The use of diagnostic laparoscopy supported by laparoscopic ultrasonography in the assessment of pancreatic cancer

Background: Pancreatic resection with curative intent is possible in a select minority of patients with carcinomas of the pancreatic head. Diagnostic laparoscopy supported by laparoscopic ultrasonography combines the proven benefits of staging laparoscopy with high-resolution intraoperative ultrasound, thus allowing the surgeon to perform a detailed assessment of the pancreatic cancer. Methods: In a prospective study of 26 patients with obstructive jaundice from a carcinoma of the head of the pancreas, the curative resectability of tumors was assessed by ultrasound (26 cases), computerized tomography (26 cases), endoscopic ultrasound (16 cases), and a combination of diagnostic laparoscopy and laparoscopic ultrasound (26 cases). Results: The findings of ultrasound and computerized tomography were comparable: 50% of patients were excluded from curative resection. Endoscopic ultrasound provided precise information on the primary tumors. The accuracy of the combined diagnostic laparoscopy and laparoscopic ultrasound, when compared with ultrasound, computerized tomography, and endoscopic ultrasound, was better with respect to minute peritoneal or hepatic metastasis: 80.7% (or a further 30.7%) of patients did not qualify for curative resection. Conclusions: Diagnostic laparoscopy supported by laparoscopic ultrasonography enables detection of previously unsuspected metastases; thus, needless laparotomy can be avoided. It should therefore be considered the first step in any potentially curative surgical procedure. Received: 12 April 1997/Accepted 30 April 1998     

Is laparoscopic sonography a reliable and sensitive procedure for staging colorectal cancer?

Background: Laparoscopic colectomy has developed rapidly with the explosion of technology. In most cases, laparoscopic resection is performed for colorectal cancer. Intraoperative staging during laparoscopic procedure is limited. Laparoscopic ultrasonography (LUS) represents the only real alternative to manual palpation during laparoscopic surgery. Methods: We evaluated the diagnostic accuracy of LUS in comparison with preoperative staging and laparoscopy in 33 patients with colorectal cancer. Preoperative staging included abdominal US, CT, and endoscopic US (for rectal cancer). Laparoscopy and LUS were performed in all cases. Pre- and intraoperative staging were related to definitive histology. Staging was done according to the TNM classification. Results: LUS obtained good results in the evaluation of hepatic metastases, with a sensitivity of 100% versus 62.5% and 75% by preoperative diagnostic means and laparoscopy, respectively. Nodal metastases were diagnosed with a sensitivity of 94% versus 18% with preoperative staging and 6% with laparoscopy, but the method had a low specificity (53%). The therapeutic program was changed thanks to laparoscopy and LUS in 11 cases (33%). In four cases (12%), the planned therapeutic approach was changed after LUS alone. Conclusions: The results obtained in this study demonstrate that LUS is an accurate and highly sensitive procedure in staging colorectal cancer, providing a useful and reliable diagnostic tool complementary to laparoscopy. Received: 2 May 1997/Accepted: 11 February 1998     

TNM staging and assessment of resectability of pancreatic cancer by laparoscopic ultrasonography

Background: Laparoscopic ultrasonography (LUS) is an imaging modality that combines laparoscopy and ultrasonography. The purpose of this prospective blinded study was to evaluate the TNM stage and assessment of resectability by LUS in patients with pancreatic cancer. Methods: Of the 71 consecutive patients admitted to our department, 36 were excluded from the study, mainly due to evident signs of metastatic disease or another condition that would preclude surgery. Thus, a total of 35 patients were enrolled in the study. All patients underwent abdominal CT scan, ultrasonography, endoscopic ultrasonography (EUS), diagnostic laparoscopy, and LUS. Histopathologic examination was considered to be the final evaluation for LUS in all but three patients, where EUS was used as the reference. Results: The accuracy of LUS in T staging was 29/33 (80%); in N staging it was 22/34 (76%); in M staging, it was 23/34 (68%); and in overall TNM staging, it was 23/34 (68%). In assessment of nonresectability, distant metastases, and lymph node metastases, the sensitivity was 0.86, 0.43 and 0.67, respectively, for LUS alone. Combining the information gleaned from laparoscopy and LUS, the accuracy in finding nonresectable tumors was 89%. Conclusions: Diagnostic laparoscopy with LUS is highly accurate in TNM staging and assessment of resectability of pancreatic cancer and should be considered an important modality in the assessment algorithm. Received: 6 July 1998/Accepted: 13 October 1998     

Cost-effectiveness of different diagnostic strategies in patients with nonresectable upper gastrointestinal tract malignancies

Background and methods: Using a simple model, this retrospective study evaluated the cost-effectiveness of different diagnostic strategies used for pretherapeutic detection of patients with disseminated or locally nonresectable upper gastrointestinal tract malignancies (UGIM). Of 162 consecutive UGIM patients referred for treatment, 73 (45%) had disseminated or locally nonresectable disease, and these patients were eligible for evaluation. Results: The noninvasive diagnostic strategies (computed tomography [CT] with ultrasonography [US] and endoscopic ultrasonography [EUS]) had a low procedure cost, but a diagnostic strategy based on CT with US or CT with US and laparoscopy was not cost-effective. The inclusion of endoscopic or laparoscopic ultrasonography seemed necessary to the provision of a cost-effective strategy because both techniques had a high diagnostic accuracy combined with a low cost. A change in diagnostic strategy from CT with US to CT with US and EUS resulted in a net saving regarding the cost of each additional nonresectable patient detected, but this strategy still required up to 20% futile explorative laparotomies. Conclusions: The combination of endoscopic and laparoscopic ultrasonography was cost-effective and had no complications in this study. We use this strategy as our standard in the pretherapeutic evaluation of UGIM patients. Received: 27 November 1998/Accepted: 12 July 1999     

Incidental laparoscopic appendectomy for acute right lower quadrant abdominal pain

Background: Removing the normal appendix when operating for suspected acute appendicitis is the standard of care. The use of laparoscopy should not alter this practice. Methods: Retrospective review of 72 patients found to have grossly normal appendices while undergoing laparoscopy for suspected appendicitis. Twenty-eight patients underwent diagnostic laparoscopy (DL) alone while 44 patients underwent diagnostic laparoscopy with incidental laparoscopic appendectomy (ILA). Results: There was no difference in length of hospitalization (DL = 44 h, ILA = 43 h, p= 0.49) or morbidity (DL = 11%, ILA = 5%, p= 0.37). One patient required appendectomy 11 days after diagnostic laparoscopy for recurrent acute right lower quadrant abdominal pain. Five percent of resected appendices (2/44) demonstrated acute inflammation upon pathologic review. Conclusions: Laparoscopic removal of the normal appendix produces no added morbidity or increase in length of hospitalization as compared to diagnostic laparoscopy. It demonstrates cost effectiveness by preventing missed and future appendicitis. Incidental laparoscopic appendectomy is the preferred treatment option. Received 3 April 1997/Accepted: 3 July 1997     

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     

Video-laparoscopic staging of gastric cancer

Background: The high proportion of gastric carcinomas present in an unresectable stage, together with the emergence of multimodal treatments, increases the usefulness of objective staging methods that avoid unnecessary laparotomies. Methods: A prospective evaluation of the accuracy of laparoscopy in the staging of 71 patients with gastric adenocarcinoma is presented. Serosal infiltration, retroperitoneal fixation, metastasis to lymph nodes, peritoneal and liver metastasis, and ascites were determined in the staging workup. Sensitivity, specificity, and predictive values were calculated and compared with those obtained with ultrasonography (US) and computed tomography (CT). Results: The diagnostic accuracy of laparoscopy in the determination of resectability was 98.6%. Consequently, over 40% of patients were spared unnecessary laparotomies. Laparoscopy yielded diagnostic indices superior to US and CT for all the tumoral attributes studied. Our technique permits accurate assessment and pathologic verification of liver and the peritoneal and retroperitoneal extent of tumor invasion in the majority of patients. Conclusions: Laparoscopy in gastric adenocarcinoma is a reliable technique that provides accurate assessment of resectability and stage, thus avoiding unnecessary laparotomies in patients in whom surgical palliation is not indicated. A stepwise diagnostic workup combining imaging and minimally invasive techniques is proposed. Received: 5 May 1996/Accepted: 10 March 1997     

Increased tumor growth and spread after laparoscopy vs laparotomy

Background: The use of laparoscopy for assessment and treatment of malignant tumors remains controversial. The aim of this study was to evaluate the impact of tumor manipulation during laparoscopy compared with that of conventional laparotomy on growth and spread of an intraperitoneal tumor in the rat in a randomized, controlled trial. Methods: Thirty 2-month-old male Lewis rats received a single-site intrapancreatic inoculation of a ductal adenocarcinoma. Fourteen days after cancer implanting, two groups of six animals each underwent a laparotomy (30 min 6 mmHg CO₂ pneumoperitoneum). The tumor was manipulated in the one group, and exclusively visualized in the other. In two other groups, a midline laparotomy with (n = 6) or without (n = 6) tumor manipulation was performed. Animals in the control group (n = 6) underwent no procedure. Tumor volume, tumor mass, local regional invasion incidence, lymph node involvement, and liver and lung metastases were evaluated on 28-day tumors. Results: No difference in tumor growth and spread was observed between laparoscopy and laparotomy when tumor manipulation was not carried out. Tumor manipulation increased tumor growth significantly in the laparotomy group, but not in the laparoscopy one. Tumor metastases were correlated to tumor growth and increased significantly after manipulation in both groups. There was no port-site or conventional wound seeding in either the surgical procedure. Conclusions: This study showed that manipulation is the main factor acting on tumor dissemination in both laparoscopy and laparotomy. Laparoscopic surgery had a beneficial effect on local tumor growth compared with laparotomy in the case of tumor manipulation. This beneficial effect of laparoscopic surgery may be related to a better preservation of immune function in the early postoperative period. Received: 16 August 1996/Accepted: 27 January 1997     

Transperitoneal laparoscopic pelvic lymphadenectomy for gynecologic malignancies (II)

Background: We reviewed the published experimental and clinical data, available in MEDLINE, and compared them with our own experience, in a university-affiliated tertiary medical center of obstetrics and gynecology in order to report on the accepted indications for laparoscopic pelvic lymphadenectomy. Methods: Surgical staging of cervical carcinoma can be performed via the laparoscopic approach. Intraperitoneal biopsies, washings, and pelvic lymphadenectomy can also be carried out with high accuracy and limited morbidity. Node-negative women are better treated by a radical hysterectomy performed either simultaneously (using frozen sections) or secondarily after routine pathologic examination of the pelvic nodes. Node-positive patients have a poor prognosis, no matter what the treatment is, and are generally considered for radiotherapy and/or chemotherapy. The use of laparoscopic pelvic lymphadenectomy in advanced cervical cancers is limited. Results: Laparoscopy has a direct therapeutic application in endometrial carcinoma. Total hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy can all be performed via laparoscopy. Thus, stage I and some stage II endometrial cancers can be treated exclusively laparoscopically. This approach seems as effective as laparotomy, but it dramatically reduces the costs and morbidity associated with conventional treatment. Conclusions: Currently, the use of laparoscopy in ovarian and tubal cancers is confined to referral centers. Laparoscopy appears to be as effective as laparotomy for second-look surgery. Treatment of stage II and more advanced ovarian cancers has been reported, but it cannot be recommended in a routine situation. Received: 3 February 1997/Accepted: 18 July 1997     

Selective use of diagnostic laparoscopy in patients with suspected appendicitis

Background: Diagnostic laparoscopy has been introduced as a new diagnostic tool for patients with acute appendicitis. We performed diagnostic laparoscopy when the clinical diagnosis of appendicitis was in doubt. The aims of this study were to evaluate this strategy and to analyze the efficacy of diagnostic laparoscopy in patients with suspected appendicitis. Patients and Methods: All patients referred to our hospital with suspected appendicitis during the period 1994–1997 were evaluated prospectively. The clinical diagnosis was determined by the surgeon or resident on call based on the patient's history, physical examination, and leukocyte count. The patients were divided into three groups: group 1: appendicitis not likely. These patients were observed for 24 h or discharged. When they showed signs of appendicitis in 24 h, they were transferred to either group 2 or 3; group 2: doubt concerning diagnosis. These patients underwent diagnostic laparoscopy, and appendectomy was performed if indicated; group 3: In these patients the diagnosis appendicitis was felt to be certain. They were treated by primary appendectomy by an open procedure. In this study, 1,050 patients, 531 women (51%), 389 men (37%), and 130 children (12%) <11 yrs, were evaluated. Results: Altogether, 377 diagnostic laparoscopies were performed, leaving 109 healthy-looking appendices in place. This reduced the negative appendectomy rate from 25% to 14% in all surgically managed patients. The negative appendectomy rate for the women in group 2 was reduced from 49% to 14%, and for the men from 22% to 11%, so it also seemed worthwhile to perform diagnostic laparoscopy in men. Because the appendix sana was left in place in only three children, the benefit from laparoscopy is relatively small for children. In 48% of these patients a second diagnosis was obtained, most of them gynecologic in nature. There were no false-negative laparoscopies and no complications resulting from the laparoscopic procedure. Conclusions: Diagnostic laparoscopy is a safe procedure that reduced the appendix sana rate without increasing the total number of operations. It is a useful method for obtaining other, mostly gynecologic, diagnoses. To further reduce the appendix sana rate, better criteria for laparoscopic assessment of the appendix are needed. Received: 7 September 1999/Accepted: 21 February 2000/Online publication: 22 August 2000     

Laparoscopic gastro- and hepaticojejunostomy for palliation of pancreatic cancer

Background: Most patients presenting with pancreatic cancer are irresectable at the time the diagnosis is made. Therefore, they are in need of palliative treatment that can guarantee minimal morbidity, mortality, and hospital stay. To address this need, we designed a study to test the feasibility of laparoscopic gastroenterostomy and hepaticojejunostomy and to compare their results with those achieved with open techniques. Methods: We performed a case control study of a new concept in laparoscopic palliation based on the findings of preoperative imaging and diagnostic laparoscopy. Laparoscopic side-to-side gastroenterostomy and end-to-side hepaticojejunostomy (Roux-en-Y) were done in irresectable cases. Of 14 patients who underwent laparoscopic palliation, three had a laparoscopic double bypass, seven had a gastroenterostomy, and four underwent staging laparoscopy only. The results were compared with a population of 14 matched patients who had conventional palliative procedures. Results: Postoperative morbidity was 7% vs 43% for laparoscopic and open palliation, respectively (p < 0.05). There were no mortalities in the laparoscopic group, as compared to 29% in the group who had open bypass surgery (p < 0.05). Postoperative hospital stay averaged 9 days in the laparoscopic group and 21 days in the open group (p < 0.06). Operating time tended to be shorter in the laparoscopic group (p < 0.25). Morphine derivatives were necessary for a significantly shorter period after laparoscopic surgery (p < 0.03). Conclusions: Our preliminary experience strongly suggests that laparoscopic palliation can reduce the three major drawbacks of open bypass surgery—i.e., high morbidity, high mortality, and long hospital stay. Received: 24 February 1999/Accepted: 13 May 1999     

The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes

Background: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. Methods: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. Results: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. Conclusions: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain. Received: 24 March 1997/Accepted: 4 September 1997     

Indications for laparoscopic colorectal surgery

Background: Between November 1991 and May 1995, a series of laparoscopic colectomies were performed in our hospital. Methods: Our main aim was to define more specifically the indications for laparoscopic colectomy. Results: A total of 69 patients underwent laparoscopic surgery for benign polypoid colorectal disease (n = 10), inflammatory bowel disease (n = 24), and colorectal malignancy (n = 35). Of the latter group, four patients underwent a palliative procedure. The conversion rate of the whole group was 29%. The main reason to convert was infiltrative growth in inflammatory disease or cancer. Respectively, seven (10%) and 12 (17%) patients sustained complications in the perioperative and early postoperative phase. Two patients died perioperatively (3%). The mean hospital stay was 12 days. On follow-up, 11 patients had developed a stenotic anastomosis, which was successfully dilated in all cases. After 3 years, the survival rate according to Kaplan-Meier is 86%, 66%, 68%, and 0% for Dukes' A, B, C, and D color carcinoma, respectively. In one patient with a Dukes B carcinoma, port site metastases were found. Conclusions: Justifiable indications for laparoscopic colorectal surgery include (a) a benign polyp 20–50 cm from the anal ring; (b) mobile, inflammatory large bowel disease; (c) palliation in case of malignant disease, preferably of the left hemicolon. It remains to be proven that laparoscopic colectomy is superior and not just equivalent to open colectomy. This is especially true for resections of colorectal carcinoma with curative intent. Therefore a cost/benefit analysis should be performed in a prospective, randomized setting. Received: 1 November 1996/Accepted: 1 July 1997     

Zum Stellenwert der laparoskopischen Sonographie für das Staging gastrointestinaler Tumoren

BACKGROUND: The objective of this study was to evaluate the impact of laparoscopic ultrasound on the staging of gastrointestinal tumors prospectively. METHODS: Between 1993 and 2000 staging laparoscopy was performed on 668 patients with various neoplasms. Laparoscopy provided adequate information regarding resectability in 366 patients. Laparoscopic ultrasonography was performed in 302 patients (45%) using an intraoperative ultrasound unit (B & K) and a semiflexible ultrasound probe (5-7.5 MHz). The results of staging laparoscopy were compared to the preoperative staging and histopathology. RESULTS: Compared to preoperative staging laparoscopic ultrasound provided additional information of therapeutic relevance in 46 of 302 cases (15%). In a group of 384 patients with tumors of the upper gastrointestinal tract, laparoscopic ultrasound was performed in 186 cases and showed occult liver metastases, M1-lymph nodes, or nonresectable disease in 26 patients. Overall, this technique improved the staging of esophageal, gastric and pancreatic cancer in 12%, 3%, and 12% of the patients, respectively. Laparoscopic ultrasound proved to be most useful in esophageal and pancreatic cancer with a rate of 52% and 20% information additional to laparoscopy. The relative contribution of laparoscopic ultrasound to the staging of gastric cancer was only 10%. CONCLUSION: Laparoscopic ultrasound improves the diagnostic accuracy of staging laparoscopy. However, routine use of this technique is only justified, if neoadjuvant therapy--particularly in controlled trials--is considered in patients with advanced gastrointestinal cancer.     

Minimally invasive surgical staging for esophageal cancer

Background: The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer. Methods: Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS. Results: In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n= 1), I (n= 1), II (n= 23), III (n= 20), IV (n= 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients. Conclusions: In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer. Received: 5 April 1999/Accepted: 15 March 2000/Online publication: 12 July 2000     

Endosonographic examination of gastrointestinal anastomoses with suspected locoregional tumor recurrence

Background: Endoscopic ultrasound is considered one of the best tools for the preoperative staging of esophageal, gastric, and rectal carcinoma. Depending on the individual investigator, the sensitivity of preoperative tumor staging by endosonography of the upper gastrointestinal tract (GEUS) is 80–92% for gastric carcinoma and 86–95% for esophageal carcinoma. However, the sensitivity and specificity of endosonography for the staging of lymph node metastases is less accurate. The accuracy of rectal endosonography (REUS) is ∼90% for tumor assessment and ∼80% for the detection of lymph node metastases. In this study, we address the question of whether endosonography enables the surgeon to distinguish scar tissue, which is rather homogeneous and echo-rich, from changes such as an anastomositis or a locoregional tumor recurrence, which are typically noninhomogeneous and echo-poor. Methods: During a 24-months period, we studied patients enrolled in a special tumor follow-up care program by either upper gastrointestinal (GEUS, n= 37 patients) or rectal endosonography (REUS, n= 49 patients) for exclusion of a locoregional tumor recurrence. In each patient, local tumor recurrence was suspected because of either medical history, clinical examination, or other diagnostic procedures. Results: As in previous studies, our retrospective analysis revealed that endosonography has a high sensitivity in the detection of local tumor recurrences (>90%) for both GEUS and REUS. Conclusion: Endosonography is a highly accurate means of detecting local tumor recurrence. Received: 9 March 1998/Accepted: 9 November 1998     

Laparoscopic repair of perforated duodenal ulcer

Background: A series of 100 consecutive patients with perforated peptic ulcer were prospectively evaluated in a multicenter study. The feasibility of the laparoscopic repair was evaluated. Methods: All patients had peritonitis, 20% were in septic shock, and 57% had delayed perforation. Conversion to laparotomy was necessary in eight patients. The morbidity rate was 9% and mortality rate 5%. Results: The mean delay of postoperative gastric aspiration (mean 3.4 days) and resumed food intake (mean 4.4 days) as well as the mean postoperative hospital stay (mean 9.3 days) were comparable to conventional surgery, but postoperative comfort was subjectively increased by laparoscopy and noticed by all laparoscopic surgeons participating in this study. Conclusions: Laparoscopic repair of perforated peptic ulcer proves to be technically feasable and carries an acceptable morbidity and mortality rate, compared with conventional surgery. Received: 16 August 1996/Accepted: 1 April 1997     

Accuracy of endorectal ultrasound after preoperative radiochemotherapy in locally advanced rectal cancer

Objectives: Factors limiting the accuracy of endorectal ultrasound in staging, locally advanced primary rectal cancer after preoperative neoadjuvant radiochemotherapy (RCT) were evaluated. Methods: Patients (n= 84) with initial locally advanced rectal cancer (uT3/uT4) undergoing R0 resection were investigated after preoperative treatment that combined radiotherapy up to 45 Gy with two cycles of chemotherapy (5-FU and leucovorin on d 1–5 and 22–28). At 4 to 6 weeks after completion of RCT and before tumor resection, preoperative endoluminal ultrasound was performed. Results: The accuracy to predict the depth of tumor infiltration (T-category) was found to correlate with downstaging. The T-category was correctly staged before surgery in 15 of the 51 responders (29%) and in 27 of 33 nonresponders (82%), whereas misinterpretation occurred in 36 of the responders (71%) and in 6 of the nonresponders (18%) (p < 0.001). Neither tumor distance from anal verge nor tumor location correlated with the staging accuracy. Lymph node involvement was correctly assessed in 48 patients (57%). Wall invasion was correctly ascertained in 42 patients (50%), with under estimation in 11 patients (13%) and overestimation in 31 patients (37%). Conclusions: After radiochemotherapy, endosonography does not provide a satisfactory accuracy for preoperative staging of rectal cancer. New interpretation and diagnostic criteria are needed for the prediction of treatment response. Received: 28 February 1999/Accepted: 2 April 1999     

The effect of immune enhancement and suppression on the development of laparoscopic port site metastasesrid=""id=""Presented at the 6th World Congress of Endoscopic Surgery, Rome, Italy, June 1998

Background: Recent clinical case reports and experimental studies have suggested that laparoscopic cancer surgery is associated with an increased risk of tumor spread to abdominal wall wounds. While the etiology of this problem was initially believed to be related to mechanical contamination of wounds, it is now recognized that there are other contributory factors, including disturbed immune function within the peritoneal cavity. To investigate this question further, we evaluated the effect of immune modulation within an established laparoscopic cancer model. Methods: Eighteen immune-competent syngeneic rats underwent modulation of their immune system, followed 18 h later by laparoscopy with the introduction of a suspension of adenocarcinoma cells into the peritoneal cavity. Rats were randomly allocated to receive either systemic cyclosporin (immune suppresser), intraperitoneal endotoxin (immune enhancer), or no agent (controls). Seven days later, all rats were killed and their peritoneal cavity was inspected for tumor implantation and port site metastases. Results: Cyclosporin did not influence the study outcome, but tumor growth (p= 0.008) and port site metastases (p < 0.0001) were less common following the administration of intraperitoneal endotoxin. Conclusion: The results of this study suggest that the immune system plays a role in the genesis of port site metastases. A preventive role for endotoxin in patients undergoing laparoscopic cancer surgery, however, remains speculative. Received: 22 July 1998/Accepted: 23 June 1999     

Intermittent pneumatic sequential compression (ISC) of the lower extremities prevents venous stasis during laparoscopic cholecystectomy

Background: Fifty patients were included in a prospective randomized trial to evaluate the efficacy of intermittent sequential compression (ISC) of the lower extremities in preventing venous stasis during laparoscopic cholecystectomy. Methods: We treated 25 patients with (+ISC) and 25 without (–ISC) intermittent sequential compression. Peak flow velocity (PFV) and cross-sectional area (CSA) of the right femoral vein were measured by Doppler ultrasound before, during, and after capnopneumoperitoneum with 14 mm Hg. Results: PFV was 26.4 (8.4) cm/s and CSA was 1.03 (0.23) cm² before pneumoperitoneum was induced. During abdominal insufflation, PFV decreased to 61% of the baseline value in the (–ISC) group but remained unchanged in the (+ISC) group (t = 5.17, df = 42.8, p < 0.01). CSA was 1.06 (0.22) cm² before insufflation. It increased to 118% of the baseline in the (–ISC) group and to 108% in the (+ISC) group (t =–1.55, df = 47.1, p= 0.13). PFV and CSA returned to baseline values within 5 min after abdominal desufflation. Conclusions: ISC effectively neutralizes venous stasis during laparoscopic surgery and may decrease the risk of postoperative thromboembolic complication. Therefore, it is recommended for all prolonged laparoscopic procedures. Received: 10 April 1996/Accepted: 24 April 1997