Long-term Outcomes of Spleen-preserving Distal Pancreatectomy With or Without Preservation of Splenic Vessels: A Bi-institutional Experience

OBJECTIVE: To compare the short- and long-term outcomes of the Warshaw (splenic vessel resection) and Kimura (splenic vessel preservation) techniques in spleen-preserving distal pancreatectomy (SPDP). SUMMARY BACKGROUND DATA: SPDP is an alternative to splenectomy that preserves immune function. Both Warshaw and Kimura are used, but comparative data on their long-term safety and indications are limited. METHODS: Retrospective bi-institutional analysis of 297 patients undergoing SPDP at Massachusetts General Hospital and Cedars-Sinai Medical Center (2002-2020). Clinicopathologic, operative, and radiologic outcomes were compared. RESULTS: Of 297 patients, 245 (82.5%) underwent Warshaw and 52 (17.5%) Kimura. Warshaw was more commonly performed for larger tumors (2.5 cm vs. 1.5 cm, P<0.001), proximal lesions (specimen 8.2 cm vs. 5.7 cm, P<0.001), and malignant or complex disease, Kimura was more commonly performed minimally invasively (MIS) (73.1% vs. 44.1%, P<0.001) and was associated with shorter operative time. Higher ASA class, larger tumor size, pancreatic ductal adenocarcinoma, and the Warshaw technique independently predicted longer operative time in MIS cases, suggesting a preferential adoption of the Warshaw technique for technically more challenging tumor dissections. Short-term morbidity, readmission, and mortality rates were comparable. With a median follow-up of 85.8 monthssplenic hypoperfusion (30.4% vs. 12.2%, P=0.010), and perigastric varices (19.6% vs. 7.3%, P=0.056) were more frequent after Warshaw, although most were clinically silent, and the need for secondary splenectomy was rare (1.2%). CONCLUSIONS: Both techniques are safe and effective for SPDP. Warshaw is preferred for proximal, malignant, or complex lesions, while Kimura may minimize long-term splenic sequelae in small, distal, benign tumors. An anatomy- and disease-driven approach remains essential to optimize outcomes.