Laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer using the ligament of Treitz approach

Evaluating the efficacy of laparoscopic radical antegrade modular pancreatosplenectomy in selected early-stage left-sided pancreatic cancer: a propensity score matching study

BACKGROUND

Laparoscopic radical pancreatectomy is safe and beneficial for recectable pancreatic cancer, but the extent of resection for early-stage tumors remains controversial.

METHODS

Consecutive patients with left-sided pancreatic cancer who underwent either laparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS, n = 54) or laparoscopic distal pancreatosplecnectomy (LDP, n = 131) between October 2020 and December 2022 were reviewed. The preoperative radiological selection criteria were as follows: (1) tumor diameter ≤ 4 cm; (2) located ≥ 1 cm from the celiac trunk; (3) didn't invade the fascial layer behind the pancreas.

RESULTS

After 1:1 propensity score matching (LRAMPS, n = 54; LDP, n = 54), baseline data were well-balanced with no differences. LRAMPS resulted in longer operation time (240.5 vs. 219.0 min, P = 0.020) and higher intraoperative bleeding volume (200 vs. 150 mL, P = 0.001) compared to LDP. Although LRAMPS harvested more lymph nodes (16 vs. 13, P = 0.008), there were no statistically significant differences in lymph node positivity rate (35.2% vs. 33.3%), R0 pancreatic transection margin (94.4% vs. 96.3%), and retroperitoneal margin (83.3% vs. 87.0%) rate. Postoperative complications did not significantly differ between the two groups. However, LRAMPS was associated with increased drainage volume (85.0 vs. 40.0 mL, P = 0.001), longer time to recover semi-liquid diet compared to LDP (5 vs. 4 days, P < 0.001) and increased daily bowel movement frequency. Tumor recurrence pattern and recurrence-free survival were comparable between the two groups, but the adjuvant chemotherapy regimens varied, and the completion rate of the 6-month intravenous chemotherapy was lower in the LRAMPS group compared to the LDP group (51.9% vs. 75.9%, P = 0.016).

CONCLUSIONS

LRAMPS did not provide oncological benefits over LDP for left-sided pancreatic cancer within the selection criteria, but it increased operation time, intraoperative bleeding, and postoperative bowel movement frequency. These factors impacted the regimen selection and completion of adjuvant chemotherapy, consequently compromising the potential benefits of LRAMPS in achieving better local control.

Laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) for adenocarcinoma of the body and tail of the pancreas - technical considerations with analysis of surgical outcomes

PURPOSE

The aim of this study was to establish whether laparoscopic RAMPS (L-RAMPS) is a safe procedure with better oncological outcomes compared to laparoscopic distal pancreatectomy (LDP) with splenectomy among patients with distal pancreatic ductal adenocarcinoma (PDAC).

METHODS

This is a retrospective study performed on consecutive patients who underwent L-RAMPS and LDP with splenectomy for resectable or borderline resectable PDAC of the body and tail. In this paper, we presented our technique of laparoscopic RAMPS and analyzed intraoperative and perioperative complications, oncological efficacy, and long-term survival.

RESULTS

The study included 12 patients in the L-RAMPS group and 13 patients in the LDP with splenectomy. L-RAMPS was associated with significantly higher rates of R0 resection (91.7% vs. 69.2%, p = 0.027). There were no differences between the L-RAMPS and LDP with splenectomy groups in intraoperative blood loss (400 mL vs 400 mL, p = 0.783) and median operative time (250 min vs 220 min, p = 0.785). No differences were found in terms of perioperative complications, including the incidence of pancreatic fistula.

CONCLUSION

Laparoscopic RAMPS is a feasible and safe procedure. It provides higher radicality as compared with LDP with splenectomy, without increasing the risk of complications. Further studies are necessary to evaluate long-term outcomes.

Minimally invasive distal pancreatectomy for pancreatic cancer: cranial-to-caudal approach with identification of Gerota's fascia (with video)

BACKGROUND

Although radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma (PDAC) has become the gold standard procedure in open distal pancreatectomy, there has been no gold standardized procedure for PDAC in minimally invasive distal pancreatectomy (MIDP). In this study, we analyzed our novel cranial-to-caudal approach (CC approach) for patients undergoing MIDP and provide a video clip illustrating the details of the CC approach.

METHODS

Ninety-four patients who underwent MIDP with splenectomy between 2016 and 2021 were included in this study. The CC approach was performed in 23 (24.5%) of the 94 patients. The concept of the CC approach is easy identification of Gerota's fascia from the cranial side of the pancreas and secure tumor removal (R0 resection) wrapped by Gerota's fascia. The short- and long-term outcomes were compared between the CC and non-CC approaches.

RESULTS

The median operation time and blood loss were similar between the two groups. The ratios of grade ≥ B postoperative pancreatic fistula and Clavien-Dindo grade ≥ III complications were also comparable. All patients in the CC approach group achieved R0 resection, and the R0 ratio was similar in the two groups (p = 0.345). The 2-year survival rate in CC and non-CC approach groups was 87.5% and 83.6%, respectively (p = 0.903).

CONCLUSIONS

The details of the CC approach for MIDP were demonstrated based on an anatomical point of view. This approach has the potential to become a standardized approach for left-sided PDAC.

Feasibility of laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) as a standard treatment for distal resectable pancreatic cancer

INTRODUCTION

Laparoscopic (Lap-) radical antegrade modular pancreatosplenectomy (RAMPS) is an attractive radical procedure that aims to achieve negative posterior retroperitoneal margin in pancreatic ductal adenocarcinoma (PDAC) resections. However, only few institutions are adapting Lap-RAMPS due to the technical difficulties and the lack of supporting evidence for the clinical applications.

METHODS

A retrospective cohort study was performed on consecutive patients who underwent RAMPS for distal resectable PDACs. We analyzed the short- and long-term outcomes including local control and the induction of adjuvant chemotherapy compared between Lap- and Open-RAMPS.

RESULTS

Of the 118 RAMPS patients, 43 patients underwent Lap-RAMPS and 75 patients underwent Open-RAMPS. The blood loss was lower (125 vs. 390 mL, p < 0.001), and postoperative hospital stay was shorter (17 vs. 21 days, p = 0.018) in the Lap-RAMPS group. There was no difference in the postoperative complications and no mortality in both groups. R0 resection rate was 100.0% in the Lap-RAMPS and 90.7% in the Open-RAMPS (p = 0.039). Among the patients eligible for adjuvant chemotherapy, the Lap-RAMPS group showed a favorable induction rate (100.0 vs. 89.6%, p = 0.037). Both groups showed a favorable 3-year local recurrence rate (8.7 vs. 10.0%, p = 0.976) and 3-year overall survival (69.8 vs. 71.1%, p = 0.996).

CONCLUSIONS

The safety and efficacy of Lap-RAMPS were comparable to those of Open-RAMPS in terms of achieving local control and adjuvant chemotherapy induction. A higher early induction of adjuvant chemotherapy is an advantage of minimally invasive surgery.

Total laparoscopic radical antegrade modular pancreato-splenectomy with left-posterior superior mesenteric artery first-approach for distal pancreatic cancer: step-by-step technique with a surgical case report (with video)

INTRODUCTION

Left-sided pancreatic cancers are uncommon but seem more aggressive than tumors of pancreatic head. Radical antegrade modular pancreato-splenectomy (RAMPS) was proved to have safe and effective advantages while comparing with standard retrograde pancreato-splenectomy (SRPS) in recent systematic literature reviews and meta-analyses. Laparoscopic SMA first-approach RAMPS was recently proceeded with optimistic perioperative outcomes.

CASE PRESENTATION

Our patient is a 67-year-old female with a medical history of diabetes and hypertension, recruited because of upper left quadrant abdominal pain. She was referred for pancreato-splenectomy because of a 3-cm-sized mass in distal pancreas. We use 5 trocars and the patient placed in a Trendelenburg position. The retroperitoneum is opened at the left-posterior side of the meso-pancreato-duodenum along to the inframesocolic space, so that the anterior surface of the aorta (AO), inferior vena cave (IVC), left renal vein (LRV), left adrenal grand (LAG), and kidney are completely exposed. The inferior border of the pancreas had been dissected and separated from the superior mesenteric vein (SMV) below the pancreatic isthmus, removed the lymph nodes (LNs) groups 14v and 17. Then, dissect of LNs groups 7,8,9,11p,12 en bloc at the superior side of the pancreas. Dissection of LNs group 14p, d or SMA LNs after transecting the pancreas. The operation time was 240 min, the estimated blood loss was 200 ml. With no postoperative complications as well as no diarrhea, the patient was discharged on the POD10 uneventfully. Pathological result: pancreatic ductal adenocarcinoma with T2N1 staging and negative margin (R0).

CONCLUSIONS

This technique was safe and effective to perform precise and complete lymphadenectomy and negative posterior resection in total laparoscopic left-posterior SMA first-approach RAMPS for distal pancreatic cancer.

Complications in Distal Pancreatectomy versus Radical Antegrade Modular Pancreatosplenectomy: A Disease Risk Score Analysis Utilizing National Surgical Quality Improvement Project Data

INTRODUCTION

Radical antegrade modular pancreatosplenectomy (RAMPS) was developed to improve R0 resections and lymph node harvests versus distal pancreatectomy (DP) in pancreatic adenocarcinoma (PDAC); relative complication rates are understudied.

METHODS

Patients undergoing distal pancreas resections from 2006 to 2020 were identified from our institutional NSQIP database, grouped by resection method, and evaluated for the following outcomes: postoperative pancreatic fistula (POPF), clinically relevant POPF (crPOPF), incisional surgical site infection (iSSI), organ space SSI (osSSI), and Clavien-Dindo grade ≥ 3 (CD ≥ 3) complications using logistic regression. Patients were matched 1:1 based on disease risk score.

RESULTS

Two-hundred-thirty-six and 117 patients underwent DP and RAMPS, respectively. POPF, crPOPF, CD ≥ 3 complications, iSSI, and osSSIs occurred in 105 (30%), 43 (12%), 74 (21%), 34 (10%) and 52 (15%) patients, respectively. Disease risk score matching yielded 89 similar patients per group. On multivariable analysis, patients undergoing RAMPS were not significantly more likely to experience POPF (OR 0.69, P = 0.26), crPOPF (OR 0.41, P = 0.72), CD ≥ 3 complication (OR 0.78, P = 0.44), iSSI (OR 0.58, P = 0.27), or osSSI (OR 0.93, P = 0.86). Of patients with PDAC (n = 108) mean nodal harvest were 14.8 (SD 11.30) and 19.4 (SD 7.19) nodes for patients undergoing DP and RAMPS, respectively (P = 0.01). Six patients (20%) undergoing DP had positive margins versus 12 (15%) undergoing RAMPS (P = 0.56). At a median follow-up of 17 months, there was no difference in locoregional recurrence-free survival (P = 0.32) or overall survival (P = 0.92) on Kaplan-Meier analysis.

CONCLUSION

RAMPS does not result in increased complications compared to DP and routine use is encouraged in pancreatic malignancies.

Comparison of laparoscopic versus open radical antegrade modular pancreatosplenectomy for pancreatic cancer: A systematic review and meta-analysis

BACKGROUND

Laparoscopic radical antegrade modular pancreatosplenectomy (l-RAMPS) provides a new surgical approach for patients with pancreatic cancers of the body and tail. However, whether it can achieve comparable outcomes to the open RAMPS (o-RAMPS) remains an issue.

METHODS

To evaluate the safety and effectiveness of l-RAMPS, the studies in the databases of Medline, Embase, and the Cochrane Library published before September 13, 2021 were searched and a meta-analysis was performed using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. The perioperative and oncological outcomes were analyzed.

RESULTS

Five retrospective cohorts involving 189 patients were included for final pooled analysis. There were no significant differences in the patients' operation time, intra-abdominal bleeding rate, intra-abdominal infection rate, mild morbidity (Clavien-Dindo classification = 1), moderate to severe morbidity (Clavien-Dindo classification ≥2), overall morbidity, wound infection rate, pancreatic fistula rate, delayed gastric emptying rate, reoperation rate, length of hospital stay, postoperative mortality, R0 resection rate, and 2-year overall survival between the 2 approaches. Besides, l-RAMPS was associated with less blood loss (mean difference (MD) = -232.69, 95% confidence interval (CI) = -316.93 to -148.46, P < 0.00001) and shorter days until oral feeding (MD = -0.79, 95% CI = -1.35 to -0.22, P = 0.006). However, the pooled analysis also indicated a significantly fewer lymph nodes dissected (MD = -3.01, 95% CI = -5.59 to -0.43, P = 0.02) in l-RAMPS approach.

CONCLUSIONS

Although l-RAMPS provides similar outcomes associated with benefits of minimal invasiveness compared to o-RAMPS, it harvested significantly fewer lymph nodes which might have potentially negative influence on the patients' long-term survival. L-RAMPS is still in the infancy stage and further investigation is needed to verify its feasibility.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Anterocranial Splenic Artery-First Approach for Left-Sided Resectable Pancreatic Cancer (with Videos)

BACKGROUND

Laparoscopic radical antegrade modular pancreatosplenectomy (Lap-RAMPS) for left-sided pancreatic cancer remains a technically challenging procedure. How to approach the splenic artery in laparoscopic surgery has not been discussed in adequate detail, and the implications of an artery-first approach in left-sided pancreatic cancer remain unclear.

PATIENTS AND METHODS

Forty-five consecutive patients with left-sided resectable pancreatic cancer underwent Lap-RAMPS between July 2018 and September 2020. They were divided according to whether Lap-RAMPS was performed using an anterocranial splenic artery-first (ASF) approach (ASF group, n = 23) or via another approach (non-ASF group, n = 22). Clinical, pathological, and short-term outcomes were reviewed and compared between the groups.

RESULTS

The ASF approach was performed safely in all patients with resectable left-sided pancreatic cancer, and none required conversion to laparotomy. The ASF group had better outcomes in terms of conspicuous bleeding from the spleen during splenic mobilization (P = 0.016) and blood pooling during posterior dissection (P = 0.035). Consequently, blood loss was significantly less and operation time was significantly shorter in the ASF group than in the non-ASF group. There was no significant between-group difference in other short-term outcomes, including mortality, length of hospital stay, or Clavien-Dindo classification.

CONCLUSIONS

The ASF approach was safe when performed for resectable left-sided pancreatic cancer and may help to prevent congestion of the pancreas and lessen intraoperative blood loss.

A comparison of robotic versus laparoscopic distal pancreatectomy: Propensity score matching analysis

BACKGROUND

The aim of this study was to assess the perioperative and pathologic outcomes of robotic distal pancreatectomy compared with a laparoscopic approach.

METHODS

A total of 121 robotic distal pancreatectomies and 992 laparoscopic distal pancreatectomies were retrospectively evaluated, comparing the demographic, perioperative and pathologic outcomes. After 1:2 propensity score matching (PSM) with 11 demographic variables, the factors were analysed again.

RESULTS

Following PSM, 104 robotic distal pancreatectomy patients were compared with 208 laparoscopic distal pancreatectomy patients. The operation time and proportion of spleen preservation were not different between the groups. The rates of open conversion were lower, whereas the hospital costs were higher in the robotic group. Other perioperative outcomes and pathologic factors did not differ between the groups.

CONCLUSIONS

Although robotic distal pancreatectomy is more expensive, this operation is feasible, with a higher probability of proceeding with the planned operation and with low open conversion rate.

Robotic Radical Antegrade Modular Pancreatosplenectomy Using the Supracolic Anterior Superior Mesenteric Artery Approach

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS) is the standardized approach in open pancreatic resection for pancreatic body and tail cancer. However, few studies have described regarding robotic RAMPS for pancreatic cancer. We herein present our techniques of robotic RAMPS using the supracolic anterior superior mesenteric artery (SMA) approach with the ventral view.

METHODS

The patient was a 75-year-old female with a diagnosis of pancreatic body cancer. Following neoadjuvant chemotherapy with gemcitabine plus nab-paclitaxel, robotic RAMPS was performed. Our techniques of robotic RAMPS include four steps: (1) gastrocolic ligament division, (2) dissection of superior and inferior border of the pancreas, (3) division of the pancreas, and (4) retroperitoneal dissection.

RESULTS

The operative time was 251 min with an estimated blood loss of 10 mL. The uneventful postoperative course was observed. The final pathology confirmed R0 surgical resection.

CONCLUSIONS

Robotic RAMPS using the supracolic anterior SMA approach is safe and feasible for pancreatic body and tail cancer. Standardization and precise anatomical knowledge are key elements of performing robotic RAMPS.

International Expert Consensus on Precision Anatomy for minimally invasive distal pancreatectomy: PAM-HBP Surgery Project

BACKGROUND

Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy-based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021).

METHODS

Twenty-five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting.

RESULTS

Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts.

CONCLUSIONS

The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide.

Surgical and oncological outcomes of laparoscopic versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma

PURPOSE

To compare the outcomes of laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) with those of open RAMPS (O-RAMPS) in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

We reviewed, retrospectively, the medical records of 50 patients who underwent RAMPS for PDAC without resection of major vessels and adjacent organs between 2007 and 2019, and analyzed the relationship between the operative method and surgical and oncological outcomes.

RESULTS

Nineteen of the 50 patients underwent L-RAMPS and 31 patients underwent O-RAMPS. L-RAMPS was associated with significantly less blood loss (P = 0.034) but a longer operative time (P = 0.001) than O-RAMPS. There were no significant differences in patient characteristics, tumor factors, or postoperative course; or in the rates of recurrence-free survival (P = 0.084) or overall survival (P = 0.402) between the L-RAMPS and O-RAMPS groups.

CONCLUSION

L-RAMPS for PDAC resulted in less blood loss but a longer operative time than O-RAMPS. Although L-RAMPS may be feasible, the operative time needs to be reduced by standardizing the procedure.

Laparoscopic radical antegrade modular pancreatosplenectomy: preliminary experience with 10 cases

BACKGROUND

The radical antegrade modular pancreatosplenectomy (RAMPS) which is a reasonable surgical approach for left-sided pancreatic cancer is emphasis on the complete resection of regional lymph nodes and tumor-free margin resection. Laparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS) has been rarely performed, with only 49 cases indexed on PubMed. In this study, we present our experience of LRAMPS.

METHODS

From December 2018 to February 2020, 10 patients underwent LRAMPS for pancreatic cancer at our department. The data of the patient demographics, intraoperative variables, postoperative hospital stay, morbidity, mortality, pathologic findings and follow-up were collected.

RESULTS

LRAMPS was performed successfully in all the patients. The median operative time was 235 min (range 212-270 min), with an EBL of 120 ml (range 100-200 ml). Postoperative complications occurred in 5 (50.0%) patients. Three patients developed a grade B pancreatic fistula. There was no postoperative 30-day mortality and reoperation. The median postoperative hospital stay was 14 days (range 9-24 days).The median count of retrieved lymph nodes was 15 (range 13-21), and four patients (40%) had malignant-positive lymph nodes. All cases achieved a negative tangential margin and R0 resection. Median follow-up time was 11 months (range 3-14 m). Two patients developed disease recurrence (pancreatic bed recurrence and liver metastasis) 9 months, 10 months after surgery, respectively. Others survived without tumor recurrence or metastasis.

CONCLUSIONS

LRAMPS is technically safe and feasible procedure in well-selected patients with pancreatic cancer in the distal pancreas. The oncologically outcomes need to be further validated based on additional large-volume studies.

Surgical approaches for minimally invasive distal pancreatectomy: A systematic review

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) was initially performed for benign tumors, but recently its indications have steadily broadened to encompass other conditions including pancreatic malignancies. Thorough anatomical knowledge is mandatory for precise surgery in the era of minimally invasive surgery. However, expert consensus regarding anatomical landmarks to facilitate the safe performance of MIDP is still lacking.

METHODS

A systematic literature search was performed using keywords to identify articles regarding the vascular anatomy and surgical approaches/techniques for MIDP.

RESULTS

All of the systematic reviews revealed that MIDP was not associated with an increase in postoperative complications. Moreover, most showed that MIDP resulted in less blood loss than open surgery. Regarding surgical approaches for MIDP, a standardized stepwise procedure improved surgical outcomes, including blood loss, operative time, and major complications. There are two approaches to the splenic vessels, superior and inferior; however, no study has ever directly compared them with respect to clinical outcomes. The morphology of the splenic artery affects the difficulty of approaching the artery's root. To select an appropriate dissecting layer when performing posterior resection, thorough knowledge of the anatomy of the fascia, left renal vein/artery, and left adrenal gland is needed.

CONCLUSIONS

In MIDP, a standardized approach and precise knowledge of anatomy facilitates safe surgery and has the advantage of a shorter learning curve. Anatomical features and landmarks are particularly important in cases of radical MIDP and splenic vessel preserving MIDP.

Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP.

METHODS

A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology.

RESULTS

Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found.

CONCLUSIONS

The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.

Comparison of minimal invasive versus open radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic ductal adenocarcinoma: a single center retrospective study

INTRODUCTION

Radical antegrade modular pancreatosplenectomy (RAMPS) was proposed a decade ago with the aim to achieve higher R0 tangential margin and radical N1 lymph node resection for left-sided pancreatic adenocarcinoma (PDAC), which has been widely accepted worldwide at present. Laparoscopic RAMPS (Lap-RAMPS) has been attempted for PDAC during last several years, however, no outcomes evaluation by comparison between laparoscopic vs open RAMPS has been reported yet.

MATERIALS AND METHODS

From August, 2012 to March, 2018, patients undergoing open or lap-RAMPS for the diagnosis of left-sided PDAC were reviewed from a prospective database. Patients excluded if they were related with combined organs or vessels resection, systematic metastasis as well as conversion from open RAMPS to lap RAMPS. The surgical and oncologic outcomes were compared.

RESULTS

A total of 48 PDAC patients were enrolled (25 underwent lap-RAMPS and 23 underwent open-RAMPS). There were no significant differences in demographic or perioperative morbidity. In the lap-RAMPS group, R0 transection margin and retroperitoneal margin were both achieved in 23 of 25 patients (92%). In the open RAMPS group, R0 transection margin was achieved in 21 of 23 patients (91.3%), R0 retroperitoneal margin was 22 of 23 patients (95.65%). There were no differences in pathological examinations. The number of lymph node (LN) retrieved between lap-RAMPS and open- RAMPS group was not significant difference (15.84 vs 18.22; P = 0.268). Median disease-free survival (DFS) was analogous in two groups (18.11 m vs 20.00 m, P = 0.999). Median overall survival (OS) was 24.53 m in lap-RAMPS group and 28.73 m in the open-RAMPS group (P = 0.633).

CONCLUSIONS

Lap-RAMPS is technically feasible, and has comparable long-term oncological outcome with open-RMAPS.

Utilization of the Falciform Ligament to Buttress the Pancreatic Transection Staple Line: A Novel Technique

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a common complication after distal pancreatectomy and is a major source of operative morbidity. Although various mechanical, biological, and synthetic aids have been used to reduce the risk of POPF, none have a proven benefit.

MATERIALS AND METHODS

The authors describe (and present a video, Supplemental Digital Content 1, http://links.lww.com/SLE/A256) a novel technique in which the autologous falciform ligament was harvested, wrapped around the pancreas at the site of proposed pancreatic transection, and secured with sutures to buttress the pancreatic transection staple line. The pancreas was then transected with a triple-row stapler.

RESULTS

Two male patients aged 40 and 57 years each with a 4.3 and 4.2 cm solid mass in the body of the pancreas respectively underwent laparoscopic anterior radical antegrade modular pancreaticosplenectomy, the former patient underwent an en block transverse colectomy for suspected malignancy. Both patients had soft pancreata. They experienced no POPF, made an uneventful recovery, and were discharged from the hospital on the second and fourth postoperative days, respectively. No pancreatic complications were encountered at 5 and 6 months follow-up, respectively.

CONCLUSIONS

The use of the falciform ligament to buttress the staple line at the time of pancreatic transection is a novel technique. Its potential benefit in reducing the risk of POPF warrants further assessment.

Minimally invasive surgery for pancreatic cancer

Pancreatic cancer is the most lethal malignancy of the digestive organs. Although pancreatic resection is essential to radically cure this refractory disease, the multi-organ resection involved, as well as sequelae such as glucose tolerance insufficiency and severe complications impose a heavy burden on these patients. Since the late twentieth century, minimally invasive surgery has become more popular for the surgical management of digestive disease and pancreatic cancer. Minimally invasive pancreatic resection (MIPR), including pancreaticoduodenectomy and distal pancreatectomy, is now a treatment option for pancreatic cancer. Some evidence suggests that MIPR for pancreatic cancer provides comparable oncological outcomes to open surgery, with some advantages in perioperative outcomes. However, as this evidence is retrospective, prospective investigations, including randomized controlled trials, are necessary. Because neoadjuvant therapy for resectable or borderline-resectable pancreatic cancer and conversion surgery for initially unresectable pancreatic cancer has become more common, the feasibility of MIPR after neoadjuvant therapy or as conversion surgery requires further assessment. It is expected that progress in surgical techniques and devices, as well as the standardization of surgical procedures and widespread educational programs will improve the outcomes of MIPR.

Laparoscopic versus open radical antegrade modular pancreatosplenectomy with artery-first approach in pancreatic cancer

BACKGROUND

An artery-first approach for pancreatic cancer (PC) is challenging to perform laparoscopically and is mainly performed using an open approach. The aims of this study were to assess the safety and feasibility of laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) with an artery-first approach (L-aRAMPS) as compared with open aRAMPS (O-aRAMPS) in resectable PC using matched-pair analysis.

METHODS

Artery-first approach is an early dissection of the superior mesenteric artery (SMA) from behind the pancreas body as the first surgical step. Data on L-aRAMPS and O-aRAMPS, performed between July 2013 and November 2019, were collected retrospectively. Additionally, the spatial characteristics of the splenic artery were analyzed using computed tomography.

RESULTS

Thirty L-aRAMPS and 33 O-aRAMPS for resectable PC were included. After matching, 15 L-aRAMPS were compared with 15 O-aRAMPS. Median intraoperative blood loss and hospital stay were significantly improved in L-aRAMPS compared to O-aRAMPS (30 vs. 220 g, p < 0.001; 12 vs. 16 days, p = 0.049). The overall morbidity was similar in both study groups. The total number of lymph nodes dissected and those harvested from around the SMA and R0 resection was similar in both study groups. We classified the width of the cross section of the pancreas body into three equal parts: the upper, middle, and lower parts of the pancreas; 63% of the splenic artery origin was located in middle and lower parts of the pancreas body.

CONCLUSION

L-aRAMPS is technically safe and oncologically feasible to secure favorable surgical outcomes for resectable PC patients.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Venous Tangential Resection: Focus on Periadventitial Dissection of the Superior Mesenteric Artery for Obtaining Negative Margin and a Safe Vascular Resection

BACKGROUND

Due to its technical complexity, laparoscopic (L-) radical antegrade modular pancreatosplenectomy (RAMPS) for left-sided pancreatic ductal adenocarcinoma (PDAC) has been described in a few series.1-4 In addition, splenomesenteric junction tumor involvement is considered a formal contraindication to L-RAMPS.

METHODS

The video shows posterior L-RAMPS with a left approach to the superior mesenteric artery (SMA) for a left-sided PDAC with suspected involvement of the splenomesenteric junction.

RESULTS

The patient was a 61-year-old woman affected by a cT3N0M0 pancreatic body PDAC. Following dissection of the superior mesenteric vein (SMV), proper/common hepatic artery, and gastroduodenal artery, the pancreatic neck is encircled and the celiac trunk (CT) skeletonized. The treitz ligament is opened, and the SMA is identified and dissected on its left anterior margin. Pancreatic mobilization en bloc with the Gerota fascia and left adrenal gland is followed by splenic artery transection and suprapancreatic lymphadenectomy completion. The mesopancreas is dissected from the right margin of the SMA and CT and the pancreas is transected. The portal vein and SMV are cross-clamped and a venous tangential resection/closure is performed. Cryostate histological examination of the venous and pancreatic stumps showed absence of tumor cells. Final pathology revealed a pT2N0(0+/42)R0G2 PDAC of the pancreatic body.

CONCLUSION

During L-RAMPS, periadvential SMA dissection through the left-anterior approach, specular to the right posterior SMA approach described for laparoscopic pancreatoduodenectomy,5^,6 has a primary role in maximizing the vascular surgical margin and, allowing for complete mobilization of the specimen before vein resection, may make a splenomesenteric junction tangential resection/closure easier and safer in case of tumor involvement of the splenomesenteric venous axis.

Laparoscopic Distal Pancreatectomy for Left-Sided Pancreatic Cancer Using the "Caudo-Dorsal Artery First Approach"

BACKGROUND

Pancreatic cancer (PC) has serious malignant potential, thus requiring complete resection and adequate regional lymphadenectomy with tumor-free margins.1,2 A standard laparoscopic distal pancreatectomy (LDP) procedure for PC is not yet established due to lack of supportive evidence.3^-6 METHODS: In our hospital, we first administered neoadjuvant chemoradiotherapy for resectable PC. Considering the benefits offered by a laparoscopic magnified caudo-dorsal view, we devised and standardized an LDP procedure for PC, which we employed in five patients with left-sided resectable tumors. First, the retroperitoneum was incised between the proximal jejunum and the inferior mesenteric vein with the transverse colon pushed up ventrally and cranially and with the proximal jejunum moved to the right. Then, the left renal vein (LRV) could be easily identified at this site. The retroperitoneal tissue was dissected along the LRV, and the origin of the superior mesenteric artery (SMA) also was identified just above the LRV easily. The left adrenal gland was removed to secure the dorsal margin, if needed. The retroperitoneal dissection was continued along the major anatomical landmarks, including the LRV, the left renal artery, the left kidney, and the crus of the diaphragm beside the origin of the SMA. Using the same operative field, lymphadenectomy around the SMA was performed before dividing the pancreas. We could safely and easily expose the left aspect of the SMA after dissecting the ligament of Treitz. The dissection around the SMA was performed toward the side of the arterial root that had already been exposed above the LRV. Thus, the most important difficult steps of LDP for PC, such as retroperitoneal dissection and lymphadenectomy around the SMA, were safely performed early in the operation with a good laparoscopic view.

RESULTS

The median operative time was 341 (range 288-354) minutes, and median blood loss was 150 (range 50-150) ml. An intraoperative transfusion was not required for any patient. Severe postoperative complications or mortality were absent. An R0 resection was achieved in all patients.

CONCLUSIONS

LDP using the "caudo-dorsal artery first approach" is safe and useful for performing a minimally invasive, curative resection for left-sided PC.

The oncological safety in minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis

The safety of minimally invasive distal pancreatectomy (MIDP) and open distal pancreatectomy (ODP) regarding oncological outcomes of pancreatic ductal adenocarcinoma (PDAC) remains inconclusive. Therefore, the aim of this study was to examine the oncological safety of MIDP and ODP for PDAC. Major databases including PubMed, Embase, Science Citation Index Expanded, and the Cochrane Library were searched for studies comparing outcomes in patients undergoing MIDP and ODP for PDAC from January 1994 to August 2018. In total, 11 retrospective comparative studies with 4829 patients (MIDP: 1076, ODP: 3753) were included. The primary outcome was long-term survival, including 3-year overall survival (OS) and 5-year OS. The 3-year OS (hazard ratio (HR): 1.03, 95% confidence interval (CI): 0.89, 1.21; P = 0.66) and 5-year OS (HR: 0.91, 95% CI: 0.65, 1.28; P = 0.59) showed no significant differences between the two groups. Furthermore, the positive surgical margin rate (weighted mean difference (WMD): 0.71, 95% CI: 0.56, 0.89, P = 0.003) was lower in the MIDP group. However, patients in the MIDP group had less intraoperative blood loss (WMD: -250.03, 95% CI: -359.68, -140.39; P < 0.00001), a shorter hospital stay (WMD: -2.76, 95% CI: -3.73, -1.78; P < 0.00001) and lower morbidity (OR: 0.57, 95% CI: 0.46, 0.71; P < 0.00001) and mortality (OR: 0.50, 95% CI: 0.31, 0.81, P = 0.005) than patients in the ODP group. The limited evidence suggested that MIDP might be safer with regard to oncological outcomes in PDAC patients. Therefore, future high-quality studies are needed to examine the oncological safety of MIDP.

Radical antegrade modular pancreatosplenectomy versus standard procedure in the treatment of left-sided pancreatic cancer: A systemic review and meta-analysis

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS), first reported by Strasberg in 2003, has attracted increasing attention in the treatment of left-sided pancreatic cancer. The limited number of cases eligible for RAMPS makes it difficult to perform any prospective randomized trial of RAMPS versus the standard procedure. Therefore, we performed this systemic review and meta-analysis of the current data to clarify the role of the RAMPS procedure.

METHODS

A literature search was performed in electronic databases, including PubMed, Medline, Embase, CNKI and the Cochrane Library. Studies comparing RAMPS with the standard procedure were included in this meta-analysis. R0 resection rate, recurrence rate at the end of the follow-up, overall survival (OS) and disease-free survival (DFS) were measured as primary outcomes. Revman 5.3 was used to perform the analysis.

RESULTS

Six retrospective cohort studies with a total number of 378 patients were included in our analysis. Meta-analysis revealed that RAMPS was correlated with higher R0 resection rates [Odds Ratio (OR) 95% confidence interval (CI), 2.19 (1.16 ~ 4.13); P = 0.02] and successful harvest of more lymph nodes [weighted mean difference (WMD) 95% CI, 7.06 (4.52 ~ 9.60); P < 0.01] compared with the standard procedure. However, no statistically significant difference was found between the procedures with respect to recurrence rates [OR 95% CI, 0.66 (0.40 ~ 1.09); P = 0.10], OS [Hazard ratio (HR) 95% CI, 0.65 (0.42 ~ 1.00); P = 0.05] or DFS [HR 95% CI, 1.02 (0.62 ~ 1.68); P = 0.93].

CONCLUSIONS

RAMPS is safe and oncologically superior to the standard procedure for the treatment of left-sided pancreatic cancer. However, high-grade evidence will be necessary to confirm the potential survival benefits of RAMPS.