Staging laparoscopy for gastric cancer

The growing role of multimodal treatment plans for advanced gastric cancer has contributed to the development of more accurate preoperative staging strategies. The high diagnostic efficacy of video-laparoscopy as regards the M factor has been reported by many; preoperative laparoscopy therefore permits to avoid unhelpful surgical exploration in case of peritoneal dissemination of tumor or liver metastases undetected by conventional staging. At Memorial Sloan Kattering Cancer Center preoperative staging laparoscopy is currently included in the diagnostic algorithm for gastric cancer. Data from a consecutive series of 103 patients demonstrated metastatic disease in 24 patients (37%) who were considered to have localized cancer by computed tomography (CT) or endoscopic ultrasonography (EUS), with an accuracy of 94% with respect to the M factor. These patients did not require open surgery. Laparoscopic washings were obtained from 127 patients with gastric cancer and a positive correlation between the extent of disease and prevalence of positive cytology was noted (T1/T2: 0%, T3/T4: 10%, M+: 59%). Our experience suggests that laparoscopy has added value in staging patients with gastric carcinoma. It appears to be a safe and effective staging modality, avoiding unnecessary explorations and providing new means of directing appropriate treatment strategy.     

Staging laparoscopy and its indications in pancreatic cancer patients

BACKGROUND: Laparoscopy has become a popular and widespread surgical technique. An important goal in the treatment of patients with pancreatic cancer is to avoid any unnecessary procedure. Laparoscopy has been suggested as a routine tool for staging in order to prevent unnecessary laparotomies in these patients. METHODS: In this article we present our experience regarding the value of laparoscopic staging and review the literature on this topic. RESULTS AND CONCLUSION: A direct and conclusive comparison of the controversial literature is difficult because of different study designs. Inconsistent use of high-quality CT scans significantly affects the results. However, recent studies reveal that not more than 14% of the patients benefit from diagnostic laparoscopy when a state-of-the-art CT scan has been performed previously. Therefore, we conclude that routine diagnostic laparoscopy is not justified in all patients with pancreatic cancer. Rather, selective use is appropriate, especially in patients in whom ascites is an indirect sign of peritoneal metastases, or if liver metastases cannot be surely excluded preoperatively. This approach is cost-effective and limits diagnostic laparoscopy to a subgroup of patients in whom a laparotomy can be avoided.     

Usefulness of staging laparoscopy for advanced gastric cancer

Purpose  

The aim of this study was to clarify the usefulness of staging laparoscopy for planning the treatment strategy in patients with advanced gastric cancer.     

加速康复外科及腹腔镜在胃癌中的应用研究

目的:评价加速康复外科(fast track surgery,FTS)新理念及腹腔镜技术常规应用于胃癌根治术的可行性.方法:回顾分析2005年3月至2010年3月由同一医师完成的胃癌根治术的临床资料,按围手术期理念和手术技术分为3组,A组(66例)采用传统围手术期处理方法行开腹手术,B组(105例)应用FTS理念行开腹...     

Staging of gastric cancer: a study with spiral computed tomography, ultrasonography, laparoscopy, and laparoscopic ultrasonography

In this study, we evaluated and compared the value of spiral computed tomography, transabdominal ultrasonography, laparoscopy, and laparoscopic ultrasonography in staging gastric cancer in 37 patients; there was a special interest in the additional information provided by laparoscopic ultrasonography. Although laparoscopy was unreliable or hindered by adhesions in 11% of the patients, the benefit of laparoscopy for staging was evident especially for the detection of peritoneal carcinomatosis that was missed by the other diagnostic modalities. Laparoscopic ultrasonography did not change the stage of the disease nor the decision whether to proceed with laparotomy for any of the patients. The decision whether to proceed with laparotomy was correctly predicted in 95% of the cases.     

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.     

Feasibility and accuracy of second-look laparoscopy after gastrectomy for gastric cancer

Background

A better method for detecting early peritoneal progression is needed. This study evaluated the feasibility and accuracy of second-look laparoscopy for patients with gastric cancer treated using systemic chemotherapy after gastrectomy.

Methods

Second-look laparoscopy was conducted for patients who had no clinical evidence of distant metastases but had peritoneal metastases or positive peritoneal cytology results without visible metastatic disease at initial surgery, patients who underwent systemic chemotherapy over a 6-month period after surgery, and patients who had no clinical evidence of disease based on imaging study after completion of primary chemotherapy.

Results

Between November 2004 and April 2008, 21 patients underwent second-look laparoscopy. At the initial surgery, 13 of these patients underwent total gastrectomy and 8 patients underwent distal gastrectomy. One or two sheets of adhesion barrier were received by 18 patients. The median interval between initial surgery and second-look laparoscopy was 9.8 months (range, 6.6–17.5 months). All second-look procedures were completed laparoscopically, and no patients required conversion to laparotomy. None of the 21 patients experienced postlaparoscopy complications. Whereas 12 patients showed no pathologic evidence of disease, 9 patients showed disease at second-look laparoscopy. There was a significant difference in median survival between the groups with negative and positive results (p = 0.017). The median survival for the negative group has not been determined. All the patients in the positive group received further chemotherapy while showing a good performance status (PS). Six patients were PS 0, and 3 patients were PS 1. The median survival time for this group was 10.1 months.

Conclusions

Second-look laparoscopy was a safe and promising approach to reassessment of peritoneal disease for patients with gastric cancer. The incidence of complications was low, particularly in this group of patients, all of whom had undergone prior gastrectomy.     

腹腔镜辅助远端胃癌根治术的临床应用

目的：探讨腹腔镜辅助远端胃癌根治术的可行性、安全性。方法：回顾性分析12例腹腔镜辅助远端胃癌根治术的临床资料。结果：12例均顺利完成手术,无中转开腹。平均手术时间240min,术中平均出血100ml,无手术并发症发生,术后病理检查淋巴结平均23.5枚,两切端无癌细胞残留。结论：腹腔镜辅助远端胃癌根治术安全、可行,近期效果满意。     

Staging laparoscopy for potentially resectable noncolorectal,nonneuroendocrine liver metastases

Background Carefully selected patients with noncolorectal, nonneuroendocrine (NCNN) liver metastases may benefit from hepatic resection. The incidence of occult unresectable disease and the possible benefits of staging laparoscopy in these patients are not known. Methods From December 1997 to July 2000, staging laparoscopy was performed in 30 consecutive patients with NCNN metastases before planned open exploration and resection. Demographies, extent of preoperative imaging, operative and postoperative findings, and factors associated with laparoscopic identification of unresectable disease were analyzed. Results Twenty-four patients (80%) had a complete laparoscopic examination, and 23 had laparoscopic ultrasonography. All patients underwent preoperative computed tomography or magnetic resonance imaging, and 21 (70%) patients had 2 or more preoperative radiological studies. Overall, nine patients had unresectable disease, six of whom were identified by laparoscopy. Of the remaining 24 patients believed to have resectable disease at laparoscopy, 21 went on to a potentially curative procedure. Laparoscopy did not identify irresectability because of vascular involvement in three patients. Laparoscopy added a median of 30 minutes of operative time to those patients going on to laparotomy. Conclusions Laparoscopy identified the majority of patients with occult unresectable disease, improved resectability, and should be routine in patients being considered for potentially curative hepatic resection. Presented in part at the 54th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.     

3D微创外科技术在胃癌中的应用与选择

正随着科学技术的进步,腔镜技术的出现使得通过微小创伤或入路进行外科手术操作的微创外科理念得以实现。腹腔镜技术应用于临床已有三十余年的历史。1987年Mouret进行的第一例腹腔镜下胆囊切除术,标志着腔镜技术首次应用于腹部手术[1]。伴随3D微创外科技术的兴起和革新,     

腹腔镜与开腹远端胃癌根治术同期临床对比研究

目的比较腹腔镜辅助下远端胃癌根治及D2淋巴结清扫术的手术方法、可行性及安全性。方法对2004年3月至2005年5月行腹腔镜胃癌根治术44例及传统开腹手术58例病人的手术安全性、术后恢复及肿瘤根治性进行比较分析。结果腹腔镜组44例病人中43例成功完成腹腔镜手术,其中行D1+α淋巴结清扫6例,D1+β2例,D2及D2+手术35例,平均清扫淋巴结(30·11±16·97)枚,1例因胃左动脉根部淋巴结融合包绕血管而中转开腹手术。腹腔镜组手术平均用时长于开腹组[(282·84±32·81)vs(223·75±23·25)min]。腹腔镜组术中出血、切口长度、术后止痛剂注射次数以及术后肛门排气时间、下床时间分别为(139·30±82·67)mL,(5·61±0·81)cm,(1·02±1·03)次,(4·10±0·75)d,(3·24±0·777)d,显著低于开腹手术组。腹腔镜组肺部感染率低于开腹组,但差异无显著性,两组间其他并发症差异无显著性。腹腔镜组肿瘤近或(远)端切缘、淋巴结清扫数量、第一及二站淋巴结转移阳性率分别为(6·05±1·27)cm、(6·37±1·12)cm、(30·11±16·97)、47·7%及31·8%,与开腹组相比差异无显著性。术后近期随访效果良好。结论腹腔镜胃癌根治术较传统开腹手术耗时长,但能达到与开腹胃癌标准根治术(D2)相同的淋巴结清扫范围及肿瘤切缘,且具有创伤小、出血少、安全、术后恢复快等优点。     

腹腔镜、胃镜联合治疗早期胃癌的临床体会

目的:探讨腹腔镜与胃镜联合行早期胃癌手术的可行性和临床价值.方法:将2007年4月至2010年6月56例早期远端胃癌患者随机分为两组,其中实验组26例,施行腹腔镜联合胃镜胃癌根治术;对照组30例,施行常规开腹胃癌根治术,对比分析两组手术时间、术中副损伤、术中出血量、术后肠功能恢复、术后并发症及住院时间.结果:实验组与对...     

Staging of gastric carcinoma

The controversies over the patterns of gastric cancer staging in western countries (UICC-AJCC), Japan (JRSGC) and more recently Hawaii (1984) are analysed with reference to the problems of definition and assignment of values to the single elements: T,N,M, location and stage grouping that were not homogeneously established in the patterns mentioned. Problems about T mainly regard T1 and T4. T1 incorporates tumours (T1m and T1sm) with quite different prognosis and therefore represents, in spite of several changes made, a dyshomogeneous group. The same can be said about T4 where prognoses are considerably different according to contiguous structures involved in the tumour and they are not held in due consideration by the various staging systems. In all these, the different lymph nodes are gathered into homogeneous groups (N1,N2,N3) progressively numbered according to the prognostic value. These groups are based, however, on inadequate information and in fact constitute heterogenous umbrellas. The greatest problems about parameter M concern subclinical M1 that, missed at the time of the tumours staging before or during operations, reveal themselves shortly after operations considered radical. Finally new views about the relationship between cancer biology and prognosis (cytofluorometry, immunohistochemistry, etc.) are examined.     

The contribution of laparoscopy to the treatment of gastric cancer

BACKGROUND: Laparoscopy plays a role in the preoperative diagnosis of gastric cancer, particularly in determining the location and extent of the neoplasia. In addition to its use in staging, laparoscopy is indicated for the gastric resection of T1-T2, and its middle- and long-term results are comparable to those obtainable with open surgery. Herein we describe our experience with the laparoscopic resection of gastric carcinomas, including the dissection of lymph nodes and the Billroth II reconstruction of digestive continuity with gastrojejunostomia. METHODS: We carried out laparoscopic gastric resections in 25 patients with adenocarcinomas. Our method involved installing five trocars, tying the left and right gastric vessels and the right gastro-epiploic vessels, sectioning the duodenum 3 cm from the pylorus, sectioning the remaining portion of the stomach obliquely 3 cm from the cardias, and performing Billroth II reconstruction. RESULTS: The average duration of the operation was 4 h 45 min. The average number of removed lymph nodes was 30.5 (range, 22-41). Five patients were converted to laparotomy. Significant complications were observed in four cases (16%). Hospitalization ranged from 5 to 16 days. The average follow-up was 38 months (range, 7-63), without evidence of relapse. CONCLUSION: In terms of morbidity, our results were similar to those obtained with open surgery. Lymphectomy according to the extent and number of lymph nodes is acceptable in the treatment of tumors of the lower third of the stomach. More case studies are needed to provide further indications of the applicability of the technique (which is currently used only in a few centers) and long-term results.     

Staging techniques for lung cancer

In summary, noninvasive clinical staging techniques aid in stratifying patients into similar prognostic and therapeutic categories. Every patient with presumed non-small cell lung cancer should undergo a thorough history and physical examination, basic routine laboratory testing, PA and lateral chest radiographs, and chest CT scan with upper abdominal cuts to allow evaluation of the liver and adrenals. Recently, FDG-PET scanning has shown tremendous promise in the noninvasive evaluation of the primary tumor, nodal involvement, and metastatic [table: see text] disease. Although valuable, clinical staging has limitations, and when pathologic confirmation of lung cancer is required, minimally invasive techniques, such as bronchoscopy, TTNA, thoracoscopy, anterior mediastinotomy, and cervical and extended mediastinoscopy, may be valuable and simple ways of obtaining tissue.     

Staging laparoscopy promotes increased utilization of postoperative therapy for unresectable intra-abdominal malignancies

Staging laparoscopy avoids unnecessary laparotomies in patients with unresectable intra-abdominal malignancies. However, the postoperative oncologic treatment of these patients has not been documented. This study compares rates and timing of postoperative chemotherapy (ChT) and/or radiation therapy (XRT) in patients with unresectable intra-abdominal malignancies initially evaluated by staging laparoscopy (SL) or exploratory laparotomy (EL). The records of patients surgically evaluated for esophageal, gastric, hepatobiliary, and pancreatic cancers or abdominal lymphoma were retrospectively reviewed. Data gathered included type of exploration (SL or EL), resectability, whether postoperative cancer treatment was given (ChT, XRT, or both), and the time from surgery to the beginning of such treatment. This study includes only patients with unresectable malignancies. Twenty-one patients underwent SL and 58 EL. Sixteen of the SL patients (76%) and 25 of the EL patients (43%) received postoperative cancer treatment (P = 0.009). The median number of days from surgery to postoperative cancer treatment was 13 days (range 5 to 41 days) for the SL group and 35 days (range 16 to 89 days) for the EL group (P = 0.0004). We conclude that patients with unresectable intra-abdominal malignancies discovered by SL are more likely to receive postoperative ChT and/or XRT than patients surgically evaluated by EL. Further studies to determine whether this better utilization of postoperative treatment results in better outcomes in these patients are needed.