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.     

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.     

腹腔镜手术治疗胰腺肿瘤的现状

Laparoscopic pancreatic surgery represents one of the most advanced applications for laparoscopic surgery currently in use.In the past,minimally invasive techniques in pancreatic surgery were only used for diagnostic laparoscopy,staging of pancreatic cancer and palliative procedures for unresectable pancreatic cancer.A growing number of case series and multi-institutional reports on safety and efficacy of minimally invasive pancreatic resection have been published.Current knowledge on minimally invasive pancreatic resection is based mainly on short-term outcomes from a small number of centers with cohorts too small to make strong arguments for or against its use.In carefully selected patients,minimally invasive pancreatic resection is safe and feasible.However,the procedure should only be attempted by surgeons who are experienced in open pancreatic surgery and in laparoscopic surgery.The role and oncologic safety of minimally invasive approach for pancreatic resection for pancreatic cancer remain unknown.     

Diagnostic laparoscopy and laparoscopic ultrasonography optimize the staging and resectability of intraabdominal neoplasms

BACKGROUND: Despite technical improvements, preoperative imaging studies often fail to predict intraoperative findings. We investigated the potential use of diagnostic laparoscopy (DL) and laparoscopic ultrasonography (LUS) for the assessment of disease in patients with abdominal neoplasms. METHODS: Fifty consecutive patients with abdominal neoplasms underwent spiral computed tomography with oral and intravenous contrast using 5-mm contiguous sections. In addition, eight patients underwent ultrasonography, six underwent magnetic resonance imaging, and eight underwent positron emission tomography. All patients then underwent DL and LUS using a 7.5-MHz ultrasound probe. RESULTS: There were 29 men and 21 women with a mean age of 63 years (range, 35-84). Most had a diagnosis of colorectal cancer (19 cases), melanoma (12 cases), or hepatoma (five cases). In nine cases (18%), DL revealed peritoneal metastatic implants not shown on preoperative images. In 18 cases (36%), LUS was more accurate than preoperative imaging. Combined DL and LUS findings radically changed the operative management in 16 patients (32%). CONCLUSION: As compared with preoperative imaging, the combination of DL and LUS provides more accurate information regarding staging and resectability. Moreover, it helps to determine the extent of operation and reduces the number of unnecessary laparotomies. DL and LUS should be used as an adjunct to preoperative imaging studies in patients with primary or metastatic intraabdominal neoplasms.     

Role of laparoscopy and laparoscopic ultrasound in staging of pancreatic tumours

BACKGROUND AND AIMS: Radiological imaging alone is not reliable enough in staging of pancreatic cancer. Not only because of poor sensitivity but also because there is a tendency to overstage tumours. The aim of the study was to compare the efficiency of spiral computed tomography (CT), transabdominal ultrasound (US), laparoscopy (LAP) and laparoscopic ultrasound (LUS) in staging of pancreatic tumours. MATERIAL AND METHODS: In this prospective study 27 patients underwent pancreatic tumour staging with CT, US, LAP and LUS. The reference standard was operative evaluation or in case of disseminated disease laparoscopic assessment. RESULTS AND CONCLUSIONS: Although LAP was hindered by adhesions in 11% of the patients the benefit of LAP staging was evident in detecting peritoneal carcinomatosis. The assessment of the local tumour expansion of a pancreatic carcinoma was difficult for all staging modalities. LUS did not change the decision whether to proceed with laparotomy once. In our experience routine use of laparoscopic staging does not benefit patients with pancreatic tumour but in selected cases it may prevent unnecessary laparotomy.     

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.     

Intraoperative ultrasonography in the staging of pancreatic head neoplasms

Tumours of the head of the pancreas constitute the fourth most common cause of cancer deaths. These tumours are characterised by low survival rates (5% at 5 years) and low surgical resectability rates (20-25%). Liver metastases, lymph-node and vascular involvement, and peritoneal metastases are, in our opinion, exclusion criteria for curative surgical resection. The aim of the study was to evaluate the impact of intraoperative ultrasonography on the staging of such tumours. Over the period from 1990 to 2000 we introduced intraoperative ultrasonography in the staging of pancreatic cancer. We evaluated 51 patients who at preoperative staging had been regarded as candidates for surgical therapy consisting in a pancreaticoduodenectomy. All patients had been staged by preoperative abdominal ultrasound, ERCP, CT and MRI. Intraoperative ultrasound and colour-Doppler imaging (from 1997 on) revealed involvement of (i) the liver, (ii) the splenomesenteric vessels and (iii) the portal vein. Intraoperative ultrasonography yielded a diagnosis of occult liver metastases in 10 cases and signs of vascular involvement (absence of cleavage, partial and total thrombosis) in 12. One false-negative was registered. Intraoperative ultrasonography in our experience showed 98% sensitivity and specificity in the detection of vascular and lymph-node involvement. Its sensitivity in the detection of liver metastases was 100%. Intraoperative ultrasound is a procedure with a very high sensitivity in the operative staging of cancer of the head of the pancreas.     

Current status of treatments of pancreatic and peripancreatic collections of acute pancreatitis

Pancreatic and peripancreatic collections are the main local complications of acute pancreatitis with a high incidence. In the early phase, most acute pancreatic and peripancreatic collections can resolve spontaneously with supportive treatment. However, in some cases, they will develop into pancreatic pseudocyst (PPC) or walled-off necrosis (WON). When causing symptoms or coinfection, both PPC and WON may require invasive intervention. Compared to PPC, which can be effectively treated by endoscopic ultrasound-guided transmural drainage with plastic stents, the treatment of WON is more complicated and challenging, particularly in the presence of infected necrosis. In the past few decades, with the development of minimally invasive interventional technology especially the progression of endoscopic techniques, the standard treatments of those severe complications have undergone tremendous changes. Currently, based on the robust evidence from randomized controlled trials, the step-up minimally invasive approaches have become the standard treatments for WON. However, the pancreatic fistulae during the surgical step-up treatment and the stent-related complications during the endoscopic step-up treatment should not be neglected. In this review article, we will mainly discuss the indications of PPC and WON, the timing for intervention, and minimally invasive treatment, especially endoscopic treatment. We also introduced our preliminary experience in endoscopic gastric fenestration, which may be a promising innovative method for the treatment of WON.     

The role of laparoscopy in the preoperative staging of pancreatic carcinoma

Between January 1990 and December 1995, a total of 398 patients underwent laparotomy for pancreatic or periampullary carcinoma at the Surgical Clinic of Mannheim. The tumor was located in the pancreatic head in 290 patients (72.9%), in the body of the pancreas in 42 patients (10.6%), and in the pancreatic tail in 19 patients (4.7%). Forty-seven patients (11.8%) presented with periampullary carcinoma. The preoperative diagnostic workup included abdominal ultrasound, CT scan, endoscopic retrograde cholangiopancreatography, and angiography. One hundred seventy-two patients (43.2%) underwent a tumor resection, 150 (37.7%) had a palliative bypass operation, and 76 (19.1%) underwent only an exploratory laparotomy. Preoperative diagnosis had predicted unresectability in 66 (87%) of the patients who underwent exploratory laparotomy. In 76 patients the intraoperative findings showed an unresectable tumor, which was located in the head of the pancreas in 54 cases (71%), in the body of the pancreas in 17 (22.4%), in the tail region in four (5.3%), and in the periampullary region in one (1.3%). Local signs of unresectability were found in 47 patients (62%) and peritoneal or hepatic metastases in 29 (28.2%). Given that local inoperability can be reliably assessed only at laparotomy, this leaves just 29 (7%) of 398 patients who did not require palliation and whose signs of unresectability could possibly have been discovered by means of the laparoscopic approach. Laparoscopy (including laparoscopic ultrasound) should be used selectively in patients considered probably unresectable who do not require a palliative procedure immediately before the planned operation.     

Laparoscopic ultrasound enhances standard laparoscopy in the staging of pancreatic cancer.

OBJECTIVE: To define the role of laparoscopic ultrasound (LUS) in the staging of pancreatic tumors. SUMMARY BACKGROUND DATA: Laparoscopy has recently been established as a valuable tool in the staging of pancreatic cancer. It has been suggested that the addition of LUS to standard laparoscopy could improve the accuracy of this procedure. METHODS: A prospective evaluation of 90 patients with pancreatic tumors undergoing laparoscopy and LUS was performed over a 27-month period. LUS equipped with an articulated curved and linear array transducer (6 to 10 MHz) was used. All patients underwent rigorous laparoscopic examination. Clinical, surgical, and pathologic data were collected. RESULTS: The median age was 65 years (range 43 to 85 years). Sixty-four patients had tumors in the head, 19 in the body, and 3 in the tail of the pancreas. Four patients had ampullary tumors. LUS was able to image the primary tumor (98%), portal vein (97%), superior mesenteric vein (94%), hepatic artery (93%), and superior mesenteric artery (93%) in these patients. LUS was particularly helpful in determining venous involvement (42%) and arterial involvement (38%) by the tumor. This resulted in a change in surgical treatment for 13 (14%) of the 90 patients in whom standard laparoscopic examination was equivocal. CONCLUSIONS: LUS is useful in evaluating the primary tumor and peripancreatic vascular anatomy. When standard laparoscopic findings are equivocal, LUS allowed accurate determination of resectability. Supplementing laparoscopy with LUS offers improved assessment and preoperative staging of pancreatic cancer.     

The effects of staging laparoscopy on trocar site and peritoneal recurrence of pancreatic cancer

Background: Staging laparoscopy (SL) has been used to assess resectability of patients with pancreatic cancer. It has lead to increased resectability rates and decreased morbidity. However, experimental data suggests that laparoscopy and peritoneal insufflation can promote tumor growth and potential recurrence. Few clinical data exist to allow assessment of whether these theoretical concerns translate into clinical problems. The purpose of this study was to determine if SL increases the incidence of trocar-site and peritoneal recurrence of pancreatic cancer. Methods: A retrospective review of all patients evaluated for pancreatic cancer from 1996 to 2001, inclusive, was included in this study. Patients were divided into five groups: nonoperative management (NM), SL followed by resection (SL-R), SL without resection (SL-NR), exploratory laparotomy with resection (EL-R), and exploratory laparotomy without resection (EL-NR). Patient records were assessed for postoperative occurrence of carcinomatosis and/or malignant ascites, trocar- or incisional-site recurrence, use of postoperative chemotherapy or radiation therapy, and survival. Results: A total of 235 patients were included. Peritoneal progression of disease: NM 15.9%, SL 24.2%, EL 31.6% (p = 0.03). Trocar/incisional recurrence: SL 3.0%, EL 3.9% (p = NS). Use of chemotherapy/radiotherapy: NM 29.4%, SL-R 76.5%, SL-NR 62.5%, EL-R 69.6%, EL-NR 41.5%. Median survival (months): NM 3; SL-R 15, EL-R 10 (p = NS); SL-NR 6, EL-NR 5 (p = NS). Conclusion: SL does not increase the occurrence of trocar-site disease or peritoneal disease progression of pancreatic cancer. Patients who are found not to be resectable by SL are more likely to receive postoperative treatment. However, this does not appear to affect survival greatly. Nevertheless, avoidance of nontherapeutic laparotomy is worthwhile in these patients. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 12–15 March 2003     

胰腺神经内分泌肿瘤诊疗现状

神经内分泌肿瘤（NEN）是一种罕见的高异质性肿瘤,起源于肽能神经元和神经内分泌细胞,可发生在支气管、肺部和胃肠、胰腺等多种部位,我国以胰腺神经内分泌肿瘤（pNEN）最为多见,近几十年来发病率显著上升。笔者主要从pNEN的分级标准、诊断、治疗等方面对该疾病的最新诊疗研究现状进行介绍,以期为临床诊疗提供指导和参考。     

CA 19-9 levels predict results of staging laparoscopy in pancreatic cancer

Laparoscopy has emerged as an important staging procedure for determining resectability of pancreatic cancer. However, a small fraction of patients with pancreatic cancer benefit from its use and therefore the routine application of laparoscopy remains controversial. We hypothesized that serum CA 19-9 levels may identify patients who will or will not benefit by laparoscopy. We retrospectively reviewed our database of 63 patients with pancreatic adenocarcinoma who underwent staging laparoscopy and correlated findings with CA 19-9 levels. Overall, laparoscopy identified metastatic disease in 12 patients (19%). None of those required any further operation. The resectability rate (patients who underwent resection after laparoscopy) was 73.5%. There was one false-negative laparoscopy (1.6%). Patients with higher CA 19-9 levels had significant higher odds of having metastasis identified by laparoscopy (odds ratio, 1.83; 95% confidence interval, 1.03-3.24; P = .04). There was no patient with CA 19-9 levels below 100 U/ml in whom metastatic disease was identified during laparoscopy: 18 patients (28.6%) with CA 19-9 levels below this cutoff point had negative laparoscopy and could have avoided the procedure had this cutoff been used for screening. This would have increased the laparoscopy yield to 26.7%. In patients with adenocarcinoma of the pancreas, low CA 19-9 levels predict low probability of metastatic disease; in those patients, laparoscopy can be spared. On the contrary, patients with elevated CA 19-9 have an increased probability of metastatic disease, and these patients may benefit from diagnostic laparoscopy. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, IL, May 14–18, 2005 (poster presentation).     

Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by Computed Tomography

Background Computed tomography (CT) is insensitive to small metastatic deposits in patients with pancreatic cancer. This study aimed to evaluate additional staging information obtained by laparoscopy in the subset of patients with locally extending pancreatic cancer but no evidence of distant disease using computed tomography.Methods Between April 2000 and February 2004, 74 patients with locally unresectable pancreatic cancer and no evidence of metastasis detected by high-quality pancreas protocol computed tomography underwent outpatient staging laparoscopy and peritoneal lavage cytology.Results Occult tumor was found during staging laparoscopy in 25 of the 74 patients (34%). The results were positive for peritoneal lavage cytology in 27% (20/74), for liver lesions in 16% (12/74), and for peritoneal implants in 7% (5/74) of the patients. Body and tail tumors were twice as likely as pancreatic head tumors to have unsuspected metastasis (53% vs 28%).Conclusions Even the best computed tomography scan is not adequate for accurate staging of locally extended pancreatic cancer because occult distant disease will be found in half of the patients with left-sided disease and one-fourth of those with right-sided pancreatic cancer.Presented as a poster at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Denver, Colorado, 26–27 March 2004     

Technique and value of staging laparoscopy

Despite significant improvements in preoperative tumor staging due to sophisticated new imaging and interventional techniques, peritoneal tumor spread and occult liver and lymph node metastases are only detected during surgery in some patients. Newer treatment modalities using neoadjuvant regimens are only given if occult tumor spread is excluded. Diagnostic laparoscopy has therefore been introduced to prevent patients with advanced tumor disease from unnecessary laparotomy and as a diagnostic tool in neoadjuvant treatment protocols. Laparoscopic ultrasound represents an important technical improvement in diagnostic laparoscopy. The main indication for diagnostic laparoscopy is therefore exact tumor staging, especially in terms of peritoneal, liver, and lymphatic tumor spread, whereas determination of local tumor resectability is not the main issue. The aim of the current review is to summarize the technique of staging laparoscopy and to discuss its clinical value for a variety of gastrointestinal malignancies.     

Laparoscopic staging and subsequent palliation in patients with peripancreatic carcinoma

OBJECTIVE: To test the hypothesis that laparoscopic staging improves outcome in patients with peripancreatic carcinoma compared to standard radiology staging. SUMMARY BACKGROUND DATA: Diagnostic laparoscopy of peripancreatic malignancies has been reported to improve assessment of tumor stage and to prevent unnecessary exploratory laparotomies in 10% to 76% of patients. METHODS: Laparoscopy and laparoscopic ultrasound were performed in 297 consecutive patients with peripancreatic carcinoma scheduled for surgery after radiologic staging. Patients with pathology-proven unresectable tumors were randomly allocated to either surgical or endoscopic palliation. All others underwent laparotomy. RESULTS: Laparoscopic staging detected biopsy-proven unresectable disease in 39 patients (13%). At laparotomy, unresectable disease was found in another 72 patients, leading to a detection rate for laparoscopic staging of 35%. In total, 145 of the 197 patients classified as having "possibly resectable" disease after laparoscopic staging underwent resection (74%). Average survival in the group of 14 patients with biopsy-proven unresectable tumors randomly allocated to endoscopic palliation was 116 days, with a mean hospital-free survival of 94 days. The corresponding figures were 192 days and 164 days in the 13 patients allocated to surgical palliation. CONCLUSIONS: Because of the limited detection rate for unresectable metastatic disease and the likely absence of a large gain after switching from surgical to endoscopic palliation, laparoscopic staging should not be performed routinely in patients with peripancreatic carcinoma.