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

<b>Introduction</b>: 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. <b>Methods</b>: 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. <b>Results</b>: 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%, <i>p</i> = 0.484; median lymph node yield: MI 16 (IQR 10-23) vs. open 19 (IQR 15-25), <i>p</i> = 0.314). Two-year overall survival was also comparable (MI: 71.6% vs. open: 66.4%, <i>p</i> = 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 (<i>p</i> = 0.093) and likelihood of receiving adjuvant chemotherapy (<i>p</i> = 0.075). <b>Conclusions</b>: 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.