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

Surgical resection of lesions of the body and tail of the pancreas
Literature review current through: Jan 2024.
This topic last updated: Jul 04, 2022.

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. Distal pancreatectomy was first performed by Billroth in 1884. 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, pancreatic cystic neoplasms, neuroendocrine tumors, and, rarely, isolated metastasis to the gland. In one series of 232 distal pancreatectomies, of which 164 were performed for pancreas-specific disease, malignant or premalignant disease was resected in 84 percent [2]. Benign indications for distal pancreatectomy include chronic pancreatitis, pancreatic pseudocysts, and trauma associated with pancreatic ductal disruption.

Adenocarcinoma — Patients with adenocarcinoma in the body and tail of the gland have historically presented with more advanced disease because lesions in this area can become larger before patients develop symptoms, the most common of which is pain. Body and tail lesions tend to be less resectable and are associated with shorter survival than adenocarcinoma of the pancreatic head, even though the biology of the tumors is the same [3,4]. Improved high-resolution pancreatic-protocol computed tomography (CT) and magnetic resonance imaging (MRI) techniques have improved the early recognition of lesions involving the body and tail of the pancreas. As a result, distal pancreatectomy for pancreatic adenocarcinoma is becoming more frequently performed. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Diagnostic approach'.)

Neuroendocrine tumors — Neuroendocrine tumors within the body and tail of the pancreas can be resected or enucleated depending upon the size and relationship of the tumor to the pancreatic duct [5]. Nonfunctioning tumors that are large or preoperatively confirmed (via endoscopic ultrasound-guided biopsy) as high grade using the World Health Organization classification system should be resected rather than enucleated to achieve a margin-negative resection and appropriate lymph node harvest. Likewise, lesions close to the main pancreatic duct should also be resected, rather than enucleated, to minimize the potential for a postoperative pancreatic leak and fistula. (See "Classification, epidemiology, clinical presentation, localization, and staging of pancreatic neuroendocrine neoplasms".)

There is ongoing debate regarding the resection of primary malignant neuroendocrine tumors in the face of metastatic disease [6,7]. Resection may be appropriate if the primary site of the tumor is causing symptoms or when primary tumor and associated liver metastases are each amenable to potentially curative resection. Current National Comprehensive Cancer Network (NCCN) guidelines suggest that tumors 2 cm or less may be observed [8]. (See "Metastatic gastroenteropancreatic neuroendocrine tumors: Local options to control tumor growth and symptoms of hormone hypersecretion", section on 'Management of the primary tumor in patients with metastatic disease'.)

Premalignant and cystic neoplasms — Premalignant and cystic pancreatic neoplasms for which distal pancreatectomy may be indicated include mucinous cystic neoplasms (MCNs), serous cystadenoma, solid pseudopapillary epithelial neoplasms (SPENs; also called papillary cystic neoplasms), and intraductal papillary mucinous neoplasms (IPMNs). MCNs and SPENs are most commonly located in the body and tail of the gland, serous cystadenomas have equal distribution throughout the gland, and IPMNs (main duct, branch duct, and mixed types) are primarily located in the head of the gland but can be found throughout the gland. (See "Pathology of exocrine pancreatic neoplasms" and "Classification of pancreatic cysts" and "Pancreatic cystic neoplasms: Clinical manifestations, diagnosis, and management".)

Until premalignant and benign lesions can reliably be differentiated from malignant cystic neoplasms, most experts argue that cysts suspicious for malignancy should be resected [9-12]. The management of premalignant and cystic neoplasms of the pancreas is discussed in other topics. (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'.)

Pseudocysts — Pseudocysts are nonepithelialized collections of pancreatic fluid that develop four to six weeks after the onset of an episode of acute pancreatitis [13]. Indications for treatment include rapidly enlarging or symptomatic cysts. Treatment options include percutaneous drainage, endoscopic drainage, internal surgical drainage, or resection, including distal pancreatectomy. Distal pancreatectomy is usually reserved for cases where disruption of the main pancreatic duct (with or without a failed attempt at stenting) has occurred or if there has been significant involvement of an adjacent structure (eg, splenic artery pseudoaneurysm) [13]. (See "Management of acute pancreatitis".)

Chronic pancreatitis — Results of distal pancreatectomy for chronic pancreatitis are mixed [14,15]. The entire gland is usually involved, and relief of chronic abdominal pain appears the greatest for resections of the head of the pancreas, rather than the tail [16]. In addition, the incidence of new-onset diabetes mellitus can be as high as 20 to 30 percent [15,17]. Thus, distal pancreatectomy is rarely needed in the management of chronic pancreatitis. (See "Overview of the complications of chronic pancreatitis" and "Chronic pancreatitis: Management".)

Trauma — Distal pancreatectomy is indicated in trauma patients when the main pancreatic duct is disrupted. This injury most commonly occurs after blunt trauma in which the pancreas is crushed against the spine [18]. (See "Management of duodenal trauma in adults" and "Management of pancreatic trauma in adults".)

Metastases to the pancreas — Renal cell tumor metastases are sometimes resected when these involve the pancreas. Other cancers can spread to the pancreas, but these are not typically resected [19-21].

PREOPERATIVE IMAGING — The preoperative evaluation, for all indications of distal pancreatic resection, should begin with a high-resolution pancreatic protocol CT scan that includes a precisely timed intravenous (IV) contrast infusion to enhance the pancreatic parenchyma and surrounding vessels, or MRI. High-resolution abdominal imaging is needed 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.

Following the injection of IV contrast, 2 to 3 mm images of the pancreas are obtained during the "pancreatic arterial phase," and then 5 mm images are later captured during the "venous phase." During the pancreatic phase, the pancreatic parenchyma, celiac axis, and superior mesenteric artery are enhanced with contrast, while during the venous phase, the superior mesenteric vein, portal vein, and splenic vein are enhanced. If the institution does not have a well-established pancreas CT protocol, then high-resolution CT with IV contrast may be sufficient.

Some surgeons prefer an MRI and cholangiopancreatogram (magnetic resonance cholangiopancreatography [MRCP]) instead of a pancreas CT protocol or high-resolution CT scan. MRCP is more precise at imaging the relationship of a mass or cyst to the main pancreatic duct but can be more difficult for nonradiologists to interpret.

DOTATATE PET/CT is a new imaging modality with >95 percent sensitivity and specificity for pancreatic neuroendocrine tumors [22]. The role for DOTATATE PET/CT in diagnosis, staging, and surveillance is still being examined, and the National Comprehensive Cancer Network (NCCN) recommendations are open ended [23].

Endoscopic ultrasound (EUS) can also provide detailed information about solid masses and cyst characteristics [24]. Endoscopic retrograde cholangiopancreatogram (ERCP) can be performed at the same time as EUS and can provide detailed information of the main pancreatic duct and its relation to the mass or cyst, but this information can usually be obtained from CT or MRCP. (See "Endoscopic ultrasound in the staging of exocrine pancreatic cancer" and "Endoscopic ultrasound in chronic pancreatitis".)

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" and "Preoperative medical evaluation of the healthy adult patient".)

For patients taking antiplatelet therapy for primary or secondary prevention of cardiovascular disease or other indications, cessation of aspirin prior to elective pancreatic surgery may not be necessary. In a retrospective review of 1017 patients undergoing pancreas resection, 28.4 percent were maintained on aspirin therapy throughout the perioperative period [25]. Among these patients, 322 underwent resection of the tail of the pancreas, 82 in the aspirin group and 240 in the no-aspirin group. Overall, there were no significant differences between the aspirin and no-aspirin groups in intraoperative blood loss, rate of blood transfusion, or other major procedure-related complications. (See "Perioperative medication management", section on 'Aspirin'.)

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. (See 'Perioperative morbidity and mortality' below.)

Bowel preparation — 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 [26]. (See "Overview of colon resection", section on 'Bowel preparation'.)

The approach to bowel preparation varies across different institutions, with a trend toward fewer using bowel preparation before surgery. 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 [27].

Antibiotics — For pancreaticobiliary surgery, antibiotic prophylaxis, which often includes a second-generation cephalosporin, is recommended prior to surgery and should be redosed as necessary during the operation. Few studies have specifically evaluated antibiotic prophylaxis and wound or other infectious complications following distal pancreatectomy. Some studies have reported that prophylactic piperacillin-tazobactam reduced the incidence of wound infection; these results are still being corroborated by the American College of Surgeons National Surgical Quality Improvement Program Hepatopancreaticobiliary Collaborative [28-30]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults".)

Patients for whom antibiotics have been initiated to manage established infection should be redosed prior to surgery [31,32].

Thromboprophylaxis — Thromboprophylaxis should be administered according to the patient's risk for thromboembolism (table 1). 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 [33]. 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 — 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

Resections for malignancy

Staging laparoscopy — When the indication for resection of the distal pancreas is adenocarcinoma, a staging laparoscopy should be performed prior to proceeding to pancreatic resection to minimize the number of cases for which the cancer appears resectable on preoperative imaging only to be found to be unresectable at the time of laparotomy due to occult peritoneal metastases or local invasion [34,35]. Metastases less than 1 cm in diameter on the surface of the liver and peritoneum are sometimes not detected by preoperative imaging techniques [36]. Staging laparoscopy has been shown to alter the management approach in up to 44 percent of patients [37].

To perform a staging laparoscopy, our preferred approach is to use a 5 mm port for the camera and one or two 5 mm working ports for atraumatic graspers and/or biopsy forceps. The liver surface and peritoneum should first be inspected for distant disease. Any suspicious nodules should be biopsied and sent for frozen section analysis. Next, the transverse colon should be lifted anteriorly to inspect the mesocolon for direct extension. The lesser sac can be explored by dividing the gastrocolic ligament, but this is rarely needed for diagnostic purposes. Vascular involvement can be assessed by direct inspection or by using a laparoscopic Doppler probe, although this technique is probably more useful for periampullary tumors where vascular involvement frequently determines resectability. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Staging laparoscopy'.)

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.

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.

Splenectomy and lymphadenectomy — 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) [38]. The resection specimen should include all of the tissue around the splenic artery and vein, including the associated lymph nodes.

Splenic preservation — Preserving the spleen during distal pancreatic resection was first introduced by Mallet-Guy and Vachon in 1943 [39]. 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) [40,41]. 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 'Laparoscopic approach' below.)

Some [2,42,43] but not all [44-47] series have demonstrated benefits to splenic preservation, including lower perioperative infectious complications. A systematic review that included 11 observational studies for a total of 897 patients identified a significantly lower incidence of intra-abdominal abscess for spleen-preserving distal pancreatectomy (open, laparoscopic) compared with distal pancreatectomy with splenectomy (5.1 versus 11.4 percent) [48]. The rate of splenic infarction with splenic salvage was 2.5 percent. No differences were identified for operative time or the incidence of bleeding, pancreatic fistula, wound infection, or thrombosis. However, splenic preservation can lead to splenic enlargement, hypersplenism, and gastric varices if the splenic vein is sacrificed at the time of pancreatic resection. Some surgeons advocate maintaining vascularization to the spleen via the splenic artery and vein, while others resect these vessels and maintain only the short gastric vessels [40,41]. We preserve at least one-half of the short gastric vessels during mobilization of the pancreas in case splenic vein preservation, which requires meticulous and tedious dissection of enumerable small and fragile venous tributaries, cannot be achieved.

Pancreatic transection and closure — Transection of the pancreas can be performed using a variety of methods, including sharp division 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. Alternative techniques include a handsewn closure, placement of a seromuscular patch, reinforcement with mesh, ultrasonic dissection, use of bipolar scissors, sealing the end with fibrin glue, and creating a pancreaticoenteric anastomosis. 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'.)

The pancreatic transection and closure technique chosen is based upon the character of the pancreas being transected and the experience and discretion of the surgeon given that there is no convincing evidence to support one technique over another [49-52]. The following is our approach:

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.

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 [53]. A systematic review that included two trials and eight observational studies found a trend toward a lower pancreatic leak rate with stapled closure [49]. Meta-analyses that have included these and other observational studies have reported similar results [51,54]. A later trial (the DISPACT [DIStal PAnCreaTectomy] trial) randomly assigned 177 patients to stapled closure and 175 patients to handsewn closure and found no significant difference in incidence of pancreatic fistula rate between the two groups [55]. A later systematic review that pooled the results of two prior randomized trials also found no significant differences [54]. This analysis suggested a possible publication bias in favor of stapled closure. A combined stapled and sutured approach may provide a more secure closure [54]. A retrospective review evaluating different methods of pancreatic stump closure found that pancreatic fistula following transection of a pancreas >12 mm thick was associated with male sex, body mass index >25 kg/m2, and stapled closure [56].

Various materials have been used to reinforce the stapler 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 [53].

Seamguard, which is a bioabsorbable staple line mesh product, has been investigated in several small nonrandomized studies for the prevention of leaks and fistulas after distal pancreatectomy [57,58]. In a trial that randomly assigned 100 patients to mesh or no mesh, the incidence of clinically important leaks, defined as International Study Group on Pancreatic Fistula (ISGPF) grade B and C, was significantly lower in the staple line mesh compared with the nonmesh group (20 versus 1.9 percent) [59]. However, this technique cannot be used in all situations, given that a thick or fibrotic pancreas may be very difficult to engage with the stapler [60].

Another trial (HiSCO-07) used reinforced staplers with a bioabsorbable polyglycolic acid polymer (Neoveil) but found no statistically significant difference in the overall incidence of clinically relevant pancreatic fistulas between the reinforced stapler and bare stapler (16 versus 27 percent, p = 0.15). In a subset of 82 patients with thin pancreas (thickness <14 mm at the transection line), however, stapler reinforcement did reduce the incidence of clinically relevant pancreatic fistulas (4.5 versus 21 percent, p = 0.01) [61].

Another trial found no benefit of reinforcing staplers with an extracellular matrix biomaterial derived from submucosal tissue from pig small intestine [62].

For nonstapled transection (either sharp or with electrocautery), the main pancreatic duct should be identified and directly sutured closed. 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), have been used as reinforcements to cover the cut surface of the pancreatic stump, with varying success [63-65]. The available data regarding the use of closure techniques are limited and somewhat inconsistent, but there is a consensus among experts that the use of an energy-based tissue sealant, 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 [53].

In a randomized trial, after a stapled or nonstapled distal pancreatectomy, the ligamentum teres was harvested from the abdominal wall and secured with sutures to cover the pancreatic stump (figure 9) [65]. Those who received a "teres ligament patch" were just as likely to develop a postoperative pancreatic fistula (POPF) of any grade (51 versus 47 percent) but less likely to develop a clinically significant POPF (22 versus 33 percent) or require reinterventions (20 versus 36 percent), reoperations (1.3 versus 13 percent, most for fistula-related reasons), or readmissions (13 versus 32 percent). Other trials have not found any significant difference in the incidence of pancreatic fistula with the adjunctive use of a teres ligament patch along with fibrin glue reinforcement following pancreatic transection and duct closure [63].

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 POPFs, 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 [66]. Round ligament patch closure outperformed seromuscular patch closure in preventing clinically relevant POPFs.

Alternatively, tissue adhesives have also been applied to the raw cut surface of the pancreas, but whether this has any benefit is uncertain [63,67-69]. A 2020 Cochrane review concluded that fibrin sealants may have little or no effect on POPF in people undergoing distal pancreatectomy [70].

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) [71]. 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 [27], the role of routine drainage after distal pancreatectomy remains ill defined [72-74]. The use of abdominal drains, in general, is highly controversial, and evidence supports the limited use of prophylactic intra-abdominal drainage for many procedures [75-77].

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) [78].

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) [79].

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), POPF, and readmissions [80]. 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. Generally, the ISGPF guidelines should be followed regarding drain management. This includes removing the drain by postoperative day 3 if the drain fluid amylase is less than three times the serum amylase [81,82].

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 an open or laparoscopic approach.

Regardless of the approach, pancreatic resection is performed under general anesthesia. For open pancreatic resection, epidural analgesia is a useful adjunct to anesthesia that also aids with postoperative pain management and improves pulmonary function.

Open surgical versus minimally invasive distal pancreatectomy — Given that there are few long-term data comparing laparoscopic with open resections for cancer, some surgeons advocate an open operation when the concern for malignancy is high, reserving laparoscopic resection for benign or premalignant indications [83,84]. This is evolving as more experience with laparoscopic resection of pancreatic cancer accumulates, and many have moved to a minimally invasive approach in the case of pancreatic adenocarcinoma [83,85]. A review of the National Inpatient Sample (NIS) database identified 8957 distal pancreatectomies [86]. 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. A robotic-assisted laparoscopic approach has also been described, but use of this technique is not widespread [87-95].

Surgical outcomes — Advantages to the laparoscopic approach include less perioperative pain, a reduced length of hospital stay, and a quicker recovery. Disadvantages with laparoscopic distal pancreatectomy include technical difficulties, the inability to manually palpate the gland and to appreciate the extent of a cyst or mass, potential difficulty securing the pancreatic duct stump, and the potential for inadequate margins in cancer resections [83,84,96,97]. It may also be more difficult to preserve the spleen. Experts do not believe that there is any difference in the postoperative pancreatic fistula rate after distal pancreatectomy between open, laparoscopic, or robotic approaches [53].

There have been many small case series reporting the technical feasibility of the laparoscopic approach [83,85,86,97-106]. A systematic review that included 29 observational studies found less blood loss, decreased time to oral intake, and reduced length of hospital stay for laparoscopic compared with open distal pancreatectomy [98]. 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 [107]. The only advantage for laparoscopic surgery was a 2.4 day shorter hospital stay. In a nationwide Danish review of adults who underwent distal pancreatectomy at 17 centers between 2005 and 2013, laparoscopic distal pancreatectomy was associated with significantly fewer major complications (16 versus 29 percent) and a shorter median hospital stay (8 versus 10 days); however, after propensity matching, these differences were not significant [101].

In a multicenter patient-blinded randomized trial (LEOPARD), 108 patients with left-sided pancreatic tumors underwent open or laparoscopic distal pancreatectomy [108]. 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 [109].

In another trial of 60 patients, laparoscopic distal pancreatectomy was associated with shorter hospital stay than open surgery, with shorter time to functional recovery and less bleeding [110].

Oncologic outcomes — Whether oncologic outcomes are equivalent is an active area of investigation for specific types of malignancies [99,111,112]:

A single-institution review compared outcomes for open, laparoscopic, and robotic-assisted laparoscopic approaches [99]. For pancreatic adenocarcinoma, oncologic outcomes were similar, with high rates of R0 resection (88 to 100 percent) for each group. The open group had a higher lymph node yield compared with the minimally invasive groups (laparoscopic: 15.4 versus 10.4; robotic-assisted: 15.4 versus 12).

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 [111]. 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 similar 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) [112]. 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.

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.)

Retrograde pancreatectomy — For distal pancreatectomy, a retrograde approach to the pancreas is usually chosen; however, an antegrade, open approach has been described and is discussed below. (See 'RAMPS procedure' below.)

For open pancreatectomy, a left upper quadrant subcostal incision that extends over the midline to the right is most commonly used [27]. 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 '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.

Mobilize the body and tail of the pancreas by first incising the peritoneum along the inferior and superior borders of the pancreas, paying particular attention to the superior border to identify and isolate the splenic artery in a cephalad direction away from the pancreas. 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).

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.

To mobilize the spleen (if splenectomy will be performed) (see 'Splenectomy and lymphadenectomy' 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 'Splenic preservation' above.)

Unlike the vein, the 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.

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. The spleen and distal pancreas should now be free and can be mobilized laterally to medially.

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 [TA], 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) may decrease the incidence of pancreatic fistula. Alternatively, the pancreatic duct and cut edge of the pancreas can be sutured using a U-stitch. (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.

Laparoscopic approach — 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. A single-incision approach has also been described [113]. Abdominal access techniques and port placement are discussed elsewhere. (See "Abdominal access techniques used in laparoscopic surgery".)

Laparoscopic resection of the body and tail of the pancreas is performed using a lateral-to-medial approach similar to retrograde, open 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 [114]. Most of the dissection in the operation can be completed with a harmonic scalpel, 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 left-sided 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, often the left lateral site. (See 'Drainage of the pancreatic bed' above.)

RAMPS procedure — The radical antegrade modular pancreaticosplenectomy (RAMPS) procedure is an alternative open approach to distal pancreatectomy [115,116]. The goal of the RAMPS procedure is to provide a more extensive lymph node dissection [117]. However, although it may retrieve a greater number of lymph nodes, it may not lead to the retrieval of more positive lymph nodes or provide a better resection margin [116]. Long-term outcomes for this procedure compared with those of conventional distal pancreatectomy (retrograde approach) are unknown.

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. In three small series in which RAMPS was used to treat pancreatic cancer, negative margins were obtained in 81, 90, and 91 percent of the patients [117-119]. The authors assert that this modified technique achieves a high rate of negative posterior resection margins and sampling of regional lymph nodes with little morbidity.

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. Central pancreatectomy can be used to treat benign and/or low-grade malignant lesions located in the neck and proximal body of the pancreas [120]. 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 systematic review identified 94 studies involving 963 patients and compared outcomes for patients undergoing central pancreatectomy versus distal pancreatectomy [121]. Central pancreatectomy was associated with a significantly higher overall incidence of postoperative morbidity (46 versus 29 percent) and a higher incidence of pancreatic fistula (31 versus 14 percent) compared with distal pancreatectomy, but a lower risk of endocrine insufficiency (4 versus 23 percent). Similar results were found in a separate systematic review [122].

Central pancreatectomy has predominantly been performed using an open approach, although a minimally invasive approach has been reported [123]. 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). A Roux-en-Y pancreaticojejunostomy, which is more commonly used, or pancreaticogastrostomy can be constructed [124]. The incidence of postoperative pancreatic fistula may be lower for pancreaticogastrostomy compared with pancreaticojejunostomy [125]; however, the risk of exocrine failure due to inactivation of digestive enzymes by gastric juice may be higher [125,126]. 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'.)

Technique — 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:

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. (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, the cut end of the pancreas can be anastomosed to the posterior stomach or a Roux-en-Y limb of jejunum.

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 cystic neoplasms. 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.

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, which may help the surgeon to avoid ductal injury and to identify a major ductal disruption if it occurs. (See "Surgical resection of lesions of the head of the pancreas", section on 'Preoperative biliary drainage'.)

Technique — An open or laparoscopic approach can be used. The general technique to gain pancreatic exposure through an open or laparoscopic technique is described above. (See 'Retrograde pancreatectomy' above and 'Laparoscopic approach' above.)

To enucleate a lesion from the pancreas:

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.

POSTOPERATIVE CARE AND FOLLOW-UP — Routine postoperative management is primarily focused on return of bowel function and management of closed-suction drain output [27]. The average length of stay is approximately five to seven days after open and three to five days after a laparoscopic distal pancreatectomy [104].

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 appropriately timed vaccinations. (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.

The drainage should be clear or straw colored in appearance. International guidelines (International Study Group on Pancreatic Fistulas [ISGPF]) suggest that the drain effluent amylase level should be routinely analyzed to determine if a pancreatic leak is present. Certainly 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 serum amylase level defines a pancreatic leak.

A multi-institutional study has identified a drain fluid amylase of 2000 U/L on postoperative day 1 as the optimal cutoff value for predicting clinically relevant fistula specifically after distal pancreatectomy [127]. However, unlike for pancreaticoduodenectomy [128], there has been no evidence to support early drain removal after distal pancreatectomy when the patient value is below the cutoff.

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.

Prophylactic somatostatin analogues — Somatostatin is a long-acting somatostatin analogue that reduces pancreatic, gastric, and enteric secretions. In theory, somatostatin should be helpful for reducing postoperative pancreatic fistula, but studies evaluating this issue are conflicting [129-136]. No significant differences in mortality have been identified in several systematic reviews whether or not somatostatin is used [129,130,132,137]. Somatostatin and its analogues may have an overall benefit in reducing morbidity following pancreatic operations, but the variable methods by which the agent is administered, outcomes reported, and complications defined, particularly the definition of a pancreatic fistula, make it difficult to compare studies or clearly identify a subgroup for whom prophylactic treatment might be considered and the optimal means by which it should be administered [138]. As a result, 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, somatostatin may be useful to control the volume of output. (See "Physiology of somatostatin and its analogues" and 'Postoperative pancreatic fistula' below.)

A systematic review and meta-analysis that included 21 trials evaluating somatostatin following a pancreatic surgery (variety of indications and types of surgery) found a decreased incidence of pancreas-specific complications in those patients who received prophylactic somatostatin postoperatively [137]. 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 rates of reoperation, anastomotic leak, postoperative pancreatitis, renal failure, bleeding, abdominal collections, delayed gastric emptying, or length of hospital stay. No differences in mortality rates with and without somatostatin have been identified in several systematic reviews [129,130,132,137].

A subsequent trial evaluated pasireotide, which has a longer half-life than octreotide and a different binding profile [139]. Three hundred patients received pasireotide (900 micrograms subcutaneously) or placebo on the morning of the pancreatic surgery (pancreatoduodenectomy or distal pancreatectomy) and continued for one week postoperatively. The overall incidence of the primary combined endpoint of grade 3 or higher postoperative pancreatic fistula, leak, or abscess (head or tail resection) was significantly lower in the pasireotide group (9.2 versus 20.9 percent) and also significantly lower for those who underwent resection of the pancreatic tail (7 versus 23 percent). The overall rate of the secondary endpoint of grade B or C postoperative pancreatic fistula was also significantly reduced in the pasireotide group (7.9 versus 16.9 percent). The character of the pancreas (eg, duct dilation, softness of pancreatic tissue) and the use of postoperative pancreatic drains, which are thought to affect the risk for postoperative pancreatic fistula, were similar between the groups. Furthermore, the interaction between the pasireotide group and a subgroup defined according to placement or nonplacement of a drain was also not significant. The two most common adverse events associated with pasireotide were hyperglycemia and dose-limiting nausea (17 percent). The benefit with pasireotide, in contrast to prior results with octreotide, may be related to differences in their pharmacologic profiles. Other studies have found mixed results and call into question the efficacy of this expensive adjunct [140].

PERIOPERATIVE MORBIDITY AND 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 (up to 13 percent) [121,141-143].

Complications following distal pancreatectomy are common, occurring in up to 40 percent of patients, primarily related to the sequelae of a pancreatic leak [27,129,137,144], which significantly increases the length of hospital stay and cost [145]. Other surgical complications include splenic vein thrombosis, new-onset insulin-dependent diabetes mellitus, intra-abdominal abscess, and postoperative bleeding [17,121,146]. There may be an increased risk of new-onset diabetes in patients with chronic pancreatitis compared with patients who undergo distal pancreatectomy for other indications (9 versus 7.5 percent, in one study) [17]. (See "Overview of the complications of chronic pancreatitis" and "Chronic pancreatitis: Management".)

Post-splenectomy sepsis has been reported following distal pancreatectomy with splenectomy [147]. (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) [148,149]. 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 [82]. 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 [2,3].

Prevention of postoperative pancreatic fistula has been attempted using various techniques for handling the pancreatic stump or anastomosis, using prophylactic somatostatin and its analogues, and using various reinforcements or tissue adhesives with varying success [150,151]. These methods are discussed above for resection of the body or tail of the pancreas and discussed separately for resection of the head of the pancreas. (See 'Pancreatic transection and closure' above and "Surgical resection of lesions of the head of the pancreas", section on 'Pancreatic-enteric anastomosis'.)

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 (CR-POPF) [79]. Independent risk factors for CR-POPF included age ≥60, obesity, hypoalbuminemia, the absence of epidural anesthesia, neuroendocrine or nonmalignant pathology, concomitant splenectomy, and vascular resection. By contrast, 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 CR-POPF by multivariable regression.

Postoperative exocrine and endocrine failure — The overall rates of 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) [17].

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.)

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 is an alternative approach.

Central pancreatectomy removes a limited portion of the pancreas, sparing the tail.

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

Preoperative preparation

Imaging – Prior to elective resection of the distal pancreas, all patients should undergo pancreatic imaging to determine the size, location, and relationship of the suspect lesion to surrounding structures and, for patients with disruption of the pancreatic duct, to assess the location and amount of peripancreatic fluid. (See 'Preoperative imaging' above.)

Antimicrobial prophylaxis – For patients undergoing elective resection of the distal pancreas, we recommend antimicrobial prophylaxis (Grade 1B). Patients for whom antibiotics have been initiated to manage established preoperative infection should be redosed prior to surgery [31,32]. (See 'Antibiotics' above and "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults".)

Thromboprophylaxis – For patients undergoing resection of the distal pancreas who are at moderate-to-high risk for thromboembolism, we recommend pharmacologic thromboprophylaxis over no prophylaxis (Grade 1B). We also place intermittent pneumatic compression devices prior to induction and continue their use until the patient is ambulatory. (See 'Thromboprophylaxis' above and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Selecting thromboprophylaxis'.)

Staging laparoscopy – For patients undergoing resection of the distal pancreas for pancreatic adenocarcinoma, we suggest staging laparoscopy immediately prior to proceeding with the pancreatic resection (Grade 2C). Staging laparoscopy identifies occult peritoneal metastases or local invasion that contraindicates resection. (See 'Staging laparoscopy' above and "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Staging laparoscopy'.)

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 – When performing pancreatectomy for a lesion of the distal pancreas that is biopsy proven or highly suspicious for cancer, we perform concomitant splenectomy. Splenectomy ensures better local control and peripancreatic lymph node sampling. Splenic preservation is acceptable when treating small neuroendocrine tumors that are likely to be benign and premalignant cystic lesions with no signs of advanced pathology. For patients in whom splenectomy is anticipated, preoperative immunization should be given prior to surgery, or postoperatively if vaccination was not possible prior to surgery. (See 'Splenectomy and lymphadenectomy' above and '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 upon 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. 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 'Pancreatic transection and closure' 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 'Perioperative morbidity and mortality' above.)

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Topic 5660 Version 30.0

References

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