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.     

Diagnostic laparoscopy prior to planned hepatic resection for colorectal metastases

HYPOTHESES: (1) A clinical risk score (CRS) is useful in selecting patients for diagnostic laparoscopy prior to planned resection of colorectal metastasis. (2) Preventing unnecessary celiotomy in these patients undergoing laparoscopy is associated with shorter hospital stays and earlier administration of systemic chemotherapy. DESIGN: Retrospective analysis of data collected in a prospective database. SETTING: Tertiary cancer hospital. PATIENTS: Two hundred seventy-six patients who underwent laparoscopy prior to planned partial hepatic resection (n = 264) for colorectal metastases or prior to hepatic artery infusion pump placement for colorectal metastases (n = 12). MAIN OUTCOME MEASURES: The yield of laparoscopy for patients with potentially resectable tumors was analyzed in the context of a CRS, calculated by assigning 1 point for each of the following adverse, disease-related factors: lymph node-positive primary tumor, disease-free interval less than 12 months, more than 1 hepatic tumor, hepatic tumor greater than 5 cm, and cardio embryonic antigen level less than 200 ng/mL. The CRS represents the sum for each patient. Length of hospital stay and time to initiation of chemotherapy were compared in those patients determined to be unresectable. RESULTS: Staging laparoscopy prevented nontherapeutic celiotomy in 10% of patients submitted to operation for a potentially curative partial hepatectomy (26 of 264) and in 33% of patients scheduled for pump placement only (4/12). The CRS correlated closely with the likelihood of identifying radiographically occult unresectable disease: 0 or 1, 4%; 2 or 3, 21%; and 4 or 5, 38%. Likewise, the percentage of patients avoiding an unnecessary celiotomy increased progressively with increasing CRS: 0 or 1, 0%; 2 or 3, 11%; and 4 or 5, 24%. Preventing an unnecessary celiotomy with laparoscopy was associated with a decreased length of hospital stay (P<.01) and earlier initiation of chemotherapy (P = .045). CONCLUSIONS: Diagnostic laparoscopy does not need to be performed routinely in all patients prior to hepatic resection for colorectal cancer metastasis. Laparoscopy has a very low yield in patients with a CRS of 1 or less and is unnecessary. The yield of laparoscopy increases with increasing CRS. Preventing celiotomy with laparoscopy is associated with a decreased length of hospital stay and earlier initiation of postoperative chemotherapy.     

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 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.     

The evolving role of staging laparoscopy in the treatment of colorectal hepatic metastasis

HYPOTHESIS: Laparoscopy is an increasingly important tool in the staging and treatment of hepatic malignancies. This study evaluates the effect of staging laparoscopy (SL) using intraoperative ultrasonography (IOUS) on the regional treatment of isolated hepatic colorectal metastasis. DESIGN: Analytic cohort study. SETTING: Tertiary care center. PATIENTS: Consecutive patients who have a colorectal metastasis confined to the liver and selected for surgical regional treatment. INTERVENTIONS: All patients underwent preoperative evaluation followed by SL/IOUS. Operative plans were based on preoperative imaging and were either carried out or altered intraoperatively according to SL/IOUS findings. MAIN OUTCOME MEASURE: Effect of SL/IOUS on surgical management. RESULTS: Between September 1996 and May 2004 one hundred fifty-two SL/IOUSs were performed in 136 patients (77 males and 59 females), who had a mean (SD) age of 63 (11) years. Data sets were complete in 138 events. All patients had isolated hepatic disease as defined by preoperative computed tomography in 152 (100%) and positron emission tomography in 107 (70%). Staging laparoscopy/IOUS identified surgically untreatable disease in 34 events (25%) because of peritoneal metastases (n = 15), nodal involvement (n = 11), diffuse hepatic disease (n = 5), no identifiable disease (n = 2), and untreatable disease (n = 1). Laparoscopic treatment events included radiofrequency ablations (n = 78), hepatic artery pump implantations (n = 40), resections (n = 26), and combined procedures (n = 37). Overall, SL/IOUS changed the treatment plan in 66 (48%) of 138 of events. This includes 32 (23%) of 138 events in which SL/IOUS findings significantly altered the actual procedure performed relative to the preoperative plan. Three minor complications occurred in the SL/IOUS-only group with a mean (SD) hospital stay of 1.3 (1) days. CONCLUSION: In the regional management of isolated colorectal hepatic metastasis, SL/IOUS avoids unnecessary laparotomies and influences definitive surgical intervention in a substantial proportion of patients.     

Intraoperative ultrasound (IOUS) is essential in the management of metastatic colorectal liver lesions

Metastatic tumors to the liver account for the majority of hepatic neoplasms. Improvement in resection has been shown to be beneficial and has remained the treatment of choice, carrying a 5-year survival rate of approximately 20 to 30 per cent. In evaluating candidates for surgery, intraoperative assessment for resectability is a key factor and dictates surgical approach, as well as patient prognosis. Historically, imaging techniques such as CT scan, magnetic resonance imaging, and CT arterial portography (CTAP) have been used in preoperative evaluation. However, the sensitivities of these diagnostic tools have been found to be less than optimal. Intraoperative ultrasound (IOUS) has emerged as an important tool in accurately staging metastatic liver disease with a sensitivity of 98 per cent. From 1994 to 1996, 23 patients have undergone IOUS for evaluation of suspected liver neoplasms in an ongoing prospective study. All patients had colorectal carcinoma. All patients received preoperative CT scan, and 11 patients with positive CT scans had CTAP. Fifteen patients were found to have colorectal metastasis to the liver. Surgical management in 7 of the 15 patients was modified because of the use of IOUS. Two patients were found to have unresectable disease thus abandoning hepatic resection, two were found to have additional lesions undetected by preoperative evaluation and were resected, and in two patients margins of resection were changed. One patient was found to have benign hepatic cysts, and no resection was performed. The use of IOUS modified the management of 44 per cent of our patients with liver metastases. IOUS should be routinely used in patients undergoing liver resection for metastatic liver disease.     

The routine use of intra-operative ultrasound in patients with colorectal cancer improves the detection of hepatic metastases

INTRODUCTION: Up to one fifth of patients with carcinoma of the colon have occult liver metastases at the time of presentation. Intra-operative hepatic ultrasonography might improve disease staging. We report the use of intra-operative ultrasonography (IOUS) in routine clinical practice over a five-year period. METHOD: Seventy-six patients with colorectal carcinoma (F 21, M 55) of median age 67 years (range 43-89 years) for whom full data were available had IOUS at the time of colonic resection. All patients had had a computerized tomography (CT), magnetic resonance imaging (MRI) or ultrasonography (USS). RESULTS: Of 76 patients, 10 had a Dukes A, 32 had a Dukes B and 34 a Dukes C carcinoma. In 20 patients IOUS detected lesions not seen on pre-operative scanning including 11 metastases (one suitable for resection), seven benign hepatic cysts and two were benign hepatic nodules. Forty-nine patients have remained free of disease and 25 have died with systemic disease (mean survival 10 months, range 2-24 months). In the seven patients diagnosed as having hepatic cysts at IOUS two have died of systemic disease. The remaining patients (n=12) who died with systemic disease had a negative IOUS. CONCLUSION: IOUS increases diagnostic yield but a significant proportion of patients with occult hepatic metastases are not detected. IOUS improves disease staging in some patients refining the indications for adjuvant therapy and enhancing the estimate of prognosis and improving decision-making.     

Influence of laparoscopy on postoperative recurrence and survival in patients with ruptured hepatocellular carcinoma undergoing hepatic resection

BACKGROUND: Use of laparoscopy in patients with gastrointestinal cancer has been associated with port-site and peritoneal tumour metastases. The effect of laparoscopy on tumour recurrence and long-term survival in patients undergoing resection of ruptured hepatocellular carcinoma (HCC) remains unknown. METHODS: Between June 1994 and December 2001, 59 patients with ruptured HCC underwent surgical exploration with a view to hepatic resection. Laparoscopy with laparoscopic ultrasonography was performed in 33 patients; the other 26 patients underwent exploratory laparotomy without laparoscopy. Perioperative and long-term outcomes were compared between the two groups. RESULTS: Exploratory laparotomy was avoided in 12 of 13 patients with irresectable HCC who had a laparoscopy. The hospital stay of these 12 patients was significantly shorter than that of eight patients found to have irresectable HCC at exploratory laparotomy (median 11 versus 15 days; P = 0.043). Twenty patients had a laparoscopy followed by open resection of HCC, whereas 18 patients underwent laparotomy and resection without laparoscopy. There were no significant differences in disease-free (16 versus 19 per cent; P = 0.525) and overall (32 versus 48 per cent; P = 0.176) survival at 3 years between the two groups. The tumour recurrence pattern was similar between the two groups, and there were no port-site or wound metastases. CONCLUSION: Use of diagnostic laparoscopy in patients with ruptured HCC helps avoid unnecessary exploratory laparotomy. The present data suggest that laparoscopy does not have an adverse effect on tumour recurrence or survival in patients who undergo resection.     

Selection of Patients for Resection of Colorectal Metastases to the Liver Using Diagnostic Laparoscopy and Laparoscopic Ultrasonography

OBJECTIVE: To assess the value of diagnostic laparoscopy (DL) and laparoscopic ultrasonography (LUS) in the staging and selection of patients with colorectal liver metastasis. SUMMARY BACKGROUND DATA: Preoperative imaging modalities such as ultrasound, computed tomography, and magnetic resonance imaging are limited in the assessment of the number and exact location of hepatic metastases and in the detection of extrahepatic metastatic disease. Consequently, the surgeon is often faced with a discrepancy between preoperative imaging results and perioperative findings, resulting in either a different resection than planned or no resection at all. METHODS: Fifty consecutive patients were planned for DL and LUS in a separate surgical sitting to assess the resectability of their liver metastases. All patients were considered to be candidates for resection on the basis of preoperative imaging studies. RESULTS: Laparoscopy could not be performed in 3 of the 50 patients because of dense adhesions. The remaining 47 patients underwent DL. On the basis of DL and LUS, 18 (38%) patients were ruled out as candidates for resection. Of the 29 patients who subsequently underwent open exploration and intraoperative ultrasonography, another 6 (13%) were deemed to have unresectable disease. CONCLUSIONS: The combination of DL and LUS significantly improves the selection of candidates for resection of colorectal liver metastases and effectively reduces the number of unnecessary laparotomies.     

Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases

BACKGROUND: Extrahepatic disease has always been considered an absolute contraindication to hepatectomy for liver metastases. The present study reports the long-term outcome and prognostic factors of patients undergoing resection of extrahepatic disease simultaneously with hepatectomy for liver metastases. METHODS: From January 1987 to January 2001, 111 (30 per cent) of 376 patients who had hepatectomy for colorectal liver metastases underwent simultaneous resection of extrahepatic disease with curative intent. RESULTS: Surgery was considered R0 in 77 patients (69 per cent) and palliative (R1 or R2) in 34 patients (31 per cent). The mortality rate was 4 per cent and the morbidity rate 28 per cent. After a median follow-up of 4.9 years, the overall 3- and 5-year survival rates were 38 and 20 per cent respectively. The 5-year overall survival rate of patients with R0 resection only (n = 75) was 29 per cent. The difference in survival between patients with and without extrahepatic disease discovered incidentally at operation was significant, as was the number of liver metastases. CONCLUSION: Extrahepatic disease in patients with colorectal cancer who also have liver metastases should no longer be considered an absolute contraindication to hepatectomy. However, the presence of more than five liver metastases and the incidental intraoperative discovery of extrahepatic disease remain contraindications to hepatic resection.     

Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma.

OBJECTIVE: This prospective study evaluates the value of laparoscopy and laparoscopic ultrasonography (USG) in avoiding exploratory laparotomy in patients with hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: Laparotomy and intraoperative USG is the gold standard to determine the resectability of HCC. No palliation can be offered to patients found to have unresectable disease, and the surgical exploration causes morbidity. METHODS: From June 1994 to June 1996, 110 of 370 patients (30%) with HCC were considered candidates for possible hepatic resection. Preoperative liver function was assessed using Child-Pugh grading and indocyanine green retention test. The extent of disease was evaluated with radiologic studies, including percutaneous USG, computerized tomography scan, and hepatic angiogram. Nineteen patients were excluded from the study because of previous upper abdominal surgery (n = 12), ruptured tumors (n = 4), refusal by patients (n = 2), and instrument failure (n = 1). Laparoscopy and laparoscopic USG was performed on 91 patients immediately before a planned laparotomy aiming at hepatic resection. Laparotomy was aborted when definite evidence of unresectable disease was found on laparoscopic examination. RESULTS: The median time required for laparoscopy and laparoscopic USG was 30 minutes (range, 10 to 120 minutes). Fifteen patients had evidence of unresectable disease on laparoscopic examination. Among the remaining 76 patients who underwent laparotomy, 9 had exploration only and 67 underwent hepatic resection. Thus, exploratory laparotomy was avoided in 63% of patients with unresectable disease. The laparoscopic examination failed to confirm unresectable disease more often when the tumor was >10 cm in diameter. The procedure accurately assessed the adequacy of the liver remnant and the presence of intrahepatic metastases, but it was less sensitive in determining the presence of tumor thrombi in major vascular structures and the extent of invasion of adjacent organs. When unresectable disease was detected without the need for a laparotomy, the postoperative recovery was faster, and the nonoperative treatment for the tumor could be initiated earlier. CONCLUSIONS: Laparoscopy with laparoscopic USG avoids unnecessary laparotomy in patients with HCC and should precede a planned laparotomy aiming at hepatic resection.     

Laparoscopy or scanning in oesophageal and gastric carcinoma?

A prospective study was undertaken of the accuracy in diagnosing intra-abdominal metastatic disease of the liver by scintigraphy, ultrasound scanning and laparoscopy. The effect of laparoscopy on management was also studied. Fifty patients were studied: 23 oesophageal carcinoma, 14 gastric carcinoma and 13 with suspected intra-abdominal metastatic spread. Accuracy was determined by laparoscopic biopsy, laparotomy and autopsy. The accuracy was 72 per cent for scintigraphy, 75 per cent for ultrasound and 96 per cent for laparoscopy (with 10 per cent failed ultrasound due to intra-abdominal gas). There was no morbidity or mortality associated with laparoscopy, with one failure due to adhesions. Thirteen patients without hepatic metastases had nodal and/or peritoneal spread diagnosed only by laparoscopy. Laparotomy was avoided in 58 per cent, and 74 per cent died in the 18 month follow-up period. Laparoscopy can obviate the need for laparotomy in inoperable cases of oesophageal carcinoma and allow better planning for potentially curable surgery. In gastric carcinoma the value of laparoscopy is doubtful as a high percentage require at least palliative surgery.     

Sequential hepatic and pulmonary resections for metastatic colorectal cancer

BACKGROUND: Resection of pulmonary or hepatic colorectal metastases is associated with a 5-year survival rate of 25-40 per cent. This report analyses outcome following sequential resection of colorectal metastases to both organs. METHODS: Seventeen patients with histologically confirmed colorectal adenocarcinoma and resection of liver and lung metastases were identified from a prospective database. RESULTS: The median interval between resection of the primary tumour and first metastasis was 21 (range 0-64) months. The interval between resection of the first and subsequent metastases was 18 (range 1-74) months. No patient died in the postoperative period and there were two perioperative complications. The overall survival rate in 17 patients was 70 per cent at 2 years from resection of metastasis to the second organ, but the disease-free survival rate at 2 years was only 24 per cent. CONCLUSION: Although few long-term survivors were observed in this small series, sequential resection of hepatic and pulmonary metastases is warranted in a highly selected group of patients.     

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.     

Laparoscopic screening of surgical candidates with pancreatic cancer or liver tumors

Background: Patients with colorectal or pancreatic cancers may have peritoneal implants which are too small to be detected by current radiologic imaging techniques. Since such implants often preclude surgical removal of the primary tumor or isolated metastasis, their detection prior to open abdominal exploration may spare patients the morbidity of a large abdominal incision when there is no benefit to resection and lifespan is limited. Methods: In the past 30 months, patients with pancreatic cancer, hepatoma, or isolated colorectal cancer metastases, who were candidates for surgical resection on the basis of standard radiologic scans, were examined with the laparoscope through a 10-mm periumbilical incision prior to undertaking open abdominal exploration. If unexpected implants were noted, biopsy was obtained through a 5-mm port placed through a convenient site. Results: Since January 1993, 11 patients with pancreatic carcinoma, three patients with primary hepatic malignancies, and 12 patients with isolated metastases from colorectal cancers have undergone laparoscopic examination prior to celiotomy. Eight of these patients had unexpected peritoneal or liver involvement which precluded resection. Laparoscopy was successful in detecting disease in six such patients (75%). Conclusion: Although adding 20–30 min to the operative time when unrevealing, laparoscopy provided an effective way to avoid celiotomy in patients with carcinomatosis.     

Liver resection for metastatic colorectal cancer: assessing the risk of occult irresectable disease

Background: Liver resection is standard therapy for selected patients with metastatic colorectal cancer. Extrahepatic metastases and inability to remove all hepatic disease usually preclude curative resection and are the most common contraindications. This study analyzes irresectability in patients considered to have resectable disease taken to operation for potentially curative hepatic resection. We describe preoperative factors associated with irresectability and propose a preoperative scoring system that identifies patients at particularly high risk for occult irresectable disease.Study Design: Patients considered to have resectable hepatic colorectal metastases were identified from a prospective database. Intraoperative findings that precluded liver resection were recorded. Demographic data, characteristics of the primary tumor, and characteristics of the hepatic metastases were recorded and analyzed.Results: From April 1992 through July 1997, 416 patients were explored with the intention of performing a potentially curative liver resection; 329 (79%) were resected. Eighty-seven patients (21%) had apparently resectable tumors on preoperative imaging but irresectable disease at laparotomy. Forty-four patients (51%) had irresectable disease limited to the liver; 32 had extensive bilobar disease not appreciated before surgery, and 12 were not resected for technical or other reasons unrelated to disease extent. Forty-three patients (49%) had extrahepatic disease, 31 of whom had resectable hepatic tumors. Of the several preoperative factors analyzed, only the estimated number of hepatic tumors was an independent predictor of irresectable findings at operation. This held true for patients with extrahepatic metastases and those with extensive hepatic disease. From these data, we devised a preoperative scoring system that estimates the probability of finding occult irresectable disease. Resectability ranged from 95% in patients with a score of 0 (solitary, unilobar) to 62% in those with a score of 3 (multiple, bilobar; p = 0.0001). The predictive value of this scoring system was then validated by applying it prospectively to an additional group of 118 patients taken to surgery for resection; the results were similar.Conclusions: Standard preoperative investigations predicted resectability in 79% of patients with hepatic colorectal metastases. Unresectable disease limited to the liver and extrahepatic disease were seen with nearly equal frequency. The majority of patients with extrahepatic metastases had resectable hepatic disease (31 of 43, 72%). A preoperative scoring system is proposed that identifies patients at high risk for unrecognized irresectable disease and may help focus the use of additional diagnostic modalities such as laparoscopy and positron emission tomography (PET).     

Intraoperative ultrasound for the colorectal surgeon: current trends and barriers

Up to two thirds of patients diagnosed with colorectal cancer (CRC) develop colorectal liver metastases (CRLMs) and one quarter of patients present with synchronous metastases. Early detection of CRLM widens the scope of potential treatment. Surgery for CRLM offers the best chance of a cure. Current preoperative staging of CRC relies on computerized tomography and magnetic resonance imaging. Intraoperative ultrasound (IOUS) scans and contrast‐enhanced IOUS (CE‐IOUS) have been demonstrated to detect additional metastases not seen on routine preoperative imaging. IOUS is not widely used by colorectal surgeons during primary resection for CRC. Confident use of IOUS/CE‐IOUS during primary resection of CRC may improve decision‐making by providing the most sensitive form of liver staging even when compared with magnetic resonance imaging. This may be particularly important in the era of laparoscopic resections, where the colorectal surgeon loses the opportunity to palpate the liver. There are several implied barriers to the routine use of IOUS/CE‐IOUS by colorectal surgeons. These include time pressure, familiarity with techniques, a perceived learning curve, cost implications and limitation of the modality due to operator variations. Inclusion of IOUS in the training of colorectal surgeons and further investigation of potential benefits of IOUS/CE‐IOUS could potentially reduce these barriers, enabling usage during primary resection for CRC to become more widespread.     

Laparoscopic staging of upper gastrointestinal malignancy

Background: Laparoscopic staging (LS) of upper gastrointestinal malignancy has decreased the number of non‐curative laparotomies. However, as radiological techniques have improved the value of this invasive staging technique has decreased, with some units either being more selective or abandoning it altogether for certain tumour types. The aim of the present study is to prospectively evaluate the additional utility of LS of upper gastrointestinal malignancy after radiological staging with modern techniques. Methods: One hundred and six consecutive patients assessed as having potentially curable upper gastrointestinal malignancy after radiological staging underwent LS between April 1999 and June 2001. Laparoscopic findings, outcome at laparotomy and complications were prospectively recorded. Results: Laparoscopic staging detected incurable disease in 28 of the 106 patients (26%). The negative likelihood ratio was 0.36 (95% CI 0.24?0.53). Twenty‐seven patients were considered incurable because of findings at laparoscopy and one on the findings of laparoscopic ultrasound. Ten patients underwent open palliative procedures and seven had non‐therapeutic laparotomies giving a non‐curative laparotomy rate of 16%. LS was most useful for primary liver and biliary tract tumours and was least useful for colorectal liver metastases. The most frequent findings denoting incurability were the presence of liver disease (12 cases) and peritoneal metastases (nine cases). Complications occurred in three patients with one death being attributable in part to the laparoscopy. Conclusions: Laparoscopy was useful in decreasing the number of non‐therapeutic laparotomies, but laparoscopic ultrasound gave little additional benefit. The utility of LS was dependent on tumour type and in particular was of marginal benefit for colorectal liver metastases. LS remains a useful staging tool but should be applied selectively.     

Diagnostic laparoscopy and laparoscopic ultrasound for staging of patients with malignant proximal bile duct obstruction

Tumor staging in patients with a malignant obstruction of the proximal bile duct is focused on selecting patients who could benefit from a resection. Diagnostic laparoscopy, which has proved its value in several gastrointestinal malignancies, has been used routinely at our hospital since 1993 in patients with a malignant obstruction of the proximal bile duct, although data in the literature with regard to its additional value are conflicting. Therefore the diagnostic accuracy of diagnostic laparoscopy in patients with malignant proximal bile duct obstruction was evaluated. From January 1993 to May 2000, diagnostic laparoscopy was performed in 110 patients (61 males and 49 females), with a mean age of 60 years (range 30 to 80 years), who had a suspected malignant proximal bile duct tumor and in whom "potential resectability" was demonstrated by means of conventional radiologic staging methods (i.e., ultrasound combined with Doppler imaging, CT, endoscopic retrograde cholangiopancreatography, and percutaneous transhepatic cholangiography). Laparoscopy revealed histologically proved incurable disease in 44 (41%) of the 110 patients (31 with metastases and 13 with extensive tumor ingrowth). Laparoscopic ultrasound imaging, however, revealed histologically proved incurable disease in one patient (1%), thereby preventing exploratory laparotomy in 46 because these patients had already been treated by palliative endoscopic stent placement. The remaining 65 patients were staged as having a resectable tumor and underwent surgical exploration. Thirty patients had an unresectable tumor (distant metastases in five; tumor ingrowth in surrounding tissues in 24) or benign disease (one patient). Sensitivity and negative predictive value of diagnostic laparoscopy for detecting unresectable disease were 60% and 52%, respectively. Diagnostic laparoscopy avoided unnecessary laparotomy in 41% of patients with a malignant proximal bile duct obstruction considered resectable according to conventional imaging studies. The additional value of laparoscopic ultrasound was limited. Therefore diagnostic laparoscopy should be performed routinely in the workup of patients with a potentially resectable proximal bile duct tumor. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (oral presentation).     

In-contiguity and non-anatomical extension of right hepatic trisectionectomy for liver metastases

BACKGROUND: In some patients undergoing right hepatic trisectionectomy for metastases, extension of the resection beyond the falciform ligament is necessary to achieve tumour clearance. The aim of the present study was to assess the early and long-term outcomes and hepatic function in patients who underwent extensive liver resection beyond right trisectionectomy. METHODS: Thirty-eight patients who had extension of a right trisectionectomy, either in contiguity (IC) or in a non-anatomical (NA) fashion, for liver metastases were included in the study. In-hospital mortality, hepatic function and other morbidity were recorded. Survival outcomes were analysed for the subgroup of patients with colorectal liver metastases. The clinical risk score described by the Memorial Sloan-Kettering Cancer Center was applied to all patients with colorectal liver metastases. RESULTS: Sixteen patients had IC resection, 15 NA resection, and seven had both IC and NA procedures. There was one in-hospital death. Hepatic dysfunction was seen in 25 patients and two developed liver failure. Disease-free actuarial 3-year survival was 42 per cent for patients with colorectal liver metastases. Survival was significantly better in patients with a clinical risk score of 3 or less. CONCLUSION: Extension of right trisectionectomy for liver metastases was associated with a low risk of death and hepatic failure.