Standard Distal Pancreatectomy Versus Radical Antegrade Modular Pancreatosplenectomy: A Systematic Review and Meta-Analysis of the Literature.

Abstract

Distal pancreatectomy is the current standard treatment for resectable distal pancreatic tumours. Radical antegrade modular pancreatosplenectomy (RAMPS) introduced a novel approach for resection to improve post-operative outcomes by optimising visualisation and vascular control through a medial-to-lateral dissection technique. This meta-analysis aims to comprehensively evaluate perioperative aspects and post-operative outcomes associated with RAMPS and standard distal pancreatectomy (SDP). A systematic literature search was conducted in PubMed, MEDLINE, Cochrane Library and Google Scholar from January 1, 2003, to August 31, 2025, using the MeSH terms 'distal pancreatectomy' and 'Radical Antegrade Modular Pancreatosplenectomy'. Eligible studies, including randomised controlled trials, cohort studies, and prospective studies, were selected for comparison using RevMan 5.3 (The Cochrane Collaboration, London, England, UK). Outcomes, such as operative time, intraoperative blood loss, length of hospital stay, lymph node yield, complications, residual margins, and recurrence, were analysed with 95% CIs, using a random-effects model. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis or PRISMA guidelines. Thirteen studies met the inclusion criteria involving a total of 2755 patients (1507 in the SDP group and 1248 in the RAMPS group). Our analysis revealed no statistically significant differences in length of hospital stay (mean difference (MD): 4.69 days; 95% CI: -2.30, 11.68), complications (OR: 1.21; 95% CI: 0.53, 2.77), or recurrence rates (OR: 1.47; 95% CI: 0.98, 2.23) between RAMPS and SDP. However, RAMPS demonstrated reduced operative time (MD: 60.44 minutes; 95% CI: 55.67, 65.20), intraoperative blood loss (MD: 197.13 millilitres; 95% CI: 169.56, 224.70), a higher number of harvested lymph nodes (MD: -5.91 lymph nodes; 95% CI: -8.17, -3.66), and achievement of R0 resection (OR: 0.51; 95% CI: 0.29, 0.88). This systematic review and meta-analysis demonstrates that RAMPS and SDP yield largely comparable perioperative and early oncological outcomes in patients with resectable distal pancreatic tumours. While overall complication rates, length of hospital stay, and recurrence were similar between the two techniques, RAMPS was associated with favourable intraoperative metrics, including shorter operative time, reduced blood loss, a greater lymph node yield, and higher rates of R0 resection. These findings suggest that RAMPS may offer technical and oncological advantages in selected patients; however, the current evidence is predominantly derived from non-randomised studies. Well-designed, adequately powered randomised controlled trials are required to confirm these potential benefits and to better define the role of RAMPS in the surgical management of distal pancreatic tumours.