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Barberio M, Pizzicannella M, Barbieri V, Benedicenti S, Mita MT, Rubichi F, Altamura A, Giaracuni G, Crafa F, Milizia A, Viola MG. Inframesocolic main pancreatic vessels-first approach for minimally invasive radical antegrade modular pancreaticosplenectomy (RAMPS): technical description and first experience. Updates Surg 2023; 75:1729-1734. [PMID: 37466897 DOI: 10.1007/s13304-023-01594-5] [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: 07/09/2023] [Accepted: 07/12/2023] [Indexed: 07/20/2023]
Abstract
Radical modular antegrade pancreaticosplenectomy (RAMPS) improves posterior tumor-free margins during resections of pancreatic neoplasia involving the body or tail. However, minimally invasive RAMPS is technically challenging and has been reported seldom. We present for the first time a minimally invasive RAMPS technique with an innovative approach providing early dissection and control of the main peripancreatic vessels from an inframesocolic embryonal window, suitable for laparoscopy and robotics. Minimally invasive RAMPS with inframesocolic main pancreatic vessels-first approach was performed at the Tricase Hospital (Italy) from May 2017 to April 2022 in 11 consecutive patients with neoplastic lesions of the pancreas (8 laparoscopic RAMPS and 3 robotic RAMPS). Among the laparoscopic cases, 1 included a portal vein tangential resection and 1 a celiac artery resection (modified Appleby procedure). There were no conversions, no Clavien-Dindo complications > 2, all resections' margins were tumor free, and no 90-day mortality.
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Affiliation(s)
- Manuel Barberio
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy.
- Department of Research, Institute Against Digestive Cancer (IRCAD), 1, Place de l'Hôpital, 67091, Strasbourg, France.
| | - Margherita Pizzicannella
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
- IHU Institute of Image-Guided Surgery, Strasbourg, France
| | - Vittoria Barbieri
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Sara Benedicenti
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Maria Teresa Mita
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Francesco Rubichi
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Amedeo Altamura
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Gloria Giaracuni
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
| | - Francesco Crafa
- Department of Surgery, Ospedale San G. Moscati, Avellino, Italy
| | - Antonio Milizia
- Department of Surgery, Ospedale Card. G. Panico, Via Pio X 4, 73039, Tricase, Italy
- Department of Surgery, Ospedale Universitario, Verona, Italy
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Nguyen TK, Nguyen HH, Luong TH, Dang KK, Le VD, Trinh HS, Tran DD. 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). World J Surg Oncol 2022; 20:224. [PMID: 35787283 PMCID: PMC9254562 DOI: 10.1186/s12957-022-02657-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/26/2022] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Thanh Khiem Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Ham Hoi Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Tuan Hiep Luong
- Department of Surgery, Hanoi Medical University, 1st Ton That Tung Street, Dong Da, Ha Noi, 11521, Vietnam.
| | - Kim Khue Dang
- Department of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Van Duy Le
- Department of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Hong Son Trinh
- Department of Oncology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Duc Dung Tran
- Department of Surgery, Thai Binh Medical University, Thai Binh, Vietnam
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Laparoscopic hepatopancreaticoduodenectomy for synchronous gallbladder cancer and extrahepatic cholangiocarcinoma: a case report. World J Surg Oncol 2022; 20:190. [PMID: 35681223 PMCID: PMC9178805 DOI: 10.1186/s12957-022-02628-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
Background Hepatopancreaticoduodenectomy (HPD) is one of the most complex procedures, and it is very rarely reported. Laparoscopic HPD (LHPD) is even rarer. To date, there are only 3 reports of LHPD for locally advanced gallbladder cancer (GBC) or extrahepatic cholangiocarcinoma (ECC). This is the first report of LHPD for synchronous GBC and ECC. Case presentation A 75-year-old female patient complained of jaundice for 2 weeks without fever or abdominal pain. She was diagnosed with synchronous GBC and ECC. After a comprehensive preparation, she underwent a laparoscopic pancreaticoduodenectomy and resection of hepatic segments of IVb and V, and her digestive tract reconstruction followed Child’s methods. She was discharged on the 12th day postoperatively without pancreatic leakage, biliary leakage, or liver failure. Conclusions LHPD is safe and feasible for selected cases of GBCs or ECCs.
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Kato T, Inoue Y, Oba A, Ono Y, Sato T, Ito H, Takahashi Y. Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Anterocranial Splenic Artery-First Approach for Left-Sided Resectable Pancreatic Cancer (with Videos). Ann Surg Oncol 2022; 29:3505-3514. [PMID: 35157192 DOI: 10.1245/s10434-022-11382-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/16/2022] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Tomotaka Kato
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Atsushi Oba
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, 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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Ban D, Garbarino GM, Ishikawa Y, Honda G, Jang JY, Kang CM, Maekawa A, Murase Y, Nagakawa Y, Nishino H, Ohtsuka T, Yiengpruksawan A, Endo I, Tsuchida A, Nakamura M. Surgical approaches for minimally invasive distal pancreatectomy: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:151-160. [PMID: 33527758 DOI: 10.1002/jhbp.902] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/23/2020] [Accepted: 01/18/2021] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Giovanni Maria Garbarino
- Department of Medical Surgical Science and Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Yoshiya Ishikawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Goro Honda
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Aya Maekawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshiki Murase
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Anusak Yiengpruksawan
- Minimally Invasive Surgery Division, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - 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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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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Zhang H, Li Y, Liao Q, Xing C, Ding C, Zhang T, Guo J, Han X, Xu Q, Wu W, Zhao Y, Dai M. Comparison of minimal invasive versus open radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic ductal adenocarcinoma: a single center retrospective study. Surg Endosc 2020; 35:3763-3773. [PMID: 33033915 DOI: 10.1007/s00464-020-07938-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/25/2020] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Hanyu Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Yatong Li
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Cheng Xing
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Cheng Ding
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Junchao Guo
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Xianlin Han
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Qiang Xu
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Wenming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China.
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Hayashi H, Baba H. Current statement and safe implementation of minimally invasive surgery in the pancreas. Ann Gastroenterol Surg 2020; 4:505-513. [PMID: 33005845 PMCID: PMC7511570 DOI: 10.1002/ags3.12366] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 12/19/2022] Open
Abstract
Minimally invasive pancreatic resection has become very popular in modern pancreatic surgery. Evidence of the benefits of a minimally invasive approach is accumulating thanks to prospective and randomized controlled studies. Minimally invasive surgery provides advantages to the surgeon due to the high definition of the surgical field and the freedom of fine movement of the robot, but should be considered only in selected patients and in high-volume centers. Minimally invasive distal pancreatectomy for benign and low-grade malignant tumors has established a secure position over open distal pancreatectomy, since it is associated with a shorter hospital stay, reduced blood loss, and equivalent complication rates. Minimally invasive distal pancreatectomy for pancreatic ductal adenocarcinoma appears to be a feasible, safe, and oncologically equivalent technique in experienced hands. On the other hand, the feasibility and safety of minimally invasive pancreaticoduodenectomy are still controversial compared with open pancreaticoduodenectomy. The choice of either technique among open, laparoscopic, and robotic approaches depends on surgeons' experience and hospital resources with a focus on patient safety. Further studies are needed to prove the perioperative and oncological advantages of minimally invasive surgery compared to open surgery in the pancreas. Here, we review the current status of minimally invasive pancreatic surgery and its safe implementation.
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Affiliation(s)
- Hiromitsu Hayashi
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Hideo Baba
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
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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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Rosso E, Manzoni A, Zimmitti G, Sega V, Treppiedi E, Giaccari S, Codignola C, Garatti M. 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. Ann Surg Oncol 2020; 27:2902-2903. [PMID: 32323087 DOI: 10.1245/s10434-020-08271-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Edoardo Rosso
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Alberto Manzoni
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Giuseppe Zimmitti
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
| | - Valentina Sega
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Elio Treppiedi
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Sara Giaccari
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Claudio Codignola
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marco Garatti
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
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