Splenic artery preservation with splenic vein sacrifice during spleen-preserving distal pancreatectomy: safety and remaining questions

Spleen-preserving distal pancreatectomy (SPDP) is widely accepted for benign and low-grade malignant lesions of the pancreatic body and tail (1,2). The Kimura technique provides ideal hemodynamic outcomes but is technically challenging (1,3). The conventional Warshaw procedure reduces surgical difficulty but leads to high rates of splenic infarction and gastric collateral enlargement (4,5).

In a recent issue of Gland Surgery, Chun et al. (6) reported long-term results of a modified Warshaw technique preserving the splenic artery while sacrificing the splenic vein. This approach markedly reduced splenic infarction (6.3% vs. 69.8%, P<0.001) and engorged gastric collaterals (25.0% vs. 55.8%, P=0.003) compared with the conventional Warshaw method (6). The planned modified subgroup also showed less intraoperative blood loss, supporting preoperative imaging-guided selection (6).

This strategy was initially described by Kim et al. (7), who reported a low rate of splenic infarction and a favorable safety profile with a median follow-up of 21.5 months. A recent case series further corroborated the safety of this technique, with no instances of splenomegaly or varix formation observed during follow-up (8). Despite theoretical concerns regarding splenic congestion, no cases of symptomatic portal hypertension or variceal bleeding have been reported to date (6-8). Adequate venous outflow is maintained through collateral drainage via the short gastric and left gastroepiploic veins.

The artery-sparing, vein-sacrificing modified Warshaw technique is a safe and effective alternative that is superior to the conventional procedure when splenic vein preservation is not feasible. This approach minimizes splenic infarction and intraoperative blood loss while avoiding clinically significant portal hypertension. However, dedicated studies on this specific technique remain limited, and long-term data on the progression of gastric collaterals are scarce. Although no variceal bleeding has been reported, the potential risk of progressive sinistral portal hypertension cannot be entirely excluded. Therefore, long-term surveillance and larger-scale studies are warranted to further validate the long-term safety of this promising strategy.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0246/coif). The authors have no conflicts of interest to declare.

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