Laparoscopy in the staging of pancreatic cancer

BACKGROUND: Over the past decade, laparoscopy has emerged as a popular method of detecting extrapancreatic metastatic disease in patients presumed to have localized pancreatic cancer. METHODS AND RESULTS: 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. CONCLUSION: 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.     

Patients with pancreatic adenocarcinoma benefit from staging laparoscopy

Background: Unnecessary laparotomy in patients with advanced pancreatic cancer may both compromise the quality of life and delay the initiation of more appropriate therapy. Very often, peritoneal small liver metastases and true local status cannot be fully determined without surgery. Laparoscopy may spare laparotomy and decrease morbidity for patients with nonresectable advanced disease. The aim of this study was to determine the impact of laparoscopy in patients with potentially resectable adenocarcinoma of the pancreas. Materials and Methods: We reviewed the records of patients undergoing pancreatic surgery at the University of Nebraska Medical Center from October 2001 to April 2005. A total of 59 patients were included in the study. All patients were staged radiographically with a high resolution helical computed tomography scan and their tumors were considered resectable. Thirty-seven patients underwent staging laparoscopy while 22 proceeded directly to laparotomy. Results: Of the 37 patients who underwent laparoscopic staging, 9 (24.3%) were detected to have metastatic disease or advanced tumor; the remaining 28 (75.7%) patients with negative laparoscopy proceeded to laparotomy. Of those, 24 patients (85.7%) underwent pancreatic resection with curative intent, while 4 patients had metastatic or locally advanced disease at subsequent laparotomy which was missed on staging laparoscopy (false negative rate of 14.3%). Of the 22 patients who proceeded directly to laparotomy, 16 (72.7%) received curative Whipple resection and 6 (27.3%) were found to have advanced disease and received bypass procedures or biopsy alone. Conclusion: These findings suggest that staging laparoscopy is beneficial in a significant proportion of patients deemed resectable by routine noninvasive preoperative studies. We plan to add intraoperative laparoscopic ultrasound to our staging protocol in order to decrease the false negative rate.     

Role of staging laparoscopy in peri-pancreatic and hepatobiliary malignancy

Even after extensive preoperative assessment, staging laparoscopy may allow avoidance of non-therapeutic laparotomy in patients with radiographically occult metastatic or locally unresectable disease. Staging laparoscopy is associated with decreased postoperative pain, a shorter hospital stay and a higher likelihood of receiving systemic therapy compared to laparotomy but its yield has decreased with improvements in imaging techniques. Current uses of staging laparoscopy include the following: (1) In the staging of pancreatic adenocarcinoma, laparoscopic staging allows for the identification of sub-radiographic metastatic disease in locally advanced cancer in approximately 30% of patients and, in radiographically resectable cancer, may identify metastatic disease in 10%-15% of cases; (2) In colorectal liver metastases, selective use of laparoscopic staging in patients with a clinical risk score of over 2 identifies unresectable disease in approximately 20% of patients; (3) In hepatocellular carcinoma, laparoscopic staging could be selectively used in high-risk patients such as those with clinically apparent liver cirrhosis and in patients with major vascular invasion or bilobar tumors; and (4) In biliary tract malignancy, staging laparoscopy may be used in all patients with potentially resectable primary gallbladder cancer and in selected patients with T2/T3 hilar cholangiocarcinoma. Because of the decreasing yield of SL secondary to improvements in imaging techniques, staging laparoscopy should be used selectively for patients with pancreatic and hepatobiliary malignancy to avoid unnecessary non-therapeutic laparotomy and to improve resource utilization. Each individual surgeon should apply his or her threshold as to whether staging laparoscopy is indicated according to the quality of preoperative imaging studies and the availability of resources at their own institution.     

Utility of tumor markers in determining resectability of pancreatic cancer

HYPOTHESIS: Despite advances in preoperative radiologic imaging, a significant fraction of potentially resectable pancreatic cancers are found to be unresectable at laparotomy. We tested the hypothesis that preoperative serum levels of CA19-9 (cancer antigen) and carcinoembryonic antigen will identify patients with unresectable pancreatic cancer despite radiologic staging demonstrating resectable disease. DESIGN AND SETTING: Academic tertiary care referral center. PATIENTS: From March 1, 1996, to July 31, 2002, 125 patients were identified who underwent surgical exploration for potentially resectable pancreatic cancer based on a preoperative computed tomographic scan; in 89 of them a preoperative tumor marker had been measured. MAIN OUTCOME MEASURES: Preoperative tumor markers (CA19-9 and carcinoembryonic antigen) were correlated with extent of disease at exploration. As CA19-9 is excreted in the biliary system, CA19-9 adjusted for the degree of hyperbilirubinemia was determined and analyzed. RESULTS: Of the 89 patients, 40 (45%) had localized disease and underwent resection, 25 (28%) had locally advanced (unresectable) disease, and 24 (27%) had metastatic disease. The mean adjusted CA19-9 level was significantly lower in those with localized disease than those with locally advanced (63 vs 592; P =.003) or metastatic (63 vs 1387; P<.001) disease. When a threshold adjusted CA19-9 level of 150 was used, the positive predictive value for determination of unresectable disease was 88%. Carcinoembryonic antigen level was not correlated with extent of disease. CONCLUSIONS: Among the patients with resectable pancreatic cancer based on preoperative imaging studies, those with abnormally high serum levels of CA19-9 may have unresectable disease. These patients may benefit from additional staging modalities such as diagnostic laparoscopy to avoid unnecessary laparotomy.     

Preoperative staging of cancer of the pancreatic head: Is there room for improvement?

Background

Despite advances in preoperative staging, cancer of the pancreatic head is frequently found to be unresectable at laparotomy. We sought to identify potential areas of improvement in preoperative staging.

Methods

We performed a retrospective institutional review of patients referred for resection of cancer of the pancreatic head over a 2-year period. The primary outcome was the rate of metastasis or unresectable disease found at laparotomy in patients who were booked for pancreaticoduodenectomy with curative intent.

Results

During the study period, 133 patients were referred with suspected cancer of the pancreatic head. All underwent preoperative computed tomography scanning. Twenty-four also underwent preoperative endoscopic ultrasonography (EUS) and 23 also underwent magnetic resonance imaging (MRI). In total, 78 patients were deemed not to be candidates for surgery, leaving 55 patients with potentially resectable cancer who were scheduled for pancreaticoduodenectomy. Of these, 32 patients (58%) underwent successful resection with curative intent, and 23 patients (42%) were found to have metastatic or locally advanced disease not identified by preoperative staging. Reasons for nonresectability were metastases (9 patients, 16%), vascular involvement (12 patients, 22%) and mesentery involvement (2 patients, 4%). One patient had a diagnostic laparoscopy immediately before planned open exploration and was found to have peritoneal seeding precluding curative resection. Of the patients who underwent EUS, 14 were not surgical candidates because of locally advanced tumours. Ten patients were offered surgery with curative intent, and 5 patients (50%) were found have unresectable tumours (4 metastatic, 1 locally advanced). Of the patients who underwent MRI, 11 were offered surgery, and 5 (45%) had unresectable tumours (2 metastatic, 3 locally advanced disease).

Conclusion

In our institution, preoperative staging for cancer of the pancreatic head misses a substantial number of metastatic and unresectable disease. There is clearly room for improvement, and newer technologies should be evaluated to enhance the detection of metastatic and locally advanced disease to prevent unnecessary laparotomy.     

The value of laparoscopic staging for patients with colorectal metastases

BACKGROUND: Resection offers the only chance of cure for hepatic colorectal metastases. However, preoperative staging does not always reliably detect unresectable disease. The aim of this study was to investigate the role that laparoscopy with ultrasound may have in detecting unresectable disease, thus sparing patients from unnecessary laparotomy with the associated morbidity and cost. METHODS: A retrospective review of all patients considered for liver resection of colorectal metastases during a 3-year period was performed, analyzing factors likely to predict resectable disease, rates of resectability, and success of laparoscopic staging at detecting unresectable disease. RESULTS: Of 73 patients with resectable disease on computed tomography, 24 were deemed to need laparoscopy, and 49 proceeded directly to laparotomy. Those first undergoing laparoscopy had shorter disease-free intervals between diagnosis of colorectal cancer and detection of hepatic recurrence and greater numbers of hepatic metastases. Twelve of the 24 patients who underwent laparoscopy had unresectable disease, and 8 of these were detected at laparoscopy. Forty-six of the 49 patients proceeding to laparotomy directly had resectable disease. CONCLUSIONS: Laparoscopic staging of hepatic colorectal metastatic disease detects most unresectable disease, preventing unnecessary laparotomy. The likelihood of disease being unresectable is in part predicted by the disease-free interval and the number of hepatic metastases.     

Staging of pancreatic and ampullary cancers for resectability using laparoscopy with laparoscopic ultrasound

Background: Cancers of the pancreas and periampullary region are rarely curable. We set out to determine the efficacy of laparoscopy with laparoscopic ultrasound in the staging of pancreatic and ampullary malignancies for resectability. Methods: Between January 1994 and September 1999, we retrospectively reviewed the laparoscopic staging (LS) of tumors already deemed resectable by standard radiologic criteria in 27 patients using laparoscopy with laparoscopic ultrasound (LUS). Patients found to be resectable by LS evaluation underwent laparotomy (LA). We then compared the results of the LS and LA findings. Results: Of the 27 patients evaluated, 17 were men and 10 were women. Their mean age was 66 years. Preoperative computerized tomography (CT) scans were done in all 27 patients (100%), and transabdominal and endoscopic ultrasound (EUS) was done in 21 (78%). By LS, seven patients (26%) were found to have unresectable disease. Two patients with mesenteric tumor infiltration (one with peritoneal implants, and one with a visible liver metastasis) were judged to be unresectable by laparoscopy alone. LUS revealed that one patient had portal vein (PV) occlusion and two had metastases to the lymph nodes or liver that were not revealed by preoperative studies or laparoscopy alone. Among 20 patients (74%) deemed resectable by LS, two (10%) were found to be unresectable at LA, one due to PV involvement and the other due to local tumor extension with superior mesenteric lymph node metastasis. Eighteen of those in whom resection was attempted (90%) were resectable, with no unexpected findings of distant lymph node or hepatic metastasis. Pathology examination showed that eight had regional metastases (44%). The sensitivity of LS in determining unresectability was 77% (seven true positives and two false negatives). The negative predictive value (reflecting resectability) was 90%. Laparoscopy alone had a sensitivity of 44%, with a negative predictive value of 78%. The sensitivity and positive predictive value of LS was 100%, reflecting no false positive examinations. Conclusions: LS can effectively stage most patients and reliably predict which of them will benefit from LA. Intervention for unresectable patients can then be limited to laparoscopic or endoscopic bypass. The main limitation is that LS may underestimate PV and regional lymph node involvement.     

Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost-effectiveness

OBJECTIVE: We sought to determine the impact of positron emission tomography/computed tomography (PET/CT) on the management of presumed resectable pancreatic cancer and to assess the cost of this new staging procedure. SUMMARY BACKGROUND DATA: PET using 18F-fluorodeoxyglucose (FDG) is increasingly used for the staging of pancreatic cancer, but anatomic information is limited. Integrated PET/CT enables optimal anatomic delineation of PET findings and identification of FDG-negative lesions on computed tomography (CT) images and might improve preoperative staging. MATERIAL AND METHODS: Patients with suspected pancreatic cancer who had a PET/CT between June 2001 to April 2004 were entered into a prospective database. Routine staging included abdominal CT, chest x-ray, and CA 19-9 measurement. FDG-PET/CT was conducted according to a standardized protocol, and findings were confirmed by histology. Cost benefit analysis was performed based on charged cost of PET/CT and pancreatic resection and included the time frame of staging and surgery. RESULTS: Fifty-nine patients with a median age of 61 years (range, 40-80 years) were included in this analysis. Fifty-one patients had lesions in the head and 8 in the tail of the pancreas. The positive and negative predictive values for pancreatic cancer were 91% and 64%, respectively. PET/CT detected additional distant metastases in 5 and synchronous rectal cancer in 2 patients. PET/CT findings changed the management in 16% of patients with pancreatic cancer deemed resectable after routine staging (P = 0.031) and was cost saving. CONCLUSIONS: PET/CT represents an important staging procedure prior to pancreatic resection for cancer, since it significantly improves patient selection and is cost-effective.     

Diagnosis and assessment of resectability for neoplasms of the pancreas and periampullary region

CT remains the initial study of choice for determining whether a patient has potentially resectable, locally advanced, or metastatic pancreatic cancer; such clinical staging is critical for accurate treatment planning. EUS has become the preferred method of tissue acquisition through the use of EUS-guided FNA biopsy. ERCP remains an important diagnostic tool, and endobiliary stenting is the preferred initial therapy for biliary obstruction. The extent to which laparoscopy should be used remains controversial. Laparoscopy is reasonable to consider before laparotomy (during the same anesthesia induction) in patients with biopsy-proven or suspected potentially resectable pancreatic cancer in whom a decision has been made to proceed with pancreatoduodenectomy.Pancreatoduodenectomy should be considered only in those patients whose tumors appear to be resectable based on high-quality CT and who have a good performance status. Furthermore, pancreatoduodenectomy should be part of a multimodality treatment program that includes preoperative or postoperative chemoradiation. Because of the modest survival rates associated with current treatments, the enrollment of all patients into clinical trials of new combinations of surgery, chemoradiation, and newly developed systemic drugs is strongly encouraged. Future progress in the treatment of pancreatic cancer will involve techniques for early diagnosis and effective systemic therapy. For now, the best results can be achieved by careful attention to patient selection, preoperative assessment of resectability, surgical technique, and postoperative care.     

腹腔镜在胰腺肿瘤诊断和分期中的价值

目的:总结胰腺肿瘤剖腹手术前先行腹腔镜探查的价值。方法:对12例经B超和CT诊断或怀疑为胰腺肿瘤的病人,在剖腹手术前先行腹腔镜探查,其中2例联合使用腹腔镜超声检查(LUS)。结果:1例CT诊断疑为胰头肿瘤伴少量腹水者,腹腔镜明确为原发性腹膜炎,作冲洗引流而愈。2例影像学检查见胰体尾增厚,怀疑胰腺肿瘤者,腹腔镜检查未见明显异常,再作LUS检查,1例为胰腺囊肿,另1例未见异常。9例腹腔镜检查确诊为胰腺恶性肿瘤病人中,3例明确已有远处转移,从而避免了开腹;另6例腹腔镜探查提示可以切除,结果其中1例由于肠系膜血管被肿瘤包绕而无法切除,余5例(5/9=55.6%)进行了根治性切除。腹腔镜探查在评估胰腺癌不可切除性的敏感性为75%,特异性为100%,阳性预测值为100%,阴性预测值为83.3%。结论:腹腔镜探查可发现影像学检查不能发现的腹膜转移,结合腹腔镜超声检查可提高胰腺肿瘤诊断、分期的准确性,使部分病人避免了不必要的剖腹手术。     

Staging laparoscopy for hilar cholangiocarcinoma in 100 patients

Purpose

Accurate preoperative radiological staging of hilar cholangiocarcinoma remains difficult, and a number of patients are found to have irresectable advanced tumours or occult metastases at exploration. Staging laparoscopy can improve the detection of irresectable disease, avoiding unnecessary laparotomy. This study examines the role of staging laparoscopy in hilar cholangiocarcinoma, with a focus on yield over different time periods and identification of preoperative factors increasing the risk of irresectable disease.

Methods

Retrospective case note review of all patients undergoing staging laparoscopy for radiologically resectable hilar cholangiocarcinoma, identified from the hepatobiliary multidisciplinary team database, was performed.

Results

One hundred consecutive patients underwent staging laparoscopy between 1998 and 2011. Of these, 34 patients were found to be irresectable due to metastatic disease, and 11, due to extensive local disease. Fifty patients proceeded to exploratory laparotomy following staging laparoscopy, and 36 % (18/50) of whom were found to have irresectable disease: 12 patients due to advanced local disease and 6 patients due to metastases. The overall yield of laparoscopy was 45 %, and the accuracy was 71 %. There was no significant difference in age, preoperative bilirubin, neutrophil/lymphocyte ratio, Ca19-9 levels or T stage between patients with resectable disease and with irresectable disease on laparoscopy. There was also no change in the yield of laparoscopy over time, despite advances in radiological imaging.

Conclusion

In this series, staging laparoscopy avoided unnecessary laparotomy in 45 % of patients with radiologically resectable hilar cholangiocarcinoma. No factor was able to predict positive yield, and therefore, all patients with potentially resectable hilar cholangiocarcinoma should undergo staging laparoscopy.     

The Role of Staging Laparoscopy in Hepatobiliary Malignancy: Prospective Analysis of 401 Cases

Background:Patients with potentially resectable hepatobiliary malignancy are frequently found to have unresectable tumors at laparotomy. We prospectively evaluated staging laparoscopy in patients with resectable disease on preoperative imaging.Methods:Staging laparoscopy was performed on 410 patients with potentially resectable hepatobiliary malignancy. The preoperative likelihood of resectability was recorded. Data on preoperative imaging, operative findings, and hospital course were analyzed.Results:Laparoscopic inspection was complete in 291 (73%) patients. In total, 153 patients (38%) had unresectable disease, 84 of whom were identified laparoscopically, increasing resectability from 62% to 78%. On multivariate analysis, a complete examination, preoperative likelihood of resection, and primary diagnosis were significant predictors of identifying unresectable disease at laparoscopy. The highest yield was for biliary cancers, and the lowest was for metastatic colorectal cancer. In patients with unresectable disease identified at laparoscopy, the mean hospital stay was 3 days, and postoperative morbidity was 9%, compared with 8 days and 27%, respectively, in patients found to have unresectable disease at laparotomy.Conclusions:Laparoscopy spared one in five patients a laparotomy while reducing hospital stay and morbidity. Targeting laparoscopy to patients at high risk for unresectable disease requires consideration of disease-specific factors; however, the surgeons preoperative impression of resectability is also important.     

Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography.

OBJECTIVE: The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region. SUMMARY BACKGROUND DATA: Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy. METHODS: A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region). RESULTS: "Occult" metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively). CONCLUSIONS: Staging laparoscopy is indispensable in the detection of "occult" intra-abdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.     

Staging of pancreatic cancer before and after neoadjuvant chemoradiation

Neoadjuvant chemoradiation therapy is used at many institutions for treatment of localized adenocarcinoma of the pancreas. Accurate staging before neoadjuvant therapy identifies patients with distant metastatic disease, and restaging after neoadjuvant therapy selects patients for laparotomy and attempted resection. The aims of this study were to (1) determine theutilityof staging laparoscopy in candidates for neoadjuvant therapy and (2) evaluate the accuracy of restaging CT following chemoradiation. Staging laparoscopy was performed in 98 patients with radiographically potentially resectable (no evidence of arterial abutment or venous occlusion) or locally advanced (arterial abutment or venous occlusion) adenocarcinoma of the pancreas. Unsuspected distant metastasis was identified in 8 (18%) of 45 patients with potentially resectable tumors and 13 (24%) of 55 patients with locally advanced tumors by CT Neoadjuvant chemoradiation therapy and restaging CT were completed in a total of 103 patients. Thirty-three patients with potentially resectable tumors by restaging CT underwent surgical exploration and resections were performed in 27 (82%). Eleven (22%) of 49 patients with locally advanced tumors by restaging CT were resected, with negative margins in 55%; the tumors in these 11 patients had been considered locally advanced because of arterial involvement on restaging CT Staging laparoscopy is useful for the exclusion of patients with unsuspected metastatic disease from aggressive neoadjuvant chemoradiation protocols. Following neoadjuvant chemoradiation, restaging CT guides the selection of patients for laparotomy but may overestimate unresectability to a greater extent than does prechemoradiation CT. Presented at the 2001 Americas Congress of the American Hepatopancreatobiliary Association, Miami, Fla., February 25, 200l.     

Experience with laparoscopic ultrasonography for defining tumour resectability in carcinoma of the pancreatic head and periampullary region

BACKGROUND: Computed tomography (CT) is currently the most widely available staging investigation for pancreatic tumours. However, the accuracy of CT for determining tumour resectability is variable and can be poor. Laparoscopic ultrasonography (LUS) is potentially a more accurate method for disease staging. The authors' experience of LUS for staging carcinoma of the pancreatic head and periampullary region is described. METHODS: Fifty-one patients with potentially resectable pancreatic tumours defined at CT underwent further investigation with LUS. Twenty-seven patients subsequently had an open laparotomy. The evaluations of tumour resectability at CT and LUS were compared with the operative findings. RESULTS: At LUS, 24 patients were considered to have resectable tumours, 21 non-resectable tumours and six patients were shown to have no pancreatic tumour mass. Twenty-two patients deemed to have a resectable tumour at LUS underwent surgery. Twenty patients were confirmed to have resectable disease and two patients had non-resectable disease. A further five patients underwent surgery. In all five the ultrasonographic diagnosis was confirmed at surgery (four patients with non-resectable disease and no pancreatic tumour in one patient). LUS prevented unnecessary extensive surgery in 53 per cent of patients. For the 22 patients who underwent surgery for potentially resectable disease, the positive predictive value of LUS for defining tumour resectability was 91 per cent. CONCLUSION: LUS is an accurate additional investigation for defining tumour resectability and directing management in patients with potentially resectable carcinoma of the pancreatic head or periampullary region.     

The value of laparoscopy in the management of ampullary, duodenal, and distal bile duct tumors

Laparoscopy identifies radiologically occult advanced disease in patients with pancreatic adenocarcinoma. The value of laparoscopy in the management of peri-ampullary tumors was determined. One hundred forty-four patients with radiologically resectable nonpancreatic adenocarcinoma, periampullary tumors were identified from a prospective database between August 1993 and December 2000. Criteria for laparoscopic unresectability included histologically proved peritoneal or hepatic metastases, distant nodal involvement, arterial involvement, and local extension outside the resection field. Median age at operation was 70 years (range 31 to 87 years) and 56% of the patients were men. An adequate laparoscopy was performed in 134 cases (93%). Laparoscopy identified 13 patients (10%) with unresectable disease. Of 121 patients with laparoscopic resectable disease, 111 (92%) went on to subsequent resection; CT correctly predicted resectability in 82%. Laparoscopy spared 36% of unresectable patients a nontherapeutic laparotomy. Patients with resectable disease were treated by pancreaticoduodenectomy (n = 91, 76%), ampullectomy (n = 12, 10%), duodenal resection (n = 10, 9%), or bile duct excision (n = 6, 5%). The addition of diagnostic laparoscopy to dynamic CT scanning in this selected patient population identifies an additional 10% of patients with unresectable disease. We believe that laparoscopy should be used in a selective manner for preoperative staging of patients suspected of having nonpancreatic periampullary tumors. Presented in part at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001. Supported by the Milton and Bernice Stern Foundation.     

The impact of laparoscopy and laparoscopic ultrasonography on the management of pancreatic cancer

HYPOTHESIS: Laparoscopy and laparoscopic ultrasonographic (LAPUS) examinations combined with a biopsy of the pancreatic lesion contribute significantly in the determination of resectability of pancreatic cancer. DESIGN: A prospective evaluation of the impact of laparoscopy and LAPUS on surgical decision making in patients with pancreatic cancer. SETTING: A general community hospital; the department of surgery serves as referral for pancreatic surgery. PATIENTS: During a 36-month period, 94 patients with pancreatic lesions were prospectively examined. Twenty-seven patients were found to have advanced disease. The remaining 67 patients were examined by laparoscopy and LAPUS to determine the resectability of the pancreatic tumor. RESULTS: Laparoscopy and LAPUS contributed new, additional data in 40 patients (60%). Advanced disease was found in 30 patients, precluding curative resection. The study indicated potentially resectable tumors in 37 patients (55%), including 3 defined by conventional imaging studies as probably unresectable, and these patients were operated on with the intention of curative resection. Thirty-three patients underwent resection, and 4 (6%) were found to have nonresectable disease and form the false-positive group of the study. A summary of the results shows that the study resulted in a change of the decision regarding surgical intervention in 24 patients (36%) and avoided unnecessary laparotomies in 21 (31%). The study had a sensitivity of 100%, a specificity of 88%, and a false-positive rate of 6%. The positive predictive value of the study is 89%, and the negative predictive value is 100%. CONCLUSIONS: Although rather invasive procedures that require general anesthesia and hospitalization, laparoscopy and LAPUS significantly contribute to the staging of patients with potentially resectable pancreatic cancer, avoiding unnecessary explorative laparotomies. These procedures should be performed in all patients with potentially resectable pancreatic cancer before explorative laparotomy.     

Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients

OBJECTIVE: To evaluate the benefit of staging laparoscopy in patients with gallbladder cancer and hilar cholangiocarcinoma. SUMMARY BACKGROUND DATA: In patients with extrahepatic biliary carcinoma, unresectable disease is often found at the time of exploration despite extensive preoperative evaluation, thus resulting in unnecessary laparotomy. METHODS: From October 1997 to May 2001, 100 patients with potentially resectable gallbladder cancer (n = 44) and hilar cholangiocarcinoma (n = 56) were prospectively evaluated. All patients underwent staging laparoscopy followed by laparotomy if the tumor appeared resectable. Surgical findings, resectability rate, length of stay, and operative time were analyzed. RESULTS: Patients underwent multiple preoperative imaging tests, including computed tomography scan, ultrasound, magnetic resonance cholangiopancreatography, and direct cholangiography. Laparoscopy identified unresectable disease in 35 of 100 patients. In the 65 patients undergoing open exploration, 34 were found to have unresectable disease. Therefore, the overall accuracy for detecting unresectable disease was 51%. There was no difference in the accuracy of laparoscopy between patients with gallbladder cancer and hilar cholangiocarcinoma. Laparoscopy detected the majority of patients with peritoneal or liver metastases but failed to detect all locally advanced tumors. In patients undergoing biopsy only, laparoscopic identification of unresectable disease significantly reduced operative time and length of stay compared with patients undergoing laparotomy. The yield of laparoscopy was 48% in patients with gallbladder cancer (56% in those who did not undergo previous cholecystectomy), but only 25% in patients with hilar cholangiocarcinoma. However, in patients with locally advanced but potentially resectable hilar cholangiocarcinoma, the yield of laparoscopy was greater, 36% (12/33, T2/T3 tumors) versus 9% (2/23, T1 tumors). CONCLUSIONS: Laparoscopy identifies the majority of patients with unresectable hilar cholangiocarcinoma or gallbladder carcinoma, thereby reducing both the incidence of unnecessary laparotomy and the length of stay. The yield of laparoscopy is lower for hilar cholangiocarcinoma but can be improved by targeting patients at higher risk of occult unresectable disease. All patients with potentially resectable primary gallbladder cancer and patients with T2/T3 hilar cholangiocarcinoma should undergo staging laparoscopy before surgical exploration.     

The Role of Laparoscopy and Ultrasonography in Pancreatic Head Carcinoma

Objective: The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region.Summary Background Data: Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy.Methods: A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region).Results: “Occult” metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively).Conclusions: Staging laparoscopy is indispensable in the detection of “occult” intraabdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.     

Laparoscopic ultrasound enhances diagnostic laparoscopy in the staging of intra-abdominal neoplasms

Routine laparoscopy and laparoscopic ultrasound (LUS) for staging intra-abdominal malignancies remains controversial. Thus, we undertook a prospective study to assess the value of preoperative laparoscopy with LUS for patients with intra-abdominal tumors judged resectable by preoperative studies. Laparoscopy was successfully performed in 76 of 77 patients, and 60 underwent LUS. Of 33 patients with presumed pancreatic cancer, laparoscopic findings changed the operative management of 11 patients, and LUS altered the management of an additional 6 patients. Laparotomy was avoided in 9 patients (27%). Among 14 patients with hepatobiliary tumors, laparotomy was avoided in 9 patients in whom laparoscopy and/or LUS revealed either benign or advanced disease. Operative management was altered in 4 of 18 patients with gastric or esophageal cancer by laparoscopic findings. LUS did not add to the management of these patients. Of 12 patients with presumed intra-abdominal lymphoma, 9 were diagnosed with lymphoma and 3 with benign disease, without laparotomy in all but 1 case. Laparoscopy and LUS are valuable tools for evaluating the resectability of pancreatic and hepatobiliary tumors. Laparoscopy, and to a lesser degree LUS, greatly facilitates diagnosing patients with intra-abdominal lymphomas and spares an occasional patient with esophagogastric carcinoma from undergoing laparotomy.