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.     

Current status of laparoscopic surgery in gastrointestinal malignancies

Laparoscopy has become a significant tool in a surgeon’s armamentarium since the first laparoscopic cholecystectomy in 1989. Oncological surgeons have been slow in adopting laparoscopy for fear of inadequate cancer operation and occurrence of port site metastasis. Neither of these concerns have stood the test of time. Laparoscopy is being used increasingly in oncological surgery both for staging and respective surgery. This article outlines the present use of laparoscopy in GI cancer surgery.     

Introducing diagnostic laparoscopy for patients with suspected acute appendicitis

Background: The diagnostic accuracy in patients with suspected acute appendicitis varies from 60% to 90% depending on age and gender. The aim of this study was to evaluate the use of diagnostic laparoscopy for diagnostic purposes in patients with suspected acute appendicitis to prevent unnecessary laparotomy and to leave a macroscopically normal appendix in place. Methods: For this study, 500 consecutive patients with suspected acute appendicitis admitted between January 1994 and October 1996 were included prospectively in a surgical training program set to provide diagnostic laparoscopy on a 24-h-a-day basis. Primary open operation was performed when no laparoscopically trained surgeon was available. Short-term outcome measurements were recorded, and a retrospective long-term follow-up evaluation was performed. Results: We succeeded in performing a diagnostic laparoscopy in 376 patients and a primary open operation in 124 patients. The overall appendicitis rate was 78%. A diagnostic laparoscopy alone was performed in 66 patients (56 of which were fertile women), with a median operating time of 36 min and a complication rate of 0%. The overall complication rate was 8.0%. During a median follow-up period of 19 months one patient returned on a later occasion with appendicitis. At completion of the study, 85% of the surgeons were skilled in diagnostic laparoscopy. Conclusions: Substantial education effort is needed to introduce diagnostic laparoscopy on a 24-h-a-day basis. Diagnostic laparoscopy has a high rate of accuracy, short operating time, and low associated morbidity, and prevents unnecessary laparotomy. It is possible to leave a macroscopically normal-appearing appendix in place. Received: 12 March 200/Accepted: 23 May 2000/Online publication: 9 August 2000     

Laparoscopic ultrasonography during laparoscopic cholecystectomy

Background: This study assessed the effectiveness of laparoscopic ultrasonography in demonstrating biliary anatomy, confirming suspected pathology, and detecting unsuspected pathology. Methods: Laparoscopic ultrasonography was performed on 48 patients (17 M:31 M) who underwent laparoscopic cholecystectomy. An Aloka 7.5-MHz linear laparoscopic ultrasound transducer was used for scanning. Results: Gallbladder stones were confirmed by laparoscopic ultrasonography in all patients and unsuspected pathology was found in five patients. Two patients were found to have common bile duct stones by laparoscopic ultrasonography and this was confirmed by laparoscopic cholangiography. Laparoscopic ultrasound was found to be helpful during dissection in four patients, particularly in a patient with Mirizzi syndrome. The entire common bile duct was visualized by laparoscopic ultrasonography in 40 patients but was poorly seen in eight patients. The mean time taken for the examination was 9 min (range 4–18 min). Conclusion: Laparoscopic ultrasound is useful during laparoscopic cholecystectomy. Received: 8 November 1995/Accepted: 5 May 1996     

Suprapancreatic and periportal lymph nodes are normally larger than 1 cm by laparoscopic ultrasound evaluation

Background Laparoscopic and endoscopic ultrasound is used to assess resectability of gastrointestinal malignancies. Lymph node size greater than 1 cm is a criterion used to identify suspicious nodes. We define size and echo characteristics of suprapancreatic and periportal nodes to determine if this criterion is reliable for suprapancreatic and periportal lymph nodes.Methods A prospective study of 21 patients with nonacute gallbladder disease was performed. Each underwent laparoscopic cholecystectomy with intraoperative ultrasound. The suprapancreatic and periportal nodes were evaluated in a transverse and longitudinal axis. Length and width measurements were taken in both orientations. Length-to-width ratios were calculated. Shape and echo textures were characterized.Results The mean size of both nodes was greater than 1 cm in the transverse and longitudinal orientation. Two nodes were round. Remaining nodes were oblong. All nodes had a hyperechoic center with a hypoechoic rim.Conclusion In suprapancreatic and periportal lymph nodes, size greater than 1 cm should not be used as criterion for malignancy.     

A new method for three-dimensional laparoscopic ultrasound model reconstruction

Background Laparoscopic ultrasound is an important modality in the staging of gastrointestinal tumors. Correct staging depends on good spatial understanding of the regional tumor infiltration. Three-dimensional (3D) models may facilitate the evaluation of tumor infiltration. The aim of the study was to perform a volumetric test and a clinical feasibility test of a new 3D method using standard laparoscopic ultrasound equipment. Methods Three-dimensional models were reconstructed from a series of two-dimensional ultrasound images using either electromagnetic tracking or a new 3D method. The volumetric accuracy of the new method was tested ex vivo, and the clinical feasibility was tested on a small series of patients. Results Both electromagnetic tracked reconstructions and the new 3D method gave good volumetric information with no significant difference. Clinical use of the new 3D method showed accurate models comparable to findings at surgery and pathology. Conclusions The use of the new 3D method is technically feasible, and its volumetrically, accurate compared to 3D with electromagnetic tracking. Online publication: 13 October 2004     

Laparoscopy and peritoneal cytology in the staging of pancreatic cancer

Staging laparoscopy in patients with pancreatic cancer allows identification of metastatic disease which is beyond the resolution of computed tomography. Laparoscopic ultrasound, dissection, and/or peritoneal cytology may be used to enhance the sensitivity of the staging procedure. Our experience at Massachusetts General Hospital with staging laparoscopy and peritoneal cytology over the past 8 years (N = 239) reveals that approximately 30% of patients without metastases by computed tomography harbor occult metastatic disease at laparoscopy. Additionally, published series demonstrate accurate determination of resectability in greater than 75% of patients after staging laparoscopy. Staging laparoscopy in patients with pancreatic cancer allows optimization of resources and avoidance of unnecessary surgery. Received for publication on Aug. 21, 1999; accepted on Sept. 2, 1999     

A prospective analysis of staging laparoscopy in patients with primary and secondary hepatobiliary malignancies

Laparoscopy and laparoscopic ultrasound are used widely in cancer staging and are perceived to prevent unnecessary open exploration in many patients. The aim of this study was to analyze the impact of staging laparoscopy in improving resectability in patients with primary and secondary hepatobiliary malignancies. Over a 10-month period (November 1, 1997 to August 31, 1998), 186 patients with primary and secondary hepatobiliary cancers were submitted to operation for potentially curative resection. One hundred four patients staged laparoscopically (LAP) before laparotomy were compared prospectively to 82 patients undergoing exploration without laparoscopy (NO LAP). Assignment to each group was not random but was based on surgeon practice. Demographic data, diagnoses, the extent of preoperative evaluation, and the percentage of patients resected were similar in the two groups. Laparoscopy identified 26 (67%) of 39 patients with unresectable disease. In the NO LAP group, 28 patients (34%) had unresectable disease discovered at laparotomy. In patients with unresectable disease and submitted to biopsy only, the operating times were similar in the two groups (LAP 83 ±22 minutes vs. NO LAP 91 ±33 minutes; P = 0.4). However, laparoscopic staging significantly reduced the length of hospital stay (LAP 2.2 ±2 days vs. NO LAP 8.5 ±8.6 days; P = 0.006). Likewise, total hospital charges, normalized to 100 in the NO LAP patients, were significantly lower in the LAP group (LAP 54 ±42 vs. NO LAP 100 ±84; P = 0.02). Staging laparoscopy identified the majority of patients with unresectable hepatobiliary malignancies, significantly improved resectability, and reduced the number of days in the hospital and the total charges. The yield of laparoscopy was greatest for detecting peritoneal metastases (9 of 10), additional hepatic tumors (10 of 12), and unsuspected advanced cirrhosis (5 of 5) but often failed to identify nonresectability because of lymph node metastases, vascular involvement, or extensive biliary involvement. Eighty-three percent of patients subjected to laparotomy after laparoscopy underwent a potentially curative resection compared to 66% of those who were not staged laparoscopically. Supported in part by grants R01 CA76416 (Dr. Fong) and R01CA/DK80982 (Dr. Fong) from the National Institutes of Health. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Efficacy of routine laparoscopy for the acute abdomen

Background: Laparoscopic surgery of selected acute abdominal conditions has been shown to be highly effective. Therefore, we investigated the diagnostic accuracy and therapeutic efficacy of routine laparoscopic surgery for the acute abdomen. Methods: After appropriate investigations, patients with acute abdomen, with or without a specific diagnosis, were offered the options of either laparoscopic or open surgery. Postoperatively, we analyzed the outcome measures of diagnostic accuracy, complications, and operating time of laparoscopy. The hospital stays for our patients were compared to case-matched controls. Results: The accuracy of laparoscopic diagnosis is the same as laparotomy. The 62% of our patients who were managed totally laparoscopically required shorter hospitalization than the case-matched controls treated by open operation. Morbidity was not increased by laparoscopy in patients who required conversion to open operation. The additional cost of laparoscopy appeared modest. Conclusions: Routine laparoscopy for the acute abdomen is safe and accurate. Patients eligible for laparoscopic treatment also require less hospitalization time. Received: 3 April 1997/Accepted: 9 June 1997     

Easy and accurate targeting of deep-seated hepatic tumors under laparoscopy with a forward-viewing convex-array transducer

Background: It is technically difficult to puncture deep-seated hepatic tumors by conventional laparoscopic ultrasonography with a linear-array probe. We have developed a laparoscopic ultrasonography system with a convex-array probe. Methods: The laparoscopic system used had a fixed forward-viewing convex-array transducer, and a guide groove for puncture was added to the back of the unit. These characteristics enabled us to continuously monitor the position of the needle tip on the ultrasonographic image immediately after puncturing on the liver surface. We attempted tumor puncture in 11 patients with hepatocellular carcinoma under a new probe guidance. Results: The mean puncturing distance up to the tumors was 38.7 mm. All punctures were successful on the first pass and the tumors were treated with radiofrequency ablation. Conclusion: Using this new equipment, puncturing hepatic tumors for treatment is relatively easy, irrespective of the position of the tumor.     

Laparoscopic Enucleation of a Pancreatic Insulinoma: Report of a Case

(Received for publication on May 14, 1997; accepted on Nov. 6, 1997)     

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.     

The role of staging laparoscopy for intraabdominal cancers: an evidence-based review

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for the staging of intraabdominal cancers. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995–2006. The level of evidence in the identified articles was graded. The search identified and reviewed seven main categories that have received attention in the literature: esophageal cancer, gastric cancer, pancreatic cancer, hepatocellular carcinoma, biliary tract cancer, colorectal cancer, and lymphoma. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.     

A new flexible videoendoscope for minimal access surgery

Summary This study was designed to evaluate the efficacy of a new flexible videolaparoscope. The Fujinon EVL-F has standard control knobs which deflect a flexible tip at the end of a rigid section. In addition, there are standard controls for irrigation and suction as well as an instrument channel. Twenty-eight procedures were performed on 22 patients. The advantages of this instrument include the ability to perform a more thorough exploration of the abdomen and improved image quality. In addition, the instrument channel provides the capability to irrigate, suction, perform cholangiograms, or pass dissecting instruments via the laparoscope, thus reducing the required number of trocar sites.     

Preoperative prediction of complete resection in pancreatic cancer

BACKGROUND: Accurate preoperative staging is essential in pancreatic cancer to select the 15% of patients who can benefit from surgery and avoid surgery in the 85% with advanced disease. With improvements in computed tomography (CT) scanning, the value of routine laparoscopy for preoperative staging of pancreatic cancer has been questioned because it changes the preoperative plan in less than 20% of unselected cases. METHODS: We retrospectively reviewed our experience with preoperative staging in 88 consecutive patients with pancreatic cancer. All patients had preoperative CT scans, and selective criteria were used to determine which patients would also undergo preoperative staging laparoscopy. Patients were categorized preoperatively as resectable or not resectable (locally advanced or metastatic). Medical records, operative, and pathology reports were reviewed to determine the accuracy of preoperative predictions. RESULTS: Thirty patients were deemed resectable based on CT alone and 27 (90%) were resected (25 R0, 2 R1). Two (7%) had metastatic disease discovered at laparotomy and one (3%) had a R2 resection. Only 19 patients (39%) of 49 patients deemed resectable by CT met our selective criteria for preoperative staging laparoscopy. Laparoscopy changed the treatment plan in 11 (58%) of these patients. Eight were still deemed resectable after staging laparoscopy and 7 (88%) were resected (6 R0, 1 R1). One patient (12%) had metastatic disease diagnosed at laparotomy. If selective staging laparoscopy were eliminated from our algorithm, 49 patients would have been deemed potentially resectable based on CT alone, 34 (69%) would have been found to be resectable at laparotomy (31 R0, 3 R1), and 15 (31%) would have been found to be unresectable at laparotomy (positive predictive value of 69%). The addition of selective staging laparoscopy avoided unnecessary laparotomy in 11 patients and increased the positive predictive value to (34/38) 89%. CONCLUSION: Selective use of laparoscopy increases the positive predictive value of preoperative staging in pancreatic cancer and avoids unnecessary laparoscopy in the majority of patients.     

胃肠肿瘤患者营养风险与营养支持调查分析

目的 调查胃肠肿瘤住院患者营养风险及住院期间的营养支持状况,分析营养风险与肿瘤分期、营养支持及并发症的关系.方法 选择我院2009年9月至2011年6月期间住院的胃肠肿瘤患者,入院时使用营养风险筛查工具2002(NRS2002)进行营养风险筛查,并调查住院期间的营养支持状况,统计患者的肿瘤分期及并发症发生率.结果 共有961例住院患者入选,总营养风险发生率为38.9％(374/961),胃肿瘤和结直肠肿瘤分别为49.2％(176/358)和32.8％(198/603).Ⅳ期的胃肿瘤和结直肠肿瘤营养风险最高[87.3％(48/55)和58.8％(50/85)],ⅡA期的胃肿瘤和Ⅰ期的结直肠肿瘤营养风险最低[16.1％(5/31)和9.8％(6/61)].有营养风险和无营养风险胃肿瘤患者的营养支持率分别为62.3％(152/244)和48.6％(144/296),有营养风险和无营养风险结直肠肿瘤患者的营养支持率分别为37.7％(92/244)和51.4％ (152/296),肠外营养和肠内营养比值为1.25:1.有营养风险的胃肠肿瘤患者并发症发生率为32.4％(121/374),明显高于无营养风险患者的20.4％(120/587),P=0.000 0.有营养风险的胃肠肿瘤患者应用营养支持者并发症发生率为27.5％(67/244),明显低于未用营养支持患者的40.8％(53/130),P=0.008 6.在无营养风险的胃肿瘤患者中应用营养支持者并发症发生率明显低于未用营养支持者(P=0.039 6),而在无营养风险的结直肠肿瘤患者中应用营养支持与否与并发症发生率无关(P=0.464 7).结论 胃肠肿瘤住院患者营养风险较高,营养风险发生率与肿瘤分期有关;有营养风险的胃肠肿瘤患者并发症发生率高于无营养风险者;给予有营养风险的胃肠肿瘤患者营养支持可以减少并发症的发生.     

消化道恶性肿瘤术后肠梗阻的原因与处理

目的 分析消化道恶性肿瘤术后发生肠梗阻的原因,探讨再手术的价值.方法 回顾性分析1986年1月至2005年12月经手术治疗的104例术后发生肠梗阻的消化道恶性肿瘤患者的临床资料.结果 恶性肿瘤复发致术后发生肠梗阻者占59.7%(62/104);良性原因占40.3%(42/104).恶性梗阻多在术后1-2年出现,而良性梗阻多发生在术后半年内(71.4%,30/42).42例良性梗阻中有2例因未及时手术而死亡,其余经手术全部解除梗阻;恶性梗阻经手术解除者67.7%(42/62).结论 应提高对消化道恶性肿瘤术后发生肠梗阻原因的分析能力,积极而慎重地手术解除梗阻是有效的治疗方法 .     

Minimally invasive surgery for gastric stromal cell tumors: intermediate follow-up results

Laparoscopic wedge resection of the stomach (LWS) has become the treatment of choice for patients with benign gastric tumors. The technical consideration and long-term follow-up data of LWS for gastrointestinal stromal tumors (GISTs) of the stomach are limited. We present our experience of 28 LWSs for gastric GISTs with a mean follow-up of 43 months. From October 1995 to December 2002, we successfully performed 28 LWSs for 29 patients with GISTs of the stomach, and one patient needed conversion to laparotomy because of suspected bowel injury when establishing pneumoperitoneum. Patient demographics, perioperative parameters, and outcomes of the 28 patients were assessed retrospectively. The tumors were located in the upper third of the stomach in 13 patients, in the middle third, in eight patients, and in the lower third, in seven patients. The mean size of tumors was 3.4 ± 1.6 cm in diameter. The duration of operation ranged from 95 to 390 minutes: 189.6 ± 79.5 minutes with the stapler method and 194.3 ± 50.5 minutes with the hand-sewn method (P = 0.8870). No blood transfusion was given in the perioperative period in all cases. Cholecystectomy in three patients and repair of hiatal hernia in one patient were performed during the same operation. The oral intake was restored at the third to fourth postoperative days. The hospital stay ranged from 3 to 11 days (mean, 6.7 ± 1.8 days). The follow-up period ranged from 12 to 95 months (mean, 43.3 ± 23.5 months, median 42 months). There has been no evidence of tumor recurrence, including one patient with microscopic invasion of section margin. LWS can be performed safely with a satisfactory remission rate for patients with gastric stromal cell tumors. Presented at the 94th Annual Meeting of the Surgical Association of Taiwan, March 27, 2005, Tao-Uan, Taiwan.     

Routine laparoscopic ultrasonography in biliary surgery

A new technique of intraoperative imaging of the biliary tract in laparoscopic cholecystectomy is described. A specifically designed laparoscopic ultrasonographic probe is used to obtain both transverse and longitudinal views of the entire extrahepatic biliary tract. This technique was successfully used in 28 patients. The ultrasonographic imaging quality achieved equals our experience with intraoperative ultrasonography in open biliary surgery. It may be assumed, therefore, that the advantages of ultrasonography over cholangiography as documented in conventional open surgery will also apply to laparoscopic operations.     

Laparoscopic Drainage of Pyogenic Liver Abscesses

Purpose To report our experience of performing laparoscopic drainage of liver abscesses in patients who failed to respond to conservative treatment.Methods We retrospectively compared the results and complications of 18 patients who underwent laparoscopic liver abscess drainage with those of 5 patients who underwent open drainage between June 1999 and October 2002.Results The operation times were shorter and oral intake was recommenced earlier in the laparoscopic group, which also tended to have less blood loss and shorter hospitalization. One case of recurrence, which developed 1 month postoperatively, was successfully treated with percutaneous drainage. There was no mortality in either group.Conclusion Laparoscopic drainage of liver abscesses, combined with intravenous antibiotics, is a safe alternative for patients requiring surgical drainage when medical treatment has failed.