The Role of Laparoscopy and Ultrasonography in Pancreatic Head Carcinoma

Objective: The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region.Summary Background Data: Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy.Methods: A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region).Results: “Occult” metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively).Conclusions: Staging laparoscopy is indispensable in the detection of “occult” intraabdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.     

Surgery for Recurrence of Periampullary Malignancies

Aim  Few studies have addressed the surgical treatment of recurrent disease after pancreatic resection. The aim of this study was to evaluate the indications, the short- and long-term outcome, and the prognostic factors impacting survival in patients undergoing a re-laparotomy for recurrence of periampullary malignancies. Methods  Between 1990 and 2007, 16 re-laparotomies were performed in 15 patients (one patient had a second re-laparotomy) with a median age of 61 years (range 31–84). Patients were identified from a prospective database and records were reviewed retrospectively. Results  Seven re-laparotomies were performed for a surgical emergency and nine patients had a re-laparotomy for recurrence found at imaging studies. Perioperative mortality was observed in three patients presenting with surgical emergency and a poor performance status (Eastern Cooporative Oncology Group score ≥3). Perioperative morbidity was 40%. Median survival after the first re-laparotomy for the 15 patients was 7.4 months, and was not different for patients presenting a surgical emergency versus no emergency. Patients with peritoneal carcinomatosis had a median survival of 1.4 month. In a univariate analysis of survival, a performance status of ECOG score ≥2 and a pre-operative hemoglobin level <12 g/dl were predictors of poor survival. Conclusion  In selected patients, a re-laparotomy for recurrence of periampullary malignancies is feasible. Peritoneal recurrence was not a good indication for surgery. The predictors of poor survival after the re-laparotomy were a poor performance status and a low preoperative hemoglobin level.     

Predicting Distant Metastasis in Patients With Suspected Pancreatic and Periampullary Tumors for Selective Use of Staging Laparoscopy

Background  

In patients with pancreatic or periampullary tumor, staging laparoscopy (SL) can detect metastases that are occult on computed tomography (CT), thereby precluding nontherapeutic laparotomy. Routine SL is not advocated, but some studies suggest its selective use. The aim of this study was to identify patients at risk for metastasis in whom SL could be beneficial.     

Epidemiology of Pancreatic and Periampullary Cancer

Pancreatic cancer is an important public health problem, although infrequent but with an exceptionally high mortality rate worldwide. Given that the majority of cancers occur in association with smoking, diabetes, pancreatitis, genetic factors, and others and with a growing population worldwide in mind, more cases would be expected in the near future giving further impetus to investigating prevention and treatment strategies to this international issue. The representative data on epidemiology of carcinoma of pancreas in India and Nepal are very poor. While there are many questions to be resolved, it is apparent that many facets of pancreatic cancer are becoming increasingly understood, and prospects for prevention are becoming apparent. Hence, screening research, recommendations, and implementation is an obvious priority. Although previous studies have contributed to the knowledge of carcinoma of pancreas epidemiology, such association needs to be further verified with proper epidemiological work. A new and global approach to the study of carcinoma of pancreas epidemiology is required if the disease prevention and treatment strategies are to be adequately directed and supported in the coming years. The collection and analysis of epidemiologic carcinoma of pancreas data will play a critical role in guiding future disease prevention strategies and optimizing patient management.     

Single-Access Transumbilical Diagnostic Laparoscopy for Pancreatic Tumor Using Curved and Reusable Instruments

Introduction

Diagnostic laparoscopy in pancreatic tumors remains controversial. The main argument in favor of this procedure is that it helps prevent a delay of chemotherapy in cases of unresectable tumors or peritoneal/lymph node metastasis. We report a technique of performing this exploration through single-incision laparoscopy.

Video

The umbilicus is incised, and a purse-string suture is applied. An 11-mm nondisposable trocar is inserted for a 10-mm, 30° angled scope. Curved and reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany) are inserted transumbilically. Laparoscopic exploration of the cavity allows the visualization of suspected peritoneal or lymph node metastasis. Peritoneal lavage for cytology is performed. Biopsy is accomplished through the curved shape of the instruments, which establishes the working triangulation inside the abdomen as well as externally. Laparoscopic ultrasonography of the liver and of the pancreas (after opening the lesser sac) is performed after replacement of the 11-mm trocar with a 13-mm trocar and the use of a 5-mm scope. The procedure can be continued either by laparoscopy or by open surgery. At completion, the umbilicus is meticulously closed to avoid complications.

Results

Operative time is 45–60 minutes, blood loss is minimal, and the size of the umbilical incision is less than 15 mm.

Conclusions

In case of unresectable tumors or peritoneal metastasis, single-access diagnostic laparoscopy for pancreatic tumors permits the start of chemotherapy after less than 7 days. Curved and reusable instruments allow the achievement of ergonomic conditions as classic laparoscopy, without increasing of conventional laparoscopic cost.     

The Role of Laparoscopy in Peritoneal Surface Malignancies Selected for Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Background

Cytoreductive surgery (CS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) was developed as locoregional treatment for primary or secondary peritoneal tumors. The role of laparoscopy over several stages of diagnosis and the treatment of the patients affected by peritoneal carcinomatosis and selected for CS?+?HIPEC shows some peculiarities, and their potential application in this field is not fully known. Our aim was to review and summarize the applications, the results, and the future directions of laparoscopy in the management of the patients affected by carcinomatosis and scheduled for CS?+?HIPEC.

Methods

Appropriate keywords were adopted to identify the relevant studies on this topic in PubMed/Medline electronic databases.

Results

The role of laparoscopy in diagnosis and staging of patients selected for CS?+?HIPEC seems to have a great but probably underestimated potential. Laparoscopic CS?+?HIPEC is technically feasible with an acceptable morbidity profile, especially in patients with low tumor load. In selected patients with malignant ascites, laparoscopic HIPEC achieves a good palliative effect, with a low morbidity profile.

Conclusions

Laparoscopy plays a partially explored role in diagnosis and staging of patients selected for CS?+?HIPEC. The use of laparoscopic HIPEC with an adjuvant, curative, or palliative intent seems feasible, but further studies are required in order to explore and validate all potential indications. For all these reasons, it would be advisable to provide every HIPEC center with specific laparoscopic skills.     

Adjuvant/Perioperative Therapy in Pancreatic and Periampullary Cancer

The delivery of postoperative combined modality adjuvant therapy for completely resected pancreatic adenocarcinoma was initially shown to be beneficial based on a prospective, randomized trial published 30 years ago. Since then, oncologists have debated whether chemotherapy alone, chemoradiation, or both are optimal adjuvant therapies following pancreatectomy for pancreatic ductal adenocarcinomas (PDAC). No global consensus has emerged, and there is no one superior modality despite randomized trials in part, to poor trial design, poor patient selection, and poor therapy options itself. We need to have a disciplined approach to the selection of patients for pancreatectomy, pathologic assessment of surgical resection margins, and postoperative (pre-treatment) imaging. In the era of the multidetector CT optimized for pancreatic imaging, tumors of “borderline resectability” have emerged as a distinct subset of PDAC. The attempt to standardize the definition of borderline resectable is a work in progress and modified with time. This distinction (between resectable and borderline resectable) is essential to minimize potentially confounding results of clinical trials. Additionally, preoperative therapy is not only preferred but mandatory in a large population of borderline resectable patients. Ultimately, as we develop more effective systemic therapies for PDAC, proceeding with surgery after a period of induction therapy will be even more compelling especially if there is a clear positive impact on overall survival.     

Diagnostic Laparoscopy for Primary and Secondary Liver Malignancies: Impact of Improved Imaging and Changed Criteria for Resection

Background Diagnostic laparoscopy (DL) combined with laparoscopic ultrasonography (LUS) has previously shown positive results as a staging modality for liver malignancies. Recent improvements in noninvasive diagnostic imaging techniques such as multiphasic spiral computed tomography, together with the policy that bilobar disease or the number of lesions is no longer considered an absolute exclusion criterion for curative resection, could reduce the additional value of DL. This study retrospectively analyzed the efficacy of DL combined with LUS for liver malignancies to assess the effect of improved imaging and changed criteria for resection.Methods All patients with primary or metachronous secondary liver malignancy eligible for resection in 1997 to 2002 were included.Results DL combined with LUS was performed in 84 consecutive patients (56 men and 28 women; mean age, 59 years) with primary (n = 33) or secondary (n = 51) liver malignancies. DL showed unresectability in 13 patients (39%) with primary malignancy. Exploratory laparotomy showed that an additional 5 (25%) of the remaining 20 patients had unresectable disease. DL showed unresectability in 5 patients (12%) with colorectal liver metastasis (n = 43). At laparotomy, another 7 (18%) of the remaining 38 patients had unresectable disease. In five patients (13%) from the latter group, LUS could not be performed because of adhesions from previous surgery.Conclusions DL combined with LUS is an adequate staging modality for primary liver malignancies. For colorectal liver metastasis, more liberal resection criteria, a high failure rate due to adhesions from previous surgery, and better preoperative imaging probably resulted in a lower efficacy.     

Prognostic Factors in Periampullary and Pancreatic Tumor Resection in Elderly Patients

Background More than half of all patients with pancreatic adenocarcinoma are over 70 years of age. Life expectancy for the elderly population is increasing and currently major pancreatic resection provides the only meaningful chance of cure for periampullary and pancreatic tumors. Controversy over what constitutes the correct treatment of these tumors in elderly patients continues to this day. The aim of our study was to determine whether age alone or age plus some prognostic factors constitute contraindications to major pancreatic resections. Methods Between 2000 and 2005, data from 88 consecutive patients who had major pancreatic resection for periampullary or pancreatic tumors were entered into a prospective database. Fifty-three patients under 70 years of age (young patients), and 35 patients 70 years of age or older (elderly patients) were compared with respect to several characteristics and the postoperative course. Results Postoperative mortality and morbidity, length of hospital stay, and long-term survival were similar in the two groups. In the elderly group, the mortality rate was significantly higher in patients with chronic obstructive pulmonary disease (COPD), and the morbidity rate was significantly higher in patients with ASA 3 than in patients with ASA 1–2, in whom a pancreaticoduodenectomy or total pancreatectomy had been performed. Conclusions Age alone is not a contraindication for major pancreatic resection. In elderly patients a careful evaluation of the co-morbidities and of the type of surgical procedure is mandatory in order to allow the proper selection of those patients best suited for surgery in specialized centers.     

Utility of Staging Laparoscopy in Subsets of Peripancreatic and Biliary Malignancies

OBJECTIVE: To determine the relative benefit of staging laparoscopy in peripancreatic and biliary malignancies. SUMMARY BACKGROUND DATA: Staging laparoscopy has been used in a variety of peripancreatic and biliary malignancies. The utility of the technique in subsets of these types of cancer has not been systematically compared. METHODS: One hundred fifty-seven patients underwent laparoscopy after conventional tumor staging; 89 were also staged with laparoscopic ultrasonography. Diagnostic categories were cancer of the pancreatic head and uncinate process, cancer of the body and tail of pancreas, cancer of the extrahepatic bile duct, cancer of the gallbladder, and cancer of the ampulla of Vater/duodenum. RESULTS: In patients with cancer of the head of the pancreas, metastatic disease or vascular invasion was discovered frequently by laparoscopy (31%), whereas in ampullary/duodenal cancer it was never found. The laparoscopic findings in cancer of the head of the pancreas had an important influence on treatment decisions, whereas in cancer of the ampulla/duodenum, laparoscopy had no effect on clinical decisions. Laparoscopy also substantially influenced the treatment of gallbladder cancer; in other tumor types, results were intermediate. Laparoscopic ultrasonography was valuable in cancer of the head of the pancreas. CONCLUSIONS: The utility of staging laparoscopy depends on diagnosis. It is recommended for continued use in pancreatic head and gallbladder cancers but not in ampullary malignancies.