- Open Access
The impact of splenectomy on outcomes after distal and total pancreatectomy
© Koukoutsis et al; licensee BioMed Central Ltd. 2007
- Received: 13 October 2006
- Accepted: 02 June 2007
- Published: 02 June 2007
Several authors advocate spleen preserving distal pancreatectomy, because of the increased complication rate after splenectomy.
Postoperative complications and survival after distal and total pancreatectomy, were recorded and retrospectively analyzed according to spleen preservation. Patients, who underwent distal and total pancreatectomy without histologically proven adenocarcinoma, or extrapancreatic disease, were included in the cohort which was divided into splenectomy and no splenectomy groups. Statistical analysis was performed using Fisher's test.
The study group consisted of 62 patients who underwent distal and total pancreatectomy between 26/11/1987 to 6/1/2006. Splenectomy was performed in 35 out of 62 patients (56.5%), distal pancreatectomy was performed in 49 out of 62 patients (79%). Morbidity rate was 28.6% in splenectomy group and 14.8% in the no splenectomy group (p = 0.235), while 30 days mortality rate was 2.9%; one patient died in the splenectomy group (p = 1).
Spleen-preservation did not influence the outcomes after distal and total pancreatectomy in our series.
- Chronic Pancreatitis
- Distal Pancreatectomy
- Benign Disease
- Total Pancreatectomy
Pancreatectomy may be accompanied with splenectomy in distal and total pancreatic resections. Elective peripheral pancreatectomy is safer than pancreaticoduodenectomy, but carries a high morbidity rate [1–4]; intraabdominal abscess, intraabdominal hemorrhage and pancreatic fistula are the main causes [5–9]. In the past decade splenectomy was associated with increased septic complications rate [10, 11]. Furthermore, several authors [12–15], suggested spleen preserving distal pancreatectomy in order to reduce postoperative septic complications. The technique of spleen preserving distal pancreatectomy and its absolute and relative contraindications have been described elsewhere [3, 13, 17, 18]. Few retrospective studies have analyzed the influence of splenectomy in the postoperative course after distal pancreatectomy, while one study has analyzed this relationship after total pancreatectomy [3, 19, 20]. These studies included patients with benign diseases ; mainly with chronic pancreatitis ; only with chronic pancreatitis ; with malignant and benign diseases [9, 23] ; mainly with pancreatic trauma  and only with adenocarcinoma .
In our study, postoperative complications after distal and total pancreatectomy, were recorded and analyzed according to spleen preservation, in patients with pancreatitis (chronic and acute), benign neoplasms and other benign diseases.
Prospective collected data were retrospectively analyzed for patients who underwent distal or total pancreatectomy with or without splenectomy between 28th of November 1987 and 6th of January 2006. Patients with histologically proven adenocarcinoma, patients with cystadenocarcinoma, patients who underwent completion pancreatectomy after postoperative complication of pancreaticoduodenectomy, patients who underwent pancreatectomy because of abdominal trauma, patients who had hepatic metastases in laparotomy, patients who had cancer in the pancreatic head or lower common bile duct and patients who had additional procedures such as gastrectomy and colectomy were excluded from the study. The patients were divided into splenectomy and no splenectomy group. The following parameters were recorded and analyzed for each of the above mentioned groups: sepsis (SIRS and MODS), acute renal failure, pulmonary complications (atelectasia, pneumonia, pleural effusion), ARDS (acute onset, bilateral infiltrates on chest radiography, pulmonary-artery wedge pressure ≤ 18 mm Hg or the absence of clinical evidence of left atrial hypertension, acute lung injury considered to be present if PaO2 :FiO2 is ≤ 300 Acute respiratory distress syndrome considered to be present if PaO2 :FiO2 is ≤ 200), cardiac complications (atrial fibrillation, dysarrythmia), central nervous system complications (confusion, stroke), intra abdominal abscess (defined as an infected fluid collection identified by CT or ultrasound scan-guided needle aspiration and microbiologic culture), postoperative primary intra abdominal hemorrhage (1ry IA, diagnosed by the presence of fresh blood through the drains or by hypovolemic shock and abdominal distension in patients without drains), postoperative primary gastrointestinal hemorrhage (1ry GI), delayed gastric emptying, wound infection, wound dehiscence, first 30 postoperative days mortality.
Statistical analysis was performed using Fisher's two-tailed test, in the "Statistical Package for the Social Sciences" version 12 for Windows (SPSS®, Chicago, IL, USA). A p value less than 0.05 was considered significant.
Study group characteristics and types of operations.
Type of pancreatectomies
Distal (spleen preservation)
Total (spleen preservation)
Final diagnoses after pancreatic resection in the total of 62 patients.
Other benign diseases
Benign neuroendocrine tumor
Splenectomy vs no splenectomy group
Analysis of complications in splenectomy and no splenectomy groups.
Splenectomy group (n)
No splenectomy group (n)
Splenectomy group (n)
No splenectomy group (n)
1ry IA *
The two cases of intra abdominal access were treated by the radiologist with a CT guided drainage. The only case of primary postoperative hemorrhage needed a reintervention after a failed embolization.
30 days mortality analysis
The 30 days mortality rate in the study group of patients was 2.9%. One patient died (stroke) in the splenectomy group (p = 1). There was not recorded any postoperative death due to postsplenectomy sepsis.
Spleen preserving distal pancreatectomy has been advocated by many authors, because of splenectomy associated immunologic alterations and septic postoperative complications [13, 16, 24, 25]. Holdsworth et al.,  and Benoist et al.,  studied patients with benign diseases and Sledzianowski et al.,  studied patients with malignant and benign diseases, failed to prove the importance of spleen preservation in distal pancreatectomy, supporting the fact that the risk of overwhelming postsplenectomy sepsis in adult population with benign disease is very low (0.28%–1.9% with a 2.2% mortality rate) [15, 27]. Aldridge et al.,  in a group of patients with chronic pancreatitis concluded that postoperative course was similar after distal pancreatectomy regardless of splenectomy. Richardson and Scott- Conner  demonstrated that spleen preservation did not increase the complications rate after distal pancreatectomy. However, the study group was small (21 patients), and mainly consisted of trauma patients who underwent major additional procedures in most of the cases. Schwarz et al.,  studied the outcomes in a group of patients (326 patients, 37 underwent splenectomy) with adenocarcinoma after distal and total pancreatectomy with or without splenectomy, concluded that splenectomy was a statistically significant unfavorable prognostic factor in survival, but not in postoperative morbidity. Shoup et al., , in a cohort with benign and low-grade malignant diseases (125 patients), reported that spleen preserving distal pancreatectomy is associated with lower infectious complications rate and reduced hospital stay, than the distal pancreatectomy with splenectomy (p = 0.01 and p < 0.01 respectively). To our knowledge, there is no other series, studying the relation of spleen preservation with all the postoperative parameters we recorded together, after distal and total pancreatectomy. Infectious complications including wound and pulmonary complications, intra abdominal abscess formation and sepsis were not statistically significant associated with splenectomy. There was no significant obvious predilection in the selection of distal or total pancreatectomy and splenectomy or spleen preservation. The mortality rate recorded in our cohort is similar to the reported in some studies [1, 2] and lower than the published in other articles [3, 4, 28] after distal pancreatectomy. In our series there was not statistically significant difference recorded in morbidity, in the first 30 postoperative days mortality (p = 0.592 respectively). In order to fully assess the influence of splenectomy on survival after distal and total pancreatectomy, future studies including larger series of patients are required.
The authors conclude that spleen preservation does not influence the outcome after distal or total pancreatectomy, in benign diseases and selected benign neoplasms.
The authors would like to thank Mr. Chris Coldham (Liver Unit) for helping in collecting the data and Mr. Peter G. Nightingale (Statistician, Wellcome Trust Clinical Research Facility, Birmingham UK) for his help in statistical analysis.
- Balcom JH, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C: Ten years experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg. 2001, 136: 391-398. 10.1001/archsurg.136.4.391.View ArticlePubMedGoogle Scholar
- Lillemoe KD, Knushal S, Cameron JL, Sohn TA, Pitt HA, Yeo CJ: Distal pancreatectomy: indications and outcomes in 235 patients. Ann Surg. 1999, 229: 593-598. 10.1097/00000658-199905000-00012.View ArticleGoogle Scholar
- Aldridge MC, Williamson RC: Distal pancreatectomy with and without splenectomy. Br J Surg. 1991, 78: 976-979. 10.1002/bjs.1800780827.View ArticlePubMedGoogle Scholar
- Fahy B, Frey C, Hung S, Beckett L, Bold R: Morbidity, mortality, and technical factors of distal pancreatectomy. Am J Surg. 2002, 183: 237-241. 10.1016/S0002-9610(02)00790-0.View ArticlePubMedGoogle Scholar
- Sugo H, Mikami Y, Matsumoto F, Tsumura H, Watanabe W, Futagawa S: Comparison of ultrasonically activated scalpel versus conventional division for the pancreas in distal pancreatectomy. J Hepatobil Pancreat Surg. 2001, 8: 349-352. 10.1007/s005340170007.View ArticleGoogle Scholar
- Marezell AP, Stierer M: Partial pancreaticoduodenectomy (Whipple procedure) for pancreatic malignancy: occlusion of an non-anastomosed pancreatic stump with fibrin sealant. HPB Surg. 1992, 5: 251-259.View ArticleGoogle Scholar
- Suc B, Msika S, Fingerhut A, Fourtanier G, Hay JM, Holmieres F, Sastre B, Fagniez PL, the French Associations for Surgical Research: Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Ann Surg. 2003, 237: 57-65. 10.1097/00000658-200301000-00009.PubMed CentralView ArticlePubMedGoogle Scholar
- Martin FM, Rossi RL, Munson L, ReMine SG, Braasch JW: Management of pancreatic fistulas. Arch Surg. 1989, 124: 571-573.View ArticlePubMedGoogle Scholar
- Montorsi M, Zago M, Mosca F, Capussotti L, Zotti E, Ribotta G, Fegiz G, Fissi S, Roviaro G, Peracchia A: Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized trial. Surgery. 1995, 117: 26-31. 10.1016/S0039-6060(05)80225-9.View ArticlePubMedGoogle Scholar
- Ziemski JM, Rudowski WJ, Jascowiak W, Rusiniak L, Scharf R: Evaluation of the postsplenectomy complications. Surg Gynecol Obstet. 1987, 165: 507-514.PubMedGoogle Scholar
- Francke EL, Neu HC: Postsplenectomy infection. Surg Clin North Am. 1981, 61: 135-154.PubMedGoogle Scholar
- Warshaw AL: Conservation of the spleen with distal pancreatectomy. Arch Surg. 1988, 123: 550-553.View ArticlePubMedGoogle Scholar
- Kimura W, Inoue T, Futakawa N, Shinkai H, Han I, Muto T: Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. Surgery. 1996, 120: 885-890. 10.1016/S0039-6060(96)80099-7.View ArticlePubMedGoogle Scholar
- Cooper MC, Williamson RC: Conservative pancreatectomy. Br J Surg. 1985, 72: 801-803. 10.1002/bjs.1800721009.View ArticlePubMedGoogle Scholar
- Holdsworth RJ, Irving AD, Cuschieri A: Postsplenectomy sepsis and its mortality rate: actual versus perceived risk. Br J Surg. 1991, 78: 1031-1038. 10.1002/bjs.1800780904.View ArticlePubMedGoogle Scholar
- Cooper MC, Williamson RCN: Splenectomy: indications, hazards and alternatives. Br J Surg. 1984, 71: 173-180. 10.1002/bjs.1800710302.View ArticlePubMedGoogle Scholar
- Beger HG, Buchler M, Bittner R, Dettinger W, Roscher R: Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results. Ann Surg. 1989, 209: 273-278. 10.1097/00000658-198903000-00004.PubMed CentralView ArticlePubMedGoogle Scholar
- Jovine E, Biolchini F, Cuzzocrea DE, Lazzari A, Martuzzi F, Selleri S, Lerro FM, Talarico F: Spleen-preserving total pancreatectomy with conservation of the spleen vessels: operative technique and possible indications. Pancreas. 2004, 28: 207-210. 10.1097/00006676-200403000-00013.View ArticlePubMedGoogle Scholar
- Richarson DQ, Scott-Conner CE: Distal pancreatectomy with and without splenectomy. A comparative study. Am Surg. 1989, 55: 21-25.Google Scholar
- Schwarz RF, Harrison LE, Conlon KC, Klimstra DS, Brennan MF: The impact of splenectomy on outcomes after resection of pancreatic adenocarcinoma. J Am Coll Surg. 1999, 188: 516-521. 10.1016/S1072-7515(99)00041-1.View ArticlePubMedGoogle Scholar
- Benoist S, Dugue L, Sauvanet A, Valverde A, Maurais F, Paye F, Farges O, Belghiti J: Is there a role of preservation of the spleen in distal pancreatectomy?. J Am Coll Surg. 1999, 188: 255-260. 10.1016/S1072-7515(98)00299-3.View ArticlePubMedGoogle Scholar
- Govil S, Imrie CW: Value of splenic preservation during distal pancreatectomy for chronic pancreatitis. Br J Surg. 1999, 86: 895-898. 10.1046/j.1365-2168.1999.01179.x.View ArticlePubMedGoogle Scholar
- Shoup M, Brennan M, Mc White K, Leung D, Klimstra D, Conlon K: The value of spleen preservation with distal pancreatectomy. Arch Surg. 2002, 137: 164-188. 10.1001/archsurg.137.2.164.View ArticlePubMedGoogle Scholar
- Hsieh CH, Yeh CN, Chen MF: Spleen-preserving distal pancreatectomy without division of splenic artery and vein as a procedure for benign distal pancreatic lesion. Chang Gung Med J. 2002, 25: 23-28.PubMedGoogle Scholar
- Watanabe Y, Sato M, Kikkawa H, Shiozaki T, Yoshida M, Yamamoto Y, Kawachi K: Spleen preserving laparoscopic distal pancreatectomy for cystic adenoma. Hepatogastroenterology. 2002, 49: 148-152.PubMedGoogle Scholar
- Sledzianowski JF, Duffas JP, Muscari F, Sue B, Fourtanier F: Risk factors for mortality and intra-abdominal morbidity after distal pancreatectomy. Surgery. 2005, 137: 180-185. 10.1016/j.surg.2004.06.063.View ArticlePubMedGoogle Scholar
- Lynch A, Kapilla R: Overwhelming postsplenectomy infection. Infect Dis Clin North Am. 1996, 10: 695-703. 10.1016/S0891-5520(05)70322-6.View ArticleGoogle Scholar
- Wisner DH, Wold RL, Frey CF: Diagnosis and treatment of pancreatic injuries. An analysis of management principles. Arch Surg. 1990, 125: 1109-1113.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.