Clinical Research About The Outcomes Of Laparoscopic Spleen-preserving Distal Pancreatectomy Through Pancreatic Tail First Approach And The Artery Pattern Of Splenic Hilus

PartⅠ An radiological research on the artery pattern of splenic hilusObjectives:To research and analyze the artery branch and pattern of splenic hilus by CTA and to provide the anatomical basis for laparoscopic spleen preserving distal pancreatectomy through pancreatic tail first approach.Methods:One hundred patients underwent CT angiography in Qilu hospital were randomly enrolled.The imaging datas were reconstructed by using the maximum intensity projection and multi planar reformation ways.The features of main splenic artery,splenic lobar artery,left gastroepiploic artery,splenic pole artery and innominate artery were observed.Results:1.Of these one hundred patients,the distribution of the main splenic artery was as follows:type one in 17 cases(17%),type two in 27 cases(27%),type tree in 10 cases(10%),type four in 46 cases(46%).2.For the splenic lobar artery,there were 65 compact type cases(65%),28 distributed type cases(28%)and 7 comb-type cases(7%).In addition,there were 3 cases with one branch of the splenic lobar artery(3%),66 cases with two branch of the splenic lobar artery(66%),22 cases with three branch of the splenic lobar artery(22%)and 9 cases with multiple branch of the splenic lobar artery(9%).Concerning the relationship between pancreatic tail and origin of splenic lobar artery,there were 62 cases whose splenic lobar artery origin located in the left side of the pancreatic tail.The mean distance between the origin to the pancreatic tail was 1.52±0.88 cm.And there were 38 cases whose splenic lobar artery origin located in the right side of the pancreatic tail.The mean distance between the origin to the pancreatic tail was 1.38±0.89 cm.3.There were 57 cases with the left gastroepiploic artery originating in the main splenic artery and 43 cases with the left gastroepiploic artery originating in splenic lobar artery.The mean distance between the origin of left gastroepiploic artery and the origin of splenic lobar artery was 1.56±0.85cm.And,the mean distance between the origin of left gastroepiploic artery and splenic hilus was 1.72±0.77cm.Besides,there were 61 cases whose left gastroepiploic artery origin located in the left side of the pancreatic tail.The mean distance between the origin to the pancreatic tail was 1.55±0.96cm.And there were 39 cases whose left gastroepiploic artery origin located in the right side of the pancreatic tail.The mean distance between the origin to the pancreatic tail was 1.21 ±0.79 cm.4.There were 16 cases with superior splenic pole artery,27 cases with inferior splenic pole artery and 4 cases with both superior and inferior splenic pole artery.In our research,93.7%of the superior splenic pole artery originating in the main splenic artery and 6.3%of superior splenic pole artery originating in superior splenic lobar artery.And all the inferior splenic pole artery originating in left gastroepiploic artery.5.There were 2 cases with the innominate artery(2%).Conclusion:1.The splenic artery is the main feeding artery for the spleen and has close relationship with the pancreatic body and tail.The splenic artery branches such as splenic lobar artery and splenic pole artery have many variation and the collateral circulation in the splenic hilus is plentiful,which should be paid attention to in the laparoscopic spleen-preserving distal pancreatectomy.2.Preoperative CTA give us a general knowledge about the detail of splenic hilus vessel variation,which will be helpful for the feasibility and safety of laparoscopic spleen-preserving distal pancreatectomy through pancreatic tail first approach.Part II Clinical research about the outcomes of laparoscopic spleen-preserving distal pancreatectomy through pancreatic tail first approachObjectives:To describe the method of laparoscopic spleen-preserving distal pancreatectomy through pancreatic tail first approach,and to evaluate it’s feasibility,security and clinical value.Methods:The clinical datas of 93 patients who underwent laparoscopic distal pancreatectomy in Qilu hospital from Jan.2015 to May.2018 were collected and analyzed retrospectively.Two groups were divided into laparoscopic distal pancreatectomy and open distal pancreatectomy according to the operation method.According to the operation approach,the laparoscopic group was divided into pancreatic tail first-approach group and pancreatic neck-approach group.Operation time,intraoperative blood transfusion,intraoperative blood loss,spleen-preserving method,postoperative oral intake time,postoperation stay and complications of these three groups were statistically ananlyzed.Results:There were 32 patients underwent laparoscopic spleen-preserving distal pancreatectomy through pancreatic tail first approach.The spleen was preserved successfully in 27 cases.During to the intraoperative hemorrhage,2 laparoscopic cases converted to open surgery.The average operative time was 258.40±61.74 minutes and the average intraoperative blood loss was 221.71±204.31ml.There were 12 cases underwent this spleen-preserving operation by the Kimura method and 15 cases by the Warshaw method.Both splenic artery and vein were cut off in 8 cases,only splenic artery was cut off in 2 cases and only splenic vein was cut off in 5 cases.The postoperative recovery situation was as follows:the average postoperative oral intake time was 2.10±1.09 days and the average postoperative stay was 8.56±3.12 days.The postoperative pancreatic fistula occurred in 8 cases including 5 biochemical leak cases,3 grade B cases and no grade C cases.As for the other complication,only one postoperative acute hemorrhage case occurred.No deaths occurred during perioperative period.Although pancreatic tail first-approach LDP group was longer than ODP group in operation time significantly,the intraoperative blood loss was less and the proportion of spleen preservation was higher(P<0.05).Besides,both the postoperative oral intake time and postoperation stay were shorter in pancreatic tail first-approach LDP group than in ODP group(P<0.05).There was no statistical difference between the two groups regarding the intraoperative blood transfusion,pancreatic fistula and other postoperative complications(P>0.05).There was no death occurring during perioperative period in both group.Compared with the pancreatic neck-approach LDP,the ratio of spleen blood vessel preservation in Warshaw method in the pancreatic tail first-approach LDP(P<0.05).And in the other aspect,there was no significant difference in both groups(P>0.05).Conclusion:The pancreatic tail first-approach LDP is a safe,feasible surgical procedure,which can reduce the risk of bleeding and improve both the spleen blood vessel and the spleen organ preservation ratio.