Staging of pancreatic and ampullary cancers for resectability using laparoscopy with laparoscopic ultrasound

Background: Cancers of the pancreas and periampullary region are rarely curable. We set out to determine the efficacy of laparoscopy with laparoscopic ultrasound in the staging of pancreatic and ampullary malignancies for resectability. Methods: Between January 1994 and September 1999, we retrospectively reviewed the laparoscopic staging (LS) of tumors already deemed resectable by standard radiologic criteria in 27 patients using laparoscopy with laparoscopic ultrasound (LUS). Patients found to be resectable by LS evaluation underwent laparotomy (LA). We then compared the results of the LS and LA findings. Results: Of the 27 patients evaluated, 17 were men and 10 were women. Their mean age was 66 years. Preoperative computerized tomography (CT) scans were done in all 27 patients (100%), and transabdominal and endoscopic ultrasound (EUS) was done in 21 (78%). By LS, seven patients (26%) were found to have unresectable disease. Two patients with mesenteric tumor infiltration (one with peritoneal implants, and one with a visible liver metastasis) were judged to be unresectable by laparoscopy alone. LUS revealed that one patient had portal vein (PV) occlusion and two had metastases to the lymph nodes or liver that were not revealed by preoperative studies or laparoscopy alone. Among 20 patients (74%) deemed resectable by LS, two (10%) were found to be unresectable at LA, one due to PV involvement and the other due to local tumor extension with superior mesenteric lymph node metastasis. Eighteen of those in whom resection was attempted (90%) were resectable, with no unexpected findings of distant lymph node or hepatic metastasis. Pathology examination showed that eight had regional metastases (44%). The sensitivity of LS in determining unresectability was 77% (seven true positives and two false negatives). The negative predictive value (reflecting resectability) was 90%. Laparoscopy alone had a sensitivity of 44%, with a negative predictive value of 78%. The sensitivity and positive predictive value of LS was 100%, reflecting no false positive examinations. Conclusions: LS can effectively stage most patients and reliably predict which of them will benefit from LA. Intervention for unresectable patients can then be limited to laparoscopic or endoscopic bypass. The main limitation is that LS may underestimate PV and regional lymph node involvement.