Current status and future perspectives of minimally invasive and open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma: a review

Radical antegrade modular pancreatosplenectomy (RAMPS) is a commonly used standardized technique to obtain sufficient tangential retroperitoneal resection margins for left-sided pancreatic ductal adenocarcinoma (PDAC) during open surgery. Despite recent developments in minimally invasive (MI) surgery, evidence of MI RAMPS over open RAMPS for PDAC is still lacking. Although the recent Miami International Evidence-based Guidelines on MI Pancreas Resection have stated that MI distal pancreatectomy for PDAC appears to be a safe, feasible, and oncologically efficient, there has been no statement regarding the adoption of RAMPS for PDAC. Herein, we review the current evidence of RAMPS for left-sided PDAC, focusing on the comparison between MI and open RAMPS. Indications and patient selection should be carefully determined, especially when performing MI RAMPS. Although data on MI RAMPS over open RASMPS are limited, the safety and feasibility of MI RAMPS have been reported from retrospective series. Considering favorable outcomes following MI RAMPS compared with open RAMPS, the use of MI RAMPS should be expanded in well-selected patients with PDAC. However, further high-level evidence is needed to confirm the efficacy of MI and open RAMPS for PDAC. The results of current ongoing randomized controlled trials investigating the efficiency of MI RAMPS may determine the future direction of RAMPS for PDAC.