Laparoscopic versus open radical antegrade modular pancreatosplenectomy for pancreatic cancer: a single-institution comparative study

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.

Robotic Versus Laparoscopic Versus Open Surgery for Non-Metastatic Pancreatic Neuroendocrine Tumors (pNETs): A Systematic Review and Network Meta-Analysis

Background: This systematic review, using pairwise and network meta-analyses, aimed to compare the intraoperative, short-term, and long-term postoperative outcomes of minimally invasive surgery (MIS) and open surgery (OS) for the management of pancreatic neuroendocrine tumors (pNETs). Methods: Studies reporting on the effects of robotic, laparoscopic, and open surgery on pNETs published before November 2023 on PubMed, Scopus, and CENTRAL were analyzed. Results: Thirty-two studies with 5379 patients were included in this review, encompassing 2251 patients undergoing MIS (1334 laparoscopic, 508 robotic, and 409 unspecified MIS) and 3128 patients undergoing OS for pNETs management. Pairwise meta-analysis revealed that the MIS group had a significantly shorter length of hospital stay ((a low certainty of evidence), MD of -4.87 (-6.19 to -3.56)); less intraoperative blood loss ((a low certainty of evidence), MD of -108.47 (-177.47 to -39.47)); and decreased tumor recurrence ((a high certainty of evidence), RR of 0.46, 95% CI (0.33 to 0.63)). Subgroup analysis indicated a higher R0 resection rate and prolonged operative time for laparoscopic surgery than for OS. The network meta-analysis ranked the robotic approach as superior in terms of the length of hospital stay, followed by the laparoscopic and OS arms. Furthermore, it favored both MIS approaches over OS in terms of the R0 resection rate. No significant differences were found in severe postoperative complications, postoperative fistula formation, mortality, readmission, reoperation, or conversion rates. Conclusions: This review supports the safety of MIS for the treatment of pNETs. However, the varying certainty of evidence emphasizes the need for higher-quality studies.

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

PURPOSE

The aim of this study was to establish whether laparoscopic RAMPS (L-RAMPS) is a safe procedure with better oncological outcomes compared to laparoscopic distal pancreatectomy (LDP) with splenectomy among patients with distal pancreatic ductal adenocarcinoma (PDAC).

METHODS

This is a retrospective study performed on consecutive patients who underwent L-RAMPS and LDP with splenectomy for resectable or borderline resectable PDAC of the body and tail. In this paper, we presented our technique of laparoscopic RAMPS and analyzed intraoperative and perioperative complications, oncological efficacy, and long-term survival.

RESULTS

The study included 12 patients in the L-RAMPS group and 13 patients in the LDP with splenectomy. L-RAMPS was associated with significantly higher rates of R0 resection (91.7% vs. 69.2%, p = 0.027). There were no differences between the L-RAMPS and LDP with splenectomy groups in intraoperative blood loss (400 mL vs 400 mL, p = 0.783) and median operative time (250 min vs 220 min, p = 0.785). No differences were found in terms of perioperative complications, including the incidence of pancreatic fistula.

CONCLUSION

Laparoscopic RAMPS is a feasible and safe procedure. It provides higher radicality as compared with LDP with splenectomy, without increasing the risk of complications. Further studies are necessary to evaluate long-term outcomes.

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.

Comparison of laparoscopic versus open radical antegrade modular pancreatosplenectomy for pancreatic cancer: A systematic review and meta-analysis

BACKGROUND

Laparoscopic radical antegrade modular pancreatosplenectomy (l-RAMPS) provides a new surgical approach for patients with pancreatic cancers of the body and tail. However, whether it can achieve comparable outcomes to the open RAMPS (o-RAMPS) remains an issue.

METHODS

To evaluate the safety and effectiveness of l-RAMPS, the studies in the databases of Medline, Embase, and the Cochrane Library published before September 13, 2021 were searched and a meta-analysis was performed using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. The perioperative and oncological outcomes were analyzed.

RESULTS

Five retrospective cohorts involving 189 patients were included for final pooled analysis. There were no significant differences in the patients' operation time, intra-abdominal bleeding rate, intra-abdominal infection rate, mild morbidity (Clavien-Dindo classification = 1), moderate to severe morbidity (Clavien-Dindo classification ≥2), overall morbidity, wound infection rate, pancreatic fistula rate, delayed gastric emptying rate, reoperation rate, length of hospital stay, postoperative mortality, R0 resection rate, and 2-year overall survival between the 2 approaches. Besides, l-RAMPS was associated with less blood loss (mean difference (MD) = -232.69, 95% confidence interval (CI) = -316.93 to -148.46, P < 0.00001) and shorter days until oral feeding (MD = -0.79, 95% CI = -1.35 to -0.22, P = 0.006). However, the pooled analysis also indicated a significantly fewer lymph nodes dissected (MD = -3.01, 95% CI = -5.59 to -0.43, P = 0.02) in l-RAMPS approach.

CONCLUSIONS

Although l-RAMPS provides similar outcomes associated with benefits of minimal invasiveness compared to o-RAMPS, it harvested significantly fewer lymph nodes which might have potentially negative influence on the patients' long-term survival. L-RAMPS is still in the infancy stage and further investigation is needed to verify its feasibility.

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.