# Minimally Invasive Versus Open Radical Antegrade Modular Pancreaticosplenectomy (RAMPS): A Multicenter Cohort Study on Surgical Radicality and Postoperative Outcomes

## TL;DR

This study compares minimally invasive and open RAMPS surgeries for pancreatic cancer, finding similar outcomes with potential benefits for the minimally invasive approach.

## Contribution

The study provides evidence of oncologic equivalence between minimally invasive and open RAMPS surgeries.

## Key findings

- Both surgical approaches achieved similar R0 tumor resection rates and lymph node yields.
- Postoperative outcomes at 90 days were comparable between the two approaches.
- Minimally invasive RAMPS showed non-significant trends toward shorter hospital stays and higher adjuvant chemotherapy rates.

## Abstract

We present our experience in the procedure of minimally invasive (MI) and open Radical Antegrade Modular Pancreatosplenectomy (RAMPS). For the resection of pancreatic ductal adenocarcinoma (PDAC), both surgical approaches produce similar results regarding R0 tumor resection rates and lymph node yields. Postoperative outcomes at 90 days are similar, even when non-PDAC patients are included in the analysis. The MI approach may be favored due to a shorter median length of stay and a higher probability of receiving adjuvant chemotherapy, although these differences are not statistically significant.

Introduction: Radical Antegrade Modular Pancreatosplenectomy (RAMPS) was developed to improve surgical radicality for left-sided pancreatic ductal adenocarcinoma (PDAC). Although widely accepted, the optimal surgical approach—open versus minimally invasive (MI)—is still being debated. Methods: We conducted a multicenter retrospective cohort study across three Austrian centers, including all patients undergoing RAMPS between 2016 and 2023 indicated for suspected (pre-)malignant pancreatic lesions. Patients were grouped based on the surgical approach (MI vs. open). The primary endpoints were resection margin status and lymph node yield following PDAC resection. Secondary outcomes included survival for PDAC patients and postoperative complications; non-PDAC resections were also taken into account. Results: A total of 57 patients were included, of whom 34 had PDAC. In PDAC patients, the rate of tumor-free margins and the median lymph node yield were equivalent between the MI and open approaches (R0 rate: MI 92.9% vs. open 85%, p = 0.484; median lymph node yield: MI 16 (IQR 10–23) vs. open 19 (IQR 15–25), p = 0.314). Two-year overall survival was also comparable (MI: 71.6% vs. open: 66.4%, p = 0.479). Postoperative outcomes at 90 days, like CR-POPF and major complications (Clavien–Dindo ≥ IIIa), did not differ between the two approaches. MI-RAMPS showed non-significant favorable trends in median length of stay (p = 0.093) and likelihood of receiving adjuvant chemotherapy (p = 0.075). Conclusions: In our experience, MI-RAMPS demonstrates oncologic equivalence and similar early postoperative outcomes to open RAMPS, with potential advantages such as shorter length of stay and likelihood of receiving adjuvant chemotherapy.