Risk factors and clinical impact of splenic infarction and gastric varices after the warshaw procedure: a comparative study with the kimura technique.

PURPOSE: The Warshaw procedure, a spleen-preserving distal pancreatectomy with splenic vessel ligation, is associated with splenic infarction and gastric varices. We evaluated the risk factors and clinical impacts of these conditions. METHODS: We retrospectively analyzed 65 patients who underwent minimally invasive spleen-preserving distal pancreatectomy between 2014 and 2024. The outcomes were compared between the Warshaw (n = 40) and Kimura (n = 25) groups. The risk factors for splenic infarction and gastric varices were evaluated. Grade 2 splenic infarction was subdivided into 2a (50-89%) and 2b (90-99%). RESULTS: Grade 2 splenic infarction occurred only in the Warshaw group (19/40, 47.5%), including seven Grade 2b cases. No complications related to splenic infarction or variceal bleeding occurred. Larger tumor size and shorter pancreatic tail-to-splenic hilum distance were associated with gastric varices; the latter was also associated with Grade 2 splenic infarction. CONCLUSIONS: Extensive splenic infarction after the Warshaw procedure was not associated with clinically relevant adverse outcomes. Gastric varices were associated with larger tumor size rather than surgical procedures. The pancreatic tail-to-splenic hilum distance was consistently associated with splenic infarction and gastric varices. These findings suggest that splenic infarction and gastric varices alone may not justify avoiding the Warshaw procedure when splenic vessel preservation is difficult.