTectomy) trial, mechanical bowel preparation (mostly enemas) was standard at 8 hospitals, but 14 hospitals did not use any kind of bowel preparation before distal pancreatectomy [2].

There are no randomized trials directly evaluating the outcomes of bowel preparation versus no bowel preparation for distal pancreatectomy. One review that compared bowel preparation with no bowel preparation for patients undergoing pancreaticoduodenectomy found no difference between the groups with respect to complications [3]. No such data exist for distal pancreatectomy. (See "Overview of colon resection", section on 'Bowel preparation'.)

Antibiotics — For pancreaticobiliary surgery, antibiotic prophylaxis is recommended prior to surgery and should be redosed as necessary during the operation. Patients for whom antibiotics have been initiated to manage established infection should be redosed prior to surgery [4,5]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal surgery in adults".)

Despite the antibiotic prophylaxis generally recommended for pancreatic surgery (table 1), a prospective randomized trial by the American College of Surgeons National Surgical Quality Improvement Program Hepatopancreatobiliary Collaborative found, in patients undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative surgical site infection (SSI), pancreatic fistula, and other sequelae of SSI compared with cefoxitin [6]. We have extrapolated the data and use piperacillin-tazobactam for distal pancreatectomy as well. Few studies have specifically evaluated antibiotic prophylaxis and wound or other infectious complications following distal pancreatectomy.

Thromboprophylaxis — Thromboprophylaxis should be administered according to the patient's risk for thromboembolism (table 2). Patients undergoing major pancreatic resection are at moderate to high risk for venous thromboembolism due to the nature of the surgery (major open surgery >45 minutes). The presence of malignancy increases the risk [7]. Thus, we recommend pharmacologic prophylaxis. Specially, we give subcutaneous heparin immediately before surgery, low molecular weight heparin postoperatively while the patient is in the hospital, and for cancer patients, additional low molecular weight heparin after discharge until day 28. Additionally, we also place intermittent pneumatic compression devices prior to induction and continue their use until the patient is ambulatory. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

Immunization — Once a decision has been made to proceed with surgery, the patients should be informed of the possibility of splenectomy and the potential for splenectomy-related complications. For patients in whom concomitant splenectomy is anticipated, preoperative immunization directed against encapsulated organisms (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae) should be given. The current vaccine recommendations are discussed in detail elsewhere (see "Prevention of infection in patients with impaired splenic function", section on 'Vaccinations').

If vaccination was not possible prior to surgery or unanticipated splenectomy was performed, the patient should be vaccinated postoperatively, usually two to three weeks after surgery when the immune system has returned to homeostasis.

GENERAL PRINCIPLES

Staging laparoscopy — When the indication for distal pancreatomy is adenocarcinoma, a staging laparoscopy should be performed prior to proceeding to pancreatic resection to minimize the number of futile laparotomies due to small-volume metastatic disease undetected by preoperative imaging. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Staging laparoscopy'.)

The techniques of staging laparoscopy for digestive system cancers are discussed elsewhere. (See "Diagnostic staging laparoscopy for digestive system cancers", section on 'Pancreatic cancer'.)

Extent of resection — For most pancreatic lesions, the pancreas should be transected to achieve a disease-free margin on frozen section analysis and ultimately on permanent section [8,9].

In the case of main duct intraductal papillary mucinous neoplasms (IPMN), a transection margin without high-grade dysplasia or invasive cancer is often sufficient for those with a dominant lesion in the body or tail but with less advanced involvement of the remainder of the gland; low-grade dysplasia at the margin is acceptable [10,11]. (See "Intraductal papillary mucinous neoplasm of the pancreas (IPMN): Evaluation and management", section on 'Surgical therapy'.)

Splenectomy versus splenic preservation — Traditionally distal pancreatectomy was performed with splenectomy for anatomical reasons. Newer techniques of distal pancreatectomy allow perfusion of the spleen by preserving either the splenic vein or the short gastric vessels [12]. In contemporary practice, the choice between splenectomy and splenic preservation is usually determined by the pathology and anatomy of the lesion.

●When performing pancreatectomy for a distal lesion that is biopsy proven or highly suspicious for cancer, splenectomy should generally be performed to provide a margin-negative resection and to ensure sampling of at least 15 regional lymph nodes (figure 8) [13]. The resection specimen should include all of the tissue around the splenic artery and vein, including the associated lymph nodes. (See 'Standard distal pancreatectomy' below.)

●An attempt at splenic preservation can be made when treating small neuroendocrine tumors in the body and tail of the pancreas that are likely benign and premalignant cystic lesions without any objective signs of advanced pathology (eg, large size, mural nodules, or solid component) [14,15]. However, splenic salvage may not be technically possible for lesions that involve the splenic vessels, for large cysts or tumors, or for lesions associated with significant inflammation that obscure the borders of the distal pancreas. Whether to preserve the spleen should be decided on a case-by-case basis. Distal pancreatectomy with splenic preservation can be accomplished using an open or laparoscopic approach. (See 'Minimally invasive distal pancreatectomy' below.)

A 2017 meta-analysis reported that patients who underwent spleen-preserving distal pancreatectomy for benign and low-grade malignant tumors had significantly less operative blood loss, shorter duration of hospitalization, lower incidence of fluid collection and abscess, lower incidence of postoperative splenic and portal vein thrombosis, lower incidence of new-onset postoperative diabetes, and lower incidence of grade B or C pancreatic fistulas compared with those who underwent splenectomy [16].

Techniques of splenic preservation — Two main techniques of splenic preservation exist:

●The Warshaw technique divides the main splenic artery and vein and maintains only the short gastric vessels to supply the spleen [14,15]. However, division of the splenic vein may lead to splenic enlargement, hypersplenism, and gastric varices [17,18].

●The Kimura technique preserves the splenic vein by meticulously dissecting enumerable small and fragile venous tributaries, which may not be feasible for larger tumors or tumors adherent to the splenic vein [19,20].

When performing distal pancreatectomy with intended splenic preservation, we preserve at least one-half of the short gastric vessels during mobilization of the pancreas in case splenic vein preservation cannot be achieved.

Pancreatic transection and closure — Distal pancreatectomy requires the pancreas to be transected to the right of the pathology as far as the neck of the gland. Gastrointestinal reconstruction is usually not necessary because the remaining pancreatic duct drains into the duodenum via the ampulla. The cut surface, however, needs to be closed or else a pancreatic leak or fistula will develop.

Transection techniques — Transection of the pancreas can be performed using one of two methods, either division using electrocautery and subsequent oversewing of the transection line or using stapling devices (with or without staple line reinforcement) that simultaneously divide and close the cut end. For nonstapled transection (either sharp or with electrocautery), the main pancreatic duct should be identified and directly sutured closed. Most experts believe that there is no difference in the fistula rate after distal pancreatectomy between the handsewn and stapler techniques and that a stapling technique cannot be used in all cases because of variations in pancreatic size and texture [21].

A 2015 Cochrane review found that neither stapler nor scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy showed any benefit compared with the other method in terms of postoperative pancreatic fistula, overall postoperative mortality, or operation time [22]. This meta-analysis included the DISPACT (DIStal PAnCreaTectomy) trial, which found no significant difference in the incidence of pancreatic fistula between stapling and hand-sewn closure [23].

Reinforcement of closure — Various materials have been used to reinforce either the stapler or the closed-cut surface of the pancreas with the hope of reducing pancreatic leaks. However, due to inconsistent data, more studies are required before this method can be recommended for routine use [21].

●Stapler guards – Materials that have been used to reinforce the stapler used to transect the pancreas include a bioabsorbable staple line mesh product (Seamguard) [24-26], a bioabsorbable polyglycolic acid polymer (Neoveil) [27,28], and an extracellular matrix biomaterial derived from submucosal tissue from pig small intestine [29].

●Vascularized pedicles – For both stapled and nonstapled transections, vascularized pedicles, such as omental flap, falciform ligament, and round ligament of the liver (ie, ligamentum teres that contains remnant of fetal umbilical vein (figure 9)), have been used as reinforcements to cover the cut surface of the pancreatic stump, with varying success [30-32]. In a network meta-analysis of 16 trials of distal pancreatectomy, patch coverage of the pancreatic stump after stapled or sutured closure appeared to be the most favorable closure technique in terms of producing lower rates of clinically relevant postoperative pancreatic fistulas, lower volumes of intraoperative blood loss, fewer intra-abdominal abscesses, and lower rates of overall complications and 30-day mortality compared with seven other stump closure techniques [33]. Round ligament patch closure outperformed seromuscular patch closure in preventing clinically relevant postoperative pancreatic fistulas.

●Tissue sealants – There is a consensus among experts that the use of an energy-based tissue sealant, the use of an additional chemical sealant device, or combinations of these do not impact the postoperative pancreatic fistula rate after left pancreatectomy in comparison with other methods for management of the transection plane on the pancreatic stump [21]. A 2020 Cochrane review concluded that fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy [34].

Pancreaticoenteric anastomosis — Some surgeons have performed a pancreaticoenteric anastomosis in an attempt to further reduce the incidence of postoperative pancreatic fistula compared with the more common divide and closure technique. However, in two separate randomized trials, neither pancreaticojejunostomy (compared with stapled closure [35]) nor pancreaticogastrostomy (compared with hand-sewn closure [36]) reduced the fistula rate.

General issues related to creating a pancreaticoenteric anastomosis, which is more commonly used for gastrointestinal reconstruction following pancreaticoduodenectomy, are discussed elsewhere. (See "Surgical resection of lesions of the head of the pancreas", section on 'Pancreatic-enteric anastomosis'.)

Our approach — Based on the character of the pancreas being transected, the following is our approach to pancreatic resection and closure:

●We generally use a stapled technique for distal pancreatectomy. Our preference is to divide the pancreas with a triple-height stapler including 4, 4.5, and 5 mm staples, and we rarely reinforce the stapler with other materials (eg, Seamguard).

●If the pancreas is too thick for the stapler to seal, we transect it with either electrocautery, an energy device, or a combination of the two. We then attempt to ligate the main pancreatic duct and oversew the cut edge of the parenchyma with sutures.

●In both cases, we try to cover the pancreatic stump with a patch fashioned from the falciform ligament.

The splenic vein can either be ligated and divided separately from or together with the pancreatic parenchyma. A trial showed comparable grade B or C pancreatic fistula rates (27.1 percent separate division; 28.6 percent combined division) [37]. The authors of this topic attempt to divide the splenic artery, vein, and pancreas separately. The artery and vein are ligated with a Tri-stapler (2.0 or 2.5 mm). In cases where the vein is inseparable from the pancreatic parenchyma, it can be transected along with the pancreas (Tri-stapler, 3.5 or 4.8 mm).

Drainage of the pancreatic bed — Once hemostasis has been confirmed, we place a large-bore, closed-suction drain adjacent to the cut edge of the pancreas. The rationale for leaving a drain after distal pancreatectomy is to provide controlled drainage and prevent an undiagnosed pancreatic leak, which can lead to a large intra-abdominal abscess or pancreatic-cutaneous fistula. (See 'Postoperative pancreatic fistula' below.)

Although drain placement after pancreatic resection remains commonplace [2], the role of routine drainage after distal pancreatectomy remains ill defined [38-40]. The use of abdominal drains, in general, is highly controversial, and evidence supports the limited use of prophylactic intra-abdominal drainage for many procedures.

●A multicenter randomized trial that included 344 patients undergoing distal pancreatectomy showed no difference in the rate of grade 2 or higher complications (44 versus 42 percent), pancreatic fistulas (18 versus 12 percent), and mortality (0 versus 1 percent), with or without intraperitoneal drainage. Not having a drain was only associated with a higher incidence of intra-abdominal fluid collection (9 versus 22 percent) [41].

●Another large retrospective series showed that intraoperative drainage was associated with a greater fistula rate (odds ratio 2.09, 95% CI 1.51-3.78) but reduced fistula severity (p<0.001) [42].

●A 2022 systematic review and meta-analysis of one randomized trial and four nonrandomized comparative studies associated no drain placement after distal pancreatectomy with a lower rate of major complications (Clavien-Dindo grade at least III), postoperative pancreatic fistula, and readmissions [43]. Rates of radiological intervention and reoperation did not differ. No study has reported on high-risk subgroups.

It should be noted that these findings are only correlative and do not mean that drains cause a higher fistula rate. Instead, this may be interpreted to mean that more leaks are identified when a drain is in place.

DISTAL PANCREATECTOMY — 

Distal pancreatectomy removes the body and tail of the pancreas to the left of the superior mesenteric artery and vein and can be accomplished using either a standard (retrograde) technique, or one of the radical techniques (radical antegrade modular pancreaticosplenectomy [RAMPS] or celiac axis resection) [44].

Anesthesia and patient position — Regardless of the approach, pancreatic resection is performed under general anesthesia. For open pancreatic resection, epidural analgesia or transversus abdominis plane blocks are a useful adjunct to anesthesia that also aids with postoperative pain management and improves pulmonary function. (See "Approach to the management of acute pain in adults", section on 'Regional anesthesia techniques'.)

For distal pancreatectomy, the patient should be positioned supine or in a partial right lateral decubitus position (ie, left side up 30 to 45 degrees). During laparoscopic surgery, reverse Trendelenburg may aid in shifting the colon and small bowel inferiorly away from the field of dissection.

If the indication for the operation is cancer or a mass or cyst that is suspicious for cancer, a staging laparoscopy should be performed before proceeding to formal resection. If there is no evidence of unresectability on laparoscopy, pancreatic resection can proceed. (See 'Staging laparoscopy' above.)

Standard distal pancreatectomy — For distal pancreatectomy, a retrograde (left-to-right) approach to the pancreas is usually chosen. The procedure can be performed open or minimally invasively (laparoscopic or robotic).

Open distal pancreatectomy — For open distal pancreatectomy, a left upper quadrant subcostal incision that extends over the midline to the right is most commonly used [2]. Alternatively, a midline incision may be suitable in thin patients. Once the incision has been made, the abdomen should be thoroughly re-explored to confirm resectability. (See "Incisions for open abdominal surgery".)

To mobilize the pancreas and identify the lesion:

●Enter the lesser sac by dividing the gastrocolic ligament (figure 10 and figure 11). Mobilize the omentum from the splenic flexure toward the hepatic flexure to provide adequate exposure of the pancreas from the spleen to the duodenum.

●Separate the greater curvature of the stomach and the spleen by ligating and dividing the gastrosplenic ligament (figure 12), which carries the short gastric vessels. If the spleen will be preserved, we prefer to take only one-half of the short gastric vessels in case the splenic vein must be sacrificed during the pancreatectomy. (See 'Techniques of splenic preservation' above.)

●Retract the stomach cranially. With the lesser sac exposed, the posterior aspect of the stomach should be relatively free from the anterior surface of the pancreas. The stomach and pancreas are usually easily separated, but prior episodes of pancreatitis can produce adhesions that can complicate the dissection.

●Incise the inferior border of the pancreas in a right-to-left direction from the approximate site of planned transection laterally to the tail of the pancreas and inferior pole of the spleen (if splenectomy is planned).

●Mobilize the retroperitoneal attachments to the splenic flexure of the colon and retract the colon medially and inferiorly. Divide the splenorenal ligament and incise the lateral peritoneal attachments of the spleen.

●Develop the plane posterior to the pancreas by lysing the attachments to the retroperitoneum.

●Incise the peritoneum along the superior border of the pancreas. The splenic artery usually runs along the superior border at the body of the gland and should be taken en bloc with the pancreas if splenectomy is planned.

●The spleen and distal pancreas should now be free and can be mobilized laterally to medially. Palpate the body and tail of the gland circumferentially to identify the lesion. If not visually apparent, or if the procedure is being performed laparoscopically, use an ultrasound probe on the anterior aspect of the pancreas to identify the lesion and delineate the proximal extent of resection. Based upon these findings, choose a transection point on the pancreas.

●The splenic artery can be ligated at the point of planned transection, either from an anterior approach or via the undersurface of the gland, especially if near the midline and takeoff from the celiac artery. On the undersurface of the gland, identify and gently dissect the splenic vein from the pancreas, creating a window for the introduction of the stapler (5 mm).

To mobilize the spleen (if splenectomy will be performed) (see 'Splenectomy versus splenic preservation' above):

●Ligate the splenic artery and vein near their origins or just to the right of the planned transection plane (figure 5 and figure 6). The splenic vein can be divided separately or divided along with the pancreas using a linear stapler. When the spleen will be preserved, an attempt to preserve the vein can be made but requires meticulous dissection. (See 'Techniques of splenic preservation' above.)

●Unlike the vein, the splenic artery should be ligated independent of the pancreatic parenchyma. The splenic artery can be quite calcified, and care must be taken when dividing it; a vascular stapler, large clips, or suture ligation can be used. Following ligation and division, the splenic artery stump will retract into the celiac axis and surrounding perineural tissue, making it difficult to regain control of the stump. In this circumstance, the surgeon should focus on controlling the inflow through the celiac artery followed by ligation of the splenic artery stump.

To transect the pancreas:

●Divide the pancreas at the level of the superior mesenteric vein or at a location that is appropriate for the particular pathology to ensure an appropriate margin.

●Transect the pancreas (thoracic, gastrointestinal [GIA], endo GIA stapler) (figure 8) using an appropriate staple size for the thickness of the pancreatic tissue (eg, 3.5, 4.5, or 4.8 mm). Staple line reinforcement (eg, Seamguard) has not consistently been shown to reduce the risk of pancreatic fistula. The staple line may need to be reinforced with suture if the staple line does not hold well for hemostasis and to reduce the risk of fistula. If the gland is too thick for the stapler, it can be divided with electrocautery with suture reinforcement. (See 'Pancreatic transection and closure' above.)

●For resection of pancreatic malignancy, take tissue from the transection site for frozen section analysis; this should be negative for malignancy or high-grade dysplasia. (See 'Extent of resection' above.)

Minimally invasive distal pancreatectomy — For a laparoscopic approach, the abdomen is accessed in a standard fashion. The procedure is commonly performed using four or five ports. Two large ports are used for the camera and stapling devices, and two to three smaller ports are used for retracting and dissecting instruments. The arrangement we prefer (figure 13) is one of many variations. (See "Minimally invasive pancreatectomy (MIP)", section on 'Laparoscopic distal pancreatectomy and splenectomy'.)

Laparoscopic resection of the body and tail of the pancreas is performed using a lateral-to-medial approach similar to retrograde, open distal pancreatectomy as described above. A common alternative approach is a medial-to-lateral resection, where the splenic vessels and pancreas are transected first, and then the rest of the gland and spleen are freed [45]. Most of the dissection in the operation can be completed with a harmonic scalpel or LigaSure, and an endo GIA stapler is used to transect the pancreas.

Once the specimen is mobilized, it should be placed in a specimen bag and can be removed through one of the port sites, which may require enlargement. In cases where the spleen will be removed but malignancy is not suspected, the spleen can be morcellated to allow removal through a smaller incision.

A drain may or may not be left in place at the discretion of the surgeon. When used, the drain can be placed through one of the port sites. (See 'Drainage of the pancreatic bed' above.)

The spleen salvage rates reported in retrospective series are higher (up to 90 percent) with robotic than with either open or laparoscopic distal pancreatectomy [46-48]. Robotic distal pancreatectomy is described elsewhere. (See "Minimally invasive pancreatectomy (MIP)", section on 'Robotic distal pancreatectomy and splenectomy'.)

Radical distal pancreatectomy — Techniques of radical distal pancreatectomy include antegrade, as opposed to the standard retrograde pancreatic dissection, and the resection of the celiac axis. These complex procedures should only be performed at high-volume centers for locally advanced tumors that defy standard resection.

RAMPS procedure — The RAMPS procedure is an alternative open approach to distal pancreatectomy [49,50]. The goal of the RAMPS procedure is to ensure a negative resection margin and more extensive lymph node dissection [51].

The dissection includes early division of the neck of the pancreas and splenic vessels and a celiac node dissection. The plane of dissection then runs posteriorly along the superior mesenteric artery and celiac artery to the level of the aorta and then laterally to the adrenal gland.

A 2017 meta-analysis of six retrospective cohort studies with a total number of 378 patients correlated RAMPS with higher R0 resection rates and successful harvest of more lymph nodes compared with the standard procedure [52]. However, RAMPS conferred no benefit on recurrence or survival. As RAMPS is gaining popularity in Japan and Korea, randomized trials are being conducted to compare it with standard distal pancreatectomy [53].

Distal pancreatectomy with celiac axis resection — A distal pancreatectomy, splenectomy, and celiac axis resection can occasionally be performed for pancreatic neck/proximal body tumors that involve the celiac axis (also known as modified Appleby procedure) [54].

This is a complex operation and should be performed at specialized centers and in select cases where the biology of the tumor points to potential efficacy with an aggressive local approach. For pancreatic cancers, patients should be treated upfront with chemotherapy and, in select cases, radiation therapy before surgery [55]. Pancreatic neck/body tumors that involve the celiac axis are categorized by the National Comprehensive Cancer Network (NCCN) as borderline resectable and not locally advanced because of this surgical technique.

In this case, the celiac axis is resected en bloc with the distal pancreas and spleen. The arterial flow to the liver is via the superior mesenteric artery and retrograde flow through the gastroduodenal artery (figure 4). As the left gastric artery is also taken, the blood flow to the stomach is through the right gastric and right gastroepiploic arteries. As a result, the most common complication after this surgery is liver or stomach ischemia, which should be monitored closely after surgery [56-59].

In a 2022 systematic review of 11 retrospective series with 1070 patients, distal pancreatectomy with celiac axis resection was associated with lower R0 resection and three-year survival rates, higher postoperative mortality rates, and longer operation time and hospital stay compared with standard distal pancreatectomy [60]. However, there was no difference in one-year and two-year survival rates, and celiac axis resection provided better survival and quality of life than palliative treatment.

Open versus minimally invasive distal pancreatectomy — In contemporary surgical practice, distal pancreatectomy can be performed using open surgical or minimally invasive techniques (laparoscopic, robotic).

●A 2016 Cochrane review of laparoscopic versus open distal pancreatectomy performed for pancreatic cancer did not find any significant differences in terms of mortality, morbidity, recurrences, positive resection margins, or clinically significant pancreatic fistulas [61]. The only advantage of laparoscopic surgery was a 2.4-day shorter hospital stay.

●In a 2019 multicenter patient-blinded randomized trial (LEOPARD), 108 patients with left-sided pancreatic tumors underwent open or laparoscopic distal pancreatectomy [62]. Compared with open surgery, laparoscopic distal pancreatectomy incurred less blood loss (150 versus 400 mL) but required a longer operative time (217 versus 179 minutes). Although the overall complication rates were comparable, those who underwent laparoscopic surgery reported less delayed gastric emptying, a reduced time to functional recovery, and hence better quality of life, all achieved without increasing costs [63].

●In another trial of 60 patients published in 2020, laparoscopic distal pancreatectomy was associated with shorter hospital stay than open surgery, with a shorter time to functional recovery and less bleeding [64].

●A case-control study with propensity score matching found no difference in overall survival at three years (42 percent laparoscopic versus 36 percent open) between 605 patients who underwent laparoscopic distal pancreatectomy and 1342 patients who underwent open surgery from the National Cancer Database between 2010 and 2013 [65]. Other outcomes, including median time to chemotherapy, median number of nodes examined, 30-day mortality and readmission rate, and positive margin rate, were comparable as well. The median hospital stay was a day shorter in the laparoscopic group.

●A propensity score matched study (DIPLOMA) of 1212 patients from 34 centers in 11 European countries found comparable median overall survival after laparoscopic versus open distal pancreatectomy (28 versus 31 months) [66]. Although the R0 resection rate was higher (67 versus 58 percent) after laparoscopic surgery, Gerota's fascia resection (31 versus 60 percent) and lymph node retrieval (14 versus 22) were lower compared with open distal pancreatectomy. Given the opposing differences, the authors of the study called for a randomized trial to confirm the oncologic safety of laparoscopic distal pancreatectomy [67].

●Additional trials (eg, DISPACT-2 [68], LAPAN [69]) are ongoing.

Given the available data, the 2020 Miami international guidelines on minimally invasive pancreatic resection advocate minimally invasive distal pancreatectomy for benign and low malignant potential lesions due to lower morbidity and higher quality of life, reserving open operation for when the concern for malignancy is high [70]. This is evolving as more experience with minimally invasive resection of pancreatic cancer accumulates, and many have moved to a minimally invasive approach in the case of pancreatic adenocarcinoma [71,72]. A review of the National Inpatient Sample database identified 8957 distal pancreatectomies [73]. Overall, 4.3 percent were performed using a minimally invasive approach, with the rate tripling from 1998 to 2009 from 2.4 to 7.3 percent [74-82].

Minimally invasive distal pancreatectomy is discussed in detail elsewhere. (See "Minimally invasive pancreatectomy (MIP)", section on 'Open versus MIP'.)

CENTRAL PANCREATECTOMY — 

Central (middle) pancreatectomy is a parenchyma-sparing technique that removes the neck and proximal body of the pancreas while preserving the head and tail of the pancreas. When performing central pancreatectomy, the stump of the head of the pancreas is closed primarily (staple or sutured, as discussed above), while the transected proximal margin of the tail of the pancreas is drained into the gastrointestinal tract (figure 14).

Central pancreatectomy can be used to treat benign and/or low-grade malignant lesions located in the neck and proximal body of the pancreas [83]. These include endocrine neoplasms, cystadenomas, noninvasive intraductal mucinous tumors, solid cystic papillary tumors, and other less common benign lesions. Central pancreatectomy has a limited role in the treatment of malignant lesions, although it may be an option in the palliative treatment of metastatic disease to the pancreas (eg, renal carcinoma).

A 2020 systematic review of 24 studies compared the outcomes of 593 central pancreatectomy with 1226 distal pancreatectomy [84]. Central pancreatectomy was associated with a significantly higher overall incidence of postoperative morbidity (50 versus 39 percent) and a higher incidence of pancreatic fistula (40 versus 26 percent) compared with distal pancreatectomy, but a lower risk of endocrine insufficiency (5 versus 22 percent) and exocrine insufficiency (9 versus 17 percent).

Technique of central pancreatectomy — The pancreas is exposed and assessed for the extent of the tumor and its relationship to the surrounding vasculature using Duplex ultrasound, as needed, as described above for distal pancreatectomy.

To perform central pancreatectomy [85]:

●Identify the superior mesenteric vein at the inferior border of the pancreas and dissect it free from the gland. Create a tunnel anterior to the superior mesenteric vein extending cephalad to where the vein joins the portal vein.

●Identify the hepatic artery cephalad to the superior border of the pancreas. Divide the tissue between the superior border of the pancreas and the hepatic artery to expose the portal vein. Dissect anterior to the portal vein until it meets the caudal tunnel.

●Place vertical mattress stay sutures on either side of the superior and inferior borders of the pancreatic neck, incorporating enough pancreatic tissue to include the major arteries of the pancreas that run within the parenchyma at this location. Transect the pancreatic tissue and close the proximal stump. (See 'Pancreatic transection and closure' above.)

●Rotate the body of the pancreas and divide the retroperitoneal attachments. Carefully dissect the pancreas from the splenic vessels. Transect the distal pancreas sharply using a scalpel followed by fine figure-of-eight sutures to ligate small bleeding points. Once frozen section confirms that the margins are negative, perform a pancreaticoenteric anastomosis to drain the distal segment of the pancreatic gland.

●A Roux-en-Y pancreaticojejunostomy, which is more commonly used, or pancreaticogastrostomy can be constructed [86]. The incidence of postoperative pancreatic fistula may be lower for pancreaticogastrostomy compared with pancreaticojejunostomy [87]; however, the risk of exocrine failure due to inactivation of digestive enzymes by gastric juice may be higher [87,88]. General issues related to creating a pancreaticoenteric anastomosis, which is more commonly used for gastrointestinal reconstruction following pancreaticoduodenectomy, are discussed elsewhere. (See "Surgical resection of lesions of the head of the pancreas", section on 'Pancreatic-enteric anastomosis'.)

Techniques of laparoscopic [89] and robotic [90] central pancreatectomy have also been described.

ENUCLEATION PROCEDURES — 

Some pancreatic pathologies do not require formal resection of the pancreas and can be managed with local excision or enucleation, depending upon their relationship to the pancreatic duct. Enucleation is most commonly performed for pancreatic neuroendocrine tumors or, less often, for mucinous cysts. Enucleation should not be used when the lesion is large (usually >2 cm), in the presence of nodal or metastatic disease, or in close proximity to the common bile or pancreatic ducts such that enucleation could injure the duct, resulting in a pancreatic fistula. (See "Surgical resection of sporadic pancreatic neuroendocrine neoplasms", section on 'Enucleation'.)

In a 2015 meta-analysis of 22 observational studies (1148 patients), duration of surgery, blood loss, length of hospital stay, and postoperative endocrine and exocrine insufficiency were lower after enucleation than after standard resection [91]. Mortality, overall complications, reoperation rate, and delayed gastric emptying were not significantly different between the two approaches. The overall rate of postoperative pancreatic fistula was higher after enucleation than after standard resection. However, this higher postoperative pancreatic fistula rate did not result in higher mortality or overall morbidity.

Technique — An open or minimally invasive (laparoscopic or robotic) approach can be used. A 2023 meta-analysis reported at least similar short-term outcomes of open versus minimally invasive enucleation of pancreatic lesions [92].

Prior to enucleation procedures in patients with tumors in close proximity to the ductal system, some surgeons advocate preoperative placement of a pancreatic duct stent [93], which may help the surgeon avoid ductal injury and identify a major ductal disruption if it occurs.

To enucleate a lesion from the pancreas [94]:

●Use intraoperative ultrasound to identify the tumor relative to the pancreatic duct.

●Make an incision directly over the tumor through the pancreatic parenchyma using a scalpel or electrocautery. The tumor will often bulge through the parenchyma at this point.

●Divide the pancreatic tissue using a combination of blunt dissection, bipolar cautery, small clips, and/or fine sutures to expose the tumor. A simple stitch or figure-of-eight suture passed through the tumor greatly facilitates enucleation by providing steady, careful retraction.

●Dissect the tumor free from the surrounding pancreatic parenchyma, being careful to avoid using thermal energy adjacent to the pancreatic duct to prevent ductal injury. The dissection should be carried directly adjacent to the tumor; the extent of any further resection is based upon gross findings in the operative field.

●Once the tumor has been enucleated, obtain hemostasis using cautery or occasional sutures (eg, Prolene) as needed.

●Place a drain in the region of enucleation to gravity (ie, not suction); the leak rate with enucleation is relatively high.

Techniques of laparoscopic [95] and robotic [96] enucleation have also been described.

POSTOPERATIVE CARE — 

Routine postoperative management is primarily focused on return of bowel function and management of closed-suction drain output [2]. The average length of stay is approximately five to seven days after open and three to five days after a laparoscopic distal pancreatectomy [97].

The nasogastric tube placed in the operating room can be removed at the end of the operation or morning after surgery. A diet is initiated within the first 24 to 48 hours after surgery. (See "Inpatient placement and management of nasogastric and nasoenteric tubes in adults", section on 'Prophylactic placement' and "Overview of perioperative nutrition support".)

If preoperative vaccination was not given and the patient underwent splenectomy, the patient should receive appropriate vaccinations two to three weeks after surgery. (See 'Immunization' above.)

Drain removal — The closed-suction drain placed at the time of surgery is usually removed once the patient is tolerating a regular diet, provided there is no evidence of pancreatic leak. If a pancreatic leak is present and the patient is ready for discharge, the drain should remain in place and be removed in the outpatient setting once the fistula has resolved.

The drainage should be clear or straw colored in appearance. If the fluid is cloudy or turbulent, a pancreatic leak should be suspected and a fluid amylase level should be obtained. A drain fluid amylase level that is more than three times higher than the serum amylase level defines a pancreatic leak [98].

Somatostatin analogues — We do not routinely use prophylactic somatostatin for patients undergoing resection of the body or tail of the pancreas. For selected patients who develop high-output fistulas (>500 mL per day), somatostatin may be useful to control the volume of output. We give subcutaneous octreotide 50 to 200 micrograms every eight hours. The duration of treatment is determined individually for each patient.

Octreotide and other long-acting somatostatin analogues reduce exocrine pancreatic, gastric, and enteric secretions. In theory, somatostatin analogues should be helpful for reducing postoperative pancreatic fistula, but studies evaluating this issue are conflicting [99-106].

A Cochrane meta-analysis that included 21 trials found a decreased incidence of pancreas-specific complications in those patients who received prophylactic somatostatin postoperatively [107]. The incidence of pancreatic fistula was reduced among those who received somatostatin analogues compared with controls (relative risk [RR] 0.66, 95% CI 0.55-0.79); however, there were no significant differences in clinically significant pancreatic fistula among the four trials that made a clear distinction. A significant decrease in the incidence of sepsis (RR 0.42, 95% CI 0.21-0.85), risk for any complication, and number of complications was seen in the somatostatin analogue group (RR 0.70, 95% CI 0.61-0.80; RR 0.70, 95% CI 0.60-0.82). No significant differences were identified for mortality, rates of reoperation, anastomotic leak, postoperative pancreatitis, renal failure, bleeding, abdominal collections, delayed gastric emptying, or length of hospital stay.

A subsequent trial evaluated pasireotide, which has a longer half-life than octreotide and a different binding profile [108]. In that trial of 300 patients undergoing pancreatoduodenectomy or distal pancreatectomy, the rate of grade 3 or higher postoperative pancreatic fistula, leak, or abscess after distal pancreatectomy was significantly lower among patients who received pasireotide than placebo (7 versus 23 percent; RR 0.32, 95% CI 0.10-0.99). However, studies from other institutions have found mixed results and call into question the efficacy of routine use of this expensive adjunct [109].

MORBIDITY AND MORTALITY

Mortality — The rate of perioperative mortality for most types of pancreatic resections at high-volume centers is low, ranging from 0.8 to 5 percent; however, the mortality associated with more aggressive resections for cancer is higher (0.7 percent for standard distal pancreatectomy, 1.3 percent with venous resection, 3 percent with multivisceral resection, 8.7 percent with major arterial resection) [110-112].

Morbidities — Complications following distal pancreatectomy are common, occurring in up to 40 percent of patients, primarily related to the sequelae of a pancreatic leak [2,99,107,113], which significantly increases the length of hospital stay and cost [114]. Other surgical complications include splenic vein thrombosis, new-onset insulin-dependent diabetes mellitus, intra-abdominal abscess, and postoperative bleeding [110,115,116].

Post-splenectomy sepsis has been reported following distal pancreatectomy with splenectomy [117]. (See "Clinical features, evaluation, and management of fever in patients with impaired splenic function" and "Prevention of infection in patients with impaired splenic function".)

Postoperative pancreatic fistula — Postoperative pancreatic fistula is diagnosed when the amylase content of any measurable volume of fluid on or after postoperative day 3 is greater than three times the serum amylase, based on standards from the International Study Group on Pancreatic Fistulas (ISGPF) [118,119]. The reported incidence of pancreatic fistulas after distal pancreatectomy is 0 to 64 percent, probably related to various historical nonstandard definitions for defining postoperative pancreatic fistula [120,121]. The 2016 update of the ISGPF classification system classifies patients with an elevated amylase but no other worrisome findings as having a biochemical leak, not a postoperative pancreatic fistula [122].

Leaked pancreatic juice can trigger a plethora of secondary complications such as intra-abdominal abscess, delayed gastric emptying, and postoperative hemorrhage. Systemic inflammation may also result in sepsis, multiple organ failure, or death [123].

Prevention of postoperative pancreatic fistula has been attempted using various techniques to close the pancreatic stump, using various reinforcements or tissue adhesives, and using prophylactic somatostatin and its analogues with varying success [124,125]. (See 'Pancreatic transection and closure' above and 'Somatostatin analogues' above.)

However, whether a fistula develops after a distal pancreatectomy may depend more on the underlying disease/patient factors than on surgical technique. In a multicenter retrospective analysis of 2026 patients who underwent distal pancreatectomy, 306 (15 percent) developed a clinically relevant postoperative pancreatic fistula [42]. Independent risk factors for clinically relevant postoperative pancreatic fistula included age ≥60, obesity, hypoalbuminemia, the absence of epidural anesthesia, neuroendocrine or nonmalignant pathology, concomitant splenectomy, and vascular resection. By contrast, the method of resection; suture ligation of the pancreatic duct; staple size; and the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide did not impact the likelihood of clinically relevant postoperative pancreatic fistulas by multivariable regression.

Pancreatic exocrine and endocrine failure — The overall rates of pancreatic endocrine or exocrine insufficiency are variable in the literature and range from 10 to 30 percent for each type. There is a trend toward an increased risk of new-onset diabetes in patients with chronic pancreatitis who undergo distal pancreatectomy compared with those who undergo distal pancreatectomy for other indications (9 versus 7.5 percent) [115]. (See "Overview of the complications of chronic pancreatitis" and "Chronic pancreatitis: Management".)

By preserving a greater portion of pancreatic parenchyma, techniques such as central pancreatectomy and enucleation result in lower rates of endo- and exocrine failures but higher rates of complications such as pancreatic leaks and fistulas compared with standard resections such as distal pancreatectomy [126]. (See 'Central pancreatectomy' above and 'Enucleation procedures' above.)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pancreatic cancer".)

SUMMARY AND RECOMMENDATIONS

●Indications – A variety of pancreatic pathologies, malignant or benign, may indicate the need to resect the pancreatic tissue to the left of the superior mesenteric artery and vein (ie, distal pancreas). These include pancreatic adenocarcinoma, neuroendocrine tumors, premalignant and cystic tumors, pseudocyst, pancreatic trauma, and chronic pancreatitis. (See 'Indications for distal pancreatectomy' above.)

●Staging laparoscopy – For patients undergoing resection of the distal pancreas for pancreatic adenocarcinoma, we suggest staging laparoscopy prior to proceeding with the pancreatic resection. Staging laparoscopy identifies occult peritoneal metastases or local invasion that contraindicates resection. (See 'Staging laparoscopy' above.)

●Extent of resection – For most pancreatic lesions, the extent of resection of pancreatic tissue should be sufficient to achieve a disease-free margin on intraoperative frozen section analysis. An exception may be main duct intraductal papillary mucinous neoplasms (IPMNs), where low-grade dysplasia at the margin is acceptable. (See 'Extent of resection' above.)

●Splenectomy – For small neuroendocrine tumors that are likely to be benign and premalignant cystic lesions with no signs of advanced pathology, we suggest performing splenic preservation with distal pancreatectomy if technically feasible (Grade 2C). Spleen-preserving techniques have been associated with superior perioperative outcomes. (See 'Splenectomy versus splenic preservation' above.)

Distal pancreatectomy for a lesion of the distal pancreas that is biopsy proven or highly suspicious for cancer should be performed with splenectomy to ensure better local control and peripancreatic lymph node sampling. Immunization should be given prior to planned splenectomy, or two to three weeks after surgery for urgent or unexpected cases. (See 'Immunization' above and "Prevention of infection in patients with impaired splenic function".)

●Pancreatic transection and closure – The pancreatic transection and closure technique chosen should be based on the character of the pancreatic tissue and the experience of the surgeon. There is no convincing evidence to support any one technique over another. Among the available techniques, we prefer a stapled pancreatic closure but perform sutured closure when the pancreas is too thick for the stapler to seal. (See 'Transection techniques' above.)

For patients who have undergone distal pancreatectomy, we suggest covering the pancreatic stump with a falciform patch (Grade 2C). Limited data have associated patch coverage with a lower pancreatic fistula rate compared with other closure techniques. (See 'Reinforcement of closure' above.)

●Types of resection – The nature of the lesion determines the extent of resection (see 'Distal pancreatectomy' above and 'Central pancreatectomy' above and 'Enucleation procedures' above):

•Distal pancreatectomy involves resecting the body and tail of the pancreas with or without splenectomy. This is typically accomplished using a retrograde anatomic approach, but the radical antegrade modular pancreaticosplenectomy (RAMPS) procedure and distal pancreatectomy with celiac axis resection are alternative approaches to radical resections. (See 'Distal pancreatectomy' above.)

•Central pancreatectomy removes a limited portion of the pancreas, sparing the tail. (See 'Central pancreatectomy' above.)

•Enucleation is used to remove focal (<2 cm) benign lesions, depending upon their relationship to the pancreatic duct. (See 'Enucleation procedures' above.)

•Whenever possible, minimally invasive distal pancreatectomy is preferred for benign and low malignant potential lesions due to lower morbidity and higher quality of life, reserving open operation for when the concern for malignancy is high. (See 'Open versus minimally invasive distal pancreatectomy' above.)

●Morbidities and mortality – Perioperative mortality is overall low at high-volume centers but increases with more aggressive resections for cancer. Complications following distal pancreatectomy are common, occurring in up to 40 percent of patients, primarily related to the sequelae of pancreatic leak. Other surgical complications include splenic vein thrombosis, new-onset insulin-dependent diabetes mellitus, intra-abdominal abscess, and postoperative bleeding. (See 'Morbidity and mortality' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Timothy R Donahue, MD, who contributed to earlier versions of this topic review.