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MODIFIED RADICAL ANTEGRADE MODULAR PANCREATOSPLENECTOMY: METHODOLOGY AND INITIAL RESULTS Zipeng Lu*, Kuirong Jiang, Jianmin Chen, Feng Guo, Jishu Wei, Yi Miao Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China Objective: Radical antegrade modular pancreatosplenecotomy (RAMPS) has been reported to increase the chance of R0 resection as well as long-term survival. However, the range of lymph node dissection as well as the clearance of perivascular connective tissue have been poorly defined in literature. We aim to propose a modified RAMPS procedure to achieve better oncological results. Method: Our modifications for RAMPS targeted at the following key points: 1. An extended range of lymphadenectomy including No.7 (proximal), 8, 9, 10, 11, 12a/p, 14 (left-sided), 16a1/a2/b1 lymph node (LN) station; 2. A radical clearance of the perivascular connective tissue at common hepatic artery (CHA), beginning of left gastric artery (LGA), the left side of celiac trunk (CT) and left side of superior mesentery artery (SMA), especially at the "triangular area" between the origin of CT, SMA and aorta. Results: From December 2015 to July 2017, a total of 11 patients underwent modified RAMPS in our institute. There were 7 male and 4 female patients, with a median age of 61(59.5, 69.5) year old. All procedures were carried out as open surgery. There were 3 cases of anterior approach, and 8 posterior approach in our cohort. Combined modified Appleby's procedure were carried out in 3 cases. Median surgical time was 245(237, 295) min, and 4 patients (36.4%) received blood transfusion with a median 2.5U of packed RBC. Postoperative morbidity occurred in 8 patients (72.7%), with the highest incidence of grade B pancreatic fistula in 6 patients (54.5%), and delayed gastric emptying in 2 (18.2%). Hemorrhage and mortality were nil. The postoperative hospital stay was 11(11,18) days. All cases were T4 tumor with a median diameter of 4(3.25, 4.5) cm, were classified as stage III with 8th AJCC TNM staging system. R0 resection was achieved in 6 patients (54.5%), and R0 rate at posterior tangential margin was 72.7%. N stage were positive in 9 cases (81.8%), with 4 cases of positive No.16 LN station and 2 of No.8. Conclusion: Modified RAMPS can be safely applied in our cohort, while extended LN dissection should be emphasized in radical resection for pancreatic body-tail adenocarcinoma.
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