The role of echo-laparoscopy in intra-operative diagnosis of duodeno-pancreatic diseases

Abstract

Introduction: Laparoscopic inspection before pancreatic surgery for malignancy or benign disease is a widely accepted approach, and has been changing the surgical strategy in 20–50% of the patients, over the last ten years. The addition of intra-operative ultrasound to laparoscopy has recently further refined surgical judgment, allowing accurate definition of mesenteric axis infiltration, presence of enlarged lymphnodes, relationships of pancreatic cysts or nodules to the splenic vessels and Wirsung duct. All this information is vital for successful pancreatic surgery. Materials and methods: We hereby report our experience of 56 cases of pancreatic diseases (malignant n.42, benign n.14) treated at the Dept. of General Surgery, Monaldi Hospital, Naples, Italy, in the years 2002–2007.. Among malignant pathologies, 11 (19.6%) were judged non radically resectable and were scheduled for either palliative surgery, endoscopic or trans-hepatic stenting. All patients were studied with pre-operative ultrasound, triphasic spiral CT, tumor markers. Intra-operative echo-laparoscopy was performed for surgical staging, by means of an Aloka SSD-5500 equipment (Aloka Co. LTD, Tokyo, Japan), provided with linear laparoscopic multifrequency flexible probe. Results: Out of 31 pancreatic tumors selected for radical surgery, 7 (22.6%) were excluded by echo-laparoscopy, either because of mesenteric vein infiltration or for the presence of celiac and/or para-aortic nodes or hepatic micro-metastatic lesions. Among benign pathologies, 5 were pancreatic pseudocysts, 5 cystadenomas (serous n.2, mucinous n.3), 2 insulinomas, and 2 duodenal GIST. In all these cases echo-laparoscopy gave relevant information on anatomic relationships of the lesions to splenic vessels and Wirsung duct, allowing guidance for intra-operative fluid aspiration in 3 pseudocysts and 2 cystadenomas. In the 2 cases of duodenal tumors it defined resectability as related to Vater papilla. Conclusions: In our experience echo-laparoscopy determined surgical attitude in 11 patients (19.6%), including 7 non resectable malignant tumors, 2 insulinomas and 2 GIST tumors; it confirmed resectability in 24 malignancies (42.8%) and helped to better define diagnosis in 5 pseudocysts and 5 cystadenomas.