Radical Antegrade Modular Pancreatosplenectomy Procedure Research Articles

Rare cystic lesion of pancreas : A case report

Hydatid disease also known as Hydatidosis or echinococcosis, the cause of which is the larval stage of Echinococcus granulosus. Pancreatic hydatidosis is very rare, with an incidence ranging from 0.14 to 2%. In this report we present a case of 51 years old female patient admitted in our hospital with a cystic lesion in the body of pancreas. Pre-operative computed tomography findings were suggestive of mucinous cystademona for which radical antegrade modular pancreatosplenectomy procedure was done.

Radical Antegrade Modular Pancreatosplenectomy for Left-Sided Pancreatic Ductal Adenocarcinoma May Reduce the Local Recurrence Rate

Introduction: Although several clinical applications have reported the usefulness of the radical antegrade modular pancreatosplenectomy (RAMPS) procedure for left-sided pancreatic ductal adenocarcinoma, few studies have reported the advantages of RAMPS with respect to the local recurrence (LR) rate. Methods: As of 2018, 68 and 62 patients underwent RAMPS and standard retrograde pancreatosplenectomy (SRPS). The first recurrence and all subsequent recurrence sites observed on images during a follow-up period and/or chemotherapy. The clinical variables are collected retrospectively. Results: LR only was found in 5 patients in the RAMPS group (5/68, 7.3%) and in 15 patients in the SRPS group (15/62, 24.2%; p = 0.008) as the first recurrence site. Any chemotherapies were not a risk factor for the incidence of LR. The 5-year cumulative LR rate was significantly lower in patients in the RAMPS group compared with those in the SRPS group (23.6% vs. 49.6%; p = 0.019). The 5-year overall survival was 42.2% in the RAMPS group and 33.0% in the SRPS group (p = 0.251). Conclusion: The RAMPS procedure for left-sided pancreatic ductal adenocarcinoma may reduce the LR, cumulative LR rates.

Minimally invasive surgery versus open surgery in radical antegrade modular pancreatosplenectomy (RAMPS): a systematic review and meta-analysis

Background: Background: RAMPS was first reported in 2003 by Strasberg for the treatment of pancreatic body and tail cancer. Today, minimally invasive distal pancreatectomy can also be performed as a RAMPS procedure. Yet, the safety and efficacy of minimally invasive RAMPS (M-RAMPS) is still controversial. To assess whether M-RAMPS is beneficial in patients with pancreatic body and tail cancer compared with open RAMPS (O-RAMPS) in a systematic review and meta-analysis.

The standardized technique in robotic radical antegrade modular pancreatosplenectomy using the flip-up approach.

Radical antegrade modular pancreatosplenectomy (RAMPS) was first introduced in 2003. It has been accepted as an alternative technique for pancreatic cancer of the body and tail. However, robotic RAMPS is not yet popular because of its technical difficulty and lack of standardized technique. This study describes in detail the standard steps of robotic RAMPS using the flip-up approach with the benefit of a robotic view when treating pancreatic cancer of the body and tail. We took advantage of our single-center experience to provide a step-by-step technique of robotic RAMPS procedure using the da Vinci Si system. We divided the procedure into 11 key steps. The surgical steps are optimized to achieve margin-negative curative resection and sufficient regional lymphadenectomy. The artery-first approach is usually used to determine tumor resectability early before performing an irreversible operative step. We also determine the borders of surgical resection and divide the splenic artery after dividing the pancreatic neck and the splenic vein, which facilitates a complete lymphadenectomy around the celiac axis with a bottom-up view. Robotic RAMPS using the flip-up approach is safe and feasible in performing curative resection for well-selected pancreatic cancer of the body and tail. A randomized controlled trial comparing open and robotic RAMPS is needed in the future.

Pure laparoscopic radical antegrade modular pancreato-splenectomy (RAMPS) procedure

Purpose: Laparoscopic left pancreatectomy for pancreatic cancer has recently increased worldwide. With the attempt to improve its oncological safety by enlarging the resection margins, the radical antegrade modular pancreato-splenectomy (RAMPS) have been introduced. However, this procedure is technically challenging and it still needs to be standardized. We herein describe a standardized, step-by-step approach of the laparoscopic RAMPS at our center highlighting some technical tips and tricks. Methods: This procedure was performed on a 59-year-old man with a past history of diabetes and hypertension with non-specific abdominal pain. In the CT scan a 3 cm sized low attenuated mass in the body of the pancreas was detected with suspicious invasion of the posterior capsule. Results: After creation of a pneumoperitoneum via a 12 mm infra-umbilical port, three additional trocars are inserted. As showed in the video, surgery is started with division of the greater omentum. The inferior pancreatic border is dissected until the superior mesenteric vein and the origin of the splenic vein are exposed. Thereafter, the splenic artery and vein are dissected and divided. A window is opened between the pancreas and splenic vessels, and the neck of the pancreas is transected. The left side of the superior mesenteric artery is exposed until the left renal vein is identified. The retroperitoneal dissection continues along the anterior surface of the renal vein and kidney. Conclusions: Laparoscopic RAMPS procedure is a safe and feasible technique in experienced centers with advanced minimally invasive skills; it is recommended to standardize the technique for teaching purposes, replicability and to ensure patient safety

Radical antegrade modular pancreatosplenectomy: Report of two cases and review of the literature

Introduction. The radical antegrade modular pancreatosplenectomy (RAMPS) procedure was introduced as a modification of standard retrograde pancreatosplenectomy (SRPS). It was designed to establish a new surgical approach, with intension to increase possibility of achieving negative posterior (retroperitoneal) resection margin, as well as to provide complete N1 lymph node clearance. Outline of cases. We present two cases with diagnosed left-sided pancreatic tumors, who were surgically treated in our hepato-pancreato-biliary department. Both patients underwent posterior RAMPS procedure. Postoperative course was uneventful in both patients. Conclusion. RAMPS is a safe procedure because it provides complete vascular and bleeding control. It is a superior procedure in oncologic terms compared to SRPS, as it increases the rate of R0 resection, and provides larger number of lymph nodes harvested. Furthermore, RAMPS is associated with better overall survival.

Radical antegrade modular pancreatosplenectomy for all pancreatic body and tail tumors: rationale and results.

Radical antegrade modular pancreatosplenectomy (RAMPS) has been propagated as the standard of care for pancreatic cancers involving the body and tail of the pancreas. This procedure has been shown to have promising results in enhancing the microscopically negative tangential resection margins as well as the lymph node yield. This is a retrospective analysis of prospectively maintained database on the resections performed for all pancreatic body and tail tumors at Tata Memorial Centre. Sixty-five patients underwent RAMPS without any perioperative mortality. The various pathologies comprised of adenocarcinoma (41.5%), neuroendocrine tumors (12.3%), solid pseudopapillary epithelial neoplasm (15.3%), cystic neoplasms (15.2%), etc. The R0 resection rate was 87.7%. Among this cohort, 27 patients had pancreatic adenocarcinoma. The 3-year OS and DFS for distal pancreatic cancers were 56% and 38%, respectively, but 3-year OS and DFS for other distal pancreatic tumors were 97% and 73%, respectively. On multivariate analysis, R0 resection significantly improved disease-free survival (p = 0.023) for pancreatic cancer. RAMPS procedure aids to achieve high negative tangential margins for all tumors involving the body and tail of the pancreas and not just pancreatic cancer in isolation. Since preoperative histologic diagnosis is not routinely indicated and also a number of other distal pancreatic tumors carry a relatively better prognosis compared with pancreatic cancer, our results provide further evidence that RAMPS should be considered as the procedure of choice for all operable tumors involving body and tail of the pancreas.

Assessement of postoperative long-term survival quality and complications associated with radical antegrade modular pancreatosplenectomy and distal pancreatectomy: a meta-analysis and systematic review

BackgroundThis study evaluated the perioperative complications and the long-term pancreatic survival outcomes in patients treated with radical antegrade modular pancreatosplenectomy (RAMPS) and distal pancreatectomy (DP).MethodWe performed a computer search on the PubMed, Embase and Cochrane Library databases to retrieve the RCT or clinical trials comparing RAMPS and DP published before July of 2018. The quality of the included trials was assessed according to the inclusion and exclusion criteria by two researchers independently. The RevMan 5.3 software was used to extract and analyze the data.ResultA total of 5 retroprospective clinical trial articles comprising 285 patients were included in the study. The number of patients who underwent RAMPS were 135 and 150 for DP. There were significant differences (P < 0.05) in the operation time [WMD = − 63.93, 95% CI (− 68.86 ~ − 58.99), P<0.00001], and bleeding volume [WMD = − 184.62, 95% CI (− 211.88 ~ − 157.37), P<0.00001] between the two groups. However, no significant differences were observed between RAMPS and DP in terms of pancreatic fistula, postoperative complications, postoperative hospital stay, and mortality (P>0. 05). As for pathological examination, there were statistically significant differences between RAMPS and DP in the R0 resection rate [RR = 2.37, 95% CI (1.19 ~ 4.72), P = 0.01] and the number of lymph node excision [WMD = 7.08, 95% CI (4.59 ~ 9.58), P<0.000013]. The one-year overall survival rate was higher in RAMPS patients compared to DP patients [RR = 1.20, 95% CI (1.02 ~ 1.41), P = 0.02]. But there were no significant difference in postoperative recurrence [RR = 0.85, 95% CI (0.70 ~ 1.04), P = 0.13] between the two groups. Conclusion: RAMPS is an effective procedure for clinical application. Nevertheless, large, multicenter prospective randomized controlled trias are required to validate these findings.ConclusionThe RAMPS procedure was associated with good postoperative outcomes and overall survival, indicating that it is an effective procedure for clinical application. Large, multicenter prospective randomized controlled trials are needed to validate these findings.

Laparoscopic anterior RAMPS for pancreatic ductal adenocarcinoma

Background: Radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic body or tail adenocarcinoma has been designed to increase the rate of negative margin and to obtain better N1 nodes clearance. However, laparoscopic RAMPS has been rarely reported. Methods: Herein, we describe our technique for laparoscopic RAMPS. Following dissection of the gastro-colic ligament, proximal and distal control of the mesenteric-portal confluence is obtained and a retropancreatic tunnel is developed. Common hepatic artery is dissected from right to left until identification and dissection of celiac axis and of splenic artery, which is ligated. The pancreatic neck is transected, the splenic vein is dissected and divided. At this point, Treitz dissection is performed in order to identify the left renal vein, representing the posterior margin of dissection and the left side of superior mesenteric artery and of celiac axis, which represent the left dissection margin. The splenic artery is then divided and the dissection is continued posteriorly until distal pancreatosplenectomy is completed. Results: The operative time was 368 minutes, estimated blood loss 150 cc. The postoperative period was uneventful and the length of stay was 10 days. Pathologic exam showed complete resection of a pT3N1 (n+ 2/tot 20) adenocarcinoma, all resection margins were >1mm. Conclusion: RAMPS procedure with laparoscopic approach seems to be safe, feasible and effective.

RAMPS – Surgical Treatment for a Pancreatic Tumor

Background: Radical antegrade modular pancreatosplenectomy (RAMPS) is not the standard procedure for cancers of the body and tail of the pancreas but this approach provides improvement in the establishment of an operation with oncologic rationales both for the dissection planes used to achieve negative margins and the extent of lymph node dissection. The authors present a clinical case report. Methods: The authors present a clinical case report. Results: 55-year-old lady, without comorbidities, felt epigastric pain and noted weight loss (10Kg) for a month. Had a CT scan that showed a pancreatic body mass (4x2cm) with splenic vessels encasement and segmental involvement of splenoportal confluent. The case was discussed in a multidisciplinary meeting and decided with surgery. We performed a radical antegrade modular pancreatosplenectomy with side wall portal ressection. This procedure has complicated with the development of diabetes and a type b pancreatic fistula (conservative treatment). Pathology showed an invasive pancreatic ductal adenocarcinoma (6.5cm) with perineural invasion and metastases in 9 of 27 identified lymph nodes (pT4N2). Conclusion: RAMPS procedure for lesions of the body and tail of the pancreas can retrieve significantly more lymph nodes than standard distal pancreatectomy and splenectomy and, therefore, improving tumor staging and outcome.

Left kidney mobilization technique during radical antegrade modular pancreatosplenectomy (RAMPS)

Objective: Radical antegrade modular pancreatosplenectomy, originally proposed by Strasberg, has been accepted as a standard operation for distal pancreatic cancer. This step of lateral retroperitoneal dissection is technically challenging due to the depth of organs under the left costal margin. Methods: As the original RAMPS procedure, celiac lymphadenectomy, division of pancreas and medial retroperitoneal dissection around SMA were already completed until left renal vein is exposed as a landmark for the posterior boarder. At this point, left kidney is mobilized and medialized for further lateral peritoneal dissection. The parietal peritoneum at the left lateral gutter is incised and the plane behind the kidney is entered. This plane is always avascular and easily dissectable with the operator's finger, up to the diaphragm superiorly, and the aorta medially. The dissected space is packed with lap sponges, which lift the spleen, tail of the pancreas and kidney up to the anterior surgical field. Then, the rest of retroperitoneal dissection was completed lateral to medial fashion using the surface of the left kidney as a posterior landmark. Results: The advantages of mobilization of left kidney in RAMPS are two folds; (i) it can provide better exposure of left sided organs and allow meticulous retroperitoneal dissection, (ii) left kidney can be used as a landmark for a safe dissection boarder. We performed RAMPS with this modification on 147 patients since 2005, and achieved only 5 % of positive retroperitoneal margins. Conclusion: Left kidney mobilization technique is useful for safe, and oncologically sound lateral retroperitoneal dissection during RAMPS procedure.

The short- and long-term outcomes of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas.

BackgroundRadical antegrade modular pancreatosplenectomy (RAMPS) is a relatively new modification of the standard distal pancreatosplenectomy. In this method, dissection proceeds from right-to-left to achieve negative posterior resection margins. However, short-term and long-term outcomes of RAMPS for pancreatic cancer have not yet been clarified. The aim of this study is to evaluate short-term and long-term outcomes in the patients who have undergone RAMPS.MethodsConsecutive 49 patients were selected from the retrospective database of the Kanagawa Cancer Center from 2000 to 2014. Data from the operative notes, pathology reports, postoperative data, and outpatient data (recurrence and survival) were entered into the database.ResultsAll patients were undergone anterior RAMPS. The median operation time was 278 min (range from 140 to 625 mins). The median blood loss in operation was 850 ml (range from 60 to 2790 ml). The overall incidence of morbidity was 51.4 % and the incidence of mortality was 0 %. Forty-one patients (83.7 %) had negative resection margins. The mean number of lymph nodes harvested was 15 and 27 patients had lymph node metastasis. After the median follow-up period was 41.1 months, 1-year and 3-year overall survival rates were 84.1 and 38.6 %, respectively. Median overall survival was 22.6 months.ConclusionsThe present study results suggested that RAMPS procedure might be safe and feasible without an increase in morbidity and morbidity and have survival benefit compared with standard DP.

Comparison of Standard Distal Pancreatectomy and Splenectomy with Radical Antegrade Modular Pancreatosplenectomy

Radical antegrade modular pancreatosplenectomy (RAMPS) has been reported to provide improved margin resection and lymph node retrieval for tumors of the body and tail of the pancreas compared with standard resection. We examined our experience with RAMPS and standard resection to determine differences in clinicopathologic outcomes. A comparison of RAMPS procedures was made to standard distal pancreatectomy and splenectomy examining various clinicopathologic variables through retrospective chart review. Twenty-six patients underwent distal pancreatectomy with or without splenectomy between November 2004 and June 2011. Twenty patients underwent standard resection and six patients underwent RAMPS procedures for a variety of histologies. As a result of the heterogeneity of diseases, which included benign lesions, margin status was not applicable in some cases and therefore was not assessed overall. Fisher's exact test and Wilcoxon rank sum tests demonstrated a significant difference in number of lymph nodes removed with mean of 4.3 and 11.2 lymph nodes obtained for standard resection and RAMPS, respectively (P = 0.03). The RAMPS procedure for lesions of the body and tail of the pancreas retrieved significantly more lymph nodes than standard distal pancreatectomy and splenectomy. It should be the preferred surgical approach when lymph node count is important for tumor staging.

Role of Radical Antegrade Modular Pancreatosplenectomy for Adenocarcinoma of the Body and Tail of the Pancreas

Studies have claimed that in the surgical treatment of pancreas body and tail cancer, radical antegrade modular pancreatosplenectomy (RAMPS) is associated with effective tangential margin and extensive lymph node dissection. In the present study, the authors have compared the surgical outcomes between RAMPS and conventional distal pancreatosplenectomy (DPS) in patients with adenocarcinoma of the pancreas body and tail, and also identified prognostic factors associated with survival after surgery. Retrospective review of 92 consecutive patients who underwent surgical resection for pancreas body and tail adenocarcinoma with curative intent between 1995 and 2010. Median follow-up duration was 16.1 months. Of the 92 patients, 38 patients received RAMPS and 54 patients received DPS. Patients who underwent RAMPS had a greater number of retrieved lymph nodes than patients undergoing DPS [median 14 (5-52) vs. 9 (1-36), p < 0.05]. Conventional DPS, no adjuvant chemoradiation therapy (CRT), and non-curative resection were associated with poor overall survival (OS) on univariate analysis. After multivariate analysis for these variables, only the lack of adjuvant CRT and resection margin status were found to adversely affect OS. While the RAMPS procedure is effective in performing an extensive LN dissection, it is not associated with better retroperitoneal resection margin or retrieval of more positive LNs, and it does not lead to better curability or OS survival compared to DPS. Lack of adjuvant CRT and resection margin status are poor prognostic factors in patients with pancreas body and tail cancer.

Long-Term Results of Resection of Adenocarcinoma of the Body and Tail of the Pancreas Using Radical Antegrade Modular Pancreatosplenectomy Procedure

The radical antegrade modular pancreatosplenectomy (RAMPS) procedure is a modification of standard distal pancreatosplenectomy. It was designed to provide the operative approach developed for cancers of the head of the pancreas to cancers of the body and tail of the pancreas, particularly with respect to the extent of node dissection and emphasis on obtaining microscopically negative tangential margins. The purpose of this report is to provide long-term survival results. Forty-seven patients had RAMPS between 1999 and 2008. The decision to perform anterior vs posterior RAMPS was based on the position of the tumor as assessed by preoperative computed tomograms. Patients were entered in a prospective database and followed at intervals. Thirty-two patients had anterior RAMPS and 15 had posterior RAMPS. Twenty-four patients had resection of 33 organs in addition to the left adrenal gland in the posterior RAMPS. Specimens were inked in the operating room. Mean tumor size was 4.4 cm. Negative tangential margins were obtained in 89% of specimens. Overall, the R0 rate was 81%. Mean lymph node count was 18. There were no 30-day or in-hospital mortalities. Mean and median follow-up times of living patients were 44.4 and 26.4 months. Median survival was 26 months and 5-year overall actuarial survival was 35.5%. The actual survival of 23 patients whose surgery was performed more than 5 years before the time of analysis was 30.4%. RAMPS is associated with high negative tangential margin rates and very satisfactory survival rates for this aggressive tumor.

Radical Antegrade Modular Pancreatosplenectomy Procedure for Adenocarcinoma of the Body and Tail of the Pancreas: Ability to Obtain Negative Tangential Margins

Radical Antegrade Modular Pancreatosplenectomy Procedure for Adenocarcinoma of the Body and Tail of the Pancreas: Ability to Obtain Negative Tangential Margins

Radical Antegrade Modular Pancreatosplenectomy Procedure for Adenocarcinoma of the Body and Tail of the Pancreas: Ability to Obtain Negative Tangential Margins

Positive resection margins and low lymph node counts are common in resections of cancers of the body and tail of the pancreas. In 2003, we described a novel approach for resection of the pancreas called radical antegrade modular pancreatosplenectomy (RAMPS), which was directed toward these problems. We now present results of treatment of patients with adenocarcinoma using RAMPS with particular reference to the ability of this procedure to obtain negative tangential margin rates. Data from 23 patients treated with RAMPS procedure were collected in a prospective database. Data from the operative notes, pathology reports, and postoperative data were entered into the database. Mean (+/-SD) operative time was 6.3 (+/-1.8) hours. Fifteen patients had anterior RAMPS procedure and eight posterior RAMPS procedure. There were no postoperative (30 days) or hospital deaths. Eighteen postoperative complications developed in 12 of 23 (52%) patients. Mean tumor size was 5.1 cm. Invasion outside the pancreatic capsule was identified in 78% of patients. Median number of nodes was 15. Ninety-one percent had negative tangential margins, which is the main finding of the study. Median survival was 21 months. The 5-year overall survival is 26%, but followup is still short. RAMPS procedure can achieve negative tangential margins in a high percent of patients with resectable carcinoma of the body and tail of the pancreas. Median and overall survival rates are quite satisfactory for this tumor and are similar to rates reported for the Whipple procedure.