Radical Antegrade Research Articles

A LASSO Cox Regression Predictive Model for Patients Undergoing Surgery for Pancreatic Body and Tail Adenocarcinoma Patients: Comparative Long-Term Survival Analysis of Radical Antegrade Modular Pancreatosplenectomy (RAMPS) and Standard Retrograde Pancreatosplenectomy (SPRS).

This study was designed to assess the advantages of radical antegrade modular pancreatosplenectomy (RAMPS) over standard retrograde pancreatosplenectomy (SPRS) in terms of disease-free survival (DFS) by comparing clinical outcomes. Clinical data from 154 patients who underwent distal pancreatectomy at Tianjin Medical University Cancer Institute and Hospital between January 2015 and August 2018 were collected. We compared the preoperative conditions, postoperative complications, and survival outcomes of patients who underwent two different surgical procedures. By creating a LASSO-Cox model, we determined the parameters affecting DFS and the risk ratios of the two surgical procedures on DFS. The R0 resection rate (85.23% vs. 68.18%, P = 0.003), negative posterior margin rate (96.59% vs. 75.76%, P < 0.001), and tumor bed recurrence rate (15.29% vs. 40.00%, P = 0.001) significantly differed between the RAMPS and SPRS groups. The 1-, 3-, and 5-year survival and DFS rates of the RAMPS group were significantly better than those of the SPRS group (P < 0.05). Disease-free survival analysis based on Kaplan-Meier curves revealed that RAMPS was superior to SPRS (P < 0.001). We recommend RAMPS as the preferred procedure for treating ductal adenocarcinoma of the pancreatic body and tail due to its enhanced lymph node repair capacity and visualization of posterior pancreatic sections, which can increase DFS in patients.

Left gastric vein to adrenal vein anastomosis: intraoperative solution for gastric venous congestion following extended distal pancreatectomy.

Extended distal pancreatectomy often requires resection of vascular structures and adjacent organs, potentially leading to gastric venous congestion. This case report describes a 49-year-old female who underwent radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma. During the procedure, segmental gastric venous congestion was observed and resolved by anastomosing the left gastric vein to the left adrenal vein. The in-hospital postoperative recovery was initially uneventful; however, the patient was readmitted because of intra-abdominal fluid collection that was managed with antibiotics. Pathological examination confirmed moderately differentiated ductal adenocarcinoma with lymphovascular invasion. The patient received adjuvant mFOLFIRINOX therapy and remains disease-free 12months after surgery with adequate patency of the anastomosis. This case highlights the importance of recognizing and addressing gastric venous congestion during radical antegrade modular pancreatosplenectomy to prevent complications, such as delayed gastric emptying or gastric necrosis, and proposes left gastric vein to left adrenal vein anastomosis as an effective intraoperative solution.

ASO Author Reflections: Added Value of the Robotic Approach in Posterior Radical Antegrade Modular Pancreatosplenectomy.

ASO Author Reflections: Added Value of the Robotic Approach in Posterior Radical Antegrade Modular Pancreatosplenectomy.

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.

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

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

Minimally Invasive Radical Antegrade Pancreatosplenectomy with Vascular Resection: Preoperative Selection, Vascular Reconstruction Technique and Post-operative Results

Minimally Invasive Radical Antegrade Pancreatosplenectomy with Vascular Resection: Preoperative Selection, Vascular Reconstruction Technique and Post-operative Results

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.

Role and Efficacy of Robotic-assisted Radical Antegrade Modular Pancreatosplenectomy (RAMPS) in Left-sided Pancreatic Cancer.

Distal pancreatectomy with splenectomy is the gold-standard surgery for the treatment of left-sided pancreatic cancer. Margin negative resection accompanied by effective lymphadenectomy are the deciding factors affecting the outcome of tail-body pancreatic adenocarcinoma. Radical antegrade modular pancreatosplenectomy (RAMPS) is considered as a reasonable approach for margin-negative and systemic lymph node clearance. Herein, we aim to present all existing data regarding this novel approach including surgical technique and comparison with standardized procedures. RAMPS has shown oncological superiority comparing to distal pancreatectomy with splenectomy due to radical lymphadenectomy and improved dissection of the posterior pancreatic aspects. Robotic-assisted RAMPS has recently been described as a valuable alternative to open RAMPS. With this novel technique, anterior, posterior or modified approaches can be achieved; favorable clinical and oncological outcomes have been reported in the current literature, with reduced conversion rates compared to other minimally invasive approaches, as well as vastly improved maneuverability, accuracy and vision. Robotic-assisted RAMPS is not only technically feasible but also oncologically safe in cases of well-selected, left-sided pancreatic cancer.

The efficacy of radical antegrade modular pancreatosplenectomy: A systematic review and meta-analysis.

Previous systematic reviews have shown that radical antegrade modular pancreatosplenectomy (RAMPS) had favorable outcomes including prognosis. However, recent large studies have shown opposite results, thus necessitating clarification of RAMPS efficacy. We aimed to update existing evidence on the clinical outcomes of RAMPS for left-sided pancreatic cancer by comparing them to those of the conventional approach. Electronic databases and registries were searched until August 2021 to perform random-effect meta-analysis. Methodological quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The protocol was registered at protocols.io (https://doi.org/10.17504/protocols.io.bxhfpj3n). Thirteen cohort studies (1641 patients) and four ongoing randomized controlled trials (RCTs) were identified. RAMPS increased disease-free survival (hazard ratio [HR] 0.62, 95% confidence interval [CI]=0.42-0.91), but it had little effect on overall survival (HR 0.92, 95% CI=0.79-1.09) and recurrence-free survival (HR 0.72, 95% CI=0.37-1.38) with low certainty of evidence. The meta-analysis of recent studies suggests that RAMPS may have little effect on clinical outcomes. These findings highlight the necessity of further studies, including RCTs to determine the efficacy and subsequent indication of RAMPS in clinical cases.

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

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. 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. 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. 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.

Laparoscopic radical antegrade modular pancreatosplenectomy: Ukrainian single center experience

Background: Laparoscopic standard distal pancreatectomy nowadays is a standard operation technic in management of malignant and benign lesions of pancreatic body and tail. But promising data about advantages of radical antegrade modular pancreatosplenectomy (RAMPS) such as higher R0 resection rate and number of lymph nodes gives us new field to implement this technic in our practice in laparoscopic way. We think that performing by experienced laparoscopic HPB surgeon laparoscopic RAMPS can be as safe as laparoscopic standard distal pancreatectomy is.

Effect of laparoscopic surgery for pancreatic cancer after neoadjuvant chemotherapy

Objective: To evaluate the safety and feasibility of laparoscopic surgery after neoadjuvant chemotherapy for pancreatic cancer. Methods: Clinical data of 8 patients underwent laparoscopic surgery after neoadjuvant chemotherapy for pancreatic cancer at Fudan University Shanghai Cancer Center from September 2019 to June 2020 were reviewed retrospectively. There were 5 males and 3 females,aged from 47 to 72 years old. All patients underwent abdominal enhanced CT and PET-CT before operation to accurately evaluate the tumor stage and exclude distant metastasis. Results: Neoadjuvant chemotherapy with AG regimen(gemcitabine 1 000 mg/m2 and albumin bound paclitaxel 125 mg/m2) was received for 2 to 6 cycles before surgery. All 8 patients successfully completed the operation,including 5 cases of pancreaticoduodenectomy,2 cases of radical antegrade modular pancreatosplenectomy(RAMPS),and 1 case of total pancreatectomy. No conversion to laparotomy or laparoscopic assisted surgery. The operation time was 240 to 450 minutes,the blood loss was 100 to 500 ml,the postoperative length of stay was 10 to 16 days. During the follow-up period up to December 31, 2020, there was 1 case suffered grade B pancreatic leakage and abdominal infection. The numbers of resected lymph nodes were 9 to 31. All patients received R0 resection. The follow-up times were 4.5 to 9.5 months. One patient underwent RAMPS was diagnosed as liver metastasis after 2 months of the operation,and the other 7 patients still survived without tumor recurrence. Conclusion: Minimally invasive surgery of pancreatic cancer after neoadjuvant chemotherapy is safe and feasible in experienced pancreatic minimally invasive centers.

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.

Radical Antegrade Modular Pancreatosplenectomy (RAMPS): Does Adrenalectomy Alter Outcomes?

Background: Radical antegrade modular pancreatosplenectomy (RAMPS) was first described in 2003 by Strasberg et al. The technique has oncologic superiority compared to a standard distal pancreatectomy (DP). For tumors invading into the adrenal gland, a posterior RAMPS takes the left adrenal gland en bloc with the pancreas specimen. The aim of this analysis is to determine whether addition of adrenalectomy (posterior RAMPS) alters the outcomes of DP. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Procedure-Targeted Pancreatectomy database was accessed from 2014 to 2019. Patients with pancreatic ductal adenocarcinoma (PDAC) undergoing DP with adrenalectomy were compared to patients having a standard DP. 30-day outcomes were analyzed between groups using multivariable regression. Results: 3,467 patients with PDAC underwent DP; 159 (4.6%) also underwent adrenalectomy. Posterior RAMPS patients were younger (65.6 vs. 67.5 years, p=0.03), less often white (65.4% vs. 76.8%, p<0.01), had lower BMI (26.6 vs. 27.7, p=0.03), and higher T stage (T3-4 76.9% vs. 57.5%, p<0.01). On multivariable analysis controlling for age, race, and BMI, posterior RAMPS patients had worse perioperative outcomes including more transfusions (OR 2.78, p<0.01), serious morbidity (OR 1.45, p=0.04), prolonged hospital stay (OR 1.36, p<0.05), and less optimal pancreatic surgery (OR 0.61, p<0.01) (Table). Conclusion: Radical antegrade modular pancreatosplenectomy with adrenalectomy (posterior RAMPS) is associated with worse perioperative outcomes compared to a standard distal pancreatomy (DP). Improved long-term oncologic outcomes must be weighed against higher perioperative morbidity when selecting patients for this more extensive surgical resection.

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

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

Laparoscopic radical antegrade modular pancreatosplenectomy: preliminary experience with 10 cases

BackgroundThe 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.MethodsFrom 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.ResultsLRAMPS 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.ConclusionsLRAMPS 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.

Minimally Invasive Distal Pancreatectomy for the Management of Left-Sided Pancreatic Cancer

Curative surgical resection is considered the most effective treatment option to achieve long–term survival in patients with pancreatic cancer. In performing a Distal Pancreatectomy (DP) for left–sided pancreatic cancer, there are two main approaches to dissection: proceeding from left to right and from right to left. The conventional DP procedure was the Standard Retrograde Pancreatosplenectomy (SRPS), with a left–to–right dissection, and then the radical antegrade Modular Pancreatosplenectomy (RAMPS), with a right–to–left dissection, was developed. A greater number of harvested lymph nodes and an increase in R0 resection have been achieved in RAMPS as compared to SRPS; however, oncological outcomes, including patient survival, are comparable in these procedures. Recently, Minimally Invasive Distal Pancreatectomy (MIDP) using laparoscopy for pancreatic cancer has been advanced. The MIDP also has not been enough to show oncological benefits as compared with an open DP. Additional randomized controlled trials should be conducted to clarify the impacts and benefits of each surgical approach in performing DP for cancer of the body or tail of the pancreas

Laparoscopic distal pancreatectomy for pancreatic arteriovenous malformation complicated with portal hypertension.

Pancreatic arteriovenous malformation (PAVM) is defined as a vascular anomaly with an abnormal anastomosis of the arterial and portal networks within the pancreas. Treatment modalities of PAVM include transarterial embolisation (TAE), irradiation and operation. Most patients treated with TAE alone will experience recurrence, so surgery is the best radical treatment. A female patient was admitted to our institution for the treatment of haematemesis. Examination revealed varices in the oesophagus and stomach, collateral circulation development caused by portal hypertension and PAVM of the pancreas. Surgical treatment was intended to reduce left portal hypertension. In this case, collateral circulation were considered dangerous points for unexpected bleeding. TAE was performed on the splenic artery before surgery to reduce blood flow in the areas with collateral circulation. En bloc resection of retroperitoneal tissue using the surgical procedure of radical antegrade modular pancreatosplenectomy was effective to minimise blood loss.

The Role of Radical Antegrade Modular Pancreatosplenectomy Compared to Conventional Distal Pancreatosplenectomy in Patients with Left-sided Pancreatic Cancer: A Retrospective Multicenter Propensity- Score Matching Analysis

Introduction: The purpose of this study aimed to evaluate the role of radical antegrade modular pancreatosplenectomy (RAMPS) in terms of postoperative outcomes compared to conventional distal pancreatosplenectomy (DPS) in patients with left- sided pancreatic ductal adenocarcinoma (PDAC). Method: From 2005 to 2017, consecutive 316 left-sided PDAC patients who underwent RAMPS (n=236) or DPS (n=80) for curative intent in four tertiary referral hospitals in Korea were included in this study. Among these, after 1:2 Propensity score matching with age, sex, differentiation, T and N stage, 71 patients with DPS and 139 patients with RAMPS were analyzed for clinicopathological outcomes. Result: There was no difference in complication rate between the two groups. RAMPS was superior than DPS in terms of R0 rate (99.3% vs 88.6%, p< 0.01) and harvested LN numbers (16.3±10.57 vs. 10.3±7.06, p< 0.01). RAMPS showed prolonged DFS (median survival 11 vs 9months), but statistically not significant (p=0.148). In a subgroup analysis with node-negative patients (n=107), RAMPS showed superior disease-free survival than DPS with statistically marginal significance (MS 15 vs 9m, p= 0.05). After multivariate analysis, preoperative CA19-9≥37, tail cancer, poorly or undifferentiated carcinoma, R1 resection, and absence of adjuvant treatment were identified as independent risk factors for survival. Also, preoperative CA19-9≥37, advanced T stage, LN metastasis, poorly or undifferentiated carcinoma were independent risk. Conclusion: Although we could not find an eminent survival benefit of RAMPS, it could be considered a standard surgical method for left-sided PDAC because of the similar complication rate and several oncologic benefits.

Comparison of conventional distal pancreatectomy and splenectomy with radical antegrade modular pancreatosplenectomy, multicenter, retrospective study

Comparison of conventional distal pancreatectomy and splenectomy with radical antegrade modular pancreatosplenectomy, multicenter, retrospective study