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Nakata K, Abe T, Ideno N, Nakamura S, Ikenaga N, Nagayoshi K, Mizuuchi Y, Moriyama T, Ohuchida K, Nakamura M. Minimally invasive distal pancreatectomy for pancreatic cancer: cranial-to-caudal approach with identification of Gerota's fascia (with video). Surg Endosc 2023; 37:8901-8909. [PMID: 37845535 DOI: 10.1007/s00464-023-10438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/31/2023] [Indexed: 10/18/2023]
Abstract
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.
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Affiliation(s)
- Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Toshiya Abe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Noboru Ideno
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - So Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kinuko Nagayoshi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yusuke Mizuuchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Taiki Moriyama
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kenoki Ohuchida
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Wu S, Cai H, Peng B, Cai Y. "Plane first" approach for laparoscopic radical antegrade modular pancreatosplenectomy. Surg Endosc 2022; 36:7471-7476. [PMID: 35768737 DOI: 10.1007/s00464-022-09165-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/18/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has not been widely performed due to its technical challenging. We introduce a novel approach, named "Plane first" approach, for L-RAMPS in this study. METHODS From January 2015 to August 2021, we performed 51 cases of L-RAMPS. Patients were divided into two groups basing on the surgical approach: conventional approach (group 1) and "Plane first" approach (group 2). Data were retrospectively collected in terms of demographic characteristics, intra-operative variables, post-operative variables, and follow-up outcomes. RESULTS The age, sex, BMI, and tumor size were comparable between two groups. Two patients in the group 1 required converting to open surgery. The patients in the group 2 required fewer operative time (210.5 ± 65.5 min vs. 252.4 ± 24.7 min, p < 0.01). They also suffered from less blood loss (136.0 ± 100.0 ml vs. 158.8 ± 137.0 ml, p = 0.15). The overall complications for patients in two groups were comparable. In terms of oncological outcomes, posterior margin was positive in two patients (10.5%) in the group 1. One patient (3.1%) in the group 2 had positive pancreatic neck margin. The number of lymph nodes harvested and overall survival between the two groups were comparable. CONCLUSION "Plane first" approach RAMPS for patients with pancreatic adenocarcinoma in the left pancreas is safe and feasible, even in patients with PV/SMV involvement.
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Affiliation(s)
- Shangdi Wu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - He Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Yunqiang Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041, Sichuan, China.
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Minimally Invasive Versus Open Radical Antegrade Modular Pancreatosplenectomy: A Meta-Analysis. World J Surg 2021; 46:235-245. [PMID: 34609574 DOI: 10.1007/s00268-021-06328-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced to improve the tangential resection margin rates and N1 node clearance following resection of malignancies of the pancreatic body and tail. Owing to its technical complexity, minimally invasive RAMPS (MI-RAMPS) has only been reported by a few centers worldwide. We performed this meta-analysis to compare both short- and long-term outcomes between open RAMPS (O-RAMPS) and minimally invasive RAMPS (MI-RAMPS). METHODS A systematic search of the electronic databases PubMed, Medline (via PubMed), Cochrane Register of Controlled Trials (CENTRAL), EMBASE, Scopus and Web of Science was performed to identify eligible studies published in the English language regardless of study design. The outcomes of interest were operation time, estimated blood loss, transfusion rates, overall complications, Grade B/C post-operative pancreatic fistula (POPF) rates, post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), length of stay (LOS), R0 resection rates, lymph node (LN) yield and overall survival (OS). RESULTS Five non-randomized studies comprising of a total 229 patients (89 MI-RAMPS, 140 O-RAMPS) were included for analysis. Intra-operative blood loss was observed to be significantly reduced in MI-RAMPS as compared to O-RAMPS (MD -256.16, P < 0.001), while LN yield was higher in O-RAMPS as compared to MI-RAMPS (MD -2.73, P = 0.02). There were no statistically significant differences observed for the other perioperative, oncologic and survival outcomes. CONCLUSIONS This meta-analysis provides early evidence to suggest that MI-RAMPS may produce comparable short- and long-term outcomes to O-RAMPS, when undertaken by appropriately skilled surgeons in well-selected patients. Further large-scale prospective studies are required to corroborate these findings.
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Suwa Y, Watanabe J, Ozawa M, Ishibe A, Suwa H, Ota M, Kunisaki C, Endo I. Direct Approach to the Superior Mesenteric Artery for Dissection of the Proximal Lymph Nodes in Patients With Splenic Flexure Colon Cancer With an Accessory Middle Colic Artery. Dis Colon Rectum 2021; 64:e583. [PMID: 34001708 DOI: 10.1097/dcr.0000000000002042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Yusuke Suwa
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Jun Watanabe
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Mayumi Ozawa
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Atsushi Ishibe
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hirokazu Suwa
- Department of Surgery, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Mitsuyoshi Ota
- Department of Surgery, Yokohama Red Cross Hospital, Yokohama, Japan
| | - Chikara Kunisaki
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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A systematic scoping review of the initial experience with laparoscopic radical antegrade modular pancreatosplenectomy for pancreatic malignancy. Surg Endosc 2021; 35:4930-4944. [PMID: 33988769 DOI: 10.1007/s00464-021-08528-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is a validated surgical approach for the surgical treatment of pancreatic malignancies of the body and tail of the pancreas. Open (O-) RAMPS is an established technique that offers oncological efficacy and acceptable post-operative outcomes when compared to standard distal pancreatectomy for pancreatic malignancies. This review aimed to determine the types of evidence available for L-RAMPS, and its selection criteria and reported outcomes, using systematic scoping review methodology. METHODS A systematic review of available literature was performed in September 2020. Data extracted included patient selection criteria, technical details, total number of L-RAMPS procedures performed, lymph nodes retrieved, resection margins, survival, LOS and complications. RESULTS Eight papers were eligible for inclusion, totalling 92 cases. There were no studies that directly compared O- to L-RAMPS. All reports were small retrospective cohorts with 3-30 patients. Selection criteria were reported in 4/8 studies and differed between studies. Technique descriptions were included in 6/8 studies. Studies reported a median of 5 (range 1-9) out of ten operative and clinical outcomes, including operative time median range 188-431 min, intraoperative blood loss median range 18-445 mL, R0 resection rate median range 91-100%, number of lymph nodes median range 11-43, and length of stay median range 12-20 days. CONCLUSIONS L-RAMPS is infrequently reported in the literature. There are currently no data to allow for direct comparison of O- and L-RAMPS. Reports of L-RAMPS have an acceptable oncological and safety profile. A standardised description of the operative technique and outcome reporting, as well as specific training initiatives may be beneficial to broaden the application of L-RAMPS.
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Zhang RC, Gan XJ, Song W, Shi ST, Yu HF, Mou YP. Laparoscopic radical antegrade modular pancreatosplenectomy: preliminary experience with 10 cases. BMC Surg 2021; 21:78. [PMID: 33568109 PMCID: PMC7877104 DOI: 10.1186/s12893-021-01090-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 02/03/2021] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Ren-Chao Zhang
- Department of Gastrointestinal & Pancreatic Surgery, Zhejiang Provincial People's Hospital, Key Laboratory of Gastroenterology of Zhejiang Province, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou, 310014, Zhejiang, China.
| | - Xin-Jun Gan
- Department of Gastrointestinal Surgery, The First People's Hospital of Jiashan, 1218 Tiyu Road, Jiashan, 314100, Zhejiang, China
| | - Wei Song
- Department of Gastrointestinal Surgery, The First People's Hospital of Jiashan, 1218 Tiyu Road, Jiashan, 314100, Zhejiang, China
| | - Song-Tao Shi
- Department of Gastrointestinal Surgery, The First People's Hospital of Jiashan, 1218 Tiyu Road, Jiashan, 314100, Zhejiang, China
| | - Hui-Fang Yu
- Department of Gastrointestinal Surgery, The First People's Hospital of Jiashan, 1218 Tiyu Road, Jiashan, 314100, Zhejiang, China
| | - Yi-Ping Mou
- Department of Gastrointestinal & Pancreatic Surgery, Zhejiang Provincial People's Hospital, Key Laboratory of Gastroenterology of Zhejiang Province, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou, 310014, Zhejiang, China
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Nishino H, Zimmitti G, Ohtsuka T, Abu Hilal M, Goh BKP, Kooby DA, Nakamura Y, Shrikhande SV, Yoon YS, Ban D, Nagakawa Y, Nakata K, Endo I, Tsuchida A, Nakamura M. Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:136-150. [PMID: 33527704 DOI: 10.1002/jhbp.903] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/23/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Giuseppe Zimmitti
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Mohammed Abu Hilal
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore City, Singapore
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | | | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University, Seoul, Korea
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Miyasaka Y, Ohtsuka T, Nakamura M. Minimally invasive surgery for pancreatic cancer. Surg Today 2020; 51:194-203. [PMID: 32857251 DOI: 10.1007/s00595-020-02120-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Yoshihiro Miyasaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Kagoshima, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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Safe exposure of the left renal vein during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: anatomical variations and pitfalls. Surg Today 2020; 50:1664-1671. [DOI: 10.1007/s00595-020-02053-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/31/2020] [Indexed: 01/09/2023]
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Kawabata Y, Hayashi H, Kaji S, Fujii Y, Nishi T, Tajima Y. Laparoscopic versus open radical antegrade modular pancreatosplenectomy with artery-first approach in pancreatic cancer. Langenbecks Arch Surg 2020; 405:647-656. [PMID: 32524466 DOI: 10.1007/s00423-020-01887-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/22/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Yasunari Kawabata
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Hikota Hayashi
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan
| | - Shunsuke Kaji
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan
| | - Yusuke Fujii
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan
| | - Takeshi Nishi
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan
| | - Yoshitsugu Tajima
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan
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11
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Ome Y, Seyama Y, Doi M, Muto J. Laparoscopic Distal Pancreatectomy for Left-Sided Pancreatic Cancer Using the "Caudo-Dorsal Artery First Approach". Ann Surg Oncol 2019; 26:4464-4465. [PMID: 31502021 DOI: 10.1245/s10434-019-07789-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Yusuke Ome
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.
| | - Yasuji Seyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Manami Doi
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Jun Muto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
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12
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Yamamoto M, Zaima M, Yamamoto H, Harada H, Kawamura J, Yamada M, Yazawa T, Kawasoe J. New laparoscopic procedure for left-sided pancreatic cancer-artery-first approach laparoscopic RAMPS using 3D technique. World J Surg Oncol 2017; 15:213. [PMID: 29197396 PMCID: PMC5712113 DOI: 10.1186/s12957-017-1284-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 11/23/2017] [Indexed: 01/28/2023] Open
Abstract
Background For left-sided pancreatic ductal adenocarcinoma (PDAC), radical antegrade modular pancreatosplenectomy (RAMPS) is a reasonable surgical approach for tumor-free margin resection and systemic lymph node clearance. In pancreaticoduodenectomy for PDAC, the superior mesenteric artery (SMA)-first approach (or the “artery-first approach”) has become the standard procedure. With improvements in laparoscopic instruments and techniques, some surgeons attempted to apply laparoscopic RAMPS (L-RAMPS) for carefully selected patients with left-sided PDAC. However, owing to several technical difficulties in this procedure, its application remains uncommon. Moreover, the artery-first approach in L-RAMPS has not been reported. Here, we developed the artery-first approach L-RAMPS for left-sided PDAC and have presented the same in this report. Case presentation Between June 2014 and July 2015, 16 patients with left-sided PDAC were referred to our division for pancreatic resection. The following technique was used for performing L-RAMPS on 3 of the 16 patients (19%). Six trocars were placed. After opening the omental bursa, only the middle segment of the pancreas was initially separated from both the left renal vein and the SMA. We termed this procedure as the “artery-first approach using a dome-shaped dorsomedial dissection (3D) technique.” This 3D technique enabled the interruption of the entire arterial supply to the specimen while preserving the venous drainage through the splenic vein for preventing venous congestion. The technique also contributed to the early detection of no tumor infiltration into the SMA and the early determination of posterior dissection plane. After pancreatic neck transection, the splenic artery and vein were divided. Finally, the pancreatic tail and spleen were dissected in a right-to-left direction. All operations were completed without any intraoperative complications. The median blood loss and retrieved lymph node count were 75 mL and 37, respectively, which were superior to those reported by other previous studies on L-RAMPS. All resection margins were free of carcinoma. No severe postoperative complications were observed. Conclusions The artery-first approach L-RAMPS using 3D technique is safe and feasible to perform. The significance of our proposed procedure is minimal blood loss and precise lymphadenectomy. Therefore, this novel technique may become the preferred treatment for left-sided PDAC in selected cases.
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Affiliation(s)
- Michihiro Yamamoto
- Department of Surgery, Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama-city, Shiga-prefecture, 524-8524, Japan.
| | - Masazumi Zaima
- Department of Surgery, Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama-city, Shiga-prefecture, 524-8524, Japan
| | - Hidekazu Yamamoto
- Department of Surgery, Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama-city, Shiga-prefecture, 524-8524, Japan
| | - Hideki Harada
- Department of Surgery, Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama-city, Shiga-prefecture, 524-8524, Japan
| | - Junichiro Kawamura
- Department of Surgery, Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama-city, Shiga-prefecture, 524-8524, Japan
| | - Masahiro Yamada
- Department of Surgery, Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama-city, Shiga-prefecture, 524-8524, Japan
| | - Tekefumi Yazawa
- Department of Surgery, Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama-city, Shiga-prefecture, 524-8524, Japan
| | - Junya Kawasoe
- Department of Surgery, Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama-city, Shiga-prefecture, 524-8524, Japan
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Ome Y, Hashida K, Yokota M, Nagahisa Y, Michio O, Kawamoto K. Laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer using the ligament of Treitz approach. Surg Endosc 2017; 31:4836-4837. [PMID: 28409377 DOI: 10.1007/s00464-017-5561-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/01/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (Lap-DP) for benign lesions or those with low malignant potential has been proven safe and effective, and its performance is now widespread [1-3]. Lap-DP for left-sided pancreatic cancer (PC) is also being increasingly performed. According to some reports, Lap-DP has superior short-term outcomes (blood loss, postoperative hospital stay) and comparable oncological outcomes and overall survival with those of open distal pancreatectomy (Op-DP) [4-6]. PC has highly malignant potential; thus, complete resection and sufficient regional lymphadenectomy with tumor-free margins are very important. Radical antegrade modular pancreatosplenectomy (RAMPS) is an accepted standard Op-DP technique for PC and is reportedly useful for achieving R0 resection and radical lymphadenectomy [7-10]. However, laparoscopic RAMPS (Lap-RAMPS) is not yet popular because of its technical difficulty and lack of adequate evidence. Few reports have described the detailed surgical technique of Lap-RAMPS [11-13]. We employ Lap-RAMPS using the ligament of Treitz approach with the benefit of a laparoscopic view and herein describe the usability of this laparoscopic procedure with a video. METHODS Our indication for Lap-RAMPS is left-sided PC located ≥1 cm away from the origin of the splenic artery (SPA) without invasion of the superior mesenteric artery (SMA), celiac artery (CA), common hepatic artery (CHA), or portal vein (PV). We apply either anterior or posterior RAMPS to achieve tumor-free margins. Therefore, the left adrenal gland and the nerve plexus around the SMA and CA are resected depending on the extent of the cancer. Three patients underwent Lap-RAMPS for left-sided PC using the ligament of Treitz approach from April to December 2016. This video shows our Lap-RAMPS procedure performed in a 67-year-old man with pancreatic body cancer who was being followed up for autoimmune pancreatitis. The tumor was suspected to have invaded the SPA, splenic vein, and retroperitoneum but was not close to the SMA, CA, CHA, or PV. The patient was put in the supine position with his legs opened, and the operation was performed using five trocars. Early in the operation, we incised the retroperitoneum just beside the ligament of Treitz, and the inferior vena cava and left renal vein (LRV) were exposed with resection of Gerota's fascia under a good laparoscopic view. The left adrenal gland was resected in this case to obtain sufficient tumor-free margins. The origin of the SMA was easily identified above the LRV. The most posterior dissection was carried out early in the operation, making it easy and safe to determine the resected margin and enabling curative resection with sufficient regional lymphadenectomy. After division of the pancreas with a linear stapler, the lymph nodes around the SMA and CA were safely removed. RESULTS The operative time was 358 min, and the estimated blood loss was 1 ml. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. Pathological examination revealed invasive ductal carcinoma (stage III, T3N1M0 according to the 7th edition of the Union for International Cancer Control system) with tumor-free margins. In all three patients, the median operative time and blood loss were 358 (328-451) min and minimal (minimal to 1 ml). One patient underwent anterior RAMPS and the other two patients, including the case mentioned above, underwent posterior RAMPS. One patient developed a grade B pancreatic fistula according to the International Study Group for Pancreatic Fistula (ISGPF) classification, but he recovered promptly with conservative treatment. No life-threatening complications occurred. The median postoperative hospital stay was 14 (10-16) days. CONCLUSIONS Lap-RAMPS using the ligament of Treitz approach is feasible and extremely helpful in performing minimally invasive, curative resection for well-selected left-sided PC.
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Affiliation(s)
- Yusuke Ome
- Department of Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan.
| | - Kazuki Hashida
- Department of Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Mitsuru Yokota
- Department of Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Yoshio Nagahisa
- Department of Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Okabe Michio
- Department of Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| | - Kazuyuki Kawamoto
- Department of Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
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Aosasa S, Nishikawa M, Hoshikawa M, Noro T, Yamamoto J. Inframesocolic Superior Mesenteric Artery First Approach as an Introductory Procedure of Radical Antegrade Modular Pancreatosplenectomy for Carcinoma of the Pancreatic Body and Tail. J Gastrointest Surg 2016; 20:450-4. [PMID: 26601979 DOI: 10.1007/s11605-015-3034-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/16/2015] [Indexed: 01/31/2023]
Abstract
Superior mesenteric artery (SMA)-first approaches are operative tactics used to determine tumor resectability early during pancreatoduodenectomy. With locally advanced carcinoma of the pancreatic body and tail, early determination of SMA involvement also helps establish whether curative resection is feasible. During either radical antegrade modular pancreatosplenectomy (RAMPS) or classic left-to-right distal pancreatectomy, dissection of the SMA is performed after transection of the pancreas or wide detachment of the distal pancreas and spleen. Herein, we describe an inframesocolic SMA-first approach as an introductory procedure when treating carcinoma of the pancreatic body and tail. This first approach procedure provides a reliable and safe introduction to RAMPS.
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Affiliation(s)
- Suefumi Aosasa
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan.
| | - Makoto Nishikawa
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Mayumi Hoshikawa
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Takuji Noro
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Junji Yamamoto
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
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15
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Kuroki T, Eguchi S. Laparoscopic distal pancreatosplenectomy for pancreatic ductal adenocarcinoma. Surg Today 2014; 45:808-12. [DOI: 10.1007/s00595-014-1021-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 08/10/2014] [Indexed: 01/11/2023]
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