Hemodynamic adaptation after splenic vein sacrifice in spleen-preserving distal pancreatectomy

We are truly grateful for the insightful and academic feedback from Chen and Ye (1) on our recent research concerning spleen-preserving distal pancreatectomy (SPDP) with splenic artery preservation and splenic vein sacrifice (2). Their commentary offers a valuable chance to further situate our results within the developing surgical methods for spleen preservation. As the authors pointed out, the primary challenge in SPDP is balancing technical feasibility with physiological preservation. The Kimura technique, while providing excellent vascular integrity, often faces limitations due to anatomical and technical factors (3). On the other hand, the traditional Warshaw procedure simplifies the surgery but compromises splenic perfusion and venous drainage (4). Positioned between these approaches, the strategy of preserving the artery while sacrificing the vein offers a physiologically moderate solution.

Importantly, our study expands on earlier research by presenting long-term follow-up data, demonstrating that the modified Warshaw technique not only results in improved initial outcomes but also maintains stable splenic hemodynamics over an extended period. This is particularly crucial because previous studies, including our initial series, were limited by shorter follow-up durations (5).

Chen and Ye have highlighted a significant issue regarding the possible onset of sinistral portal hypertension after ligating the splenic vein. We completely concur that this hypothetical risk deserves thorough attention. Nonetheless, growing evidence indicates that the spleen possesses an impressive ability for adaptive venous remodeling (6,7). It has been consistently noted that collateral drainage through the short gastric, left gastroepiploic, and omental venous systems effectively compensates for any obstruction in splenic venous outflow.

Significantly, this adaptive process is not exclusive to instances where the splenic vein is sacrificed. Even when the splenic vein is preserved during SPDP, its long-term openness is not always guaranteed. Earlier research has shown that splenic vein blockage or narrowing occurs in a considerable number of patients during follow-up, despite successful preservation during surgery (8). This can be attributed to the anatomical and physiological traits of the splenic vein, which is often situated within the pancreatic tissue and becomes more exposed after dissection. Additionally, its low-pressure flow characteristics and vulnerability to inflammation during surgery make it prone to thrombosis and eventual blockage (8). However, this radiological loss of openness seldom leads to significant clinical outcomes. In most instances, collateral venous routes form naturally, ensuring sufficient splenic drainage and blood flow. Even when splenic vein blockage happens, the resulting effects are usually limited to minor vessel swelling or the formation of perigastric collaterals, while serious complications like variceal bleeding, symptomatic left-sided portal hypertension, or the need for intervention are extremely rare (8). These findings imply that the long-term openness of the splenic vein may be less clinically significant than previously thought, as effective physiological compensation occurs in the majority of patients.

In this context, our results align with earlier studies indicating that, while collateral pathways can be detected through imaging, they do not always lead to clinically significant issues. Additionally, the occurrence of engorged gastric collaterals in our group was lower than what is typically observed after the traditional Warshaw technique, implying that maintaining arterial inflow might reduce excessive collateral formation by ensuring sufficient splenic perfusion. From a hemodynamic standpoint, the spleen seems to reach a new balance after the splenic vein is sacrificed, where preserved arterial inflow and altered venous drainage sustain its functional viability. In this sense, the modified Warshaw technique might provide a beneficial balance by preventing severe ischemic damage while allowing for controlled venous adaptation. Another crucial factor is the surgical strategy and preoperative planning. Our subgroup analysis revealed that a planned modified Warshaw approach, informed by preoperative imaging, significantly decreased intraoperative blood loss while maintaining similar safety outcomes. This supports the idea that the technique should be viewed not just as a last-resort option, but as a proactive, anatomy-based surgical strategy.

We completely agree that additional research is essential, especially in terms of understanding long-term results and the development of collateral pathways. Conducting prospective multicenter studies that include both functional and immunological evaluations of the spleen would be beneficial in this context.

Our comprehensive data, along with increasing evidence, suggest that opting to preserve the splenic artery while sacrificing the splenic vein is a safe and physiologically sound approach when preserving the splenic vein is not feasible. This technique appears to promote adaptive hemodynamic changes without causing clinically significant portal hypertension and also aids in minimizing ischemic complications.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gland Surgery. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0276/coif). The author has no conflicts of interest to declare.

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References

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