Spleen-preserving distal pancreatectomy with resection of the splenic vessels. Should one rely on the short gastric arteries?

CONTEXT: Knowing the collaterals is essential for a spleen-preserving distal pancreatectomy with resection of the splenic vessels. OBJECTIVE: To ascertain the sources of the blood supply to the spleen after a spleen-preserving distal pancreatectomy with resection of the splenic vessels. METHODS: Perfusion of the cadaveric left gastric and right gastroepiploic arteries with methylene blue after occlusion of all the arteries except the short gastric arteries (n=10). Intraoperative color Doppler ultrasound was used for the evaluation of the hilar arterial blood flow at distal pancreatectomy (n=23) after 1) clamping of the splenic artery alone, 2) clamping of the splenic and left gastroepiploic arteries and 3) clamping of the splenic and short gastric arteries. CT angiography of the gastric and splenic vessels before and after a spleen-preserving distal pancreatectomy (n=10). RESULTS: Perfusion of the cadaveric arteries revealed no effective direct or indirect (through the submucous gastric arterial network) communication between the left gastric and the branches of the short gastric arteries. In no case did intraoperative color Doppler ultrasound detect any hilar arterial blood flow after the clamping of the splenic and left gastroepiploic arteries. The clamping of the short gastric arteries did not change the flow parameters. In none of the cases did a post-spleen-preserving distal pancreatectomy with resection of the splenic vessels CT angiography delineate the short gastric vessels supplying the spleen. In all cases, the gastroepiploic arcade was the main arterial pathway feeding the spleen. CONCLUSION: Experimental, intra- and postoperative instrumental investigations did not show the short gastric arteries to be engaged in the blood supply to the spleen after a spleen-preserving distal pancreatectomy with resection of the splenic vessels. In all cases, the left gastroepiploic artery was the main collateral vessel.

Pancreas-preserving duodenal resections with bile and pancreatic duct replantation for duodenal dystrophy. Two case reports.

CONTEXT: Duodenal dystrophy is a rare disease, characterized by the chronic inflammation of the aberrant pancreatic tissue in the duodenal wall. CASE REPORTS: Two middle-aged men were admitted with upper abdominal pain of several months duration, periodic nausea and vomiting after meals, intermittent jaundice and weight loss. A diagnosis of cystic dystrophy of the vertical part of the duodenum without chronic inflammation of the orthotopic pancreas was established in both cases by multi-detector computed tomography, magnetic resonance imaging and endosonography. Both patients were successfully treated by two modifications of pancreas-preserving duodenal resections with reimplantation of the bile and pancreatic ducts into the neoduodenum. CONCLUSION: These cases are a good example of a pancreas-preserving approach to duodenal dystrophy treatment and can be an alternative to the Whipple procedure in cases of mild changes of the orthotopic gland.