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.     

Staging laparoscopy and laparoscopic ultrasonography in more than 400 patients with upper gastrointestinal carcinoma.

BACKGROUND: Resection offers the only chance of cure to patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. Staging is essential to select patients who will benefit from operation because palliation can also be performed nonoperatively. Several studies, including limited numbers of patients, have shown that laparoscopic staging prevents unnecessary laparotomies, but it is doubtful whether general application of this staging method can be advised. The aim of this study was to assess the benefit of diagnostic laparoscopy for staging patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. STUDY DESIGN: Between June 1992 and December 1996, 420 patients with a resectable tumor after conventional staging underwent diagnostic laparoscopy combined with laparoscopic ultrasonography. Histologic proof of metastases or ingrowth was used to cancel laparotomy. RESULTS: Laparoscopic staging avoided laparotomy in 20% of patients (sensitivity 0.70): 5% with an esophageal tumor, 20% with a gastroesophageal junction tumor, 15% with a periampullary tumor, 40% with a proximal bile duct tumor, 35% with a liver tumor, and 40% with a pancreatic body or tail tumor. Complications and port-site metastases were seen in 4% and 2% of patients, respectively. CONCLUSIONS: Laparoscopic staging is a safe procedure with low morbidity and without mortality in this series. It has shown no benefit in esophageal cancer, but seems beneficial for staging tumors located at the gastroesophageal junction, proximal bile duct tumors, liver tumors, and pancreatic body and tail tumors. The value of laparoscopic staging for patients with periampullary tumors is not as great as stated in previous studies and is still the subject of investigation.     

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.     

Current attitudes in the management of obstructive biliary tract disease

The current attitudes of surgeons towards the management of obstructive biliary tract disease were assessed by analyzing the responses of general surgeons to a 20-item questionnaire. The responses indicate that ultrasound is the most favored initial diagnostic test for suspected choledocolithiasis. Ninety-nine per cent of the respondents always or almost always insert a T-tube following exploration of the common bile duct for stones. For patients with stone impacted at the ampulla of Vater, sphincterotomy with or without sphincteroplasty is recommended by 86 per cent of surgeons. However, differences are noted in the approach to management of malignant lesions in the biliary tract. For carcinoma of the head of the pancreas, at laparotomy, if the lesion is resectable, 59 per cent of the surgeons will perform a Whipple procedure, nine per cent a total pancreatectomy, and 28 per cent recommend bypass only. For unresectable carcinoma of the head of the pancreas, 73 per cent perform cholecystojejunostomy, and 26 per cent prefer choledocojejunostomy. In addition to the biliary bypass, only 57 per cent perform a gastric bypass routinely. The favored treatment (62%) for unresectable common bile duct tumors is an internal bypass. However, following bypass, only 45 per cent recommend further treatment with radiation and/or chemotherapy. Therefore, it appears that there is agreement on the treatment of biliary obstruction due to stones. Differences are noted, however, in the approach to the management of malignant disease.     

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.     

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.     

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.     

肝外胆管梗阻性疾病的MRCP诊断价值

目的探讨磁共振胆胰管成像技术对肝外胆管梗阻性疾病的诊断价值。方法对52例经病理或随访证实的肝外胆管梗阻性疾病患者的MRCP资料进行回顾性分析,总结良恶性肝外胆管梗阻的不同MRCP表现。结果52例中,MRCP均能够准确测定胆管扩张程度和梗阻的水平,其中良性梗阻27例,MRCP主要表现为胆管均匀扩张及逐渐狭窄,肝外胆管较肝内胆管扩张明显,肝内胆管呈“枯树枝状”;恶性梗阻25例,MRCP主要表现为胆管截断,胆胰管扩张,出现“双管征”,肝内外胆管扩张一致。恶性梗阻患者的肝内外胆管扩张程度明显大于良性梗阻者。结论MRCP作为一种无创的影像检查方法,对肝外胆管梗阻性疾病的诊断具有较高准确性,     

Early experience of laparoscopic ultrasonography in the management of pancreatic carcinoma

Summary A 7.5-MHz linear array ultrasound probe has been developed for the evaluation of solid organs at laparoscopy. Twelve patients with suspected carcinoma of the head of the pancreas, considered at initial investigation to have resectable disease, were submitted to laparoscopy. In 4 patients, diagnostic laparoscopy revealed hepatic metastases (4 patients), peritoneal dissemination of tumor (2), and malignant ascites (1). Laparoscopic ultrasonography demonstrated hepatic metastases in four patients and hepatic cysts in two further patients. Ultrasound evaluation of the pancreas revealed lymphadenopathy (4 patients), local infiltration (2), and portal vein displacement or invasion (4). An anomalous right hepatic artery arising from the superior mesenteric artery was identified in one patient. Overall, laparoscopy identified advanced disease in four patients. Laparoscopic ultrasonography, while detecting advanced disease in a further two patients, predicted resectable disease in six patients (50%). Only one of the six patients submitted to laparotomy was found to have irresectable disease due to lymph-node metastases. Laparoscopic ultrasound examination of the pancreas and liver has improved the early staging of pancreatic carcinoma and should be undertaken at an early stage in the management of such patients.     

Laparoscopic Deployment of Biliary Self-Expandable Metal Stent (SEMS) for One-Step Palliation in 23 Patients with Advanced Pancreatico-Biliary Tumors—a Pilot Trial

Background Exploratory laparoscopy is commonly undertaken in patients with highly suspicious biliary and pancreatic lesions to facilitate diagnosis and staging cancer is present. If an unresectable tumor is identified, a second endoscopic procedure may be required do deploy a self-expandable metal stent (SEMS) for palliation. As endoscopic retrograde cholangio pancreatography (ERCP) may be unsuccessful in up to 20% of patients, we evaluated the feasibility and safety of deployment of self-expandable metal stents at the same time as the initial laparoscopy. Patients and Methods A total of 23 eligible patients (8 male and 15 female) with malignant obstruction of the common bile duct underwent deployment of SEMS at laparoscopy. Primary outcome measure was the successful laparoscopic deployment of stent and secondary outcome measure was complications rates. Results Indications for stent deployment were unresectable pancreatic cancer in 18, cholangiocarcinoma in two, neuroendocrine tumor in one and ampullary adenocarcinoma in two patients. The median age was 73 years (range 49–93). Twenty-two of 23 stents were deployed successfully: 17 stents were deployed transcystically and five via a choledochotomy. Median times for laparoscopic exploration and SEMS deployment were 165 min (range 105–230) and 20 min (range 10–50), respectively. Pre- and post-procedures median total bilirubin were 9.4 mg/dl (range 5.4–17.5) and 4.0 (range 2.6–7.1). The median size of the pancreatic mass was 3 cm (range 2–5 cm) and that of the common bile duct (CBD) from 9.2 mm (range 7.2–17.4). The mean duration of laparoscopy was 170 min (range 120–230 min) and that for stent deployment 23 min (range 10–50 min). Complications included bleeding, obstruction, and wound infection. Bleeding occurred on day 7 in two patients and on day 30 in one patient; bleeding occurred at the gastrojejunal anastomosis site and was successfully treated with endoscopic hemostasis. A total of three stent obstructions were identified: one each at 60, 90, and 120 days follow-up. All complications were successfully managed endoscopically. There were a total of seven deaths, six as a result of progressive cancer and one of surgical wound infection and ensuing complications. Conclusion This study demonstrates that laparoscopic deployment of self-expandable metal bile duct stents is feasible and safe. This option appears to be a reasonable option in patients with inoperable malignant obstruction of the distal common bile duct.     

Cytology of peritoneal lavage performed during staging laparoscopy for gastrointestinal malignancies: is it useful?

OBJECTIVE: To evaluate the potential benefit of cytology of the peritoneal lavage obtained during diagnostic laparoscopy for staging gastrointestinal (GI) malignancies. SUMMARY BACKGROUND DATA: Peritoneal lavage is a simple procedure that can be performed during laparotomy for GI tumors. Tumor cells in the lavage fluid are thought to indicate intraperitoneal tumor seeding and to have a negative effect on survival. For this reason, peritoneal lavage is frequently added to diagnostic laparoscopy for staging GI malignancies. METHODS: Patients who underwent peritoneal lavage during laparoscopic staging for GI malignancies between June 1992 and September 1997 were included. Lavage fluids were stained using Giemsa and Papanicolaou methods. Cytology results were correlated with the presence of metastases and tumor ingrowth found during laparoscopy and with survival. RESULTS: Cytology of peritoneal lavage was performed in 449 patients. Tumor cells were found in 28 patients (6%): 8/87 with an esophageal tumor, 2/32 with liver metastases, 11/72 with a proximal bile duct tumor, 7/236 with a periampullary tumor, and none in 7 and 15 patients with a primary liver tumor or pancreatic body or tail tumor, respectively. In 19 of the 28 patients (68%) in whom tumor cells were found, metastatic disease was detected during laparoscopy, and 3 of the 28 patients had a false-positive (n = 1) or a misleading positive (n = 2) lavage result. Therefore, lavage was beneficial in only 6/449 patients (1.3%); in these patients, the lavage result changed the assessment of tumor stage and adequately predicted irresectable disease. Univariate analysis showed a significant survival difference between patients in whom lavage detected tumor cells and those in whom it did not, but multivariate analysis revealed that these survival differences were caused by metastatic or ingrowing disease. CONCLUSION: Cytology of peritoneal lavage with conventional staining should no longer be performed during laparoscopic staging of GI malignancies because it provides an additional benefit in only 1.3% of patients and has limited prognostic value for survival in this group of patients.     

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.     

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.     

Tumour antigens CA 195 and CA 19-9 in pancreatic juice and serum for the diagnosis of pancreatic carcinoma.

OBJECTIVE--To see if tumour associated antigens CA 195 and CA 19-9 were able to differentiate between patients with pancreatic carcinoma, and those with chronic pancreatitis or stones in the common bile duct. DESIGN--Prospective, open, clinical study. SETTING--47 patients with histologically confirmed pancreatic adenocarcinoma, 38 with chronic pancreatitis diagnosed by endoscopic retrograde cholangiopancreatography (ERCP), and 26 with stones in the common bile duct diagnosed and treated by ERCP. INTERVENTIONS--Samples of serum taken from all patients just before ERCP, and samples of pancreatic juice obtained from 18, 11, and 12 patients, respectively during ERCP. RESULTS--Assay of the two tumour markers in pancreatic juice failed to differentiate between patients with benign and malignant disease. When assayed in serum, however, CA 195 detected those with carcinoma with a sensitivity of 72% and a specificity of 92%, and CA 19-9 with a sensitivity of 81% and a specificity of 88%. The patients with unresectable tumours had significantly higher concentrations of both markers in serum than patients with resectable tumours (p less than 0.05). CONCLUSIONS--CA 195 and CA 19-9 concentrations in serum are equally successful in differentiating between benign and malignant pancreatic disease. Assay of markers in pancreatic juice does not provide useful diagnostic information.     

Endoscopic bile duct drainage in malignant obstructive jaundice--an alternative procedure to palliative surgery

74 patients suffering from malignant bile duct obstruction were treated by endoscopic endoprosthesis placement. Improvement and standardization of the technique resulted in successful decompression in 97% of the cases. Also, the complication rate could be reduced to 6.9% (fatal complications, 4.6%). The mean survival time after decompression was 4.5 months, 25 patients of them being still alive. The endoprosthesis had to be replaced after an average of 2.3 months due to occlusion. The endoscopic bile duct decompression is better than surgical palliation in patients with proximal bile duct obstruction. At present, endoscopic endoprothesis placement can be recommended as an alternative method for the palliation of malignant bile duct obstruction.     

The role of diagnostic laparoscopy in staging of pancreatic cancers

Authors report elective diagnostic laparoscopy, and the role of this method in evaluating operability of pancreatic cancer. At their department 11 diagnostic laparoscopic procedures of pancreatic cancer were performed during the last 5 years. In 3 cases tumor proved to be resectable despite preoperative imaging results of unresectable condition. On the basis of international literature authors give brief summary of indications, cost and benefit of diagnostic laparoscopy, and its place in the diagnostic algorythm of pancreatic cancer.     

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.     

Laparoscopy in the management of colorectal cancer metastatic to the liver

BACKGROUND: This investigation was undertaken to define the value of laparoscopy in the staging of patients with colorectal carcinoma metastatic to the liver. METHODS: The clinical details of 59 consecutive patients with colorectal liver metastases undergoing laparoscopy prior to planned hepatectomy were entered prospectively on a computerized database. All patients were staged preoperatively with thin slice (5-7 mm) helical computed tomography chest, abdomen and pelvis. Synchronous metastases were defined as those found during, or on imaging carried out within 1 month of, colorectal resection. Criteria for laparoscopic unresectability were: (i) histologically proven extrahepatic disease; (ii) bilateral inflow or outflow involvement; (iii) the presence of cirrhosis in patients requiring an extended resection (lobectomy or greater); or (iv) hepatic metastases involving more than six hepatic segments. RESULTS: In 24 patients with synchronous metastases (median age 65 years, range 32-81 years) all were resectable on laparoscopic criteria, of whom 21 were resected. Extrahepatic disease was found at laparotomy in three patients. In 35 patients with metachronous metastases (median age 64 years, range 32-81 years) laparoscopy could not be performed in five patients because of adhesions, and three patients were deemed unresectable on laparoscopic criteria. Of the remaining 27 patients, 25 underwent resection while two proved unresectable. Overall eight of 54 evaluable patients had unresectable disease and laparoscopy correctly identified three patients. CONCLUSIONS: Following computed tomography scan, 15% of patients with metastatic colorectal carcinoma will be found to have unresectable disease. Laparoscopy will identify approximately half. Laparoscopy is of no greater value in staging synchronous versus metachronous metastases.     

Diagnosis and therapy of stenosis or obstruction of the intrahepatic bile ducts]

15 patients are reviewed who had stenosis or obstruction at the hilus of the bile duct. Percutaneous transhepatic or endoscopic transduodenal cholangiography is indispensable for establishing the diagnosis before operation. Primary carcinomas involving the junction of the hepatic ducts may be regarded as resectable if proximal extension of the tumor is limited to below the second bifurcation of the intrahepatic bile ducts in both the right and left lobes and if the proper hepatic artery and portal vein are still free from tumor invasion. Our favourable operation procedures for resection or palliative decompression of the biliary tree are discussed.     

Preoperative CA 19-9 and the Yield of Staging Laparoscopy in Patients with Radiographically Resectable Pancreatic Adenocarcinoma

Background  Staging laparoscopy for patients with radiographically resectable pancreatic adenocarcinoma has been reported to yield an 8–15% finding of unresectable disease. Factors associated with the likelihood of subradiographic unresectable disease have not been clearly defined. Methods  A prospectively maintained pancreatic database was reviewed and patients were identified who underwent staging laparoscopy for radiographically resectable pancreatic adenocarcinoma between January 2000 and December 2006. Preoperative carbohydrate antigen 19-9 (CA 19-9) values were assessed for their association with the presence of subradiographic unresectable disease. Results  Four hundred ninety-one patients underwent staging laparoscopy. Resection was performed in 80% (n = 395). Of the 96 patients with unresectable disease, 75 (78%) had metastases either in the liver (n = 60) or peritoneum (n = 15). Preoperative CA 19-9 values were available for 262 of the 491 patients. Fifty-one of these patients had unresectable disease, of which 78% were due to distant disease. The median preoperative CA 19-9 value for patients who underwent resection was 131 U/ml versus 379 U/ml for those patients with unresectable disease (P = 0.003). A receiver operating characteristics (ROC) curve was developed for preoperative CA 19-9 value and tumor resectability. The statistically optimal cutoff value was determined to be 130 U/ml. Unresectable disease was identified in 38 of the 144 patients (26.4%) with a preoperative CA 19-9 ≥ 130 U/ml, and in 13 of the 118 patients (11%) with a CA 19-9 < 130 U/ml (P = 0.003). CA 19-9 values greater than 130 U/ml remained a predictor of tumor unresectability on multivariate regression analysis [hazard ratio (HR) 2.70, 95% confidence interval (CI) 1.34–5.44; P = 0.005]. Conclusion  In this study, preoperative CA 19-9 values were strongly associated with the identification of subradiographic unresectable disease. Preoperative CA 19-9 values may allow surgeons to better select patients for staging laparoscopy.