A Modification of Radical Antegrade Modular Pancreatosplenectomy for Adenocarcinoma of the Left Pancreas: Significance of En Bloc Resection Including the Anterior Renal Fascia

Abstract

BackgroundRadical antegrade modular pancreatosplenectomy (RAMPS) has theoretical advantages for curative resection of adenocarcinomas of the left pancreas. The anterior renal fascia is a key structure, and resection planes should run posterior to this fascia. However, it is difficult to delineate this fascia and set a precise dissection plane. We modified RAMPS to achieve such a precise dissection plane with ease.MethodsAfter clamping the splenic artery, the third duodenal portion was mobilized from the left to the right to locate the inferior vena cava, which was covered by the anterior renal fascia. Here, the anterior renal fascia was incised while approaching the dissection plane. Dissection then continued cephalad, with this plane along the inferior vena cava, and then turned along the left renal vein at the confluence of the left renal vein toward the renal hilum. At this point, dissection continued along the coronal plane to the superior edge of the pancreas.ResultsBetween July 2007 and December 2012, a total of 24 pancreatic adenocarcinoma patients underwent modified RAMPS. Tumor extension beyond the pancreatic parenchyma (T3) and lymph node metastases was confirmed in 17 and 13 cases, respectively. Histologically clear surgical margins were achieved (R0 resection) in 21 patients (88 %). The 5-year overall survival rate was 53 %. Six patients survived for over 5 years without recurrence.ConclusionsThis modification of RAMPS is advantageous for en bloc resection while actually including removal of the anterior renal fascia. It is associated with satisfactory survival rates for patients with distal pancreatic carcinomas.

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

“…The current survival results are probably very close to the true population results. Although there are a number of reports regarding survival in patients having RAMPS for adenocarcinoma , there are not yet other reports of 5‐year survival in 50 or more patients. Murakawa et al reported 3‐year survival of 38.6% in 49 patients .…”

“…RAMPS is a right‐to‐left operation, whereas laparoscopic abdominal surgery seems best suited for inferior to superior dissection. Modifications described by Rosso et al and Kitagawa et al to facilitate exposure of the left renal vein in the open procedure may aid the laparoscopic approach. Laparoscopic anterior RAMPS seems to provide the usual benefits of laparoscopy and should be explored further especially in thin patients .…”

“…Three prior studies have been published by our group covering these issues and long term outcome of RAMPS for adenocarcinoma . A number of articles by other groups using the RAMPS approach have been published as well . The purpose of this study is to present a larger group of patients and thus more reliable data on the outcomes of RAMPS for pancreatic adenocarcinoma especially the tangential margin status, node clearance and long term survival.…”

Neoadjuvant chemotherapy with gemcitabine‑based regimens improves the prognosis of node positive resectable pancreatic head cancer

“…Although the advent of nab-paclitaxel (nab-PTX) plus gemcitabine (GEM) therapy (GnP therapy) and 5-FU, leucovorin, irinotecan and oxaliplatin (FOLFIRINOX) therapy improved treatment outcome of unresectable PDAC (3,4), surgery is the only method to achieve long-term survival. Curative (R0) resection comprising wide lymph node dissection and complete removal of the extrapancreatic nerve plexus of the superior mesenteric artery (SMA) or celiac axis (5)(6)(7)(8)(9)(10) has been shown to be one of the key factors influencing survival of patients with PDAC. However, even in patients who undergo resection, 5-year survival is poor at <30% and the prognosis of PDAC has not improved.…”

Neoadjuvant chemotherapy for pancreatic cancer: Effects on cancer tissue and novel perspectives

“…Indeed, even in patients who undergo resection, the 5-year survival rate is poor at between 7 and 24%, whereas the median survival time is ~1 year in the majority of series, indicating that surgery alone is inadequate. A number of surgeons have attempted radical pancreatic resection, comprising wide lymphadenectomy and removal of the extrapancreatic nerve plexus, to improve outcomes (6)(7)(8)(9)(10). However, no improvement in the prognosis of pancreatic cancer has been achieved.…”