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Three Types of Collateral Arterial Supply to the Spleen After Spleen-Preserving Distal Pancreatectomies with Splenic Vessel Resection—How to Use This Knowledge for Organ(s) Preservation in Locally Advanced and Borderline Resectable Pancreatic Head Cancers Surgery—Hemodynamic, Surgical and Oncological Outcomes of 134 Spleen-Preserving Pancreatectomies
by
, , , , , and
Viacheslav Egorov
1,2,*,
Soslan Dzigasov
1,
Alexey Kolygin
1,
Mikhail Vyborniy
1,
Grigoriy Bolshakov
1,
Roman Petrov
1,3,
Pavel Kim
1,
Anna Demchenkova
1 and
Alexander Sorokin
4 1
Ilyinskaya Hospital, 143421 Moscow, Russia
2
Burnasyan State Research Center of the Federal Medical Biological Agency, 119435 Moscow, Russia
3
National Medical Research Centre “Treatment and Rehabilitation Centre”, Federal State Autonomous Institution, Ministry of Health of the RF, 125367 Moscow, Russia
4
Department of Mathematical Methods in Economics, Plekhanov Russian University of Economics, 117997 Moscow, Russia
*
Author to whom correspondence should be addressed.
Cancers 2026, 18(10), 1675; https://doi.org/10.3390/cancers18101675
Submission received: 9 April 2026
/
Revised: 16 May 2026
/
Accepted: 18 May 2026
/
Published: 21 May 2026
(This article belongs to the Special Issue Pancreatic Neoplasms in the 21st Century: Challenges and Opportunities in Diagnosis and Management)
Simple Summary
Short gastric arteries (SGAs) are considered the basis of spleen preservation in the Sutherland–Warshaw procedure, but the sources of blood supply to the SGAs are not described. This work showed that after this surgery (1) three types of collateral blood supply to the spleen are observed: left gastric (LGA), gastroepiploic arcade (GEA) and mixed. (2) LGA plus mixed types’ incidence is ~90%, and spleen can be preserved following the excision of up to 10 cm of the splenic artery (SA). The excision of long SA fragments and its rotation to replace excised superior mesenteric or common hepatic arteries can be safely performed with spleen and distal pancreas preservation in surgery for locally advanced pancreatic head cancer (LAPHC). Revascularization of the SA after resection of the celiac trunk and LGA can preserve not only the spleen and distal pancreas, but also the stomach. Using the blood flow through the collateral network “LGA-branches–SGAs–LGEA–SA” can allow for radical LAPHC operations to also be organ-preserving.
Abstract
Background: Spleen-preserving (SP) distal pancreatectomy (DP) with splenic vessel resection (SVR) (Warsaw procedure, WP) is an option for the treatment of tumors with low malignant potential. The reverse blood flow through the short gastric arteries (SGA) explains the preservation of the spleen after SVR, but leaves the source of the blood supply to the SGAs hidden. The types of blood supply to the spleen after WP and their incidence have not been previously described, nor has the significance of these types for locally advanced pancreatic head cancer (LAPHC) surgery been determined. Aim: To determine the main types of spleen blood supply after WP, and to assess the feasibility and safety of splenic artery (SA) rotation for the organ-preserving surgery of LAPHC. Methods: Retrospective analyses of demographic and perioperative data, including CT scans, overall (OS) and progression-free (PFS) survival after 71 SP DP SVR and 41 SP SVR pancreaticoduodenectomies (PD) and total pancreatectomies (TP) for LAPHC (2007–2025). Results: In 134 SP procedures, SA was resected in 115 cases (71DP, 9 TP, 3 central, and 32 PD). Indications for surgery were MCN (41), IPMN (14), CSA (3), NEN (25), SPPN (8), PHDAC (40), sarcoma (1), autoimmune (1), and calculous chronic pancreatitis (1). There were no deaths or ischemia-related splenectomies. Morbidity—31% (n23); Dindo–Clavien (D-C) > 3b-2.8%; POPF-grade B-n7 (10.6%); splenic infarctions on CT after SVR-n18 (23%), one symptomatic. CT revealed three types of arterial blood supply to the spleen after SPDP SVR: left gastric artery (LGA) type (n50, 70, 5%), gastro-epyploic arcade (GEA) type (n9, 12, 5%), and an intermediate type (n12, 17%). Spleen- and pancreas tail-preserving SVR pancreatectomies for LAPHC (n41) were accompanied by rotation of the SA to substitute resected SMA (n19) and CHA (n15) for 26 Whipples and 8TPs. There were no ischemic complications. D-C > 3–19.5%. Median OS and PFS for PDAC were 35 and 21 months for 29.5 months median follow-up. Conclusions: Despite the preservation of blood flow through all potential sources of splenic blood supply following resection of the splenic artery, the main collaterals supplying the spleen after WP are LGA branches (~90%). This knowledge, with strict adherence to the developed criteria, allows for the safe preservation of the spleen, pancreatic tail, and stomach during pancreatectomies with SA resection, including its rotation for the substitution of the SMA and CHA in LAPHC.
