Evaluating the efficacy of laparoscopic radical antegrade modular pancreatosplenectomy in selected early-stage left-sided pancreatic cancer: a propensity score matching study

Abstract

Background: Laparoscopic radical pancreatectomy is safe and beneficial for recectable pancreatic cancer, but the extent of resection for early-stage tumors remains controversial.

Methods: Consecutive patients with left-sided pancreatic cancer who underwent either laparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS, n = 54) or laparoscopic distal pancreatosplecnectomy (LDP, n = 131) between October 2020 and December 2022 were reviewed. The preoperative radiological selection criteria were as follows: (1) tumor diameter ≤ 4 cm; (2) located ≥ 1 cm from the celiac trunk; (3) didn't invade the fascial layer behind the pancreas.

Results: After 1:1 propensity score matching (LRAMPS, n = 54; LDP, n = 54), baseline data were well-balanced with no differences. LRAMPS resulted in longer operation time (240.5 vs. 219.0 min, P = 0.020) and higher intraoperative bleeding volume (200 vs. 150 mL, P = 0.001) compared to LDP. Although LRAMPS harvested more lymph nodes (16 vs. 13, P = 0.008), there were no statistically significant differences in lymph node positivity rate (35.2% vs. 33.3%), R0 pancreatic transection margin (94.4% vs. 96.3%), and retroperitoneal margin (83.3% vs. 87.0%) rate. Postoperative complications did not significantly differ between the two groups. However, LRAMPS was associated with increased drainage volume (85.0 vs. 40.0 mL, P = 0.001), longer time to recover semi-liquid diet compared to LDP (5 vs. 4 days, P < 0.001) and increased daily bowel movement frequency. Tumor recurrence pattern and recurrence-free survival were comparable between the two groups, but the adjuvant chemotherapy regimens varied, and the completion rate of the 6-month intravenous chemotherapy was lower in the LRAMPS group compared to the LDP group (51.9% vs. 75.9%, P = 0.016).

Conclusions: LRAMPS did not provide oncological benefits over LDP for left-sided pancreatic cancer within the selection criteria, but it increased operation time, intraoperative bleeding, and postoperative bowel movement frequency. These factors impacted the regimen selection and completion of adjuvant chemotherapy, consequently compromising the potential benefits of LRAMPS in achieving better local control.

Keywords: Early-stage tumor; Laparoscopic distal pancreatosplecnectomy; Laparoscopic radical antegrade modular pancreatosplenectomy; Left-sided pancreatic cancer; Oncologic prognosis; Surgical complication.

Fig. 1

Preoperative CT images of left-sided PDAC meeting the selection criteria and the extent of surgical resection under laparoscopy. A and B Preoperative CT images (A) of a pancreatic tail cancer meeting the selection criteria and the corresponding surgical field after laparoscopic distal pancreatectomy (B); C and D: Preoperative CT images (C) of a pancreatic tail cancer meeting the selection criteria and the corresponding surgical field after laparoscopic radical antegrade modular pancreatosplenectomy (D). CT Computed tomography, PDAC pancreatic ductal adenocarcinoma

Fig. 2

Flow chart of the study. PDAC Pancreatic ductal adenocarcinoma, LRAMPS laparoscopic radical antegrade modular pancreatosplenectomy, LDP laparoscopic distal pancreatosplecnectomy. *: only the main reason for exclusion is presented

Fig. 3

Recurrence-free survival for left-sided PDAC meeting the selection criteria. A Recurrence-free survival of the PSM cohort, B recurrence-free survival between LRAMPS and LDP patients. PDAC Pancreatic ductal adenocarcinoma, LRAMPS laparoscopic radical antegrade modular pancreatosplenectomy, LDP laparoscopic distal pancreatosplecnectomy