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Background: Distal pancreatectomy is being performed more commonly for patients with benign findings, and minimally invasive techniques are frequently applied in this population. As a result, the role of spleen preservation during distal pancreatectomy has been debated. Many conflicting and under-powered case series have been published but no randomized trial comparing these techniques has been initiated. As a result, there is significant controversy about the impact of splenectomy on distal pancreatectomy complication rates. We therefore undertook a systematic review and subsequent meta-analysis in order to provide objective evidence to this debate. Methods: A comprehensive search for published English-literature studies of left pancreatectomy from 1980-2012 was undertaken. All studies were screened for our inclusion criteria: > than 10 pts, non-traumatic indication, treatment of spleen detailed, and postoperative complications described in relation to treatment of spleen. Two generations of ancestral searching was used. When multiple series from a single institution were encountered, the largest and highest quality series was selected for inclusion. Continuous variables were calculated as a variable weighted by the proportion of patients in each study. Results: More than 1000 articles were found using the initial search criteria, and after detailed review, 52 studies with 3355 patients were included. Of these, 15 studies including 1482 patients both compared distal pancreaticosplenectomy (DPS) to spleen-preserving distal pancreatectomy (SPDP) and detailed postoperative complications. This group is the focus of this report. The mean age was 52.8 years, and 41% were male. A wide variety of pathologic diagnoses were included with 37.4% being for cystic disease, 21.2% pancreatitis, 16.8% neuroendocrine tumors, and only 9.4% pancreatic cancer. When the groups were compared, there were more with pancreatitis in the SPDP group, and more with pancreatic cancer in the DPS group (Table 1). Weighted values for length of surgery and length of stay were similar, but there was a trend towards higher blood loss in the DPS group. When postoperative complications were analyzed, there was no significant difference between groups (see Table). Importantly, there was no difference in rates of infectious complications, pancreatic fistulae, or thrombotic complications. Notably, spleen related complications (infarcts or delayed splenectomy) occurred in 8.8% of patients with splenic preservation. Conclusion: Although DPS is performed more often in patients with malignancy and may have slightly higher blood loss, this meta-analysis does not demonstrate any increase in complication rates when compared SPDP. In fact, the 9% complication rate related to spleen preservation raises the question of if organ preservation offers any substantive advantage.

	DP with splenectomy (DPS)	DP with spleen preservation (SPDP)	p value
Demographics
Number	948	534
Mean age (yrs)	54.3	51.7	NA
Gender (%male)	44.4%	32.8%	0.0003
Diagnosis (n,%)
Pancreatitis	140 (19.7%)	111 (25.3%)	0.044
Pancreatic cancer	82 (11.5%)	10 (2.3%)	0.0001
Cystic disease	269 (37.8%)	186 (42.5%)	NS
Operative Variables
Length of surgery (min)	198.8	181.7	NA
Estimated Blood Loss (mL)	499.9	303.7	NA
Length of hospital stay (days)	10.4	8.9	NA
Postoperative Complication (n, %)
Pancreatic leak	208 (21.9%)	113 (21.2%)	NS
Infectiouscomplications	64 (6.8%)	26 (4.9% )	NS
Thrombotic complications	9 (0.95%)	3 (0.56%)	NS
Hemorrhagic complications	13 (1.4%)	5 (0.94%)	NS
Reoperation	28 (2.95%)	16 (3.0%)	NS
Mortality	6 (0.6%)	2 (0.4%)	NS
Spleen-related complication	NA	47 (8.8%)	NA