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

Scope transition and early arterial inflow control provide safe and comfortable dissection in robotic distal pancreatectomy

PURPOSE

We describe details and outcomes of a novel technique for optimizing the surgical field during robotic distal pancreatectomy (RDP) for distal pancreatic lesions, which has become common with potential advantages over laparoscopic surgery.

METHODS

For suprapancreatic lymph node dissection and splenic artery ligation, we used the basic center position with a scope through the midline port. During manipulation of the perisplenic area, the left position was used by moving the scope to the left medial side. The left lateral position is optionally used by moving the scope to the left lateral port when scope access to the perisplenic area is difficult. In addition, early splenic artery clipping and short gastric artery dissection for inflow block were performed to minimize bleeding around the spleen. We evaluated retrospectively the surgical outcomes of our method using a scoring system that allocated one point for blood inflow control and one point for optimizing the surgical view in the left position.

RESULTS

We analyzed 34 patients who underwent RDP or R-radical antegrade modular pancreatosplenectomy (RAMPS). The left position was applied in 14 patients, and the left lateral position was applied in 6. Based on the scoring system, only the 0-point group (n = 8) had four bleeding cases (50%) with splenic injury or blood pooling; the other 1-point or 2-point groups (n = 13, respectively) had no bleeding cases (p = 0.0046).

CONCLUSION

Optimization of the surgical field using scope transition and inflow control ensured safe dissection during RDP.

Technical Strategy for Pancreatic Body Cancers: A Raison d'etre of Distal Pancreatectomy with Portal Resection

BACKGROUND

Advancements in multiagent chemotherapy have expanded the surgical indications for pancreatic cancer. Although pancreaticoduodenectomy (PD) with portal vein resection (PVR) has become widely adopted, distal pancreatectomy (DP) with PVR remains rarely performed because of its technical complexity. This study was designed to assess the feasibility of DP-PVR compared with PD-PVR for pancreatic body cancers, with a focus on PV complications and providing optimal reconstruction techniques when DP-PVR is necessary.

METHODS

A retrospective review was conducted on consecutive pancreatic body cancer patients who underwent pancreatectomy with PVR between 2005 and 2020. An algorithm based on the anatomical relationship between the arteries and PV was used for optimal surgical selection.

RESULTS

Among 119 patients, 32 underwent DP-PVR and 87 underwent PD-PVR. Various reconstruction techniques were employed in DP-PVR cases, including patch reconstruction, graft interposition, and wedge resection. The majority of PD-PVR cases involved end-to-end anastomosis. The length of PVR was shorter in DP-PVR (25 vs. 40 mm; p < 0.001). Although Clavien-Dindo ≥3a was higher in DP-PVR (p = 0.002), inpatient mortality and R0 status were similar. Complete PV occlusion occurred more frequently in DP-PVR than in PD-PVR (21.9% vs. 1.1%; p < 0.001). A cutoff value of 30 mm for PVR length was determined to be predictive of nonrecurrence-related PV occlusion after DP-PVR. The two groups did not differ significantly in recurrence or overall survival.

CONCLUSIONS

DP-PVR had higher occlusion and postoperative complication rates than PD-PVR. These findings support the proposed algorithm and emphasize the importance of meticulous surgical manipulation when DP-PVR is deemed necessary.

Intraoperative paraaortic lymph node sampling during resection for pancreatic cancer: evolving role in the modern chemotherapy era

BACKGROUND

The role of paraaortic lymph node (PALN) sampling for pancreatic cancer (PC) remains controversial. This study aimed to assess the yield of PALN sampling and its impact on long-term outcomes.

METHODS

Patients treated from 2005 to 2018 were included. Since 2015, patients with borderline resectable or unresectable (BR/UR) tumours received standardized neoadjuvant therapy (NAT), whereas patients with resectable tumours underwent upfront resection.

RESULTS

Among 771 patients with PALN excision, metastasis was confirmed in 76 patients (10%) and 59 proceeded to planned resection. PALN metastasis was associated with early recurrence and shorter survival after upfront resection (1-year recurrence-free rate: 23% vs 57% for resectable tumours, P < 0.001, 9% vs 52% for BR/UR tumours, P = 0.006; median overall survival (OS): 19 vs 31 months for resectable tumours, P < 0.001, 17 vs 23 months for BR/UR tumours, P = 0.057). In contrast, they were both similar between patients with/without PALN metastasis following NAT for BR tumours (1-year recurrence-free rate, 50% vs 58%, P = 0.88; median OS, 28 vs 35 months, P = 0.45, respectively).

CONCLUSIONS

Occult metastasis to PALNs is not uncommon in patients with potentially resectable PC. Its prognostic impact depends on the treatment strategy, and the intraoperative decision for resection should be individualized.

Clinical Efficacy of Neoadjuvant Chemotherapy with Gemcitabine plus S-1 for Resectable Pancreatic Ductal Adenocarcinoma Compared with Upfront Surgery

BACKGROUND

The efficacy of neoadjuvant chemotherapy with gemcitabine plus S-1 (NAC-GS) in the prognosis of patients with resectable pancreatic ductal adenocarcinoma (PDAC) has been reported. NAC-GS is now assumed to be a standard regimen for resectable PDAC in Japan. However, the reason for this improvement in prognosis remains unclear.

METHODS

In 2019, we introduced NAC-GS for resectable PDAC. From 2015 to 2021, 340 patients were diagnosed with resectable PDAC (anatomical and biological [carbohydrate antigen (CA) 19-9 < 500 U/mL]) and were divided according to the treatment period (upfront surgery [UPS] group, 2015-2019, n = 241; NAC-GS group, 2019-2021, n = 80). We used "intention-to-treat" analysis to compare the clinical outcomes of NAC-GS to those of UPS.

RESULTS

Of the 80 patients with NAC-GS, 75 (93.8%) completed two cycles of NAC-GS, and the resection rate of the NAC-GS group was comparable to that of the UPS group (92.5 vs. 91.3%, P = 0.73). The R0 resection rate was significantly higher in the NAC-GS group than in the UPS group (91.3 vs. 82.6%, P = 0.04), even though the surgical burden was smaller. Progression-free survival tended to be better (hazard ratio [HR] = 0.70, P = 0.06), and overall survival was significantly better in the NAC-GS group than in the UPS group (HR 0.55, P = 0.02).

CONCLUSIONS

NAC-GS provided improvements in microscopic invasion leading to a high R0 rate and smooth administration and completion of adjuvant therapy, which might lead to an improved prognosis in patients with resectable PDAC.

Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy

Because distal pancreatectomy (DP) has no reconstructive steps and less frequent vascular involvement, it is thought to be the easier counterpart of pancreaticoduodenectomy. This procedure has a high surgical risk and the overall incidences of perioperative morbidity (mainly pancreatic fistula), and mortality are still high, in addition to the challenges that accompany delayed access to adjuvant therapies (if any) and prolonged impairment of daily activities. Moreover, surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes. From this perspective, new surgical approaches, and aggressive techniques, such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection, could lead to improved survival in those affected by more locally advanced tumors. Conversely, minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress. The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications, length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy. Because a dedicated multidisciplinary team is crucial to pancreatic surgery, hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign, borderline, and malignant diseases of the pancreas. The purpose of this review is to examine the state of the art in distal pancreatectomies, with a special focus on minimally invasive approaches and oncological-directed techniques. The widespread reproducibility, cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.

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

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.

Radical antegrade modular pancreatosplenectomy enhances local control of the disease in patients with left-sided pancreatic cancer

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS) was developed to enhance curability in patients with left-sided pancreatic cancer. However, no evidence is available regarding the prognostic superiority of RAMPS compared with conventional distal pancreatectomy (cDP). Here, we aimed to assess the oncological benefit of RAMPS by comparing surgical outcomes between patients who underwent cDP and RAMPS with propensity score (PS) adjustment.

METHODS

Clinical data of 174 patients undergoing cDP and RAMPS between 2009 and 2016 at two high-volume centers were analyzed with PS matching. Recurrence-free survival (RFS), overall survival (OS), and local recurrence rates were compared between patients who underwent cDP and RAMPS.

RESULTS

The cDP and RAMPS groups were successfully matched with baseline characteristics. No differences were found in the 3-year RFS and OS rates between the two groups (3-year RFS: cDP 46% vs RAMPS 40%, p = 0.451, 3-year OS: cDP 57% vs RAMPS 53%, p = 0.692). However, the 3-year local recurrence rate was lower in the RAMPS (10%) than that in the cDP group (34%) (hazard ratio 0.275, 95% confidence interval 0.090-0.842, p = 0.02).

CONCLUSION

RAMPS is oncologically superior to conventional procedure in achieving local control of the disease in patients with left-sided pancreatic cancer.

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

BACKGROUND

Laparoscopic radical antegrade modular pancreatosplenectomy (Lap-RAMPS) for left-sided pancreatic cancer remains a technically challenging procedure. How to approach the splenic artery in laparoscopic surgery has not been discussed in adequate detail, and the implications of an artery-first approach in left-sided pancreatic cancer remain unclear.

PATIENTS AND METHODS

Forty-five consecutive patients with left-sided resectable pancreatic cancer underwent Lap-RAMPS between July 2018 and September 2020. They were divided according to whether Lap-RAMPS was performed using an anterocranial splenic artery-first (ASF) approach (ASF group, n = 23) or via another approach (non-ASF group, n = 22). Clinical, pathological, and short-term outcomes were reviewed and compared between the groups.

RESULTS

The ASF approach was performed safely in all patients with resectable left-sided pancreatic cancer, and none required conversion to laparotomy. The ASF group had better outcomes in terms of conspicuous bleeding from the spleen during splenic mobilization (P = 0.016) and blood pooling during posterior dissection (P = 0.035). Consequently, blood loss was significantly less and operation time was significantly shorter in the ASF group than in the non-ASF group. There was no significant between-group difference in other short-term outcomes, including mortality, length of hospital stay, or Clavien-Dindo classification.

CONCLUSIONS

The ASF approach was safe when performed for resectable left-sided pancreatic cancer and may help to prevent congestion of the pancreas and lessen intraoperative blood loss.

Impact of Tumor Size on the Outcomes of Patients with Resectable Distal Pancreatic Cancer: Lessons Learned from a Series of 158 Radical Resections

BACKGROUND

Neoadjuvant therapy is used for borderline resectable pancreatic ductal adenocarcinoma (PDAC) with high risk of incomplete resection and early recurrence. Because distal PDAC is rare, the optimal criteria for neoadjuvant therapy specific for distal PDAC remain unclear. We hypothesized large distal PDAC would recur earlier than small distal PDAC.

OBJECTIVE

The aim of this study was to identify the risk factors for failure of upfront resection for resectable distal PDAC.

METHODS

The study cohort comprised 158 patients with resectable distal PDAC who underwent radical resection. The long-term outcomes were recurrence-free survival (RFS), disease-specific survival (DSS), and post-recurrence survival (PRS).

RESULTS

R0 resection was achieved in 92% of patients, and median DSS for the entire cohort was 31 months. Among 103 patients who developed recurrence, 32 (31%) developed recurrence within 6 months. The median PRS and DSS for those with early recurrence was 6 and 10 months, respectively, compared with 11 and 30 months, respectively, for those with late recurrence (p = 0.017 and p < 0.001, respectively). Patients with tumors > 4 cm had higher rates of R1 resection (16%) and concomitant resection of another organ (19%) than those with smaller tumors (4% and 2%, p = 0.009 and p < 0.001, respectively). In multivariate analysis, tumor > 4 cm remained a significant predictor of early recurrence (p < 0.001, hazard ratio [HR] 6.51), shorter RFS (p = 0.018, HR 1.71), and shorter DSS (p = 0.002, HR 2.07).

CONCLUSION

Tumor size > 4 cm is a reliable predictor of early recurrence after resection of distal PDAC, and neoadjuvant therapy may help select patients who can benefit from radical resection.

Details and Outcomes of Distal Pancreatectomy with Celiac Axis Resection Preserving the Left Gastric Arterial Flow

BACKGROUND

To describe the technical details and efficacy of distal pancreatectomy with celiac axis resection (DP-CAR) and left gastric artery (LGA) flow preservation for pancreatic ductal adenocarcinoma (PDAC).

METHOD

This single-center, retrospective analysis investigated short- and long-term outcomes of DP-CAR performed on 55 patients with PDAC from 2011 to 2019. Our method included LGA reconstruction after total resection of the CA (rDP-CAR group; 24 patients) or LGA preservation if the tumor invasion was away from its root (pDP-CAR group; 31 patients), a CA-first approach to reduce blood loss during dissection, and conservative drain management with or without jejunal serosal patching at the pancreatic stump.

RESULTS

Among the study patients, 23 had locally advanced PDAC and 22 had borderline resectable PDAC. Median operation duration was 443 min (248-810), estimated blood loss was 600 mL (150-2280), and incidence of transfusion was 2%. Ischemic complications occurred exclusively in the rDP-CAR group, including two patients with ischemic gastropathy (8%) and three patients with findings of liver ischemia on computed tomography (13%). One patient underwent relaparotomy for stomach perforations, and 19 patients (35%) had pancreatic fistula, including 8 patients who underwent conservative drain placement for more than 3 weeks without specific symptoms. There were no Clavien-Dindo grade 4 or higher postoperative complications. Preoperative therapy showed improved 3-year overall survival rates than without (54% vs. 37%, p = 0.027).

CONCLUSIONS

Using the standardized technique, DP-CAR was safely performed with no mortality and acceptable long-term survival.

Improvement in distal pancreatectomy for tumors in the body and tail of the pancreas

Background

Pancreatic resections are complex and technically challenging surgical procedures. They often come with potential limitations to high-volume centers. Distal pancreatectomy is a relatively simple procedure in most cases. It facilitates the development of up-to-date minimally invasive surgical procedures in pancreatic surgery including laparoscopic distal pancreatectomy and robot-assisted distal pancreatectomy.

Main body

To obtain a desirable long-term prognosis, R0 resection and adequate lymphadenectomy are crucial to the surgical management of pancreatic cancer, and they demand standard procedure and multi-visceral resection if necessary. With respect to combined organ resection, progress has been made in evaluating and determining when and how to preserve the spleen. The postoperative pancreatic fistula, however, remains the most significant complication of distal pancreatectomy, with a rather high incidence. In addition, a safe closure of the pancreatic remnant persists as an area of concern. Therefore, much efforts that focus on the management of the pancreatic stump have been made to mitigate morbidity.

Conclusion

This review summarized the historical development of the techniques for pancreatic resections in recent years and describes the progress. The review eventually looked into the controversies regarding distal pancreatectomy for tumors in the body and tail of the pancreas.

Regional pancreatoduodenectomy versus standard pancreatoduodenectomy with portal vein resection for pancreatic ductal adenocarcinoma with portal vein invasion

Background

Pancreatoduodenectomy (PD) with portal vein resection (PVR) is a standard operation for pancreatic ductal adenocarcinoma (PDAC) with portal vein (PV) invasion, but positive margin rates remain high. It was hypothesized that regional pancreatoduodenectomy (RPD), in which soft tissue around the PV is resected en bloc, could enhance oncological clearance and survival.

Methods

This retrospective study included consecutive patients who underwent PD with PVR between January 2005 and December 2016 in a single high‐volume centre. In standard PD (SPD) with PVR, the PV was skeletonized and the surrounding soft tissue dissected. In RPD, the retropancreatic segment of the PV was resected en bloc with its surrounding soft tissue. The extent of lymphadenectomy was similar between the procedures.

Results

A total of 268 patients were included (177 SPD, 91 RPD). Tumours were more often resectable in patients undergoing SPD (60·5 per cent versus 38 per cent in those having RPD; P = 0·014), and consequently they received neoadjuvant therapy less often (7·9 versus 25 per cent respectively; P < 0·001). R0 resection was achieved in 73 patients (80 per cent) in the RPD group, compared with 117 (66·1 per cent) of those in the SPD group (P = 0·016), although perioperative outcomes were comparable between the groups. Median recurrence‐free (RFS) and overall (OS) survival were 17 and 32 months respectively in patients who had RPD, compared with 11 and 21 months in those who had SPD (RFS: P = 0·003; OS: P = 0·004).

Conclusion

RPD is as safe and feasible as SPD, and may increase the survival of patients with PDAC with PV invasion.