BACKGROUND: 'Shoulder' pancreatic cancer is a challenging situation owing to its close proximity to the branches of the celiac artery and portal vein (PV). A pioneering study demonstrated the feasibility of retrograde artery first approach pancreatosplenectomy (RAFAPS) in treating 'shoulder' pancreatic cancer. However, comparative studies on this topic are lacking. METHODS: In this single-centre cohort study, we retrospectively enrolled consecutive 'shoulder' pancreatic cancer cases from September 2019 to May 2023. Based on propensity score-matching analysis, we compared the safety and short-term oncological outcomes between RAFAPS and radical antegrade modular pancreatosplenectomy (RAMPS) for 'shoulder' pancreatic cancers. The primary outcome was a negative retroperitoneal margin rate. RESULTS: In total, 135 (17.0%) 'shoulder' pancreatic cancers were identified among 794 pancreatic cancers during the study period. After matching based on body mass index, tumour size, distance from the right edge of the tumour to the left wall of the PV, and neoadjuvant chemotherapy, a cohort of 78 patients was selected for analysis (1:1 match, 39 per group). Invasion of splenic vein, splenic artery and PV were found in 40 (51.3%), 28 (35.9%) and 23 (29.5%) patients, respectively. RAFAPS was associated with a higher rate of negative retroperitoneal margins (100% vs 84.6%
relative risk = 1.18, 95% confidence interval [CI]: 1.034-1.351
P = 0.025) and less estimated blood loss (150 vs 300 ml
estimated difference: - 100 ml, 95% CI: - 200-0
P = 0.039) when compared to that of RAMPS. CONCLUSION: RAFAPS is a safe and effective alternative to RAMPS for managing 'shoulder' pancreatic cancers in a minimally invasive era, with decreased blood loss and favourable retroperitoneal margin.