Radical Antegrade Modular Pancreatosplenectomy Research Articles

Periarterial and Sub-adventitial Divestment Along with Triangle Operation and RAMPS for Pancreatic Body Cancer.

Locally advanced cancers of the pancreatic body can abut or involve the celiac axis, hepatic artery, or superior mesenteric artery. Recent evidence suggests that these tumors are amenable to surgery after neoadjuvant chemotherapy (Hackert et al., Locally advanced pancreatic cancer: neoadjuvant therapy with FOLFIRINOX results in resectability in 60 % of the patients. Ann Surg 264:457-463, 2016; Rangelova et al., Surgery improves survival after neoadjuvant therapy for borderline and locally advanced pancreatic cancer: a single-institution experience. Ann Surg 273:579-86, 2021). An arterial divestment technique can be used for these cancers to get an R0 clearance, thereby avoiding morbid arterial resections (Miao et al., Arterial divestment instead of resection for locally advanced pancreatic cancer (LAPC). Pancreatology 16:S59, 2016; Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). Two techniques are described for arterial divestment. In the periarterial divestment technique, the plane of the dissection is between the tumor and the adventitia (Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). In sub-adventitial dissection, the plane of dissection is between the tunica adventitia and the external elastic lamina (Gao et al., Sub-adventitial divestment technique for resecting artery-involved pancreatic cancer: a retrospective cohort study. Langenbecks Arch Surg 406:691-701, 2021). The TRIANGLE operation also is one of the surgical techniques to achieve R0 resection in locally advanced pancreatic cancer (Hackert et al., The TRIANGLE operation: radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single-arm observational study. HPB Oxford 19:1001-1007, 2017). This multimedia article aims to demonstrate peri-arterial and sub-adventitial divestment techniques as well as the TRIANGLE operation for a locally advanced cancer of the body of the pancreas. The video also highlights the technique of posterior radical antegrade modular pancreato-splenectomy (RAMPS) together with lymph node clearance. A 57-year-old women was detected to have pancreatic body adenocarcinoma with tumor contact of the artery and superior mesenteric artery. After neoadjuvant chemotherapy, she was planned to undergo surgical resection. The surgical technique consisted of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS (Fig. 1). The procedure was performed within 240 min and involved blood loss of 250 mL. After the procedure, pancreatic leak (POPF-B), chyle leak and diarrhea developed, which were managed conservatively. The final histopathology showed residual, viable, moderately differentiated adenocarcinoma (ypT2N1M0) with all resection margins free. The surgical technique consisting of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS helps in R0 resection of locally advanced pancreatic body cancer without any compromise in oncologic outcomes and offers an alternative surgical approach to morbid arterial resection.

Comparison of Survival Outcomes between Radical Antegrade Modular Pancreatosplenectomy and Conventional Distal Pancreatosplenectomy for Pancreatic Body and Tail Cancer: Korean Multicenter Propensity Score Match Analysis.

(1) Background: The aim of this study was to compare the survival benefit of radical antegrade modular pancreatosplenectomy (RAMPS) with conventional distal pancreatosplenectomy (cDPS) in left-sided pancreatic cancer. (2) Methods: A retrospective propensity score matching (PSM) analysis was conducted on 333 patients who underwent RAMPS or cDPS for left-sided pancreatic cancer at four tertiary cancer centers. The study assessed prognostic factors and compared survival and operative outcomes. (3) Results: After PSM, 99 patients were matched in each group. RAMPS resulted in a higher retrieved lymph node count than cDPS (15.0 vs. 10.0, p < 0.001). No significant differences were observed between the two groups in terms of R0 resection rate, blood loss, hospital stay, or morbidity. The 5-year overall survival rate was similar in both groups (cDPS vs. RAMPS, 44.4% vs. 45.2%, p = 0.853), and disease-free survival was also comparable. Multivariate analysis revealed that ASA score, preoperative CA19-9, histologic differentiation, R1 resection, adjuvant treatment, and lymphovascular invasion were significant prognostic factors for overall survival. Preoperative CA19-9, histologic differentiation, T-stage, adjuvant treatment, and lymphovascular invasion were independent significant prognostic factors for disease-free survival. (4) Conclusions: Although RAMPS resulted in a higher retrieved lymph node count, survival outcomes were not different between the two groups. RAMPS was a surgical option to achieve R0 resection rather than a standard procedure.

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

The aim of this study was to establish whether laparoscopic RAMPS (L-RAMPS) is a safe procedure with better oncological outcomes compared to laparoscopic distal pancreatectomy (LDP) with splenectomy among patients with distal pancreatic ductal adenocarcinoma (PDAC). This is a retrospective study performed on consecutive patients who underwent L-RAMPS and LDP with splenectomy for resectable or borderline resectable PDAC of the body and tail. In this paper, we presented our technique of laparoscopic RAMPS and analyzed intraoperative and perioperative complications, oncological efficacy, and long-term survival. The study included 12 patients in the L-RAMPS group and 13 patients in the LDP with splenectomy. L-RAMPS was associated with significantly higher rates of R0 resection (91.7% vs. 69.2%, p = 0.027). There were no differences between the L-RAMPS and LDP with splenectomy groups in intraoperative blood loss (400 mL vs 400 mL, p = 0.783) and median operative time (250 min vs 220 min, p = 0.785). No differences were found in terms of perioperative complications, including the incidence of pancreatic fistula. Laparoscopic RAMPS is a feasible and safe procedure. It provides higher radicality as compared with LDP with splenectomy, without increasing the risk of complications. Further studies are necessary to evaluate long-term outcomes.

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.

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma.

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.

Short- and long-term outcomes of robotic versus open radical antegrade modular pancreatosplenectomy: a retrospective propensity score-matched cohort study.

Robotic distal pancreatectomy has increasingly been accepted as it has overcome some of the limitations of open distal pancreatectomy, whilst the outcomes following robotic radical antegrade modular pancreatosplenectomy (RAMPS) in patients with pancreatic ductal adenocarcinoma (PDAC) are still uncertain. This study aimed to evaluate the short and long-term outcomes of robotic RAMPS and open RAMPS for PDAC. The patients who underwent robotic RAMPS and open RAMPS for PDAC at our clinical centre between January 2017 and December 2021 were reviewed. After a propensity score matching (PSM) at a 1:1 ratio, the perioperative and pathological outcomes in the both groups were reviewed. Univariable and multivariable Cox regression analyses were used to identify independent prognosis factors for overall survival (OS) and recurrence-free survival (RFS) of these patients. 318 cases were recorded in robotic and open groups. The robotic group showed advantages in operative time [205.00 (166.00, 240.00) min vs 235 (184.75, 270.00) min, P = 0.002], estimated blood loss [100 (50, 100) ml vs 300 (100, 400) ml, P < 0.001], delayed gastric emptying [0 vs 5.03%, P = 0.007] and postoperative hospital stay [7.00 (5.00, 10.00) days vs 11.00 (8.00, 14.00) days, P < 0.001]. There were no significant differences in rate of severe postoperative complications between the robotic group and the open group. Multivariable analysis showed that carbohydrate antigen 19-9, estimated blood loss, N stage, tumour differentiation, chemotherapy and vascular invasion were independent risk factors for OS and RFS of these patients. Robotic RAMPS was safe and had some advantages over open RAMPS for PDAC. There were no significantly differences in oncological outcomes and long-term survival rates between the robotic and open groups. Robotic RAMPS expanded the indications for minimally invasive surgeries for PDAC to a certain extent.

Splenectomy and tumor size are risk factors for serious perioperative morbidity of laparoscopic distal pancreatectomies.

&lt;b&gt;&lt;br&gt;Introduction:&lt;/b&gt; The determinants influencing the risk for complications of laparoscopic distal pancreatectomies (LDP) are not yet fully defined, thus we aimed to determine risk factors for serious perioperative morbidity after LDP with spleen preservation, LDP and radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas (RAMPS).&lt;/br&gt; &lt;b&gt;&lt;br&gt;Material and methods:&lt;/b&gt; Retrospective cohort study of consecutive patients that underwent LDP between January 2019 and December 2022. The study group included cases of serious perioperative morbidity (III-V grades in Clavien-Dindo classification) during a 30-day period after operation. The control group consisted of patients without serious perioperative morbidity. As many as 142 patients were included in the study.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Results:&lt;/b&gt; Serious perioperative morbidity was found in 33 (23.24%) operated patients, while mortality in 3 cases (2.11%). Serious perioperative morbidity after LDP with spleen preservation was found in 9/68 (13.2%) patients (27.3% of the perioperative morbidity group). Thirteen out of 51 patients, i.e. 25.5%, after LDP with splenectomy were included in the perioperative morbidity group (39.4%). Serious perioperative morbidity after RAMPS was found in 11/23 (47.8%) patients (33.3% of the perioperative morbidity group). In multivariate logistic regression, the need for splenectomy during pancreatectomy (OR 3.66, 95%CI 1.20-11.18) and tumor above 28 millimeters in size (OR 3.01, 95%CI 1.19-9.59) were independent risk factors for serious perioperative morbidity.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Conclusions:&lt;/b&gt; The need for splenectomy during laparoscopic distal pancreatectomy and tumor size above 28 millimeters were independent risk factors for serious perioperative morbidity after laparoscopic distal pancreatectomies.&lt;/br&gt.

Minimally invasive versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma: an entropy balancing analysis

BackgroundThe safety and efficacy of minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS) remain to be established in pancreatic cancer (PDAC) MethodsEighty-five open (O)-RAMPS were compared to 93 MI-RAMPS. The entropy balance matching approach was used to compare the two cohorts, eliminating the selection bias. Three models were created. Model 1 made O-RAMPS equal to the MI-RAMPS cohort (i.e., compared the two procedures for resectable PDAC); model 2 made MI-RAMPS equal to O-RAMPS (i.e., compared the two procedures for borderline-resectable PDAC); model 3, compared robotic and laparoscopic RAMPS. ResultsO-RAMPS and MI-RAMPS showed “non-small” differences for BMI, comorbidity, back pain, tumor size, vascular resection, anterior or posterior RAMPS, multi-visceral resection, stump management, grading, and neoadjuvant therapy. Before reweighting, O-RAMPS had fewer clinically relevant postoperative pancreatic fistulae (CR-POPF) (20.0% vs. 40.9%; p = 0.003), while MI-RAMPS had a higher mean of lymph nodes (25.7 vs. 31.7; p = 0.011). In model 1, MI-RAMPS and O-RAMPS achieved similar results. In model 2, O-RAMPS was associated with lower comprehensive complication index scores (MD = 11.2; p = 0.038), and CR-POPF rates (OR = 0.2; p = 0.001). In model 3, robotic-RAMPS had a higher probability of negative resection margins. ConclusionIn patients with anatomically resectable PDAC, MI-RAMPS is feasible and as safe as O-RAMPS.

Radical antegrade modular pancreatosplenectomy (RAMPS) versus standard retrograde pancreatosplenectomy (SRPS) for resectable body and tail pancreatic adenocarcinoma: protocol of a multicenter, prospective, randomized phase III control trial (CSPAC-3)

BackgroundPancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy. Radical surgical resection offers the only potential cure. There is increasing agreement that radical antegrade modular pancreatosplenectomy (RAMPS) may benefit patients with tumors in the body and tail of the pancreas. To address this, the Chinese Study Group for Pancreatic Cancer (CSPAC)-3 trial is proposed to compare the effect of RAMPS and standard retrograde pancreatosplenectomy (SRPS) on patient survival and preoperative safetyMethodsThe randomized controlled trial will be multicenter and two-armed with blinded outcomes and intention-to-treat analysis. Three hundred patients with resectable body and tail pancreatic adenocarcinoma will be enrolled and randomly assigned to RAMPS or SRPS. Adjuvant chemotherapy based on an initial regimen will be recommended 4–6 weeks after surgery if no serious complication occurs. The hypothesis that RAMPS improves survival outcomes compared with SRPS will be tested using a superiority trial. The primary outcome will be overall survival (OS). Secondary outcomes will include recurrence-free survival (RFS), R0 resection rate, the number of harvested lymph nodes, postoperative complications, and quality of life scores.DiscussionThe use of RAMPS has increased over the past decade. It is reported that RAMPS is superior to SRPS in improving both the rate of R0 resection and lymph node yield. Despite these advantages, however, there is little high-level documentation of the superiority of RAMPS in terms of survival and this needs to be investigated. To address this issue, CSPAC has instigated the first prospective, randomized phase III control trials, aiming to explore the optimal surgical strategy for improving the prognosis and OS of patients with left-sided pancreatic cancerTrial registrationChinese Clinical Trial Registry ChiCTR2100053844; pre-results. Registered on December 1, 2021.

Practical implications of tumor proximity to landmark vessels in minimally invasive radical antegrade modular pancreatosplenectomy

Careful preoperative planning is key in minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS). This retrospective study aims to show the practical implications of computed tomography distance between the right margin of the tumor and either the left margin of the spleno-mesenteric confluence (d-SMC) or the gastroduodenal artery (d-GDA). Between January 2011 and June 2022, 48 minimally invasive RAMPS were performed for either pancreatic cancer or malignant intraductal mucinous papillary neoplasms. Two procedures were converted to open surgery (4.3%). Mean tumor size was 31.1 ± 14.7 mm. Mean d-SMC was 21.5 ± 18.5 mm. Mean d-GDA was 41.2 ± 23.2 mm. A vein resection was performed in 10 patients (20.8%) and the pancreatic neck could not be divided by an endoscopic stapler in 19 operations (43.1%). In patients requiring a vein resection, mean d-SMC was 10 mm (1.5–15.5) compared to 18 mm (10–37) in those without vein resection (p = 0.01). The cut-off of d-SMC to perform a vein resection was 17 mm (AUC 0.75). Mean d-GDA was 26 mm (19–39) mm when an endoscopic stapler could not be used to divide the pancreas, and 46 mm (30–65) when the neck of the pancreas was stapled (p = 0.01). The cut-off of d-GDA to safely pass an endoscopic stapler behind the neck of the pancreas was 43 mm (AUC 0.75). Computed tomography d-SMC and d-GDA are key measurements when planning for MI-RAMPS.

Comparison of survival outcomes between radical antegrade modular pancreato-splenectomy (RAMPS) and conventional distal pancreato-splenectomy for pancreatic body and tail cancer

Comparison of survival outcomes between radical antegrade modular pancreato-splenectomy (RAMPS) and conventional distal pancreato-splenectomy for pancreatic body and tail cancer

Objective Research Priorities in Pancreatic Surgery – Results of a Worldwide Online Expert Survey

Abstract Background Several evidence gaps still need to be addressed in pancreatic surgery research. In our times of scarcity of resources in finances and time, research activities should be prioritized according to their clinical and political relevance. Aims Prioritize research topics in pancreatic surgery based on existing evidence and expert voting. Methods A digital survey among national and international pancreatic societies was performed over the course of six months. International experts were asked to rate their “Top 5” research topics requiring an RCT based on the 76 research topics from the Evidence Map of Pancreatic Surgery. Moreover, experts rated the importance of having an RCT for existing evidence gaps i.e. from the eleven research topics currently without an existing RCT. Results A total of 149 surgeons from 30 countries contributed to this study. Currently, the most relevant research topic is vascular resection in pancreatic surgery (39 votes). Radical antegrade modular pancreatosplenectomy (RAMPS) versus standard distal pancreatectomy was ranked second (30 votes). Celiac axis resection versus standard resection and spleen management in distal pancreatectomy were ranked third and fourth (both 27 votes). Finally, the time point for surgery for chronic pancreatitis was ranked fifth with 25 votes. With regard to the eleven evidence gaps, the topic of RAMPS versus standard distal pancreatectomy and total versus partial pancreatectomy were both rated as having “very high priority” to have an RCT. Conclusions Research activities should be based on objective prioritization. The current study allows researchers and funding bodies to address the most relevant research questions based on a systematic evidence overview evaluated by pancreatic surgeons worldwide. This will allow for clinically relevant, high-quality evidence while also saving resources.

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

Laparoscopic (Lap-) radical antegrade modular pancreatosplenectomy (RAMPS) is an attractive radical procedure that aims to achieve negative posterior retroperitoneal margin in pancreatic ductal adenocarcinoma (PDAC) resections. However, only few institutions are adapting Lap-RAMPS due to the technical difficulties and the lack of supporting evidence for the clinical applications. A retrospective cohort study was performed on consecutive patients who underwent RAMPS for distal resectable PDACs. We analyzed the short- and long-term outcomes including local control and the induction of adjuvant chemotherapy compared between Lap- and Open-RAMPS. Of the 118 RAMPS patients, 43 patients underwent Lap-RAMPS and 75 patients underwent Open-RAMPS. The blood loss was lower (125 vs. 390 mL, p < 0.001), and postoperative hospital stay was shorter (17 vs. 21 days, p = 0.018) in the Lap-RAMPS group. There was no difference in the postoperative complications and no mortality in both groups. R0 resection rate was 100.0% in the Lap-RAMPS and 90.7% in the Open-RAMPS (p = 0.039). Among the patients eligible for adjuvant chemotherapy, the Lap-RAMPS group showed a favorable induction rate (100.0 vs. 89.6%, p = 0.037). Both groups showed a favorable 3-year local recurrence rate (8.7 vs. 10.0%, p = 0.976) and 3-year overall survival (69.8 vs. 71.1%, p = 0.996). The safety and efficacy of Lap-RAMPS were comparable to those of Open-RAMPS in terms of achieving local control and adjuvant chemotherapy induction. A higher early induction of adjuvant chemotherapy is an advantage of minimally invasive surgery.

Anterior versus posterior radical antegrade modular pancreatosplenectomy for pancreatic body and tail cancer: an inverse probability of treatment weighting with survival analysis.

Radical antegrade modular pancreatosplenectomy (RAMPS) is a standard procedure for patients with pancreatic body and tail cancer. There are two types of RAMPS: anterior and posterior, but their indications and surgical outcomes remain unclear. We compared the surgical outcomes, postoperative course, and prognosis between anterior and posterior RAMPS. Between 2007 and 2020, 105 consecutive patients who underwent RAMPS for pancreatic body and tail cancers were divided into an anterior RAMPS group (n = 30) and a posterior RAMPS group (n = 75). To adjust for differences in preoperative characteristics and intraoperative procedures, an inverse probability of treatment weighting (IPTW) analysis was done, using propensity scores. After IPTW adjustment, the postoperative body temperature of the posterior RAMPS group and the amount of drain discharge in the anterior RAMPS group were significantly lower, from postoperative days (PODs) 1 to 3, but there were no differences in postoperative complications, recurrence patterns, or prognosis between the two groups. Regarding the diagnostic ability of multidetector-row computed tomography (MD-CT) for direct tumor involvement of the left adrenal gland, the sensitivity and specificity were 100% and 90.0%, respectively. Pancreatic body and tail cancer without apparent preoperative direct tumor involvement of the left adrenal gland on MD-CT may be sufficient indication for anterior RAMPS.

Radical Antegrade Modular Pancreatosplenectomy (RAMPS) with 1st Jejenum Resection - An Anterior Approach

Radical Antegrade Modular Pancreatosplenectomy (RAMPS) with 1st Jejenum Resection - An Anterior Approach

Laparoscopic radical antegrade modular pancreatosplenectomy for pancreatic cancer: technical tips and pitfalls

: Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been increasingly performed for pancreatic ductal adenocarcinoma (PDAC) in the body and tail of the pancreas. However, it is technically demanding, and a lack of experience can lead to serious intraoperative and postoperative complications or local recurrence due to residual tumors at the surgical margins. There are three keys to successful L-RAMPS: understanding anatomical variations; obtaining appropriate operative fields; and familiarity with several approaches. Preoperative evaluation should be focused not only on the tumor characteristics but also on the anatomical variations of major vessels. Surgeons should choose the appropriate approach according to the tumor location and anatomical variations for each patient. Retracting the liver and stomach is crucial for obtaining appropriate operative fields around the pancreas. Optimizing the caudal view of laparoscopy is important for safe approaches to the major vessels. Adequate posterior dissection according to the extent of retropancreatic invasion and en bloc regional lymphadenectomy should be performed for oncological benefits. Additionally, proper pancreatic transection with precompression of the pancreas, adequate selection of the cartridge of stapler, and slow firing technique is crucial for the prevention of postoperative pancreatic fistulas. A review of the literature was performed and our standard L-RAMPS technique was described.

Evaluation of the Educational Quality of the Top 30 Most Viewed Laparoscopic Distal Pancreatectomy Videos on YouTube.

Background: Online surgical videos serve as useful adjuncts for surgical training. YouTube is a social media platform increasingly used for education. However, the educational qualities of these videos have not been proven. This study aims to review the topmost 30 viewed videos on laparoscopic distal pancreatectomy (LDP) on YouTube. Methods: A YouTube search was performed on August 1, 2020, using the term "laparoscopic distal pancreatectomy." Inclusion criteria were LDP with or without splenectomy. Exclusion criteria were open or robotic distal pancreatectomy and radical antegrade modular pancreatosplenectomy. To grade the videos, we used a modified version of the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) 24 of the original 37 consensus statements were used in our study. Results: Twenty-nine of the top 30 most viewed videos were included (1 video was a duplicate). The overall mean view count and number of likes were 7195 (range 2322-39,927) and 17 (range 0-108), respectively. Thirteen videos (44.8%) were on LDP with splenic preservation. The mean conformity to the modified LAP-VEGaS was 9.3 (range 4-16) with a mean of 38.8% (range 16.7%-66.7%) of the criteria met. There was weak correlation between the number of views and the number of criteria met (ρ = 0.189, P < .05). Twelve videos (41.4%) described about staple line management, nine videos (31%) about tips and tricks to reduce postoperative pancreatic fistula, including drainage tube management, and three videos (10.3%) identified the common hepatic artery. Videos with no commentary had the lowest mean percentage of criteria met (24.6%). Conclusion: The topmost viewed LDP surgical videos have gaps in meeting the educational needs of a trainee. Video uploaders should be cognizant of the learning needs of surgical trainees.

Minimally invasive radical antegrade modular pancreatosplenectomy: routine vs. modified.

Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced in 2003 by Strasberg to improve survival outcomes in left-sided pancreatic ductal adenocarcinoma. Many investigators have shown the feasibility and safety of minimally invasive RAMPS (MI-RAMPS). However, the survival benefit of RAMPS is inconclusive, and possible risks following the procedure, such as exocrine and endocrine insufficiencies, cannot be ignored. Therefore, several modifications of RAMPS were designed. Modified RAMPS is not a specific technique but rather a reduced form of RAMPS that is undertaken without compromising oncologic principles. In this literature review, the surgical technique and strategies of MI-RAMPS were examined.

A case of serous cystic neoplasm with tumor growth acceleration leading to extrapancreatic invasion.

Serous cystic neoplasm (SCN) is a potentially malignant and invasive disease. However, there are no established guidelines regarding the surgical management of SCN. Here, we report a case of SCN with jejunal invasion that ultimately required a distal pancreatectomy with partial resection of the jejunum. The patient was a 65-year-old female who was referred to our department after a diagnosis of SCN in the pancreatic tail. CT and MRI showed a 75-mm multifocal cystic mass with calcifications; the splenic vein and left adrenal vein were entrapped within the tumor. Furthermore, the tumor was in contact with the beginning of the jejunum. Finally, she underwent a posterior radical antegrade modular pancreatosplenectomy with a partial wedge-shaped resection of the jejunum. Histological findings indicated serous cystadenoma. In addition, the tumor cells were found to have infiltrated the jejunal muscularis propria in some areas, suggesting that the tumor had malignant potential. Currently, 14months have passed since surgery and there is no evidence of metastasis or recurrence. Surveillance and the decision to perform surgical resection should be made based on tumor size and growth rate to avoid malignant transformation as well as to provide SCN patients with organ-sparing, less invasive surgery.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope. The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.