Left-sided pancreatic cancer: distal pancreatectomy and its variants: radical antegrade modular pancreatosplenectomy and distal pancreatectomy with celiac axis resection. Cancer J. 2012;18:562-570. [PMID: 23187843 DOI: 10.1097/ppo.0b013e31827596c5]

Prognostic implications of resection margin status in distal pancreatectomy for pancreatic ductal adenocarcinoma

BACKGROUND

Curative resection is a well known prognostic factor in pancreatectomy. However, definition and clinical significance of resection margin in distal pancreatectomy remains controversial.

METHODS

From 2010 to 2018, 203 patients with pancreatic cancer undergoing distal pancreatectomies were included. Patients were classified into three groups: R0-wide (tumor-free margin ≥1 mm), R0-narrow (0 mm < tumor-free margin <1 mm), and R1 margin (tumor-free margin = 0 mm). We also evaluated the prognostic impact of individual margins (transection, anterior, and posterior).

RESULTS

Patients with an R0-wide margin (36.6 %) exhibited superior 5-year disease free survival rate compared to those with R0-narrow (30.4 %, p = 0.059) or R1 margin (0.1 %, p = 0.014). However, in multivariate analyses, only R1 margin (hazard ratio [95 % confidence interval], 2.02 [1.32-3.12]; p = 0.001), unlike R0-narrow margin (1.17 [0.78-1.77]; p = 0.446), was linked to shorter overall survival compared to R0-wide margin. In multivariate analyses, posterior margin involvement was uniquely identified as a poor prognostic factor (1.83 [1.07-3.13]; p = 0.027).

CONCLUSIONS

The 0 mm rule seems more suitable than the 1 mm rule for predicting prognosis in performing distal pancreatectomy, and especially, achieving microscopically negative posterior margin is crucial.

Laparoscopic radical antegrade modular pancreatosplenectomy vesus laparoscopic distal pancreatosplenectomy for left-sided pancreatic cancer: a systematic review and meta-analysis

Objective

We aimed to compare the perioperative outcomes and postoperative complications of laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) versus laparoscopic distal pancreatosplenectomy (L-DPS) for left-sided pancreatic cancer through a meta-analysis.

Methods

A systematic review and meta-analysis, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, were performed. Literature searches were conducted in PubMed, Web of Science, Cochrane Library, and Embase for studies published from their inception up to June 14th, 2024.

Results

A total of three retrospective studies involving 242 patients were included in this meta-analysis, with 116 patients in the L-RAMPS group and 126 in the L-DPS group. The meta-analysis results indicated that L-RAMPS was associated with the retrieval of more lymph nodes (MD: 3.06; 95% CI: 2.51 to 3.62, p < 0.00001) and longer operative time (MD: 20.05; 95% CI: 13.97 to 26.12, p < 0.00001) compared to L-DPS for left-sided pancreatic cancer patients. However, no significant differences were observed between the two groups in terms of R0 resection margins, the incidence of pancreatic fistula (Grade B and C), postpancreatectomy hemorrhage, or postoperative complications (Clavien-Dindo Grades II and III).

Conclusions

In patients with left-sided pancreatic cancer, L-RAMPS resulted in the retrieval of more lymph nodes, a longer operative time, and a similar incidence of postoperative complications compared to L-DPS. Larger sample sizes, extended follow-up periods, and well-conducted randomized controlled trials are needed to further validate these findings.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=558977, identifier CRD42024558977.

A comparative analysis and survival analysis of open versus minimally invasive radical antegrade modular pancreatosplenectomy for pancreatic cancer: a systematic review and meta-analysis

Background

Pancreatic ductal adenocarcinoma (PDAC) is a major public health concern, ranking as the fourth leading cause of cancer-related mortality in the United States. Traditional surgical approaches often yield suboptimal outcomes, highlighting the need for innovative surgical strategies. Radical antegrade modular pancreatosplenectomy (RAMPS) has demonstrated improvements in surgical visualization and oncological outcomes. Recently, laparoscopic RAMPS (L-RAMPS) has been introduced as a minimally invasive alternative.

Objectives

This meta-analysis aims to compare the safety and efficacy of open RAMPS (O-RAMPS) versus L-RAMPS, focusing on operative outcomes, minimally invasive outcomes, intra-abdominal outcomes, overall postoperative outcomes, and oncologic outcomes.

Methods

A systematic review and meta-analysis were conducted following PRISMA guidelines. Eligible studies included prospective or retrospective cohort studies and randomized controlled trials comparing L-RAMPS with O-RAMPS. Data were extracted from EMBASE, PubMed, and the Cochrane Library databases through September 16, 2023. The ROBINS-I tool was used to assess the risk of bias. Statistical analyses included odds ratios (OR), risk differences (RD), mean differences (MD), and survival analyses.

Results

Eight studies involving 588 patients were included. O-RAMPS was associated with longer operative times (MD = 39.39 minutes, 95% CI = 22.93 to 55.84) and greater blood loss (MD = -231.84 mL, 95% CI = -312.00 to -151.69). No significant differences were observed in blood transfusion rates, pancreatic fistula rates, delayed gastric emptying, or length of hospital stay. L-RAMPS demonstrated a shorter time to oral feeding (MD = -0.79 days, 95% CI = -1.35 to -0.22). Survival analysis suggested a potentially improved long-term prognosis for L-RAMPS.

Conclusion

L-RAMPS offers advantages over O-RAMPS in terms of reduced blood loss, faster time to oral feeding, and potentially better long-term prognosis. Further research is warranted, particularly regarding the learning curve of L-RAMPS and its broader applicability.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42024498383.

Breast Modular Resection (BMR) in Nipple-Sparing Mastectomy (NSM) With Intraoperative Laser Speckle Contrast Imaging (LSCI) Monitoring Improved Surgical Training Outcome Among Fellows

BACKGROUND

Nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) are challenging for surgical training among fellow trainees. We developed a surgical training course with novel concept of breast modular resection (BMR) for NSM/SSM procedure, and performed this study to investigate whether BMR could improve surgical outcomes compared to classical procedure resection (CPR).

METHODS

The records of 105 breast cancer patients undergoing NSM/SSM with immediate reconstruction performed by fellow trainees were reviewed. Clinicopathological characteristics and surgical outcomes were compared between 2 groups. Laser speckle contrast imaging (LSCI) was performed to intraoperatively evaluate the blood supply of the NAC, and the absolute perfusion unit (PU) values and relative perfusion unit (rPU) values were further compared.

RESULTS

Surgical training outcomes of BMR group (N = 52) were insignificantly improved compared to CPR group (N = 53). The rates of NAC necrosis, flap necrosis and implant removal all reduced respectively. Among the 60 NSM patients, the blood loss (P = .011) and surgery time (P < .001) was significantly reduced in BMR group (N = 30) and all the other outcomes were insignificantly improved. Both the absolute PU values and rPU values were significantly higher among patients without NAC necrosis (P < .001). The absolute PU values were significantly higher in BMR group (P = .002).

CONCLUSION

Compared to CPR, the BMR-based surgical training course for NSM demonstrated the reduction in complications and operating time, offering a potential streamlined, efficient, and safe method for NSM procedure. LSCI was effective for intraoperative visualized evaluation of NAC blood supply and could provide effective real-time feedback for fellow trainees.

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.

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

BACKGROUND

The safety and efficacy of minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS) remain to be established in pancreatic cancer (PDAC) METHODS: Eighty-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.

RESULTS

O-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.

CONCLUSION

In patients with anatomically resectable PDAC, MI-RAMPS is feasible and as safe as O-RAMPS.

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.

Pancreas tail adenocarcinoma tumor size is highly predictive of positive margins after a nonradical resection

BACKGROUND

Radical resection (RAMPS) of left sided pancreatic ductal adenocarcinoma (PDAC) is effective in achieving R0 margins; however, not universally accepted due to lack of improved survival. We hypothesized that only larger tumors lead to R1 in non-RAMPS procedures.

METHODS

A retrospective review of charts between 2008 and 2020 was performed. The primary outcome was evaluating R0 resection based on left-sided tumors' size and location, and secondary outcomes were OS and DFS.

RESULTS

Sixty-eight percent had R0 resection. R1 groups' tumors were larger (5.5 cm vs. 3.8 cm, p = 0.004) and had higher LVI involvement (p = 0.003). OS and DFS did not differ on multivariate analysis. Tumor size above 4 cm in the tail was associated with R1 (p = 0.01).

CONCLUSIONS

Larger tumors in the tail, but not body were associated with R1, but not worse survival. Perhaps larger tumors in the tail are a surrogate marker of poor disease biology.

The role of coeliac axis resection in resected ductal adenocarcinoma of the distal pancreas: A result of tumour topography or a prognostic factor?

BACKGROUND

Whether coeliac axis resection (CAR) results from tumour topography or a prognostic factor for distal pancreatic ductal adenocarcinoma (PDAC) remains unclear. We aimed to compare the clinicopathological data between distal pancreatectomy with en bloc CAR (DP-CAR) and distal pancreatectomy plus splenectomy (DP-S) and analyse the prognostic factors.

METHODS

We retrospectively analysed clinicopathological data from 102 patients who underwent distal pancreatectomy for PDAC and the factors affecting disease-free survival (DFS) and overall survival (OS). Of these patients, 45 and 57 underwent DP-CAR and DP-S, respectively.

RESULTS

DP-CAR was associated with more operative challenges than DP-S: more portomesenteric vein resections (48.9% vs. 14.0%), longer operations (320 vs. 242 min), and greater estimated blood loss (EBL) (600 vs. 200 ml). DP-CAR had larger tumours (5 vs. 4 cm), more perineural invasion (91.1% vs. 73.7%), and more microscopically positive surgical margins (20% vs. 3.5%), compared to DP-S. The major complication was clinically relevant postoperative pancreatic fistula (20.6%). The median DFS was 15.8 months and the median OS was 20.1 months. CAR was not associated with DFS or OS. EBL>700 ml, lymphovascular invasion (LVI), and adjuvant chemotherapy independently affected DFS and OS.

CONCLUSION

DP-CAR was associated with larger tumours and more surgical challenges but not with poorer DFS and OS than DP-S. CAR was more likely to result from tumour topography rather than from an adverse prognostic factor for resected distal PDAC. EBL>700 ml, LVI, and adjuvant chemotherapy were independent factors affecting the survival of patients with distal PDAC who underwent surgical resection.

Curing pancreatic cancer

The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.

Minimally Invasive Versus Open Radical Antegrade Modular Pancreatosplenectomy: A Meta-Analysis

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced to improve the tangential resection margin rates and N1 node clearance following resection of malignancies of the pancreatic body and tail. Owing to its technical complexity, minimally invasive RAMPS (MI-RAMPS) has only been reported by a few centers worldwide. We performed this meta-analysis to compare both short- and long-term outcomes between open RAMPS (O-RAMPS) and minimally invasive RAMPS (MI-RAMPS).

METHODS

A systematic search of the electronic databases PubMed, Medline (via PubMed), Cochrane Register of Controlled Trials (CENTRAL), EMBASE, Scopus and Web of Science was performed to identify eligible studies published in the English language regardless of study design. The outcomes of interest were operation time, estimated blood loss, transfusion rates, overall complications, Grade B/C post-operative pancreatic fistula (POPF) rates, post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), length of stay (LOS), R0 resection rates, lymph node (LN) yield and overall survival (OS).

RESULTS

Five non-randomized studies comprising of a total 229 patients (89 MI-RAMPS, 140 O-RAMPS) were included for analysis. Intra-operative blood loss was observed to be significantly reduced in MI-RAMPS as compared to O-RAMPS (MD -256.16, P < 0.001), while LN yield was higher in O-RAMPS as compared to MI-RAMPS (MD -2.73, P = 0.02). There were no statistically significant differences observed for the other perioperative, oncologic and survival outcomes.

CONCLUSIONS

This meta-analysis provides early evidence to suggest that MI-RAMPS may produce comparable short- and long-term outcomes to O-RAMPS, when undertaken by appropriately skilled surgeons in well-selected patients. Further large-scale prospective studies are required to corroborate these findings.

Combining Appleby with RAMPS - Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Celiac Trunk Resection

BACKGROUND

Radical Antegrade Modular Pancreatosplenectomy (RAMPS) minimizes the risk of a positive retroperitoneal margin and maximizes lymph node harvest in distal pancreatic cancers.1-7 In those with celiac trunk involvement, resection of the celiac trunk (modified Appleby procedure) is a surgical option in which postoperative liver perfusion relies on blood flow via superior mesenteric artery (SMA) and gastroduodenal artery (GDA).8, 9 PATIENT: A 66-year-old male was diagnosed with a 3.8 × 2.5 cm pancreatic body adenocarcinoma abutting the celiac trunk. Neoadjuvant FOLFIRINOX was initiated with a uniquely good response.

TECHNIQUE

Prior to surgery, a novel preoperative 3D simulation technique accounting for organ displacement during pneumoperitoneum with the goal of optimizing port placement and surgical decision making was employed. At surgery, a RAMPS procedure was performed with the renal vessels and adrenal gland being dissected first (reversed from typical open approach). Following dissection along the SMA towards the celiac axis, desmoplastic reaction enveloping the celiac trunk necessitated its resection. Arterial liver perfusion was confirmed with intraoperative ultrasound.

CONCLUSION

L-RAMPS and modified Appleby procedure is a curative option for patients with distal pancreatic cancers that invade the celiac trunk and in whom the tumor biology is well controlled. A preplanned approach with 3D reconstruction accounting for organ displacement due to pneumoperitoneum optimizes surgical decision making and port placement for visual alignment caudally along the SMA.

Oncologic Outcomes of Robotic Left Pancreatectomy for Pancreatic Adenocarcinoma: A Single-Center Comparison to Laparoscopic Resection

BACKGROUND

Feasibility and safety of robotic surgery for pancreatic disease has been well demonstrated; however, there is scarce literature on long-term oncologic outcomes. We compared perioperative and oncologic outcomes between robotic left pancreatectomy (RLP) and laparoscopic left pancreatectomy (LLP) for pancreatic adenocarcinoma.

METHODS

A retrospective review evaluated left pancreatectomies performed for pancreatic adenocarcinoma from 2009 to 2019 in a tertiary institution. Baseline characteristics, operative and oncologic outcomes were compared between RLP and LLP.

RESULTS

There were 75 minimally invasive left pancreatectomy cases for pancreatic adenocarcinoma identified of which 33 cases were done robotically and 42 laparoscopically. Baseline characteristics demonstrated no difference in gender, age, BMI, T stage, N stage, neoadjuvant, or adjuvant chemotherapy. An analysis of operative variables demonstrated no difference in blood loss, increased duration, and higher lymph node yield with RLP (20 vs 12; P = .0029). Postoperatively, both cohorts had 30% pancreatic fistulas and no difference in complications. There were no differences in length of stay (LOS), 30- or 90-day readmission rates, or 90-day mortality. The analysis of oncologic outcomes demonstrated similar R0 resections (RLP: 72% vs OLP: 67%), recurrence rates (RLP: 36% vs OLP: 41%), and time to recurrence (RLP: 324 vs OLP 218 days). There was increased survival in the RLP cohort that was not significant (32 vs 19 months).

CONCLUSION

This analysis demonstrates RLP is at least equivalent to LLP in perioperative and oncologic outcomes. The significantly higher lymph node yield and trend toward an improved survival suggests oncologic advantage. Randomized controlled studies are needed to clarify benefit.

Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019

Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019).

Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system.

Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion).

Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.

Robotic-assisted versus laparoscopic left pancreatectomy at a high-volume, minimally invasive center

INTRODUCTION

While minimally invasive left pancreatectomy has become more widespread and generally accepted over the last decade, opinions on modality of minimally invasive approach (robotic or laparoscopic) remain mixed with few institutions performing a significant portion of both operative approaches simultaneously.

METHODS

247 minimally invasive left pancreatectomies were retrospectively identified in a prospectively maintained institutional REDCap™ database, 135 laparoscopic left pancreatectomy (LLP) and 108 robotic-assisted left pancreatectomy (RLP). Demographics, intraoperative variables, postoperative outcomes, and OR costs were compared between LLP and RLP with an additional subgroup analysis for procedures performed specifically for pancreatic adenocarcinoma (35 LLP and 23 RLP) focusing on pathologic outcomes and 2-year actuarial survival.

RESULTS

There were no significant differences in preoperative demographics or indications between LLP and RLP with 34% performed for chronic pancreatitis and 23% performed for pancreatic adenocarcinoma. While laparoscopic cases were faster (p < 0.001) robotic cases had a higher rate of splenic preservation (p < 0.001). Median length of stay was 5 days for RLP and LLP, and rate of clinically significant grade B/C pancreatic fistula was approximately 20% for both groups. Conversion rates to laparotomy were 4.3% and 1.8% for LLP and RLP approaches respectively. RLP had a higher rate of readmission (p = 0.035). Pathologic outcomes and 2-year actuarial survival were similar between LLP and RLP. LLP on average saved $206.67 in OR costs over RLP.

CONCLUSIONS

This study demonstrates that at a high-volume center with significant minimally invasive experience, both LLP and RLP can be equally effective when used at the discretion of the operating surgeon. We view the laparoscopic and robotic platforms as tools for the modern surgeon, and at our institution, given the technical success of both operative approaches, we will continue to encourage our surgeons to approach a difficult operation with their tool of choice.

Comparison of Radical Antegrade Modular Pancreatosplenectomy with Standard Retrograde Pancreatosplenectomy for Left-Sided Pancreatic Cancer: A Meta-Analysis and Experience of a Single Center

BACKGROUND Radical antegrade modular pancreatosplenectomy (RAMPS) has been reported as a modified surgical technique used to achieve better margin resection and to retrieve more lymph nodes compared with standard retrograde pancreatosplenectomy (SRPS). MATERIAL AND METHODS A systematic literature review was performed to identify studies published in PubMed, EmBase, and Web of Science. Hazard ratio (HR), risk ratio (RR), weighted mean difference (WMD), and their 95% confidence intervals (95% CIs) were used as effect measures. In addition, the clinical data of 27 patients in our center were collected and retrospectively analyzed. RESULTS Seven studies containing 474 patients were finally enrolled in this meta-analysis. The pooled results showed that the RAMPS group had a better overall survival (OS) compared with the SRPS group (HR=0.65, 95% CI: 0.43-0.99, P=0.046; I²=41.8%, P=0.143). Significantly more lymph nodes were harvested in the RAMPS group compared with in the SRPS group (WMD=4.74, 95% CI: 0.36-9.12, P=0.034). Recurrence rate (RR=0.8, 95% CI: 0.66-0.98, P=0.028) and blood loss (WMD=-153.19 ml, 95% CI: -303.95 to -2.42, P=0.046) were both significantly reduced in the RAMPS group. Retrospective analysis results showed that only significantly more harvested lymph nodes were noted in the RAMPS group compared with the SRPS group (7.55±0.91 vs. 2.81±0.73, P=0.001). CONCLUSIONS Our study suggests that RAMPS has better prognosis and surgical outcomes than SRPS for left-sided pancreatic cancer. Nevertheless, more high-quality clinical trials are required to validate the result.

Should a standard lymphadenectomy include the No. 9 lymph nodes for body and tail pancreatic ductal adenocarcinoma?

OBJECTIVES

This study aimed to use a retrospective data base to investigate whether a standard lymphadenectomy during distal pancreatectomy should include the No. 9 lymph nodes (LNs) for resectable pancreatic ductal adenocarcinoma (PDAC) located in the body and tail of the pancreas.

METHODS

Data from 169 patients undergoing curative distal pancreatectomy for PDAC between Jan 1, 2013 and Dec 31, 2016 were collected. According to the tumor location, patients were divided into three groups: pancreatic neck tumor, pancreatic body and tail tumor with margin-to-bifurcation-distance (MTBD) ≤ 2.5 cm and pancreatic body and tail tumor with MTBD > 2.5 cm. The metastatic rate of the No. 9 LNs was compared among the 3 groups. The survival outcomes were analyzed.

RESULTS

The involvement rate for No. 9 LNs was 20.7% (6/29) for pancreatic neck tumors, 17.6% (15/85) for body and tail tumors with MTBD ≤ 2.5 cm and 1.8% (1/55) for MTBD > 2.5 cm. The No. 9 LNs were significantly more frequently involved in neck or body and tail tumors with MTBD ≤2.5 cm than with the cases with MTBD >2.5 cm (OR 0.082, P = 0.016). No. 9 LN involvement was not associated with worse survival compared with survival associated with involvement of other LNs (P = 0.780).

CONCLUSIONS

For PDAC located in the neck or in the body and tail of the pancreas with MTBD ≤ 2.5 cm, the involvement rate for No. 9 LNs is high. Standard lymphadenectomy should include the No. 9 LNs.

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

BACKGROUND

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.

METHODS

This is a retrospective analysis of prospectively maintained database on the resections performed for all pancreatic body and tail tumors at Tata Memorial Centre.

RESULTS

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.

CONCLUSION

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.

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

PURPOSE

Radical antegrade modular pancreatosplenectomy (RAMPS) has been accepted as a standard operation for distal pancreatic cancer. While enbloc retroperitoneal dissection in the "medial to lateral" direction is one of the most important steps in this oncologic procedure, it is technically challenging due to the depth of organs under the left costal margin, and poor exposure of the resecting organs in this area will increase the risk of incomplete oncologic dissection.

METHODS

To improve exposure of the left upper quadrant organs, left kidney was completely mobilized during RAMPS, and all the left upper quadrant organs were elevated and medialized by lap sponges packed in the retro-renal space. The operative and oncologic outcomes for patients who underwent our modified RAMPS with left kidney mobilization were evaluated.

RESULTS

One hundred and forty-four patients with distal pancreatic cancer underwent this procedure from 2005 through 2016. The median operation time was 310 min (range, 132-899), and blood loss was 440 ml (25-2430). There was no complication associated to left kidney mobilization. The median number of harvested lymph nodes was 27 (3-87). While 77% of the tumors had microscopic retroperitoneal invasion, 96% of patients achieved negative retroperitoneal margin.

CONCLUSIONS

Left kidney mobilization is useful for safe and oncologically sound lateral retroperitoneal dissection during RAMPS for distal pancreatic cancer.

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

BACKGROUND

This 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).

METHOD

We 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.

RESULT

A 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.

CONCLUSION

The 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.

Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer. How I do It

Approximately 30% of all pancreatic cancer patients have locally advanced (AJCC stage 3) disease. A sub-group of these patients-where the cancer only involves the celiac axis-may benefit from distal pancreatectomy with celiac axis resection (DP-CAR). Previous studies have shown that DP-CAR offers a survival benefit to a selected group of patients with otherwise unresectable pancreatic cancer, when performed by experienced pancreatic cancer treatment teams at high-volume centers. This article proposes a standardized approach to DP-CAR, including routine neoadjuvant (FOLFIRINOX) chemotherapy. This approach to selecting patients and performing DP-CAR has the potential to improve short-term outcomes and overall survival in selected patients, but it should be reserved for high-volume centers.

Radiologic evaluation of patients undergoing the modified Appleby procedure for locally advanced pancreatic neoplasms: a case series

PURPOSE

Despite advances in medical and surgical care, pancreatic ductal adenocarcinoma remains one of the most locally aggressive neoplastic processes in the abdomen. Unfortunately, most pancreatic adenocarcinomas present late and are unresectable at time of diagnosis. The modified Appleby procedure is a surgical option in patients with locally advanced pancreatic neoplasms of the body and tail with vascular invasion of the celiac trunk. To our knowledge, no radiologic journal has previously reported on the pre-operative evaluation or postoperative imaging findings of such patients.

METHODS

We report herein three patients who underwent the modified Appleby procedure, each with a unique complication, in an attempt to illustrate common pitfalls of interpretation in these advanced cases.

RESULTS

Our case series emphasizes the importance of pre-operative radiologic assessment of variant arterial anatomy, knowledge of pre- and intraoperative procedures and appearances, and familiarity with potential postoperative complications.

CONCLUSIONS

Thorough understanding of the important aspects of the pre-surgical anatomy, as well as possible post-surgical complications, is the key to the radiologist being a useful participant in the clinical care of these patients.

Extended versus peripancreatic lymph node dissection for the treatment of left-sided pancreatic cancer

Purpose

The pathways of lymphatic metastases differ according to the tumor location in pancreatic cancer patients. However, it is unclear whether extended lymph node dissection (LND) is essential for all left-sided pancreatic cancer. The aim of this study is to evaluate the survival outcomes according to the extent of LND and tumor location in patients with left-sided pancreatic cancer.

Methods

January 2005 to December 2013, we retrospectively identified 107 patients who underwent curative intent surgery for left-sided pancreatic cancer. The left-sided pancreatic cancer was defined as a tumor located in pancreatic body or tail. The extent of LND was divided into 2 groups: extended LND and peripancreatic LND. The extended LND group included celiac and superior mesenteric LNs.

Results

We included 107 patients with left-sided pancreatic cancer; 59 patients with pancreatic body cancer and 48 patients with pancreatic tail cancer. The median follow-up period was 17 months (range, 3–110 months). Fifty patients with pancreatic body cancer and 30 patients with pancreatic tail cancer underwent extended LND. In patients with pancreatic body cancer, extended LND was associated with improved disease-free survival (DFS) (P = 0.010) and overall survival (P = 0.014). However, extended LND was not associated with DFS in patients with pancreatic tail cancer.

Conclusion

Extended LND could improve survival in patients with pancreatic body cancer. However, extended LND had no survival benefit for the treatment of pancreatic tail cancer.

Normal Postoperative Computed Tomography Findings after a Variety of Pancreatic Surgeries

Pancreatic surgery remains the only curative treatment for pancreatic neoplasms, and plays an important role in the management of medically intractable diseases. Since the original Whipple operation in the 20th century, surgical techniques have advanced, resulting in decreased postoperative complications and better clinical outcomes. Normal postoperative imaging findings vary greatly depending on the surgical technique used. Radiologists are required to be familiar with the normal postoperative imaging findings, in order to distinguish from postoperative complications or tumor recurrence. In this study, we briefly review a variety of surgical techniques for the pancreas, and present the normal postoperative computed tomography findings.

Initial experience with laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer in a single institution: technical aspects and oncological outcomes

Background

Laparoscopic surgery has been performed less frequently in the era of pancreatic cancer due to technical difficulties and concerns about oncological safety. Radical antegrade modular pancreatosplenectomy (RAMPS) is expected to be helpful to obtain a negative margin during radical lymph node dissection. We hypothesized that it would also be favorable as a laparoscopic application due to unique features.

Methods

Fifteen laparoscopic RAMPS for well-selected patients with left-sided pancreatic cancer were performed from July 2011 to April 2016. Five trocars were usually used, and the operative procedures and range of dissection were similar to or the same as those of open RAMPS described by Strasberg. All medical records and follow-up data were reviewed and analyzed.

Results

All patients had pancreatic ductal adenocarcinoma. Mean operative time was 219.3 ± 53.8 min, and estimated blood loss was 250 ± 70 ml. The length of postoperative hospital stay was 6.1 ± 1.2 days, and postoperative morbidities developed in two patients (13.3%) with urinary retention. The median number of retrieved lymph nodes was 18.1 ± 6.2 and all had negative margins. Median follow-up time was 46.0 months, and the 3-year disease free survival and overall survival rates were 56.3% and 74.1%, respectively.

Conclusion

Our early experience with laparoscopic RAMPS achieved feasible perioperative results accompanied by acceptable survival outcomes. Laparoscopic RAMPS could be a safe and oncologically feasible procedure in well-selected patients with left-sided pancreatic cancer.

Laparoscopic distal pancreatectomy

After technological advances and increased experiences, more complicated surgeries including distal pancreatectomy can be easily performed with acceptable oncologic results, and decreased mortality and morbidity. Laparoscopic distal pancreatectomy (LDP) has been shown to have several advantages including less blood loss, less hospital stay, less pain. Several studies comparing open distal pancreatectomy (ODP) and LDP resulted that both techniques have similar results according to pancreas fistulas, oncological results, costs and operation indications. Morbidity is very low in high volume centers, for this reason at least ten cases should be performed for the learning curve. Several authors remarked important technical points in LDP in order to perform safe and acceptable LDP in several studies. Here in this review, we aimed to overview the results of previous studies about LDP and discuss the technical points of LDP.

Initial experience with radical antegrade modular pancreatosplenectomy in a single institution

Purpose

Radical antegrade modular pancreatosplenectomy (RAMPS) is expected to be favorable for obtaining the negative tangential margin with oncologic feasibility through the horizontal dissection in a right-to-left fashion for radical lymph node dissections.

Methods

From January 2007 to February 2015, a total of 30 RAMPS and 19 conventional distal pancreatectomy (DP) cases were enrolled. The demographics, perioperative and survival outcomes were compared according to the type of surgery.

Results

The mean operative time, blood loss and length of hospital stay were similar between 2 groups. Morbidities were reported in 14 cases of RAMPS (46.7%) and 8 cases of DP (42.1%) (P = 0.777). The rate of negative tangential margin (96.2%) and the number of harvested lymph nodes (mean ± standard deviation, 21.5 ± 8.3) were significantly higher in RAMPS group (P = 0.011, P = 0.003, respectively). In terms of survival outcomes, there was no significant difference in regard to the overall 3-year disease-free survival (DFS; 30.4% in RAMPS vs. 35.0% in DP, P = 0.354) or overall survival (OS; 29.9% vs. 29.4%, P = 0.429) between the 2 groups. After exclusion of cases with nodal invasion, however, the RAMPS group had a longer DFS than the DP group (55.6% vs. 27.3%, P = 0.048) although OS was similar without significant difference (42.4% vs. 27.3%, P = 0.197).

Conclusion

RAMPS is a safe and oncologically feasible procedure in left-sided pancreatic cancer by obtaining a successful negative tangential margin and radical lymph node dissection. The authors suggest it could also be useful for local control, especially for the limited left-sided pancreatic cancer without nodal invasion.

Single institution results of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of pancreas in 78 patients

BACKGROUND

The purpose of this report is to present results of the radical antegrade modular pancreatosplenectomy (RAMPS) procedure in 78 patients from a single center.

METHODS

Seventy-eight patients had RAMPS procedure over 13 years. A database dealing with RAMPS for adenocarcinoma of the pancreas was constructed so that it could be converted into a set of tables. Each table covered one element of the subject. The database was populated from clinical records of patients who had a RAMPS procedure from 1999 to 2013.

RESULTS

Fifty-six patients had anterior RAMPS and 22 had posterior RAMPS. Negative tangential margins were obtained in 94% of specimens. Overall the R0 rate was 85%. Mean lymph node count was 20. There were no 30-day or in-hospital mortalities but two patients died within 90 days. Pancreatic fistula and need for postoperative transfusion were the most common complications. Median survival was 24.6 months and 5-year overall actuarial survival was 25.1%.

CONCLUSIONS

The RAMPS technique resulted in high negative tangential margin rates and good lymph node retrieval. The long-term survival result in 78 patients is probably an accurate reflection of what is possible with this tumor using this technique at this time.

Celiac Axis Resection with Distal Pancreatectomy (Modified Appleby Procedure) Allows for R0 Resection of Pancreatic Body and Tail Mass Following Neoadjuvant Therapy: Case Report and Literature Review

Background: The modified Appleby procedure has been developed for cancer of the pancreatic body or tail with celiac axis invasion, historically classified as unresectable disease. Post-Appleby resection, the source of arterial blood to the liver is the superior mesenteric artery, which supplies the gastroduodenal artery and ultimately feeds the proper hepatic artery. In cases of inadequate collateralization, preoperative coiling of the common hepatic artery (CHA) or intraoperative reconstruction via an aorto-hepatic bypass has been described. Method: We describe a 74-year-old female with a pancreatic mass that was initially determined to be unresectable. She underwent extensive combination neoadjuvant chemotherapy. A favorable response was evidenced by a decrease in serum CA 19-9 levels. After 7 months, she was restaged and offered a distal pancreatectomy (DP) with the possibility of a modified Appleby procedure due to potential tumor involvement of the proximal CHA. Results: Intraoperatively, tumor was identified along the CHA traveling proximally to the celiac axis. Therefore, a modified Appleby procedure with DP and splenectomy was performed without the need for reconstruction of the CHA. Postoperative specimen pathology showed residual pancreatic ductal adenocarcinoma with marked treatment effects. The pathology confirmed an R0 resection. The patient followed our postpancreatic surgery care pathway. She remains well 7 months postoperatively. Conclusion: A pancreatic body or tail mass encasing the celiac vessels should not be an immediate referral for palliative care. Recent evidence shows that successful R0 resection can be achieved following neoadjuvant therapy. In fact, patients who have undergone a successful modified Appleby procedure show survival outcomes similar to patients with less advanced cancer who underwent standard DP. The modified Appleby procedure used in conjunction with neoadjuvant therapy can achieve complete resection in select patients previously thought to be unresectable.

Laparoscopic pancreatic surgery for benign and malignant disease

Laparoscopic surgery for benign and malignant pancreatic lesions has slowly been gaining acceptance over the past decade and is being introduced in many centres. Some studies suggest that this approach is equivalent to or better than open surgery, but randomized data are needed to assess outcomes. In this Review, we aim to provide a comprehensive overview of the state of the art in laparoscopic pancreatic surgery by aggregating high-quality published evidence. Various aspects, including the benefits, limitations, oncological efficacy, learning curve and latest innovations, are discussed. The focus is on laparoscopic Whipple procedure and laparoscopic distal pancreatectomy for both benign and malignant disease, but robot-assisted surgery is also addressed. Surgical and oncological outcomes are discussed as well as quality of life parameters and the cost efficiency of laparoscopic pancreatic surgery. We have also included decision-aid algorithms based on the literature and our own expertise; these algorithms can assist in the decision to perform a laparoscopic or open procedure.

Progress in treatment of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is a malignant tumor of the digestive system with a high degree of malignancy, accounting for about 90% of cases of pancreatic cancer. It has an occult onset and progresses rapidly, with a poor treatment effect and prognosis. It is one of malignant tumors with the worst prognosis. Surgical resection, as the only effective treatment, can be performed in only 20%-30% of patients, and the average period of survival after surgery is still less than 2 years. The main treatment strategy for PDAC are surgery-based individualized treatment modalities under comprehensive multidisciplinary collaboration. Currently, the therapeutic effect on pancreatic cancer is still not satisfactory. In recent years, various treatments for PDAC is becoming a hot spot of research. This article reviews the progress in the treatment of PDAC in terms of radical surgery, palliative surgery, adjuvant therapy, and other treatment opinions.

Borderline resectable pancreatic cancer

Surgery followed by adjuvant chemotherapy remains the only treatment option for pancreatic ductal adenocarcinoma (PDAC) with the chance of long-term survival. If a radical tumor resection is possible, 5-year survival rates of 20-25% can be achieved. Pancreatic surgery has significantly changed during the past years and resection approaches have been extended beyond standard procedures, including vascular and multivisceral resections. Consequently, borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC), which has recently been defined by the International Study Group for Pancreatic Surgery (ISGPS), has become a controversial issue with regard to its management in terms of upfront resection vs. neoadjuvant treatment and sequential resection. Preoperative diagnostic accuracy to define resectability of PDAC is a keypoint in this context as well as the surgical and interdisciplinary expertise to perform advanced pancreatic surgery and manage complications. The present mini-review summarizes the current state of definition, management and outcome of BR-PDAC. Furthermore, the topic of ongoing and future studies on neoadjuvant treatment which is closely related to borderline resectability in PDAC is discussed.

Pancreatic cancer: current management and treatment strategies

The 5-year survival of patients with pancreatic cancer is poor and, despite oncological advances over the past two decades, has not significantly improved. However, there have been several surgical and oncological advances which have improved morbidity and mortality in surgery and more efficacious chemotherapy regimens, resulting in a better patient experience and an increase in survival by a number of months. Most patients have a tumour at the head of the pancreas and those with resectable disease undergo a pancreaticoduodenectomy, which can be performed laparoscopically. Those who have a pancreatic resection have an increased survival in comparison with those receiving oncological treatment only; however, only a quarter of patients have resectable disease at diagnosis. Some centres are now performing venous resections and/or arterial resections in order to increase the number of patients eligible for curative surgery. Innovative techniques using ablation technologies to downstage tumours for resection are also being investigated. After surgery, all patients should be offered adjuvant gemcitabine-based chemotherapy. Those with locally advanced tumours not suitable for surgery should be offered FOLFIRINOX chemotherapy, after which the tumour may be suitable for surgical resection. The use of radiotherapy in this group of patients is controversial but offered by a few centres. Patients with metastatic disease at diagnosis should also be offered FOLFIRINOX chemotherapy, which can improve survival by a few months. As our knowledge of the tumour biology of pancreatic cancer progresses, a number of new agents targeting specific genes and proteins are under investigation and there is hope that median survival will continue to improve over the next decade.

The learning curve for robotic distal pancreatectomy: an analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre

BACKGROUND

Robotic distal pancreatectomy (RDP) is performed increasingly, but knowledge of the number of cases required to attain procedural proficiency is lacking. The aim of this study was to identify the learning curve associated with RDP at a high-volume pancreatic centre.

METHODS

Metrics of perioperative safety and efficiency for all consecutive RDPs were evaluated. Outcomes were followed to 90 days. Cumulative sum (CUSUM) analysis was used to identify inflexion points corresponding to the learning curve.

RESULTS

Between 2008 and 2013, 100 patients underwent RDP. There was no 90-day mortality. In two patients (2.0%), surgery was converted to laparotomy. Thirty procedures were performed for pancreatic adenocarcinoma. Precipitous operative time reductions from an initial operative time of 331 min were observed after the first 20 and 40 cases to 266 min and 210 min, respectively (P < 0.0001). The likelihood of readmission was significantly lower after the first 40 cases (P = 0.04), and non-significant reductions were observed in incidences of major (Clavien-Dindo Grade II or higher) morbidity and Grade B and C leaks, and length of stay.

CONCLUSIONS

In this experience, RDP outcomes were optimized after 40 cases. Familiarity with the platform and dedicated training are likely to contribute to significantly shorter learning curves in future adopters.

Several key issues in surgical treatment of distal pancreatic cancer

Distal pancreatic cancer is an aggressive malignancy with insidious and subtle presentation, low radical resection rate and poor prognosis. The effectiveness of treatments for this disease remains to be improved. Radical resection is the only curable treatment. Personalized therapeutic strategy with surgical resection as a core should be the standard mode for these patients, and a professional multidisciplinary team is indispensable. Patients with borderline resectable cancers may benefit from a neoadjuvant approach by initiating chemotherapy and/or chemoradiation prior to the resection. Radical antegrade modular pancreatosplenectomy (RAMPS) is designed to establish an operation with oncologic rationales and should be the standard radical resection mode for distal pancreatic cancer. The use of diagnostic laparoscopy can help find hepatic metastases and peritoneal dissemination to avoid an unnecessary open operation. Laparoscopic distal pancreatectomy has many advantages compared with open operation, but is only applicable to early-stage patients with small tumors. In addition, the long-term oncologic effects of this surgical procedure still need to be verified, and it should be carried out selectively. Radical distal (or left) pancreatectomy with resection of the celiac axis (DP-CAR) is proper for some patients with evidence of celiac arterial invasion and should be conducted meticulously. However, new breakthroughs in early diagnosis and genetically personalized therapy are urgently needed. We still need prospective, randomized studies in multicenter institutions to provide more evidence for the neoadjuvant approach and laparoscopic distal pancreatectomy.

Surgical management of pancreatic cancer--distal pancreatectomy

Distal pancreatectomy is the standard procedure for tumors located in the body and tail of the pancreas. In the last three decades, significant progress has been made with regard to technical aspects as well as perioperative care so that excellent mortality and morbidity rates can be achieved. Recently, there is growing evidence that distal pancreatectomy may be performed laparoscopically in selected patients, offering the advantages of minimally invasive surgery. Unfortunately, the oncologic outcomes for pancreatic adenocarcinoma remain poor, in part due to the late stage of presentation in most patients. We review the history of distal pancreatectomy, discuss current indications for performing this procedure, compare operative techniques in performing distal pancreatectomy, and review both the early complications seen in patients who have undergone a distal pancreatectomy and the long-term metabolic and oncologic outcomes of these patients.

Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas

Since the first report on laparoscopic distal pancreatectomy (LDP) appeared in the 1990s, the procedure has been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Many earlier publications have shown LDP to be a good alternative to open distal pancreatectomy for benign lesions, although this has never been studied in a prospective, randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as well established. The purpose of this review is to evaluate the current evidence for LDP in cases of pancreatic adenocarcinoma. We conducted a review of English language publications reporting LDP results between 1990 and 2013. All studies reporting results in patients with histologically proven pancreatic adenocarcinoma were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pancreatic adenocarcinoma (potential double publications were not eliminated). Most LDP procedures are performed in selected cases and generally involve smaller tumors than open distal pancreatectomy (ODP) procedures. Some of the papers report unselected cases and include procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.

Further characterization of HDAC and SIRT gene expression patterns in pancreatic cancer and their relation to disease outcome

Ductal adenocarcinoma of the pancreas is ranking 4 for patient' death from malignant disease in Western countries, with no satisfactory treatment. We re-examined more precisely the histone deacetylases (HDAC) and Sirtuin (SIRT) gene expression patterns in pancreatic cancer with more pancreatic tumors and normal tissues. We also examined the possible relationship between HDAC gene expression levels and long term disease outcome. Moreover, we have evaluated by using an in vitro model system of human pancreatic tumor cell line whether HDAC7 knockdown may affect the cell behavior. We analyzed 29 pancreatic adenocarcinoma (PA), 9 chronic pancreatitis (CP), 8 benign pancreatic (BP) and 11 normal pancreatic tissues. Concerning pancreatic adenocarcinoma, we were able to collect biopsies at the tumor periphery. To assess the possible involvement of HDAC7 in cell proliferation capacity, we have generated recombinant human Panc-1 tumor which underexpressed or overexpressed HDAC7. The expression of HDAC1,2,3,4,7 and Nur77 increased in PA samples at levels significantly higher than those observed in the CP group (p = 0.0160; 0.0114; 0.0227; 0.0440; 0.0136; 0.0004, respectively). The expression of HDAC7, was significantly greater in the PA compared with BP tissue samples (p = 0.05). Mean mRNA transcription levels of PA for HDAC7 and HDAC2 were higher when compared to their counterpart biopsies taken at the tumor periphery (p = 0.0346, 0.0053, respectively). Moreover, the data obtained using confocal microscopy and a quantitative method of immunofluorescence staining strongly support the HDAC7 overexpression in PA surgical specimens. The number of deaths and recurrences at the end of follow up were significantly greater in patients with overexpression of HDAC7. Interestingly, the rate of growth was significantly reduced in the case of cell carrying shRNA construct targeting HDAC7 encoding gene when compared to the parental Panc-1 tumor cells (p = 0.0015) at 48 h and 96 h (p = 0.0021). This study strongly support the notion that HDAC7play a role in pancreatic adenocarcinoma progression.

Splenic artery use for arterial reconstruction in pancreatic surgery

BACKGROUND

Extended resections in the upper GI tract, especially for pancreatic malignancies, can require resection of the hepatic or superior mesenteric artery. Besides venous or allogenous grafting, the splenic artery can be used for reconstruction in both positions.

PURPOSE

We hereby describe the different technical possibilities of interposition or transposition to use the splenic artery for restoration of arterial perfusion of the liver or the small bowel following resection of the hepatic or superior mesenteric artery, respectively.

CONCLUSION

The use of the splenic artery is a convenient and appropriate possibility to reconstruct the hepatic or superior mesenteric artery in pancreatic resection with regard to interposition and especially transposition of this vessel. It should be considered in patients suitable to undergo these procedures to extend resectability in pancreatic cancer surgery.