Analysis of long-term outcomes after minimally invasive spleen-preserving distal pancreatectomy under the 'Kimura-first' strategy

Introduction:Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation.The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up.A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group (P = 0.02). We also found less blood loss for patients who underwent KT (P = 0.02). The occurrence of gastric varices was significantly higher in the WT group (P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group (P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.Distal pancreatectomy with splenectomy is used to treat benign and borderline malignant tumours located in the distal pancreas. However, as awareness of the haematological and immunological functions of the spleen has increased,[1,2] severe complications have been reported in the context of splenectomy.[3,4] Current studies suggest that the spleen should be preserved in treating these diseases.[5,6] Moreover, with the development of minimally invasive techniques, minimally invasive spleen-preserving distal pancreatectomy (MISPDP) has become the routine, preferred operation because of fewer post-operative complications, less blood loss and shorter hospital stays compared to open procedures.[7,8]Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT),[9] which conserves the splenic artery and vein, or the Warshaw technique (WT), which ligates the splenic vessels while preserving the short gastric vessels and left gastroepiploic vessels.[10] The clinical benefits of performing either method remain unclear, and most of the current studies have reported no statistically significant difference in their perioperative results.[11-13] Therefore, the focus of studies on MISPDP is to assess the long-term outcomes, especially the haemodynamic changes in splenogastric circulation. Some studies have reported a higher incidence of gastric varices and splenic infarction after WT, which is the reason why KT should be the first choice.[12,14-16] Other studies have reported no gastrointestinal bleeding of the gastric varices during a long-term follow-up.[17] Therefore, they have urged that gastric varices should be regarded as a paraphysiologic phenomenon.[13,17-19] Patients with splenic infarction rarely need reoperation.[13,17,20,21] Moreover, WT is faster and easier than KT; therefore, some studies have recommended prioritising WT in cases, in which certain operations are difficult. [21]Advances in computed tomography (CT) scanner technology and the development of three-dimensional (3D) visualisation software have helped tremendously in the diagnosis and treatment of diseases. Vascular reconstruction provides a visualisation of the 3D spatial relationship between vessels and adjacent organs and is widely used in the mesenteric vascular system.[22] The reconstruction of perigastric veins is more difficult due to the low concentration of contrast media. In recent studies, the haemodynamic changes in splenogastric circulation were mainly evaluated on cross-sectional CT images,[16,17] but none have been visually demonstrated by means of vascular reconstruction.In a previous study, we proposed the 'Kimura-first' strategy, in which WT is used as an alternative to KT when the splenic vessels cannot be safely preserved. Moreover, we confirmed that this strategy was feasible and safe in terms of perioperative outcomes.[14]Therefore, in this study, we aimed to verify the feasibility and safety of the 'Kimura-first' strategy by comparing the long-term outcomes of the two MISPDP methods. We paid special attention to the haemodynamic changes in the splenogastric circulation and visualised them by vascular reconstruction.Introduction:Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation.The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up.A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group (P = 0.02). We also found less blood loss for patients who underwent KT (P = 0.02). The occurrence of gastric varices was significantly higher in the WT group (P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group (P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.Distal pancreatectomy with splenectomy is used to treat benign and borderline malignant tumours located in the distal pancreas. However, as awareness of the haematological and immunological functions of the spleen has increased,[1,2] severe complications have been reported in the context of splenectomy.[3,4] Current studies suggest that the spleen should be preserved in treating these diseases.[5,6] Moreover, with the development of minimally invasive techniques, minimally invasive spleen-preserving distal pancreatectomy (MISPDP) has become the routine, preferred operation because of fewer post-operative complications, less blood loss and shorter hospital stays compared to open procedures. [7,8]Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT),[9] which conserves the splenic artery and vein, or the Warshaw technique (WT), which ligates the splenic vessels while preserving the short gastric vessels and left gastroepiploic vessels.[10] The clinical benefits of performing either method remain unclear, and most of the current studies have reported no statistically significant difference in their perioperative results.[11-13] Therefore, the focus of studies on MISPDP is to assess the long-term outcomes, especially the haemodynamic changes in splenogastric circulation. Some studies have reported a higher incidence of gastric varices and splenic infarction after WT, which is the reason why KT should be the first choice.[12,14-16] Other studies have reported no gastrointestinal bleeding of the gastric varices during a long-term follow-up.[17] Therefore, they have urged that gastric varices should be regarded as a paraphysiologic phenomenon.[13,17-19] Patients with splenic infarction rarely need reoperation.[13,17,20,21] Moreover, WT is faster and easier than KT; therefore, some studies have recommended prioritising WT in cases, in which certain operations are difficult.[21]Advances in computed tomography (CT) scanner technology and the development of three-dimensional (3D) visualisation software have helped tremendously in the diagnosis and treatment of diseases. Vascular reconstruction provides a visualisation of the 3D spatial relationship between vessels and adjacent organs and is widely used in the mesenteric vascular system.[22] The reconstruction of perigastric veins is more difficult due to the low concentration of contrast media. In recent studies, the haemodynamic changes in splenogastric circulation were mainly evaluated on cross-sectional CT images,[16,17] but none have been visually demonstrated by means of vascular reconstruction.In a previous study, we proposed the 'Kimura-first' strategy, in which WT is used as an alternative to KT when the splenic vessels cannot be safely preserved. Moreover, we confirmed that this strategy was feasible and safe in terms of perioperative outcomes.[14]Therefore, in this study, we aimed to verify the feasibility and safety of the 'Kimura-first' strategy by comparing the long-term outcomes of the two MISPDP methods. We paid special attention to the haemodynamic changes in the splenogastric circulation and visualised them by vascular reconstruction.Introduction:Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation.The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up.A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group (P = 0.02). We also found less blood loss for patients who underwent KT (P = 0.02). The occurrence of gastric varices was significantly higher in the WT group (P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group (P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.Distal pancreatectomy with splenectomy is used to treat benign and borderline malignant tumours located in the distal pancreas. However, as awareness of the haematological and immunological functions of the spleen has increased,[1,2] severe complications have been reported in the context of splenectomy.[3,4] Current studies suggest that the spleen should be preserved in treating these diseases.[5,6] Moreover, with the development of minimally invasive techniques, minimally invasive spleen-preserving distal pancreatectomy (MISPDP) has become the routine, preferred operation because of fewer post-operative complications, less blood loss and shorter hospital stays compared to open procedures.[7,8]Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT),[9] which conserves the splenic artery and vein, or the Warshaw technique (WT), which ligates the splenic vessels while preserving the short gastric vessels and left gastroepiploic vessels.[10] The clinical benefits of performing either method remain unclear, and most of the current studies have reported no statistically significant difference in their perioperative results.[11-13] Therefore, the focus of studies on MISPDP is to assess the long-term outcomes, especially the haemodynamic changes in splenogastric circulation. Some studies have reported a higher incidence of gastric varices and splenic infarction after WT, which is the reason why KT should be the first choice.[12,14-16] Other studies have reported no gastrointestinal bleeding of the gastric varices during a long-term follow-up.[17] Therefore, they have urged that gastric varices should be regarded as a paraphysiologic phenomenon.[13,17-19] Patients with splenic infarction rarely need reoperation.[13,17,20,21] Moreover, WT is faster and easier than KT; therefore, some studies have recommended prioritising WT in cases, in which certain operations are difficult.[21]Advances in computed tomography (CT) scanner technology and the development of three-dimensional (3D) visualisation software have helped tremendously in the diagnosis and treatment of diseases. Vascular reconstruction provides a visualisation of the 3D spatial relationship between vessels and adjacent organs and is widely used in the mesenteric vascular system.[22] The reconstruction of perigastric veins is more difficult due to the low concentration of contrast media. In recent studies, the haemodynamic changes in splenogastric circulation were mainly evaluated on cross-sectional CT images,[16,17] but none have been visually demonstrated by means of vascular reconstruction.In a previous study, we proposed the 'Kimura-first' strategy, in which WT is used as an alternative to KT when the splenic vessels cannot be safely preserved. Moreover, we confirmed that this strategy was feasible and safe in terms of perioperative outcomes. [14]Therefore, in this study, we aimed to verify the feasibility and safety of the 'Kimura-first' strategy by comparing the long-term outcomes of the two MISPDP methods. We paid special attention to the haemodynamic changes in the splenogastric circulation and visualised them by vascular reconstruction.Introduction:Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation.The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up.A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group (P = 0.02). We also found less blood loss for patients who underwent KT (P = 0.02). The occurrence of gastric varices was significantly higher in the WT group (P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group (P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.Distal pancreatectomy with splenectomy is used to treat benign and borderline malignant tumours located in the distal pancreas. However, as awareness of the haematological and immunological functions of the spleen has increased,[1,2] severe complications have been reported in the context of splenectomy.[3,4] Current studies suggest that the spleen should be preserved in treating these diseases.[5,6] Moreover, with the development of minimally invasive techniques, minimally invasive spleen-preserving distal pancreatectomy (MISPDP) has become the routine, preferred operation because of fewer post-operative complications, less blood loss and shorter hospital stays compared to open procedures.[7,8]Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT),[9] which conserves the splenic artery and vein, or the Warshaw technique (WT), which ligates the splenic vessels while preserving the short gastric vessels and left gastroepiploic vessels.[10] The clinical benefits of performing either method remain unclear, and most of the current studies have reported no statistically significant difference in their perioperative results.[11-13] Therefore, the focus of studies on MISPDP is to assess the long-term outcomes, especially the haemodynamic changes in splenogastric circulation. Some studies have reported a higher incidence of gastric varices and splenic infarction after WT, which is the reason why KT should be the first choice.[12,14-16] Other studies have reported no gastrointestinal bleeding of the gastric varices during a long-term follow-up. [17] Therefore, they have urged that gastric varices should be regarded as a paraphysiologic phenomenon.[13,17-19] Patients with splenic infarction rarely need reoperation.[13,17,20,21] Moreover, WT is faster and easier than KT; therefore, some studies have recommended prioritising WT in cases, in which certain operations are difficult.[21]Advances in computed tomography (CT) scanner technology and the development of three-dimensional (3D) visualisation software have helped tremendously in the diagnosis and treatment of diseases. Vascular reconstruction provides a visualisation of the 3D spatial relationship between vessels and adjacent organs and is widely used in the mesenteric vascular system.[22] The reconstruction of perigastric veins is more difficult due to the low concentration of contrast media. In recent studies, the haemodynamic changes in splenogastric circulation were mainly evaluated on cross-sectional CT images,[16,17] but none have been visually demonstrated by means of vascular reconstruction.In a previous study, we proposed the 'Kimura-first' strategy, in which WT is used as an alternative to KT when the splenic vessels cannot be safely preserved. Moreover, we confirmed that this strategy was feasible and safe in terms of perioperative outcomes.[14]Therefore, in this study, we aimed to verify the feasibility and safety of the 'Kimura-first' strategy by comparing the long-term outcomes of the two MISPDP methods. We paid special attention to the haemodynamic changes in the splenogastric circulation and visualised them by vascular reconstruction.Introduction:Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation.The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up.A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group (P = 0.02). We also found less blood loss for patients who underwent KT (P = 0.02). The occurrence of gastric varices was significantly higher in the WT group (P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group (P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.Distal pancreatectomy with splenectomy is used to treat benign and borderline malignant tumours located in the distal pancreas. However, as awareness of the haematological and immunological functions of the spleen has increased,[1,2] severe complications have been reported in the context of splenectomy. [3,4] Current studies suggest that the spleen should be preserved in treating these diseases.[5,6] Moreover, with the development of minimally invasive techniques, minimally invasive spleen-preserving distal pancreatectomy (MISPDP) has become the routine, preferred operation because of fewer post-operative complications, less blood loss and shorter hospital stays compared to open procedures.[7,8]Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT),[9] which conserves the splenic artery and vein, or the Warshaw technique (WT), which ligates the splenic vessels while preserving the short gastric vessels and left gastroepiploic vessels.[10] The clinical benefits of performing either method remain unclear, and most of the current studies have reported no statistically significant difference in their perioperative results.[11-13] Therefore, the focus of studies on MISPDP is to assess the long-term outcomes, especially the haemodynamic changes in splenogastric circulation. Some studies have reported a higher incidence of gastric varices and splenic infarction after WT, which is the reason why KT should be the first choice.[12,14-16] Other studies have reported no gastrointestinal bleeding of the gastric varices during a long-term follow-up.[17] Therefore, they have urged that gastric varices should be regarded as a paraphysiologic phenomenon.[13,17-19] Patients with splenic infarction rarely need reoperation.[13,17,20,21] Moreover, WT is faster and easier than KT; therefore, some studies have recommended prioritising WT in cases, in which certain operations are difficult.[21]Advances in computed tomography (CT) scanner technology and the development of three-dimensional (3D) visualisation software have helped tremendously in the diagnosis and treatment of diseases. Vascular reconstruction provides a visualisation of the 3D spatial relationship between vessels and adjacent organs and is widely used in the mesenteric vascular system.[22] The reconstruction of perigastric veins is more difficult due to the low concentration of contrast media. In recent studies, the haemodynamic changes in splenogastric circulation were mainly evaluated on cross-sectional CT images,[16,17] but none have been visually demonstrated by means of vascular reconstruction.In a previous study, we proposed the 'Kimura-first' strategy, in which WT is used as an alternative to KT when the splenic vessels cannot be safely preserved. Moreover, we confirmed that this strategy was feasible and safe in terms of perioperative outcomes.[14]Therefore, in this study, we aimed to verify the feasibility and safety of the 'Kimura-first' strategy by comparing the long-term outcomes of the two MISPDP methods. We paid special attention to the haemodynamic changes in the splenogastric circulation and visualised them by vascular reconstruction.Introduction:Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation.The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up. A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group (P = 0.02). We also found less blood loss for patients who underwent KT (P = 0.02). The occurrence of gastric varices was significantly higher in the WT group (P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group (P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.Distal pancreatectomy with splenectomy is used to treat benign and borderline malignant tumours located in the distal pancreas. However, as awareness of the haematological and immunological functions of the spleen has increased,[1,2] severe complications have been reported in the context of splenectomy.[3,4] Current studies suggest that the spleen should be preserved in treating these diseases.[5,6] Moreover, with the development of minimally invasive techniques, minimally invasive spleen-preserving distal pancreatectomy (MISPDP) has become the routine, preferred operation because of fewer post-operative complications, less blood loss and shorter hospital stays compared to open procedures.[7,8]Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT),[9] which conserves the splenic artery and vein, or the Warshaw technique (WT), which ligates the splenic vessels while preserving the short gastric vessels and left gastroepiploic vessels.[10] The clinical benefits of performing either method remain unclear, and most of the current studies have reported no statistically significant difference in their perioperative results.[11-13] Therefore, the focus of studies on MISPDP is to assess the long-term outcomes, especially the haemodynamic changes in splenogastric circulation. Some studies have reported a higher incidence of gastric varices and splenic infarction after WT, which is the reason why KT should be the first choice.[12,14-16] Other studies have reported no gastrointestinal bleeding of the gastric varices during a long-term follow-up.[17] Therefore, they have urged that gastric varices should be regarded as a paraphysiologic phenomenon.[13,17-19] Patients with splenic infarction rarely need reoperation.[13,17,20,21] Moreover, WT is faster and easier than KT; therefore, some studies have recommended prioritising WT in cases, in which certain operations are difficult.[21]Advances in computed tomography (CT) scanner technology and the development of three-dimensional (3D) visualisation software have helped tremendously in the diagnosis and treatment of diseases. Vascular reconstruction provides a visualisation of the 3D spatial relationship between vessels and adjacent organs and is widely used in the mesenteric vascular system.[22] The reconstruction of perigastric veins is more difficult due to the low concentration of contrast media. In recent studies, the haemodynamic changes in splenogastric circulation were mainly evaluated on cross-sectional CT images,[16,17] but none have been visually demonstrated by means of vascular reconstruction. In a previous study, we proposed the 'Kimura-first' strategy, in which WT is used as an alternative to KT when the splenic vessels cannot be safely preserved. Moreover, we confirmed that this strategy was feasible and safe in terms of perioperative outcomes.[14]Therefore, in this study, we aimed to verify the feasibility and safety of the 'Kimura-first' strategy by comparing the long-term outcomes of the two MISPDP methods. We paid special attention to the haemodynamic changes in the splenogastric circulation and visualised them by vascular reconstruction.Introduction:Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation.The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up.A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group (P = 0.02). We also found less blood loss for patients who underwent KT (P = 0.02). The occurrence of gastric varices was significantly higher in the WT group (P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group (P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.Distal pancreatectomy with splenectomy is used to treat benign and borderline malignant tumours located in the distal pancreas. However, as awareness of the haematological and immunological functions of the spleen has increased,[1,2] severe complications have been reported in the context of splenectomy.[3,4] Current studies suggest that the spleen should be preserved in treating these diseases.[5,6] Moreover, with the development of minimally invasive techniques, minimally invasive spleen-preserving distal pancreatectomy (MISPDP) has become the routine, preferred operation because of fewer post-operative complications, less blood loss and shorter hospital stays compared to open procedures.[7,8]Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT),[9] which conserves the splenic artery and vein, or the Warshaw technique (WT), which ligates the splenic vessels while preserving the short gastric vessels and left gastroepiploic vessels.[10] The clinical benefits of performing either method remain unclear, and most of the current studies have reported no statistically significant difference in their perioperative results.[11-13] Therefore, the focus of studies on MISPDP is to assess the long-term outcomes, especially the haemodynamic changes in splenogastric circulation. Some studies have reported a higher incidence of gastric varices and splenic infarction after WT, which is the reason why KT should be the first choice.[12,14-16] Other studies have reported no gastrointestinal bleeding of the gastric varices during a long-term follow-up.[17] Therefore, they have urged that gastric varices should be regarded as a paraphysiologic phenomenon.[13,17-19] Patients with splenic infarction rarely need reoperation.[13,17,20,21] Moreover, WT is faster and easier than KT; therefore, some studies have recommended prioritising WT in cases, in which certain operations are difficult.[21]Advances in computed tomography (CT) scanner technology and the development of three-dimensional (3D) visualisation software have helped tremendously in the diagnosis and treatment of diseases. Vascular reconstruction provides a visualisation of the 3D spatial relationship between vessels and adjacent organs and is widely used in the mesenteric vascular system.[22] The reconstruction of perigastric veins is more difficult due to the low concentration of contrast media. In recent studies, the haemodynamic changes in splenogastric circulation were mainly evaluated on cross-sectional CT images,[16,17] but none have been visually demonstrated by means of vascular reconstruction.In a previous study, we proposed the 'Kimura-first' strategy, in which WT is used as an alternative to KT when the splenic vessels cannot be safely preserved. Moreover, we confirmed that this strategy was feasible and safe in terms of perioperative outcomes.[14]Therefore, in this study, we aimed to verify the feasibility and safety of the 'Kimura-first' strategy by comparing the long-term outcomes of the two MISPDP methods. We paid special attention to the haemodynamic changes in the splenogastric circulation and visualised them by vascular reconstruction.Introduction:Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation.The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up.A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group (P = 0.02). We also found less blood loss for patients who underwent KT (P = 0.02). The occurrence of gastric varices was significantly higher in the WT group (P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group (P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP. Distal pancreatectomy with splenectomy is used to treat benign and borderline malignant tumours located in the distal pancreas. However, as awareness of the haematological and immunological functions of the spleen has increased,[1,2] severe complications have been reported in the context of splenectomy.[3,4] Current studies suggest that the spleen should be preserved in treating these diseases.[5,6] Moreover, with the development of minimally invasive techniques, minimally invasive spleen-preserving distal pancreatectomy (MISPDP) has become the routine, preferred operation because of fewer post-operative complications, less blood loss and shorter hospital stays compared to open procedures.[7,8]Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT),[9] which conserves the splenic artery and vein, or the Warshaw technique (WT), which ligates the splenic vessels while preserving the short gastric vessels and left gastroepiploic vessels.[10] The clinical benefits of performing either method remain unclear, and most of the current studies have reported no statistically significant difference in their perioperative results.[11-13] Therefore, the focus of studies on MISPDP is to assess the long-term outcomes, especially the haemodynamic changes in splenogastric circulation. Some studies have reported a higher incidence of gastric varices and splenic infarction after WT, which is the reason why KT should be the first choice.[12,14-16] Other studies have reported no gastrointestinal bleeding of the gastric varices during a long-term follow-up.[17] Therefore, they have urged that gastric varices should be regarded as a paraphysiologic phenomenon.[13,17-19] Patients with splenic infarction rarely need reoperation.[13,17,20,21] Moreover, WT is faster and easier than KT; therefore, some studies have recommended prioritising WT in cases, in which certain operations are difficult.[21]Advances in computed tomography (CT) scanner technology and the development of three-dimensional (3D) visualisation software have helped tremendously in the diagnosis and treatment of diseases. Vascular reconstruction provides a visualisation of the 3D spatial relationship between vessels and adjacent organs and is widely used in the mesenteric vascular system.[22] The reconstruction of perigastric veins is more difficult due to the low concentration of contrast media. In recent studies, the haemodynamic changes in splenogastric circulation were mainly evaluated on cross-sectional CT images,[16,17] but none have been visually demonstrated by means of vascular reconstruction.In a previous study, we proposed the 'Kimura-first' strategy, in which WT is used as an alternative to KT when the splenic vessels cannot be safely preserved. Moreover, we confirmed that this strategy was feasible and safe in terms of perioperative outcomes.[14]Therefore, in this study, we aimed to verify the feasibility and safety of the 'Kimura-first' strategy by comparing the long-term outcomes of the two MISPDP methods. We paid special attention to the haemodynamic changes in the splenogastric circulation and visualised them by vascular reconstruction.Introduction:Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation. The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up.A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group (P = 0.02). We also found less blood loss for patients who underwent KT (P = 0.02). The occurrence of gastric varices was significantly higher in the WT group (P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group (P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire.The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.Distal pancreatectomy with splenectomy is used to treat benign and borderline malignant tumours located in the distal pancreas. However, as awareness of the haematological and immunological functions of the spleen has increased,[1,2] severe complications have been reported in the context of splenectomy.[3,4] Current studies suggest that the spleen should be preserved in treating these diseases.[5,6] Moreover, with the development of minimally invasive techniques, minimally invasive spleen-preserving distal pancreatectomy (MISPDP) has become the routine, preferred operation because of fewer post-operative complications, less blood loss and shorter hospital stays compared to open procedures.[7,8]Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT),[9] which conserves the splenic artery and vein, or the Warshaw technique (WT), which ligates the splenic vessels while preserving the short gastric vessels and left gastroepiploic vessels.[10] The clinical benefits of performing either method remain unclear, and most of the current studies have reported no statistically significant difference in their perioperative results.[11-13] Therefore, the focus of studies on MISPDP is to assess the long-term outcomes, especially the haemodynamic changes in splenogastric circulation. Some studies have reported a higher incidence of gastric varices and splenic infarction after WT, which is the reason why KT should be the first choice.[12,14-16] Other studies have reported no gastrointestinal bleeding of the gastric varices during a long-term follow-up.[17] Therefore, they have urged that gastric varices should be regarded as a paraphysiologic phenomenon.[13,17-19] Patients with splenic infarction rarely need reoperation.[13,17,20,21] Moreover, WT is faster and easier than KT; therefore, some studies have recommended prioritising WT in cases, in which certain operations are difficult.[21]Advances in computed tomography (CT) scanner technology and the development of three-dimensional (3D) visualisation software have helped tremendously in the diagnosis and treatment of diseases. Vascular reconstruction provides a visualisation of the 3D spatial relationship between vessels and adjacent organs and is widely used in the mesenteric vascular system. [22] The reconstruction of perigastric veins is more difficult due to the low concentration of contrast media. In recent studies, the haemodynamic changes in splenogastric circulation were mainly evaluated on cross-sectional CT images,[16,17] but none have been visually demonstrated by means of vascular reconstruction.In a previous study, we proposed the 'Kimura-first' strategy, in which WT is used as an alternative to KT when the splenic vessels cannot be safely preserved. Moreover, we confirmed that this strategy was feasible and safe in terms of perioperative outcomes.[14]Therefore, in this study, we aimed to verify the feasibility and safety of the 'Kimura-first' strategy by comparing the long-term outcomes of the two MISPDP methods. We paid special attention to the haemodynamic changes in the splenogastric circulation and visualised them by vascular reconstruction.