Use Of Staging Laparoscopy Research Articles

OGC P47 Yield of staging laparoscopy in upper GI cancer; post COVID

Abstract Background Staging laparoscopy is a useful adjunct in preoperative staging process of oesophago-gastric cancer. NICE recommends use of staging laparoscopy in oesophageal cancer cases where it is likely to guide further management. In cases of gastric cancer there is strong evidence to suggest a high specificity of staging laparoscopy in detection of peritoneal metastasis. During COVID very selective use of staging laparoscopy was adopted by our unit. In this study we aimed to evaluate yield of staging laparoscopy in context of gastric and selective oesophageal cancers in our unit during post-COVID period Methods Retrospective analysis of our prospectively kept database in patients undergoing staging laparoscopy between January 2022 to May 2023 in upper GI tertiary cancer centre was performed. Age, sex, tumour grade, nodal status on radiology, histologic type, differentiation, and site of tumour was assessed against positive cytology and presence of peritoneal or occult visceral metastasis. Multivariate logistic regression was applied to identify independent factors associated with findings. Statistical analysis was carried out using EXCEL® and MedCalc® software. Results Among 104 patients, 69 had oesophageal cancer (OC) and 35 had gastric cancer (GC). In OC group cytology was positive in 4 (5.8%), peritoneal metastasis was present in 7 (10.1%) patients. In GC group positive cytology in 8 (22.8%), peritoneal metastasis was found in 8 (22.8%) patients. On multivariate analysis differentiation, T3+ tumour, lower third cancer, male sex was linked with positive findings in OC group. In GC group poor differentiation, T4 disease, mid body tumour, nodal status of N3 were associated positive findings. Yield of laparoscopy was found to be 17.6% and 34.6% in OC and GC groups respectively. Conclusions Despite of recent advances in radiological modalities, staging laparoscopy remains a useful adjunct in diagnosing peritoneal disease. With negligible complication rates and its relatively high yield in lower third and junctional oesophageal cancer it can be utilised to guide further management and reduce unnecessary laparotomies. Mid gastric body site and T4 cancers in our cohort were strong predictors of peritoneal disease further multi centre research on site of tumour is needed to affirm any such association.

62: WHICH GASTRIC CANCER PATIENTS COULD BENEFIT FROM STAGING LAPAROSCOPY? A GIRCG MULTICENTER COHORT STUDY

Abstract Background and aim Staging laparoscopy is an important step of the staging of gastric cancer patients, however, its indication are universally accepted by the different guidelines.This study aimed to define those factors which could help in defining the most appropriate use of staging laparoscopy in a western population. Methods A retrospective cohort study was carried out, including 330 (226 cM- and 104 cM+) gastric cancer patients who had undergone staging laparoscopy between 2010–2020 in seven GIRCG centers. A model including easily-accessible clinical, biochemical and pathological markers was constructed to predict the risk of carcinomatosis. ROC curve and decision curve analyses were used to verify its accuracy and net benefit. Results In the cM- population staging laparoscopy could detect 70 cases who had peritoneal carcinomatosis or positive cytology, for a yield of 31.0%. In cM+ patients staging laparoscopy could exclude carcinomatosis in 15 cases. In cM- patients, intestinal type tumors (0.36, 0.14–0.92; P = 0.035), the presence of signet ring cells (2.58, 1.04–6.33; P = 0.039) and cancers of the upper third (3.36, 1.43–7.92; P = 0.005) were associated with the presence of peritoneal carcinomatosis and/or positive cytology. The ROC curve analysis of the model including the three variables showed an AUC of 0.75 (0.66–0.80, P < 0.001). The decision curve analyses showed that the model had a higher net benefit than the treating all strategy between threshold probabilities of 16 and 50%. Conclusion Staging laparoscopy is a useful tool to address the patient with gastric cancer to the most adequate treatment. In cM- patients the assessment of the location of the tumor, the Lauren’s histotype and the presence of signet ring cells may help in providing additional elements in indicating or not the use of staging laparoscopy.

Work-Up and Outcome of Hepatic Resection for Peri-Hilar Cholangiocarcinoma (PH-CCA) without Staging Laparoscopy.

Simple SummaryThis is a single centre cohort of patients undergoing surgery for PH-CCA suggests that routine staging laparoscopy may not be necessary in the pre-operative work-up.Background: This study reports the outcome of a work-up programme for resection of peri-hilar cholangiocarcinoma (PH-CCA) without the use of staging laparoscopy. Methods: This is a clinical case cohort series of patients undergoing surgical resection of PH-CCA without the use of staging laparoscopy in the work-up algorithm. During the 13 years from 1 January 2009 to 1 January 2022, 32 patients underwent laparotomy for planned surgical resection of PH-CCA. Data were collected on demographic profile, admission biochemistry, radiology, pre-operative intervention, operation and outcome, together with post-operative complications and disease-free and overall survival. Results: All patients underwent pre-operative contrast-enhanced CT. Twenty-four (75%) underwent pre-operative MR. Twenty-three (72%) underwent pre-operative biliary drainage. Twenty-nine patients (91%) had either type III or IV peri-hilar cholangiocarcinoma. One patient (3%) in this series underwent a non-resectional laparotomy. Twenty-nine (91%) had a final histopathological diagnosis of PH-CCA. One further patient had a final diagnosis of an intraductal papillary neoplasm of the biliary tree (IPNB) with high-grade dysplasia but no invasive cancer. Eleven patients (36%) received chemotherapy after surgery. The median (95% CI) time to recurrence was 14 (7–31) months. The median survival was 25 (18-upper limit not reached) months. Conclusion: This cohort of 32 patients undergoing attempted resection for PH-CCA without the use of staging laparoscopy in the work-up algorithm indicates that with careful attention to patient fitness and cross-sectional and interventional radiologic/endoscopic imaging, a very low non-therapeutic laparotomy rate of 3% can be achieved and sustained.

Yield of routine staging laparoscopy in patients with gastric cancer in Alberta, Canada.

Background:Despite guidelines recommending diagnostic laparoscopy in patients with gastric cancer, implementation is low. We aimed to explore trends in the use of laparoscopy for staging of gastric cancer in Alberta, Canada, determine the rate of positive findings and identify factors predictive of positive staging laparoscopy (SL) findings in this patient population.Methods:In August 2018, we sent a survey to all general surgeons in Alberta who were members of the Alberta Association of General Surgeons to identify those treating gastric cancer. The survey inquired about type of practice (academic or community), gastric cancer case volume, routine versus selective use of SL and, if selective use of SL, criteria used to select cases. Participants were also asked to provide data from their SL cases from July 2007 to February 2019. We double-checked surgeon records with chart review. The primary outcome was evidence of metastatic disease on SL or cytologic examination or both. We performed logistic regression analysis to identify factors predictive of positive laparoscopy findings.Results:The survey was completed by 41 of 127 surgeons (response rate 32.3%). We reviewed 116 cases from 5 surgeons at 4 centres. Gross metastatic disease or positive findings on cytologic examination or both were identified in 37 patients (31.9%). On univariate analysis, the following were associated with an increased risk of identification of metastatic disease at laparoscopy: visualization of the primary tumour on computed tomography (CT) (odds ratio [OR] 9.8, 95% confidence interval [CI] 1.2–76.5), presence of abdominal lymphadenopathy greater than 1 cm (OR 2.4, 95% CI 1.1–5.4) and presence of ascites (OR 19.1, 95% CI 2.2–161.8). Visualization of the primary tumour on CT (OR 8.4, 95% CI 1.0–68.3) and the presence of ascites (OR 15.9, 95% CI 1.8–137.0) remained statistically significant predictors on multivariate analysis.Conclusion:Metastatic disease was identified at SL in almost one-third of cases, which suggests that SL should still be used routinely in gastric cancer staging in Canadian centres. Our study identified several preoperative imaging findings associated with evidence of metastatic disease on laparoscopy; however, further studies are needed to establish robust predictors of positive findings before advocating for a selective SL approach.

Which gastric cancer patients could benefit from staging laparoscopy? A GIRCG multicenter cohort study

BackgroundThis study aimed to investigate which gastric cancer patients could benefit the most from staging laparoscopy. MethodsA retrospective cohort study was carried out, including 316 (216 cM- and 100 cM+) gastric cancer patients who had undergone staging laparoscopy between 2010 and 2020 in seven GIRCG centers. A model including easily-accessible clinical, biochemical and pathological markers was constructed to predict the risk of carcinomatosis. ROC curve and decision curve analyses were used to verify its accuracy and net benefit. ResultsIn the cM-population staging laparoscopy could detect 67 cases who had peritoneal carcinomatosis or positive cytology, for a yield of 30.5%. In cM-patients, intestinal type tumors (0.25, 0.12–0.51; p = 0.002), cT4 tumors (2.18, 1.11–4.28; p = 0.023) and cancers of the lower third (0.31, 0.14–0.70; p = 0.004) were associated with the presence of peritoneal carcinomatosis and/or positive cytology. The ROC curve analysis of the model including the three variables showed an AUC of 0.75 (0.68–0.81, p < 0.001). The decision curve analyses showed that the model had a higher net benefit than the treating all strategy between threshold probabilities of 15 and 50%. ConclusionsStaging laparoscopy is a useful tool to address the patient with gastric cancer to the most adequate treatment. In cM-patients the assessment of the location of the tumor, the Lauren's histotype and the cT status may help in providing additional elements in indicating or not the use of staging laparoscopy.

The neutrophil/lymphocyte ratio as a predictor of peritoneal metastasis during staging laparoscopy for advanced gastric cancer: a retrospective cohort analysis

BackgroundThe use of staging laparoscopy (SL) has become widespread in patients with advanced gastric cancer (GC). This study aimed to evaluate the predictive value of the neutrophil/lymphocyte ratio (NLR) for the presence of peritoneal metastasis during staging laparoscopy in patients with advanced GC.MethodsThis retrospective analysis was performed in 35 patients with advanced GC who underwent SL at Kanazawa Medical University Hospital between January 2009 and December 2017. Clinicopathological characteristics were examined and multivariate analyses were performed to identify preoperative laboratory parameters that were independently associated with the presence of peritoneal metastasis or cytological malignancy (P/CY positive) during SL.ResultsA P/CY-positive result was confirmed during SL in 16 patients (45.7%). Patients with type 4 or diffuse type 3 tumors showed a significantly higher P/CY-positive rate than those with other tumor types (58.3% vs. 18.2%, P = 0.02). In the univariate analysis for preoperative laboratory parameters, NLR (P < 0.0001) and total protein (P = 0.03) and albumin (P = 0.04) levels were significantly correlated with a P/CY-positive result. On multivariate analysis, NLR was significantly correlated with a P/CY-positive result (P = 0.0002). In patients with type 4 or diffuse type 3 tumors, a high NLR (> 3.5) was associated with a significantly higher P/CY-positive rate than a low NLR (≤ 3.5) (83.3% vs. 33.3%, P = 0.01). Moreover, in patients without type 4 or diffuse type 3 tumors, the P/CY-positive rates were 100% and 0% in patients with NLR > 3.5 and NLR ≤ 3.5, respectively.ConclusionsThe preoperative NLR was a significant independent predictor of the presence of peritoneal metastasis during SL. Regardless of tumor type, patients with a high NLR could be reasonable candidates for SL. On the other hand, non-diffuse type tumor accompanied by a low NLR may not need to undergo SL.

Factores asociados con carcinomatosis por Cáncer Gástrico: ¿A quiénes hacemos laparoscopia?

IntroductionSeveral studies have demonstrated the effectiveness of laparoscopy in the evaluation of patients with advanced tumours. However, there is no uniformity with respect to its systematic use, with different authors having reported variable indications and outcomes. MethodsAn observational, analytical, cross-sectional study in which a model was evaluated with a group of variables associated with the laparoscopic diagnosis of peritoneal carcinomatosis. The study included all patients with gastric adenocarcinoma who were submitted to staging laparoscopy from January 2008 until the sample was completed, which was estimated in 153 cases. The variables evaluated were age, gender, weight loss, serum albumin value, endoscopic tumour location, histological type, according to Lauren classification and tumour tomography (T), presence of lymphadenopathy (N), and ascites. The presence of peritoneal carcinomatosis was defined by laparoscopic observation. ResultsA total of 153 cases of gastric adenocarcinoma patients submitted to staging laparoscopy were analysed in the Gastrointestinal Surgery Department of the National Cancer Institute. They included 102 men (66%) and 51 women (33%), aged between 28 and 86 years.Statistically significant factors associated with the presence of peritoneal carcinomatosis were, age less than 65 years (OR = 2.0, 95% CI: 1 - 4.2), female gender (OR 2.2, 95% CI: 1.06 (OR = 2.6, 95% CI: 1.25 - 5.2), presence of ascites (OR = 4.3, 95% CI: 1.3 - 15.9), and histology of the diffuse type (OR 3.0; 95% CI: 1.5 - 5.8). ConclusionsStaging laparoscopy is a valuable tool in the initial approach of patients with advanced gastric cancer, and imaging studies do not replace it. Women, younger than 65 years, with gastroesophageal junction (GEJ) tumours, of the diffuse histological type, and with documented ascites in computed tomography scan, are at greater risk of peritoneal carcinomatosis at the time of diagnosis. Thus, the systematic use of staging laparoscopy is proposed in patients who meet one or more of these characteristics.

Staging laparoscopy for advanced gastric cancer: significance of preoperative clinicopathological factors.

Although the use of staging laparoscopy (SL) for detecting peritoneal metastasis (P) and determining peritoneal lavage cytology (CY) is widespread in advanced gastric cancer, an indication for SL based on preoperative clinicopathological factors is controversial. From May 2006 to September 2015, 120 patients with advanced gastric cancer with primary tumors ≥5cm and/or with bulky regional lymph nodes (bulky N) underwent SL for assessment of P/CY status. Clinicopathological factors were analyzed retrospectively to determine their influence on peritoneal spread (P1 and/or CY1). An additional analysis of 379 consecutive patients with clinically T2 or deeper gastric cancer in the same time period was carried out to confirm the SL results. Peritoneal spread was confirmed by SL in 54 cases (45%). The presence of type-4 tumors (n=38, p<0.0001) and diffuse-type tumors (n=85, p=0.04) correlated significantly with peritoneal spread. These two factors were also correlated significantly with increased peritoneal spread in a subgroup analysis among patients with tumors with bulky N (n=44). The additional analysis of 379 patients showed results consistent with the SL results. The frequency of peritoneal spread was 78% among type-4 tumors, 47% among diffuse-type tumors ≥5cm, and 38% among diffuse-type tumors with bulky N, whereas among intestinal-type tumors, it was 18% in tumors ≥5cm and 13% among tumors with bulky N. Among tumors ≥5cm or with bulky N, type-4 tumors and diffuse-type tumors had a high potential for peritoneal spread and patients with such tumors were considered more suitable candidates for SL.

A reappraisal of staging laparoscopy in three subtypes of cholangiocarcinoma: A multi-institution analysis from the U.S. Extrahepatic Biliary Malignancy Consortium.

226 Background: Staging laparoscopy (SL) has been shown to be useful in extrahepatic biliary tumors (EHBTs) to avoid unnecessary laparotomies in unresectable disease. However, the added value of SL for EHBTs has not been well characterized in the era of modern imaging. Methods: We reviewed patients from ten institutions who underwent attempted resection of EHBTs between 1998 and 2015, including gallbladder, distal, and hilar subtypes. Yield of laparoscopy = (Number of positive SL / Total number of SL). Accuracy of laparoscopy = (Number of positive SL / Patients with unresectable disease). These data were compared by use of the chi-squared test and significance was p &lt;.05. Results: A total of 1,075 patients were taken to the OR for attempted curative resection, of which 250 patients (23%) underwent staging laparoscopy. SL identified unresectable disease in 42 patients (yield 17%). Of 208 patients who underwent exploratory laparotomy (EL) after negative SL, 19 were found to be unresectable (false negative rate 9%). Amongst gallbladder, hilar, and distal pathology types, the yield of SL were 18%, 13%, 17%, respectively (p=0.78). Accuracy of SL was 61%, 71%, and 91% respectively (p=0.17), with an accuracy of 68%. A total of 825 patients went directly to EL, of which 103 (13%) failed. The rate of failure for patients going straight to EL was significantly higher for patients with gallbladder (n=66/287, 23%) when compared with hilar (n=15/274, 6%) and distal EHBT (n=22/264, 8%) (p&lt;0.001). Conclusions: Our analysis demonstrates that staging laparoscopy still has added utility in preventing unnecessary laparotomies in unresectable disease for selected patients with EHBTs, although the overall yield is low. Patients with gallbladder cancer had high rates of failed laparotomies, representing a subset who may benefit from more frequent use of staging laparoscopy at the time of resection. [caption]Yield and accuracy of detecting unresectable disease with staging laparoscopy. [/caption] [Table: see text]

Current Recommendations for Minimally Invasive Surgical Staging in Ovarian Cancer.

Minimally invasive surgery (MIS) currently is performed to stage and treat ovarian cancer at different stages of disease; however, the higher level of evidence from existing studies is IIB. Despite the absence of randomized controlled trials, MIS represents a safe and adequate procedure for treating and staging early ovarian cancer, and its use has increased significantly in clinical practice. Major concerns are related to minimizing tumor disruption or dissemination, removing the adnexal mass intact, adequate retroperitoneal staging, and fertility-sparing surgery for young patients. The main goal for patients with advanced ovarian cancer is to determine the best therapeutic strategy by evaluating the risks and benefits of primary debulking surgery versus neoadjuvant chemotherapy followed by interval debulking surgery. The use of staging laparoscopy in patients with advanced epithelial ovarian cancer appears to be the most researched and accepted approach. Regarding other types and stages of ovarian cancer, although the evidence is very promising, clinical trials performed by expert gynecologic oncology surgeons in referral centers are still needed to prove the efficacy of such an approach in these patients. In particular, MIS has provided an opportunity to remove localized recurrences, with both retroperitoneal and intraperitoneal diffusion.

High serum CA 19-9 but not tumor size should select patients for staging laparoscopy in radiological resectable pancreas head and peri-ampullary cancer

BackgroundThe objective of this study was to validate current recommendations for the selective use of staging laparoscopy in patients with radiological resectable pancreas head and peri-ampullary tumors. MethodsData from a prospectively collected database (2007–2013) of 136 patients with peri-pancreatic head cancer were analyzed. ResultsOver a 6 year time period, 136 patients were evaluated, 126 patients were deemed radiological resectable and underwent laparotomy and 10 patients were characterized radiological unresectable. There were 111 patients with pancreas head resection and 15 without resection (8 due to extensive vascular involvement and 3 due to peritoneal/liver metastases). The sensitivity, specificity, PPV and NPV of pre-operative radiological imaging in determining unresectability due to liver/peritoneal metastases were 42%, 100%, 100% and 94.7% respectively. There was a significant difference in CA 19-9 values between metastatic and non-metastatic disease (p = 0.020). ROC curve analysis calculated the optimal CA 19-9 cutoff point for predicting metastasis at 215.37 U/ml with a sensitivity of 72.7%, a specificity of 58.3%, PPV of 15.1% and NPV of 95.5%. Tumor diameter was not a significant factor in predicting resectability. Laparoscopy would have been useful in only 5.3% of patients in the present series. ConclusionHigh CA 19-9 values (>215 U/ml) and not tumor size should select patients with radiological resectable peri-pancreatic cancer for staging laparoscopy.

Introduction of staging laparoscopy in the management of advanced epithelial ovarian, tubal and peritoneal cancer: Impact on prognosis in a single institution experience

ObjectiveTo evaluate the prognostic impact of routinely use of staging laparoscopy (S-LPS) in patients with primary advanced epithelial ovarian cancer (AEOC). MethodsAll women were submitted to S-LPS before receiving primary debulking surgery (PDS) or neoadjuvant treatment (NACT). The surgical and survival outcome were evaluated by univariate and multivariate analysis. ResultsAmong 300 consecutive patients submitted to S-LPS no complications related to the surgical procedure were registered. The laparoscopic evaluation showed that almost half of the patients (46.3%) had a high tumor load. One-hundred forty-eight (49.3%) women were considered suitable for PDS and the remaining 152 (50.7%) were submitted to NACT. The percentages of complete (residual tumor, RT=0) and optimal (RT<1cm) cytoreduction of PDS and interval debulking surgery (IDS) were 62.1% and 57.5%, 22.5% and 27.7%, respectively, p=0.07. The post-operative complications of NACT/IDS group were lower than PDS group (p=0.01). The median progression free survival in women with RT=0 at PDS was 25months (95% CI, 15.1–34.8), which was statistically significant longer than in all other patients, irrespective of the type of treatment they received (p=0.0001). At multivariate analysis, residual disease (p=0.011) and performance status (p=0.016) maintained an independent association with the PFS. ConclusionsIncluding S-LPS in a tertiary referral center for the management AEOC does not appear to have a negative impact in terms of survival and it may be helpful to individualize the treatment avoiding unnecessary laparotomies and surgical complications.

Diagnostic and Prognostic Role of Laparoscopic Staging for Gallbladder Carcinoma

Background: The aim of this study was to evaluate the diagnostic and prognostic role of staging laparoscopy in gallbladder carcinoma (GBC). Methods: From January 2007 through December 2010, 79 GBC patients without evidence of metastatic disease on preoperative imaging underwent staging laparoscopy. Peritoneal and liver metastases were assessed by a single surgeon in a systematic manner. Resection rate, safety, and survival analysis were compared between the laparoscopy group and no laparoscopy group. Results: Disseminated disease was detected in 27 patients and no further surgery was performed; the overall accuracy for detecting unresectable disease was 67.5% (27/40), with 39 (75%) and 27 (51.9%) receiving resection and curative resection. In 203 GBC patients undergoing laparotomy, 90 (44.3%) and 53 (26.1%) patients received resection and curative resection; therefore, the resection rate and curative resection rate were significantly much higher in the laparoscopy group (p < 0.000). Conclusions: Staging laparoscopy in GBC is sensitive in detecting disseminated disease and increases the curative resection rate, shortens the recovery time, and has no negative implications on overall survival; therefore, we suggest the routine use of staging laparoscopy in patients with GBC without evidence of disseminated disease on preoperative imaging.

Staging Laparoscopy in the Management of Gastric Cancer: A Population-Based Analysis

Staging laparoscopy can detect radiographically occult peritoneal metastases and prevent futile laparotomy in patients with gastric adenocarcinoma. We sought to assess the use of staging laparoscopy for gastric adenocarcinoma in a cohort of older patients and to compare outcomes after laparoscopy alone with nontherapeutic laparotomy. Using Surveillance, Epidemiology and End Results (SEER) population-based cancer registry data linked with Medicare claims, we identified patients aged 65 or older diagnosed with gastric adenocarcinoma between 1998 and 2005. We defined staging laparoscopy as a laparoscopic procedure from 1 month before the date of diagnosis until death and futile laparotomy as a laparotomy in the absence of a therapeutic intervention. We examined trends in the use of staging laparoscopy and compared outcomes between patients who underwent staging laparoscopy alone and those who had a futile laparotomy. Of 11,759 patients with gastric adenocarcinoma, 6,388 (54.3%) had at least 1 surgical procedure. Staging laparoscopy was performed in 506 (7.9%) patients who had any surgery, and 151 (29.8%) of these patients did not have a subsequent therapeutic intervention. Patients who underwent staging laparoscopy alone had a significantly lower rate of in-hospital mortality (5.3% vs 13.1%, p < 0.001) and shorter length of hospitalization (2 vs 10 days, p < 0.001) than patients who had futile laparotomy. Our findings in this large, population-based cohort suggest that staging laparoscopy is used infrequently in the management of older patients with gastric adenocarcinoma. Increased use of staging laparoscopy could reduce the substantial morbidity and mortality associated with nontherapeutic laparotomy.

Selective Use of Staging Laparoscopy Based on Carbohydrate Antigen 19-9 Level and Tumor Size in Patients With Radiographically Defined Potentially or Borderline Resectable Pancreatic Cancer

The aims of this study were to verify whether the selective use of staging laparoscopy can prevent unnecessary laparotomy and to find a surrogate marker for surgical unresectability in patients with potentially or borderline resectable pancreatic cancer. Group A consisted of consecutive 33 patients evaluated between 2005 and 2006 and who directly underwent open laparotomy for planned surgical resection. Group B consisted of consecutive 61 patients evaluated between 2007 and 2009 and of whom 16 patients (26%) had a staging laparoscopy due to the presence of high-risk markers of unresectability defined as carbohydrate antigen 19-9 level 150 U/mL or greater and tumor size 30 mm or greater. The frequency of unnecessary laparotomies for occult distant organ metastasis was significantly different between groups A and B (18% and 3%, respectively; P = 0.021). Of 16 patients who underwent staging laparoscopy in group B, 5 patients (31%) had occult metastases. The multivariate analysis showed that the presence of high-risk markers and extrapancreatic plexus invasion on multidetector-row computed tomography were significant independent risk factors for unresectability. The presence of high-risk markers was associated with surgical unresectability in patients with potentially or borderline resectable pancreatic cancer. The selective use of staging laparoscopy decreased the frequency of unnecessary laparotomy by detecting minute metastases.

Staging laparoscopy enhances the detection of occult metastases in patients with pancreatic adenocarcinoma

The use of staging laparoscopy has been highly institutional dependent. We sought to assess the incidence of occult intra-abdominal metastases identified at the time of staging laparoscopy for patients with either potentially resectable or locally advanced pancreatic adenocarcinoma (LAPC). We also compared the rate of occult metastases in patients who underwent staging laparoscopy versus laparotomy. Patients were confirmed to have potentially resectable or LAPC at a multidisciplinary hepatopancreaticobiliary conference. Patients with potentially resectable lesions were initially explored via staging laparoscopy or laparotomy, based on surgeon preference. Over a 4-year period, 25 patients with potentially resectable tumors and 33 patients with LAPC were staged with laparoscopy, with an equivalent prevalence of occult metastases found at laparoscopy (28% potentially resectable vs. 33% LAPC, P = 0.8). Fifty-two patients with potentially resectable lesions were explored initially via laparotomy. Occult peritoneal metastases were more likely to be detected in patients with potentially resectable tumors that were explored via laparoscopy than via laparotomy (32% vs. 10%, P = 0.018). Staging laparoscopy is more likely than open exploration to detect occult metastases. Current preoperative imaging inadequately identifies unresectable pancreatic adenocarcinoma; therefore, all patients with potentially resectable disease should undergo staging laparoscopy.

Current Utility of Staging Laparoscopy for Pancreatic and Peripancreatic Neoplasms

The routine use of staging laparoscopy in patients with radiographically resectable pancreatic and peripancreatic neoplasms remains controversial. We reviewed a prospective database that identified 1,045 patients who underwent staging laparoscopy for radiographically resectable pancreatic or peripancreatic tumors between 1995 and 2005. Radiographic resectability was determined by review of radiographic reports, surgeons' notes, and cross-sectional imaging studies. Factors were assessed for their association with the laparoscopic identification of radiographically occult unresectable disease. Recursive partitioning was used to build a decision tree, with laparoscopic identification of unresectable disease as the outcomes, including only patients since 1999 (modern imaging) and factors available preoperatively. Unresectable disease was identified laparoscopically in 145 of the 1,045 radiographically resectable patients (14%). Factors associated with radiographically occult unresectable disease included the time period of the study, whether imaging was performed at our institution (internal versus external imaging), primary site, histology, weight loss, and jaundice. Primary site (pancreatic versus nonpancreatic) was identified as the strongest predictor of yield. In patients with nonpancreatic tumors, the yield of laparoscopy was 4%. In patients with pancreatic tumors, the yield of laparoscopy was 14% overall, but was 8.4% in patients with internal imaging versus 17% in patients with external imaging (p < 0.01). This higher-risk subgroup was partitioned by the presence of weight loss, then by primary site within the pancreas. During the time period of this study, the yield of staging laparoscopy decreased and exceeded 10% only for patients with pancreatic adenocarcinoma. When high-quality cross-sectional imaging reveals no evidence of unresectable disease, routine staging laparoscopy may not be warranted for pancreatic or peripancreatic tumors other than presumed pancreatic adenocarcinoma.

The impact of staging laparoscopy prior to hepatic resection for colorectal metastases

Aims To evaluate the role of routine laparoscopy as a staging modality prior to laparotomy and hepatic resection for metastatic colorectal cancer. Methods Prospectively collected data were analysed from a database. In the first half of the series patients underwent selective laparoscopy before proceeding to laparotomy and in the second part of the series laparoscopy was used routinely. Patients undergoing laparotomy directly were analysed in Group 1 and those having laparoscopy before laparotomy in Group 2. The ability of laparoscopy to pick up unresectable and extrahepatic disease, resectability rate and open and close laparotomy rate were recorded. Results Of the 284 patients, 74 were in Group 1 (no laparoscopy) and 210 in Group 2 (laparoscopy as standard). The resectability rate was 81% in Group 1 and 87% in Group 2. The open and close laparotomy rate was 19% and 8%, respectively ( p = 0.025). In Group 2 alone, laparoscopy identified 39% of unresectable disease and prevented an open and close procedure. Conclusions Routine use of staging laparoscopy increases the resectability rate and reduces the inoperability rate in these patients.

Laparoscopy in the staging of pancreatic cancer.

Over the past decade, laparoscopy has emerged as a popular method of detecting extrapancreatic metastatic disease in patients presumed to have localized pancreatic cancer. The English language literature on laparoscopic staging of pancreatic cancer was reviewed. Interpretation of this literature on staging laparoscopy is difficult because (1) there has been inconsistent use of high-quality computed tomography (CT) in prospective studies, (2) many studies have included patients with locally advanced disease, and (3) the R0/R1/R2 resection rates among patients staged by laparoscopy have not been reported, making it impossible to correlate laparoscopic findings with the R0 resection rate. Laparoscopy may prevent unnecessary laparotomy in a proportion of CT-staged patients presumed to have resectable pancreatic cancer. However, routine laparoscopy is performed on patients judged to have resectable disease by high-quality CT, this fraction of patients is between 4 and 13 per cent. When state-of-the-art CT is available, the routine use of staging laparoscopy may not be easily justified from the data in the recent literature. Selective use of laparoscopy may be more appropriate and will probably be a more cost-effective staging approach. Criteria are presented for the selective use of laparoscopy in the staging of patients with localized pancreatic cancer.

Role of laparoscopy in the management of stomach cancer.

The use of laparoscopy for staging and treatment of gastric cancer has evolved in the past decade along with other advanced laparoscopic procedures. Laparoscopic staging of gastric cancer, especially with the addition of laparoscopic ultrasonography, has been shown more reliable than radiologic modalities and it effectively decreases the incidence of unnecessary laparotomy. Although it is not commonly performed in Western countries, the use of laparoscopic curative resection for gastric cancer is growing, especially in Japan. Laparoscopic resection of early gastric cancer has been shown to be safe and effective in many retrospective series though no prospective randomized studies comparing it to open resection have been performed. Despite being more controversial, laparoscopic curative resection of advanced gastric cancer also has been performed at multiple institutions with encouraging early results. This review will present the current worldwide experience of laparoscopy for gastric cancer.