What is Radical Antegrade Modular Pancreato-Splenectomy (RAMPS)?

From the Guidelines

Radical Antegrade Modular Pancreato-Splenectomy (RAMPS) is recommended for patients with tumors in the body or tail of the pancreas, as it ensures R0 resection and improves oncological outcomes. This procedure involves removing the distal portion of the pancreas along with the spleen in a manner that follows embryological planes and allows for more complete lymph node dissection 1. RAMPS differs from traditional distal pancreatectomy by approaching the pancreas from right to left (antegrade) rather than left to right, and by including a more extensive removal of regional lymph nodes and surrounding tissues.

Key Points

• The location and size of the tumor determine the type of surgery, with RAMPS being suitable for tumors in the body or tail of the pancreas 1.
• Dissection of the left hemi-circumference of the SMA to the left of the coeliac trunk is recommended to ensure R0 resection 1.
• The International Study Group of Pancreatic Surgery has recommended adhering to the guidelines of the British Royal College of Pathologists for specimen examination and microscopic tumor at the margin (R1) definition (i.e. margin <1 mm) 1.
• Minimally invasive techniques can reduce the morbidity of pancreatectomies, but data relating to these techniques are insufficient, particularly in relation to oncological results, and therefore open surgery remains the standard of care 1.

Recommendations

• RAMPS is recommended for patients with tumors in the body or tail of the pancreas 1.
• Standard lymphadenectomy is recommended and should involve the removal of 16 lymph nodes to allow adequate pathological staging of the disease 1.
• Patients undergoing surgery should receive perioperative thromboprophylaxis with either unfractionated heparin or low-molecular-weight heparin (LMWH), unless contraindicated 1.

From the Research

Overview of Radical Antegrade Modular Pancreato Splenectomy (RAMPS)

• RAMPS is a surgical procedure used to treat pancreatic cancers involving the body and tail of the pancreas 2.
• The procedure has been shown to have promising results in enhancing microscopically negative tangential resection margins and lymph node yield 2, 3.

Comparison with Standard Procedures

• Studies have compared RAMPS with standard retrograde pancreatosplenectomy (SRPS) and conventional distal pancreatectomy (DP) 4, 5, 6.
• RAMPS has been found to be correlated with higher R0 resection rates and successful harvest of more lymph nodes compared to standard procedures 5.
• However, no statistically significant difference was found between RAMPS and standard procedures with respect to recurrence rates, overall survival (OS), or disease-free survival (DFS) 5, 6.

Outcomes and Survival Rates

• The R0 resection rate for RAMPS has been reported to be as high as 87.7% 2.
• The 3-year OS and DFS for distal pancreatic cancers treated with RAMPS were 56% and 38%, respectively 2.
• Multivariate analysis has shown that R0 resection significantly improves disease-free survival for pancreatic cancer 2.

Future Studies and Trials

• A multicenter, prospective, randomized phase III control trial (CSPAC-3) is proposed to compare the effect of RAMPS and SRPS on patient survival and preoperative safety 4.
• The trial aims to explore the optimal surgical strategy for improving the prognosis and OS of patients with left-sided pancreatic cancer 4.