Abstract
Introduction
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.
Methods
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.
Results
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).
Conclusions
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.
Similar content being viewed by others
References
Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM (2014) Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res 74:2913–2921. https://doi.org/10.1158/0008-5472.can-14-0155
Siegel RL, Miller KD, Jemal A (2017) Cancer statistics, 2017. CA Cancer J Clin 1:7–30. https://doi.org/10.3322/caac.21590
van Erning FN, Mackay TM, van der Geest LGM, Groot Koerkamp B, van Laarhoven HWM, Bonsing BA, Wilmink JW, van Santvoort HC, de Vos-Geelen J, van Eijck CHJ, Busch OR, Lemmens VE, Besselink MG (2018) Association of the location of pancreatic ductal adenocarcinoma (head, body, tail) with tumor stage, treatment, and survival: a population-based analysis. Acta Oncol 57:1655–1662. https://doi.org/10.1080/0284186X.2018.1518593
Strasberg SM, Fields R (2012) Left-sided pancreatic cancer: distal pancreatectomy and its variants: radical antegrade modular pancreatosplenectomy and distal pancreatectomy with celiac axis resection. Cancer J 18:562–570. https://doi.org/10.1097/PPO.0b013e31827596c5
Strasberg SM, Drebin JA, Linehan D (2003) Radical antegrade modular pancreatosplenectomy. Surgery. 133:521–527. https://doi.org/10.1067/msy.2003.146
Strasberg SM, Linehan DC, Hawkins WG (2007) Radical antegrade modular pancreatosplenectomy procedure for adenocarcinoma of the body and tail of the pancreas: ability to obtain negative tangential margins. J Am Coll Surg 204:244–249. https://doi.org/10.1016/j.jamcollsurg.2006.11.002
Watanabe G, Ito H, Sato T, Ono Y, Mise Y, Inoue Y, Takahashi Y, Saiura A (2019) Left kidney mobilization technique during radical antegrade modular pancreatosplenectomy (RAMPS). Langenbecks Arch Surg 404:247–252. https://doi.org/10.1007/s00423-019-01767-0
Kim EY, Hong TH (2017) Initial experience with laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer in a single institution: technical aspects and oncological outcomes. BMC Surg 17:2. https://doi.org/10.1186/s12893-016-0200-z
Rosso E, Manzoni A, Zimmitti G (2020) 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 27:2902–2903. https://doi.org/10.1245/s10434-020-08271-6
Kato T, Inoue Y, Oba A, Ono Y, Sato T, Ito H, Takahashi Y (2022) Laparoscopic radical antegrade modular pancreatosplenectomy with anterocranial splenic artery-first approach for left-sided resectable pancreatic cancer (with videos). Ann Surg Oncol 29:3505–3514. https://doi.org/10.1245/s10434-022-11382-x
Kawabata Y, Hayashi H, Kaji S, Fujii Y, Nishi T, Tajima Y (2020) Laparoscopic versus open radical antegrade modular pancreatosplenectomy with artery–first approach in pancreatic cancer. Langenbecks Arch Surg 405:647–656. https://doi.org/10.1007/s00423-020-01887-y
Zhang H, Li Y, Liao Q, Xing C, Ding C, Zhang T, Guo J, Han X, Xu Q, Wu W, Zhao Y, Dai M (2021) Comparison of minimal invasive versus open radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic ductal adenocarcinoma: a single center retrospective study. Surg Endosc 35:3763–3773. https://doi.org/10.1007/s00464-020-07938-1
Hirashita T, Iwashita Y, Fujinaga A, Nakanuma H, Tada K, Masuda T, Endo Y, Ohta M, Inomata M (2022) Surgical and oncological outcomes of laparoscopic versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma. Surg Today 52:224–230. https://doi.org/10.1007/s00595-021-02326-1
Oettle H, Neuhaus P, Hochhaus A, Hartmann JT, Gellert K, Ridwelski K, Niedergethmann M, Zülke C, Fahlke J, Arning MB, Sinn M, Hinke A, Riess H (2013) Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial. Jama. 310:1473–1481. https://doi.org/10.1001/jama.2013.279201
Uesaka K, Boku N, Fukutomi A, Okamura Y, Konishi M, Matsumoto I, Kaneoka Y, Shimizu Y, Nakamori S, Sakamoto H, Morinaga S, Kainuma O, Imai K et al (2016) Adjuvant chemotherapy of S-1 versus gemcitabine for resected pancreatic cancer: a phase 3, open-label, randomised, non-inferiority trial (JASPAC 01). Lancet 388:248–257. https://doi.org/10.1016/s0140-6736(16)30583-9
Neoptolemos JP, Palmer DH, Ghaneh P, Psarelli EE, Valle JW, Halloran CM, Faluyi O, O'Reilly DA, Cunningham D, Wadsley J, Darby S, Meyer T, Gillmore R et al (2017) Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial. Lancet 389:1011–1024. https://doi.org/10.1016/s0140-6736(16)32409-6
Altman AM, Wirth K, Marmor S, Lou E, Chang K, Hui JYC, Tuttle TM, Jensen EH, Denbo JW (2019) Completion of adjuvant chemotherapy after upfront surgical resection for pancreatic cancer is uncommon yet associated with improved survival. Ann Surg Oncol 26:4108–4116. https://doi.org/10.1245/s10434-019-07602-6
Tempero MA, Malafa MP, Chiorean EG, Czito B, Scaife C, Narang AK, Fountzilas C, Wolpin BM, Al-Hawary M, Asbun H, Behrman SW, Benson AB, Binder E et al (2019) Pancreatic adenocarcinoma, version 1.2019. J Natl Compr Canc Netw 17:202–210. https://doi.org/10.6004/jnccn.2019.0014
Oba A, Ishizawa T, Mise Y, Inoue Y, Ito H, Ono Y, Sato T, Takahashi Y, Saiura A (2019) Possible underestimation of blood loss during laparoscopic hepatectomy. BJS Open 3:336–343. https://doi.org/10.1002/bjs5.50145
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae
Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 142:761–768. https://doi.org/10.1016/j.surg.2007.05.005
Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Büchler MW (2007) Postpancreatectomy hemorrhage (PPH);an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 142:20–25. https://doi.org/10.1016/j.surg.2007.02.001
Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M et al (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 161:584–591. https://doi.org/10.1016/j.surg.2016.11.014
Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP. (1982). Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 5: 649-655
Brierley JD, Gospodarowicz MK, Wittekind C (2016) TNM classification of malignant tumours, 8th edn
Park HJ, You DD, Choi DW, Heo JS, Choi SH (2014) Role of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas. World J Surg 38:186–193. https://doi.org/10.1007/s00268-013-2254-8
Abe T, Ohuchida K, Miyasaka Y, Ohtsuka T, Oda Y, Nakamura M (2016) Comparison of surgical outcomes between radical antegrade modular pancreatosplenectomy (RAMPS) and standard retrograde pancreatosplenectomy (SPRS) for left-sided pancreatic cancer. World J Surg 40:2267–2275. https://doi.org/10.1007/s00268-016-3526-x
Groot VP, Rezaee N, Wu W, Cameron JL, Fishman EK, Hruban RH, Weiss MJ, Zheng L, Wolfgang CL, He J (2018) Patterns, timing, and predictors of recurrence following pancreatectomy for pancreatic ductal adenocarcinoma. Ann Surg 267:936–945. https://doi.org/10.1097/sla.0000000000002234
Oba A, Del Chiaro M, Satoi S, Kim S-W, Takahashi H, Yu J, Hioki M, Tanaka M, Kato Y, Ariake K, Wu YHA, Inoue Y, Takahashi Y et al (2022) New criteria of resectability for pancreatic cancer: a position paper by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS). J Hepatobiliary Pancreat Sci 29:725–731. https://doi.org/10.1002/jhbp.1049
van Hilst J, de Rooij T, Bosscha K, Brinkman DJ, van Dieren S, Dijkgraaf MG, Gerhards MF, de Hingh IH, Karsten TM, Lips DJ, Luyer MD, Busch OR, Festen S et al (2019) Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): a multicentre, patient-blinded, randomised controlled phase 2/3 trial. Lancet Gastroenterol Hepatol 4:199–207. https://doi.org/10.1016/s2468-1253(19)30004-4
Sho M, Akahori T, Tanaka T, Kinoshita S, Nagai M, Tamamoto T, Ohbayashi C, Hasegawa M, Kichikawa K, Nakajima Y (2015) Importance of resectability status in neoadjuvant treatment for pancreatic cancer. J Hepatobiliary Pancreat Sci 22:563–570. https://doi.org/10.1002/jhbp.258
Fujii T, Satoi S, Yamada S, Murotani K, Yanagimoto H, Takami H, Yamamoto T, Kanda M, Yamaki S, Hirooka S, Kon M, Kodera Y (2017) Clinical benefits of neoadjuvant chemoradiotherapy for adenocarcinoma of the pancreatic head: an observational study using inverse probability of treatment weighting. J Gastroenterol 52:81–93. https://doi.org/10.1007/s00535-016-1217-x
van Dam JL, Janssen QP, Besselink MG, Homs MYV, van Santvoort HC, van Tienhoven G, de Wilde RF, Wilmink JW, van Eijck CHJ, Groot KB (2022) Neoadjuvant therapy or upfront surgery for resectable and borderline resectable pancreatic cancer: a meta-analysis of randomised controlled trials. Eur J Cancer 160:140–149. https://doi.org/10.1016/j.ejca.2021.10.023
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 et al (2022) Surgical approaches for minimally invasive distal pancreatectomy: a systematic review. J Hepatobiliary Pancreat Sci 29:151–160. https://doi.org/10.1002/jhbp.902
Ome Y, Hashida K, Yokota M, Nagahisa Y, Michio O, Kawamoto K (2017) Laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer using the ligament of Treitz approach. Surg Endosc 31:4836–4837. https://doi.org/10.1007/s00464-017-5561-6
Nagai K, Kiguchi G, Yogo A, Anazawa T, Yagi S, Taura K, Takaori K, Masui T (2020) Left-posterior approach for artery-first en bloc resection in laparoscopic distal pancreatectomy for left-sided pancreatic cancer. Langenbecks Arch Surg 405:1251–1258. https://doi.org/10.1007/s00423-020-02021-8
Conroy T, Castan F, Lopez A, Turpin A, Ben Abdelghani M, Wei AC, Mitry E, Biagi JJ, Evesque L, Artru P, Lecomte T, Assenat E, Bauguion L et al (2022) Five-year outcomes of FOLFIRINOX vs gemcitabine as adjuvant therapy for pancreatic cancer: a randomized clinical trial. JAMA Oncol. https://doi.org/10.1001/jamaoncol.2022.3829
Author information
Authors and Affiliations
Contributions
Study conception and design: Shoki Sato and Atsushi Oba. Acquisition of data: Shoki Sato and Atsushi Oba. Analysis and interpretation of data: Shoki Sato. Drafting of manuscript: Shoki Sato, Atsushi Oba, and Y.H. Andrew Wu. Critical revision of manuscript: Atsushi Oba, Tomotaka Kato, Kosuke Kobayashi, Y.H. Andrew Wu, Yoshihiro Ono, Takafumi Sato, Hiromichi Ito, Yosuke Inoue, and Yu Takahashi.
Corresponding author
Ethics declarations
Ethical approval
All authors comply with the journal’s ethical policies.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
ESM 1
(TIF 110 kb)
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Sato, S., Oba, A., Kato, T. et al. Feasibility of laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) as a standard treatment for distal resectable pancreatic cancer. Langenbecks Arch Surg 408, 217 (2023). https://doi.org/10.1007/s00423-023-02942-0
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s00423-023-02942-0