Ten years of experience with resection of left-sided pancreatic ductal adenocarcinoma: evolution and initial experience to a laparoscopic approach

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Abstract
With increasing laparoscopic experience, laparoscopic distal pancreatectomy with or without splenectomy is being regarded as a safe and effective treatment for benign and borderline malignant lesions of the pancreas; however, its application for left-sided pancreatic ductal adenocarcinoma (PDAC) is still debatable. We analyzed patients who underwent conventional distal pancreatectomy with splenectomy (DPS) for distal pancreatic cancer at our institution. We have performed laparoscopic DPS partly based on radical antegrade modular pancreatosplenectomy (RAMPS) for well-selected left-sided PDAC since 2007. We compared laparoscopic DPS to conventional DPS according to various clinicopathologic factors. From January 1999 to December 2008, 45 patients underwent conventional DPS for resectable left-sided PDAC, and 18 needed combined adjacent organ resection for potential margin negative (R0) resection. The median survival of resected left-sided PDAC was 27.9 months with a 5-year survival of 28.9%. A small amount of intraoperative bleeding [≤760 ml Exp(β) = 6.312, p = 0.001] and R0 resection [Exp(β) = 4.349, p = 0.090] were the most significant prognostic factors. To achieve bloodless and R0 resection, the potential indication for laparoscopic DPS was suspicious pancreatic cancer confined to the pancreas that could be removed by DPS without resection of the adjacent organs. Five patients underwent laparoscopic/robot-assisted DPS for left-sided PDAC. Compared to conventional DPS, only the operation time (p = 0.011) and tumor size (p = 0.031) were significantly different, but other clinicopathologic variables were comparable. All patients still are alive. Four patients have lived without tumor recurrence (follow-up = 4–22 months), and only one experienced multiple liver metastasis and subsequent retroperitoneal local recurrence. Laparoscopic/robot-assisted modified anterior RAMPS may be technically feasible for well-selected PDAC. The oncologic feasibility still remains to be determined due to limited experience.