Advantages of staging laparoscopy in gastric cancer: they are so obvious that they are not evident.

Abstract

1st Division of General Surgery, Department of Human Morphology & Surgical Sciences, Insubria University Varese-Como, Italy Department of General Surgery, Ioannina University Hospital, Centre for Biosystems & Genomic Network Medicine, Ioannina University, Ioannina, Greece *Author for correspondence: stefano.rausei@ospedale.varese.it Gastric cancer is the second most common cause of cancer death and it often presents in an advanced stage at the time of diagnosis. As treatment strategies are different for metastatic and locally advanced disease, the importance of an accurate preoperative staging is evident, especially in the era of tailored treatment. Although several improvements in radiologic imaging have occurred, extraserosal invasion, nodal involvement, peritoneal carcinomatosis and small liver metastases still are unexpected findings at the time of laparotomy. Abdominal ultrasound has a good sensitivity in detecting liver metastases with an accuracy around 53 and 76% [1], but its sensitivity significantly decreases (20%) for lesions 1 cm [2]. Finally, FDG-PET has a low resolution (4–5 mm), which limits its sensitivity in defining both nodal i nvolvement and primary tumor depth [4]. Staging laparoscopy is a minimally invasive surgical approach performed in order to evaluate the intra-abdominal involvement of disease and it is indicated in patients who have gastric cancer with no distant metastases detected on optimal pre-operative imaging. This technique enables the de visu appreciation of intraabdominal organs on their surface areas. What is more, it facilitates the bioptic harvesting, it allows free peritoneal fluid withdrawal for cytologic examination (mandatory according to the new TNM edition [5]) and it enables the use of laparoscopic ultrasounds, which has been shown to potentially further increase the accuracy of T and M parameter definition [6–9]. Technically, this minimally invasive technique is carried out during general anesthesia. It can also be performed immediately before gastrectomy. The patient position is supine (we usually perform a peri-umbilical open technique approach to the abdominal cavity). A 10‐mm trocar is introduced under the umbilical scar in order to access the abdominal cavity. Additionally, a 30° scope is introduced in order to get a clear and wide de visu assessment of the supramesocolic region. The ‘inverted TNM mode’ should be applied when this surgical procedure is performed [10]. In particular, any potential ascitic fluid must be totally harvested for immediate “...in the era of tailored treatment, the basis of optimized therapies is the correct evaluation of tumor spread and exact staging...”