title: A modification of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the left pancreas: significance of en bloc resection including the anterior renal fascia.
abstract: BACKGROUND
  Radical antegrade modular pancreatosplenectomy (RAMPS) has theoretical advantages for curative resection of adenocarcinomas of the left pancreas. The anterior renal fascia is a key structure, and resection planes should run posterior to this fascia. However, it is difficult to delineate this fascia and set a precise dissection plane. We modified RAMPS to achieve such a precise dissection plane with ease.
  
  
  METHODS
  After clamping the splenic artery, the third duodenal portion was mobilized from the left to the right to locate the inferior vena cava, which was covered by the anterior renal fascia. Here, the anterior renal fascia was incised while approaching the dissection plane. Dissection then continued cephalad, with this plane along the inferior vena cava, and then turned along the left renal vein at the confluence of the left renal vein toward the renal hilum. At this point, dissection continued along the coronal plane to the superior edge of the pancreas.
  
  
  RESULTS
  Between July 2007 and December 2012, a total of 24 pancreatic adenocarcinoma patients underwent modified RAMPS. Tumor extension beyond the pancreatic parenchyma (T3) and lymph node metastases was confirmed in 17 and 13 cases, respectively. Histologically clear surgical margins were achieved (R0 resection) in 21 patients (88 %). The 5-year overall survival rate was 53 %. Six patients survived for over 5 years without recurrence.
  
  
  CONCLUSIONS
  This modification of RAMPS is advantageous for en bloc resection while actually including removal of the anterior renal fascia. It is associated with satisfactory survival rates for patients with distal pancreatic carcinomas.
authors.affiliation: Department of Gastroenterologic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara machi, Kanazawa, 920-8641, Japan, kitagawa@staff.kanazawa-u.ac.jp.
authors.forename: Hirohisa
authors.initials: H
authors.lastname: Kitagawa
authors.forename: Hidehiro
authors.initials: H
authors.lastname: Tajima
authors.forename: Hisatoshi
authors.initials: H
authors.lastname: Nakagawara
authors.forename: Isamu
authors.initials: I
authors.lastname: Makino
authors.forename: Tomoharu
authors.initials: T
authors.lastname: Miyashita
authors.forename: Hirofumi
authors.initials: H
authors.lastname: Terakawa
authors.forename: Shinichi
authors.initials: S
authors.lastname: Nakanuma
authors.forename: Hironori
authors.initials: H
authors.lastname: Hayashi
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Takamura
authors.forename: Tetsuo
authors.initials: T
authors.lastname: Ohta
mesh_terms: D000230:Adenocarcinoma / Q000556:secondary / Q000601:surgery*; D000368:Aged; D000369:Aged, 80 and over; D004210:Dissection / Q000009:adverse effects / Q000379:methods; D000071938:Fasciotomy; D005260:Female; D006801:Humans; D007668:Kidney / Q000601:surgery*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000209:etiology*; D018365:Neoplasm, Residual; D010180:Pancreatectomy / Q000009:adverse effects / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D013156:Splenectomy / Q000009:adverse effects / Q000379:methods*; D015996:Survival Rate
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