Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_639_Библиотеки_им_академика_М_И_Перельмана.pdf
72 Part I Introduction
1. Grab
suture loop
4. Cinch slipknot 5. Pull ends in
2. Pull in
opposite
directions
opposite
directions
3. Slide knot
to tissue
6. Square knot
recreated
FIGURE 4-10 Suturing. (Reprinted with permission from Hunter JG, Terry. Minimally invasive surgery: fundamentals. In:
Cameron JL, ed. Current Surgical erapies. St. Louis: Mosby.)
maintenance of pneumoperitoneum, the insuation pressures should be lowered from the usual 15 to 12 mm Hg, or
pneumoperitoneum should be evacuated while the anesthesiologist sorts out the cardiovascular changes. Taking patients
out of the steep reverse Trendelenburg position can help to
increase venous return. Sometimes these eects can last for
hours after desuation.
e elevated intra-abdominal pressures restrict movement
of the diaphragm, which reduces diaphragmatic excursion. is
is represented as a decrease in functional residual capacity and
pulmonary compliance and an increase in inspiratory pressure.
Overall, there is no signicant change in the physiologic dead
space or shunt in patients without cardiovascular compromise.
Bardoczky and colleagues studied seven healthy patients undergoing laparoscopy with CO
pneumoperitoneum.41 After the
2
induction of pneumoperitoneum, peak airway and plateau
airway pressures increased by 50% and 81%, respectively.
Bronchopulmonary compliance decreased by 47% during the
period of increased intra-abdominal pressure. After desuation, peak and plateau pressures remained elevated by 36%
and 27%, respectively, for 2–6 hours. Compliance remained
at 86% of the preinsuation value.
Urine output often is diminished during laparoscopic
procedures and usually is the result of diminished renal
blood ow owing to the cardiovascular eects of pneu-
42
moperitoneum and direct pressure on the renal veins.
In
addition to direct eects, elevated intra-abdominal pressure
results in release of antidiuretic hormone (ADH) by the
pituitary, resulting in oliguria that may last 30–60 minutes
after the pneumoperitoneum is released. Aggressive uid
hydration during pneumoperitoneum increases urine output.
43
Positional changes can aect the collection of urine in the
Foley catheter and must be taken into consideration if
anuria is noted.
Carbon Dioxide–Related Effects
HYPERCAPNIA
Hypercapnia and acidosis are seen with pneumoperitoneum
and are likely due to the absorption of CO
toneal cavity. In the ventilated patient, increasing respiratory
rate or vital capacity must compensate for these changes. At
extremes, increases in tidal volume may risk barotraumas,
and increases in respiratory rates diminish time for gas mixing, increasing dead-space ventilation. A rst steady state in
is reached around 15–30 minutes after introduction of
PaCO
2
from the peri-
2
Chapter 4 Fundamentals of Laparoscopic Surgery 73
the pneumoperitoneum. After this period, increases in PaCO2
suggest that existing body buers (>90% exist in bone) have
been exhausted. Sudden increases may be related to port slippage and extraperitoneal or subcutaneous diusion of CO
2
is will resolve spontaneously once the port is repositioned.
Hypercapnia and acidosis that are dicult to control may
follow, especially in elderly patients, those undergoing long
operations, and patients with pulmonary insuciency. Our
response to this is to desuate the abdomen for 10–15 minutes.
If reinsuation results in recurrent hypercapnia, then we change
insuation gases (see above) or convert to an open operation.
Acidosis can persist for hours after desuation. Other complications of pneumoperitoneum that are less frequent but may be
life threatening include CO
embolism and capnothorax.
2
CARBON DIOXIDE EMBOLUS
e incidence of clinically signicant CO2 embolism is very
low, although recent reports using more sensitive tests suggest
that tiny bubbles of gas are present commonly in the right side
of the heart during laparoscopic procedures. Clinically important CO
embolism may be noted by unexplained hypoten-
2
sion and hypoxia during the operation. ere is a characteristic
millwheel murmur that can be detected with auscultation of
the chest. is is produced by contraction of the right ventricle
against the blood–gas interface. Usually the anesthesiologist
notes an exponential decrease in the end-tidal CO
, which is
2
consistent with complete right ventricular outow obstruction.
e mainstays of treatment are immediate evacuation of the
pneumoperitoneum and placement of the patient in the left
lateral decubitus, head down (Durant) position. is allows the
bubble to “oat” to the apex of the right ventricle, where it
CO
2
is less likely to cause right ventricular outow tract obstruction.
It is important to administer 100% oxygen and hyperventilate
the patient during this period. Additionally, aspiration of gas
through a central venous line may be performed.
CAPNOTHORAX/PNEUMOTHORAX
Capnothorax can be caused by CO2 escaping into the chest
through a defect in the diaphragm or tracking through fascial
planes during dissection of the esophageal hiatus. It also can be
due to opening of pleuroperitoneal ducts most commonly seen
on the right side. Pleural tears during fundoplication can lead
to pneumothorax, and additionally, the usual causes of pneumotho rax, such as ruptured bullae, may be the etiology. e
eects of CO
saturation (a result of shunting induced by lung collapse),
O
2
gas in the chest usually are noted as decreased
2
increased airway pressure, decreased pulmonary compliance,
and increases in CO
to desuate the abdomen, stop CO
and end-tidal CO2. e treatment is
2
administration, correct
2
the hypoxemia by adjusting the ventilator, apply positive endexpiratory pressure (PEEP), if possible, and decrease the intraabdominal pressure as much as possible. e recommendation
is to avoid thoracentesis because this usually resolves with anesthetic management. We generally evacuate the capnothorax
directly at the end of the procedure with a red rubber catheter
placed across the diaphragm (through the pleural defect) and
brought out a trocar site. e external end of the catheter is
placed under water as the lung is inated and then removed
.
from the water when the bubbles stop. We do not obtain chest
radiographs in the recovery room after these maneuvers if there
is no evidence of hypoxia on 2 L/min of O
ow. Patients
2
should be maintained on supplemental oxygen to help facilitate absorption of the CO
from the pleural space.
2
CONCLUSIONS
Although minimally invasive surgery is rmly established
in modern surgery, its safe performance can be ensured
only with mastery of the basics. Basic skills used in laparoscopy include evaluation of a patient based on a new set
of considerations, safe use of devices for abdominal access
and instrumentation, and mastery of complex manual skills
and intraoperative assessment of novel physiologic parameters. Laparoscopic surgery will only be employed more in
the future as technical innovations allow us to care for our
patients in new and better ways.
REFERENCES
1. Tsereteli Z, Terry ML, Bowers SP, et al. Prospective, randomized clinical
trial comparing nitrous oxide and carbon dioxide pneumoperitoneum
for laparoscopic surgery. J Am Coll Surg. 2002;195:173–179; discussion
179–180.
2. Chopra R, McVay C, Phillips E, Khalili TM. Laparoscopic lysis of adhesions.
Am Surg. 2003;69:966–968.
3. Marshall NJ, Bessell JR, Maddern GJ. Study of venous blood ow changes
during laparoscopic surgery using a thermodilution technique. ANZ J Surg.
2000;70:639–643.
4. Okuda Y, Kitajima T, Egawa H, et al. A combination of heparin and
an intermittent pneumatic compression device may be more eective to
prevent deep-vein thrombosis in the lower extremities after laparoscopic
cholecystectomy. Surg Endosc. 2002;16:781–784.
5. Prystowsky JB, Morasch MD, Eskandari MK, et al. Prospective analysis
of the incidence of deep venous thrombosis in bariatric surgery patients.
Surgery. 2005;138:759–763; discussion 763–755.
6. Goldfaden A, Birkmeyer JD. Evidence-based practice in laparoscopic surgery:
perioperative care. Surg Innov. 2005;12:51–61.
7. Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative dexamethasone
improves surgical outcome after laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled trial. Ann Surg. 2003;238:651–660.
8. Magner JJ, McCaul C, Carton E, et al. Eect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after
gynaecological laparoscopy: comparison of 30 and 10 mL kg–1. Br J Anaesth.
2004;93:381–385.
9. Maharaj CH, Kallam SR, Malik A, et al. Preoperative intravenous uid
therapy decreases postoperative nausea and pain in high risk patients.
Anesth Analg. 2005;100:675–682.
10. Epstein J, Arora A, Ellis H. Surface anatomy of the inferior epigastric
artery in relation to laparoscopic injury. Clin Anat. 2004;17:400–408.
11. Hurd WW, Amesse LS, Gruber JS, et al. Visualization of the epigastric
vessels and bladder before laparoscopic trocar placement. Fertil Steril.
2003;80:209–212.
12. Yim SF, Yuen PM. Randomized, double-masked comparison of radially
expanding access device and conventional cutting tip trocar in laparoscopy.
13. Dabirashra H, Mohammad K, Tabrizi NM, et al. e use of Veress needle
and 10-mm trocar (VN) versus direct trocar insertion (DTI) in the beginning of laparoscopy. J Am Assoc Gynecol Laparosc. 1994;1:S9.
74 Part I Introduction
14. Chandler JG, Corson SL, Way LW. ree spectra of laparoscopic entry
access injuries. J Am Coll Surg. 2001;192:478–490; discussion 490–471.
15. Hasson H. Open laparoscopy: a report of 150 cases. J Reprod Med.
1974;12:234–238.
16. Veress J. Neues Instrument Zur Ausfuhrung von brustoder Bach-
punktionen und Pneumonthoraybehund-lung. Deutsch Med Wochescr.
1938;64:1480–1481.
17. Vilos GA, Vilos AG. Safe laparoscopic entry guided by Veress needle CO2
insuation pressure. J Am Assoc Gynecol Laparosc. 2003;10:415–420.
18. Dingfelder JR. Direct laparoscope trocar insertion without prior pneumo-
peritoneum. J Reprod Med. 1978;21:45–47.
19. Clayman RV. The safety and efficacy of direct trocar insertion with
elevation of the rectus sheath instead of the skin for pneumoperitoneum.
J Urol. 2005;174:1847–1848.
20. Gunenc MZ, Yesildaglar N, Bingol B, et al. e safety and ecacy of direct
trocar insertion with elevation of the rectus sheath instead of the skin for
pneumoperitoneum. Surg Laparosc Endosc Percutan Tech. 2005;15:80–81.
21. Agresta F, De Simone P, Ciardo LF, Bedin N. Direct trocar insertion vs Veress
needle in nonobese patients undergoing laparoscopic procedures: a randomized, prospective single-center study. Surg Endosc. 2004;18:1778–1781.
22. Jacobson MT, Osias J, Bizhang R, et al. e direct trocar technique: an alternative approach to abdominal entry for laparoscopy. JSLS. 2002;6:169–174.
23. Rumstadt B, Sturm J, Jentschura D, et al. Trocar incision and closure:
daily problems in laparoscopic procedures—a new technical aspect. Surg
Laparosc Endosc. 1997;7:345–348.
24. Champault G, Cazacu F, Tander N. Serious trocar accidents in laparo-
scopic surgery: a French survey of 103,852 operations. Surg Laparosc Endosc.
1996;6:367–370.
25. Saville LE, Woods MS. Laparoscopy and major retroperitoneal vascular
injuries (MRVI). Surg Endosc. 1995;9:1096–1100.
26. Sharp HT, Dodson MK, Draper ML, et al. Complications associated with
optical-access laparoscopic trocars. Obstet Gynecol. 2002; 99:553–555.
27. Corson SL, Chandler JG, Way LW. Survey of laparoscopic entry injuries
provoking litigation. J Am Assoc Gynecol Laparosc. 2001;8:341–347.
28. Vakili C, Knight R. A technique for needle insuation in obese patients.
Surg Laparosc Endosc. 1993;3:489–491.
29. Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia.
Arch Surg. 2004;139:1248–1256.
30. Liu CD, McFadden DW. Laparoscopic port sites do not require fascial
closure when nonbladed trocars are used. Am Surg. 2000;66:853–854.
31. Bhoyrul S, Payne J, Stees B, et al. A randomized, prospective study of
radially expanding trocars in laparoscopic surgery. J Gastrointest Surg.
2000;4:392–397.
32. Kwok A, Lam A, Ford R. Incisional hernia in a 5-mm laparoscopic port-
site incision. Aust NZ J Obstet Gynaecol. 2000;40:104–105.
33. Reardon PR, Preciado A, Scarborough T, et al. Hernia at 5-mm laparoscopic port site presenting as early postoperative small bowel obstruction.
J Laparoendosc Adv Surg Tech A. 1999;9:523–525.
34. Montz FJ, Holschneider CH, Munro M. Incisional hernia following
laparoscopy: a survey of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc. 1994;1:S23–S24.
35. Lowry PS, Moon TD, D’Alessandro A, Nakada SY. Symptomatic port-site
hernia associated with a non-bladed trocar after laparoscopic live-donor
nephrectomy. J Endourol. 2003;17:493–494.
36. Di Lorenzo N, Coscarella G, Lirosi F, Gaspari A. Port-site closure: a new
problem, an old device. JSLS. 2002;6:181–183.
37. Carbonell AM, Joels CS, Kercher KW, et al. A comparison of laparoscopic
bipolar vessel sealing devices in the hemostasis of small-, medium-, and
large-sized arteries. J Laparoendosc Adv Surg Tech A. 2003;13:377–380.
38. Gebhardt H, Bautz A, Ross M, et al. Pathophysiological and clinical aspects
of the CO2 pneumoperitoneum (CO2-PP). Surg Endosc. 1997;11:864–867.
39. Kashtan J, Green JF, Parsons EQ, Holcroft JW. Hemodynamic eect of
increased abdominal pressure. J Surg Res. 1981;30:249–255.
40. Larsen JF, Svendsen FM, Pedersen V. Randomized clinical trial of the eect
of pneumoperitoneum on cardiac function and haemodynamics during
laparoscopic cholecystectomy. Br J Surg. 2004;91:848–854.
41. Bardoczky GI, Engelman E, Levarlet M, Simon P. Ventilatory eects of
pneumoperitoneum monitored with continuous spirometry. Anaesthesia.
1993;48:309–311.
42. Ninomiya K, Kitano S, Yoshida T, et al. Comparison of pneumoperitoneum
and abdominal wall lifting as to hemodynamics and surgical stress response
during laparoscopic cholecystectomy. Surg Endosc. 998;12:124–128.
43. Demyttenaere SV, Feldman LS, Bergman S, et al. Does aggressive hydra-
tion reverse the eects of pneumoperitoneum on renal perfusion? Surg
Endosc. 2006;20:274–280.
LAPAROSCOPIC STAGING AND APPROACHES TO CANCER
Kevin C. Conlon • Tom K. Gallagher
5
INTRODUCTION
e role of laparoscopy in the staging of gastrointestinal
malignancy has continued to evolve over the last decade.
Improvements in noninvasive diagnostic modalities have
led to a more selective approach being adopted. Nonetheless, minimally invasive surgical techniques for staging and
palliative bypass continue to play an important role in the
staging and management of patients with upper gastrointestinal malignancies.
RATIONALE FOR LAPAROSCOPIC
STAGING
As the multidisciplinary management of gastrointestinal cancer
has evolved over the last decade, an accurate extent of disease
workup has become essential to treatment planning. Staging
procedures should accurately de ne the extent of disease,
direct appropriate therapy, facilitate the use of adjuvant
therapies and avoid unnecessary interventions in a safe and
cost-e cient fashion.
Recent advances in radiology have provided many noninvasive tools, such as multidetector computed tomographic
(CT) scanning, magnetic resonance imaging (MRI) and combined CT with positron-emission tomographic (CT/PET)
scanning, that have had a considerable impact on the extent
of disease workup. Unfortunately, these modalities may
underestimate the extent of disease, with small-volume metastatic disease being appreciated only at open surgical exploration. For over 100 years, laparoscopy has been suggested as a
means for identifying such small-volume disease. Recently, a
signi cant amount of data has been produced to suggest that
the use of laparoscopy and laparoscopic ultrasound (LUS)
in the staging of gastrointestinal malignancies has an impact
on overall management.
(LS) is to mimic staging at open exploration while minimizing morbidity, enhancing recovery, and thus allowing for
1–7
e aim of laparoscopic staging
quicker administration of adjuvant therapies if indicated.
Proponents believe that LS should be viewed as complementary and not as a replacement for other staging modalities
such as CT scanning, MRI, or PET scanning. In simplistic
terms, the advantages of laparoscopy are that it allows the
surgeon to visualize the primary tumor, determine vascular involvement, identify regional nodal metastases, detect
small-volume peritoneal/liver metastases, and obtain tissue
for histologic diagnosis.
SURGICAL TECHNIQUE FOR
LAPAROSCOPIC STAGING
Laparoscopic staging can be performed immediately before
a planned open procedure or at a separate occasion. We have
moved to the latter approach in the main because of logistical
concerns around the availability and utilization of operating
time. Generally the procedure is performed as an ambulatory/outpatient procedure with excellent patient satisfaction.
Laparoscopic staging usually is performed under general
anesthesia with the patient positioned supine on the operating
table. A warming blanket is placed underneath the patient,
who is secured appropriately to the table with padding over
the pressure points.
e following operative equipment is considered necessary for the procedure:
1. A 30-degree angled laparoscope either 5 or 10 mm in
diameter
2. Five-millimeter laparoscopic instruments, including a
Maryland dissector, a blunt-tip dissecting forceps, a cup/
biopsy forceps, atraumatic grasping forceps, a liver retractor,
and scissors
3. A 5- or 10-mm suction/irrigation device
4. An LUS probe (optional)
In general, we prefer a multiport technique. Access is
gained into the peritoneal cavity using a blunt port placed
75
76 Part I Introduction
subumbilically by direct cutdown. By using forceps to grasp
the fascial layers, retractors can be avoided and the wound size
minimized. An alternative approach, particularly in patients
with previous midline incisions, is to place the initial port in
either the right or the left upper quadrant of the abdomen.
Many surgeons prefer to use a Veress needle to achieve pneumoperitoneum prior to placing the surgical ports. In this case,
care should be exercised to avoid visceral or vascular injury.
Laparoscopic access using an optical trocar, which combines
the advantages of the Hasson and Veress techniques, is a safe
and feasible primary insertion method, which may alleviate
this risk and is becoming an increasingly accepted technique.
8
Pneumoperitoneum is achieved with CO2 gas. Insuation commences at a low ow rate until peritoneal entry is
conrmed. An intraperitoneal pressure of 10–12 mm Hg is
considered optimal. However, in patients with cardiopulmonary compromise, a lower maximum pressure may be
chosen. A 5- to 10-mm 30-degree angled telescope is preferred, and systematic examination of the peritoneal cavity is
performed. Additional trocars then are inserted under direct
vision. Placement depends on the site of the primary tumor
(ie, colonic, gastric, pancreatic, etc) and the ndings at initial
inspection (ie, whether obvious metastatic disease is present).
In general, ports are placed along the planned open incision
line (Fig. 5-1).
Following port placement, a detailed examination of the
peritoneal cavity is performed in a similar fashion to an open
exploration. e primary tumor is assessed. Any extension
into contiguous organs can be identied. Following an initial survey, a systematic examination of the intra-abdominal
viscera is performed commencing with the liver. To facilitate
hepatic examination, the patient is placed in a 20-degree
reverse Trendelenberg position with 10 degrees of left lateral
tilt. e anterior and posterior surfaces of the left lateral segment of the liver are examined, followed by examination of
the anterior and inferior surfaces of the right lobe. Despite
the absence of tactile sensation, indirect palpation of the liver
surface can be achieved by using two instruments (Fig. 5-2).
A blunt suction device is particularly useful in compressing
the liver tissue in order to detect small metastases. Improved
visualization of diaphragmatic and posterior surfaces may be
achieved by placing the camera in the right upper quadrant
port. Any suspicious areas can be biopsied at this point. A
cup biopsy forceps is the preferred instrument for obtaining
adequate biopsies for diagnostic purposes. For this, we use a
5-mm biopsy forceps with a 2-mm cup as standard. Multiple
samples may be taken to increase diagnostic yield. e cup
is used to breech the liver capsule and a bite is taken out of
the lesion. Further scoops can then be taken from the lesion
and liver parenchyma as needed. orough hemostasis can
easily be obtained with electrocautery or use of argon beam
diathermy. If electrocautery is used, it is important to avoid
direct coupling or capacitance coupling, which can lead to
visceral injury. Direct coupling, when current ows directly
from one instrument to the other, may occur when the instruments are too close together, especially if one is just outside
of the eld of view. Capacitance coupling occurs when two
conductors have an insulator sandwiched between them. e
high frequency AC current in the active conductor generates
a magnetic eld, which then induces current in the second
conductor. Mixing of metal and plastic instruments and ports
can lead to capacitance coupling and, at least in theory, severe
burns. e incidence of complications is reduced by limiting
5 mm
5 mm
10–12 mm
10–11 mm
(Camera)
FIGURE 5-1 Port placement. FIGURE 5-2 Examination of the liver.
Chapter 5 Laparoscopic Staging and Approaches to Cancer 77
the gain of electrocautery to 30 W and possibly by using plastic rather than metallic ports.
e hilus of the liver, hepatoduodenal ligament, and
foramen of Winslow then are examined. Any abnormal
lymphadenopathy can be identied. e suspicious node can
be either excised or biopsied using the cup forceps. As in open
surgery, care must be taken not to crush the node and possibly
disseminate tumor cells during this procedure. In general, the
duodenum is not mobilized. However, for patients with pancreatic or common bile duct tumors, close attention is paid
to the presence or absence of tumor inltration in the angle
between the duodenum and the lateral aspect of the common bile duct because this may indicate signicant vascular
involvement.
The patient then is repositioned into a 10-degree Trendelenberg position without lateral tilt to facilitate examination of the transverse mesocolon and retroperitoneum.
e omentum is retracted toward the left upper quadrant,
FIGURE 5-4 Incision of the gastrocolic omentum to gain access to
the lesser sac.
elevating and enabling inspection of the transverse mesocolon an d the ligament of Treitz. e mesocolon is inspected
carefully with particular attention to the middle colic vein,
which usually is visible. Any abnormal adenopathy or inltration (Fig. 5-3) around the middle colic vein is noted
and may be biopsied. For patients with an upper gastrointestinal primary tumor, the lesser sac is examined. To
facilitate this maneuver, the patient then is returned to a
supine position, the left lobe of the liver is elevated, and the
gastrohepatic omentum is incised (Fig. 5-4). is exposes
the caudate lobe of the liver, the inferior vena cava, and the
celiac axis. If present, an aberrant left hepatic artery should
be identied and preserved. Often, adhesions between the
stomach and the pancreas require division to allow entry
into the lesser sac. By elevating the stomach, the “gastric
pillar” can be clearly identied (Fig. 5-5). is “pillar” contains the left gastric artery and vein. is structure followed
down leads us to the celiac axis, and any suspicious nodal
aspect of pancreas, hepatic artery, and left gastric artery
is also seen. Any suspicious periportal, hepatic, or celiac
nodes can be biopsied.
e diagnostic yield for LS may be increased by performing peritoneal lavage cytology. In general, the specimens
are taken at the start of the laparoscopy to avoid potential
contamination following tumor manipulation or dissection.
Between 200 and 400 mL of normal saline is instilled into
the peritoneal cavity. e abdomen is agitated gently before
aspiration. In pancreatic cases, samples are taken from the
right and left upper quadrants. An additional sample is taken
from the pelvis in patients with gastric cancer. Informing the
pathologist/cytologist of the procedure timing and clinical
question often leads to better clinical yields and is advisable
prior to undertaking the laparoscopy.
tissue can be biopsied. e hepatic artery also is identied
and followed to the hepatoduodenal ligament. e anterior
FIGURE 5-3 Inltration of the colonic mesocolon.
Gastric pillar
Hepatic artery
FIGURE 5-5 Lesser sac exposed. Solid arrow points to hepatic
artery. Dashed arrow points to “gastric pillar.”
78 Part I Introduction
If available, LUS can be performed at this stage. Laparoscopy by its nature is a two-dimensional modality, with the
result that appreciation of deep or subsurface lesions in solid
organs is often suboptimal. LUS can partially overcome this
deciency. Transducers in clinical use employ either curved
or linear-array technology and have a high-frequency performance with a range in the region of 6–10 MHz, allowing for
high-resolution images to be obtained that can detect lesions
from 0.2 cm in size. In addition, Doppler ow capability, if
present, allows for accurate vessel identication and facilitates
assessment of the tumor-vessel interface. e LUS probe is
inserted via a 10- to 12-mm port, usually in the right upper
quadrant.
e LUS is an invaluable tool for examination of the liver.
Initially, the transducer is placed over the left lateral segment
(Fig. 5-6), allowing assessment of segments I, II, and III. It is
important that the probe is placed in direct contact with the
liver surface to maximize acoustic coupling. Examination of
the right lobe commences with the probe on the dome of the
liver. e vena cava is visualized at the back and as the probe
is moved forward slowly to identify the hepatic and portal
veins. Within the liver, these can be identied by virtue of
their surrounding brous sheath. e remaining hepatic segments (IV, V, VI, VII, and VIII) are examined by rotating
the probe over the rest of the liver. Suspicious lesions can be
biopsied either by ne-needle aspiration (FNA) or by percutaneously inserting core biopsy needles under LUS guidance.
With the probe over segment V, the gallbladder is assessed,
and with transverse placement of the probe over the hepatoduodenal ligament, the common hepatic duct, common
bile duct, and hepatic arteries along with the portal vein can
be identied (Fig. 5-7). e portal vein can be followed to
its conuence with the splenic and superior mesenteric vein.
e superior mesenteric artery also can be seen and its relationship to a pancreatic tumor, if present, determined. e
pancreas can be examined, and any lesion can be identied.
FIGURE 5-6 LUS examination of the liver. Note the supercial
metastasis (solid arrow).
Tumor
FIGURE 5-7 LUS examination of the retropancreatic structures.
Red arrow points to superior mesenteric artery and blue arrow points
to obstructed pancreatic duct secondary to a lesion in the head of the
gland.
ESOPHAGEAL CARCINOMA
Esophageal cancer is the eighth most common cancer and is
the sixth leading cause of cancer death worldwide.
geal cancer was diagnosed in 16,470 new patients in the
United States in 2008, with an overall annual incidence of
approximately 5.4 cases per 100,000 population.
mated that more than 14,000 patients will die of this disease
each year. Unfortunately, the prognosis remains poor; with
an overall survival rate of approximately 5–10% in spite of
the availability of new chemotherapeutic and biologic agents
in both neoadjuvant and adjuvant settings. Surgical resection
remains the treatment of choice for patients with localized
disease. In addition, in the last few years, there has been a signicant progress in palliative nonsurgical treatment options.
erefore, accurate staging for esophageal cancer is of paramount importance.
7,11–14
Common diagnostic modalities are listed in Table 5-1. e
results of a meta-analysis in 2008 suggest that endoscopic
ultrasonography (EUS), CT, and uorine-18-urodeoxyglucose (FDG)-PET each play a distinctive role in the
detection of metastases in esophageal cancer patients. For
the detection of regional lymph node metastases, EUS is
most sensitive, whereas CT and FDG-PET are more specic
tests. For the evaluation of distant metastases, FDG-PET
has probably a higher sensitivity than CT.
been discussed in detail elsewhere in this book. Endoscopy remains the diagnostic gold standard. Biopsies can be
9
Esopha-
10
It is esti-
15
ese have
Chapter 5 Laparoscopic Staging and Approaches to Cancer 79
TABLE 5-1: DIAGNOSTIC MODALITIES FOR
STAGING ESOPHAGOGASTRIC CANCERS
History and clinical examination
Ultrasonography
Endoscopic ultrasonography
MDR-computed tomography
Magnetic resonance imaging
Computed tomography/Positron emission tomography (CT/PET)
Laparoscopy
Laparoscopic ultrasonography
obtained and an assessment of local disease extent made.
In patients considered unsuitable for surgical resection, a
number of palliative options such as endoscopic dilation,
laser ablation, or placement of luminal stents exist.
Multislice CT scanning of the thorax and abdomen is the
radiologic staging modality of choice. e primary tumor
can be visualized and metastatic disease detected. However,
while data suggest that current-generation high-resolution
multislice CT scanning is of signi cant value, its capacity
to accurately T stage the disease and predict lymphatic and
16
peritoneal spread remains between 65% and 80%.
EUS enables detailed imaging of the esophageal wall, local
lymph nodes, and contiguous structures, making it the ideal
11,
12,
tool for tumor node metastasis (TNM) staging.
17 e
shape, pattern, and demarcated borders of nodes are exam-
18,
ined to assess metastatic potential.
to CT scanning for locoregional staging.
19 EUS appears superior
13,
20 Harewood and
Wiersema from the Mayo Clinic compared the cost of EUSFNA with CT-FNA and a surgical approach in staging patients
with nonmetastatic esophageal cancer. ey suggested that by
avoiding unnecessary surgery, primarily by detecting celiac
21
node involvement, EUS-FNA was the least costly strategy.
It appears that combined CT scan and EUS is a better
prediction of tumor resectability than CT scan alone (81%
22
vs 65% with p < 0.05) reported by de Graaf et al.
In a study
of the impact of EUS-FNA in the management of patients
with esophageal cancer, Morris et al found that EUS-FNA
altered management in 28 (67%) patients and appeared to
help direct patients toward appropriate treatment strategies
23
including palliative and neoadjuvant therapies.
In a meta-
analysis and systematic review of studies that included over
24
2500 patients, Puli et al
concluded that EUS performs
better with advanced (T4) than early (T1) disease and that
FNA substantially improves the sensitivity and speci city of
EUS in evaluating N stage disease (from 84.7% [95% CI:
82.9–86.4] to 96.7% [95% CI: 92.4–98.9]). However, while
most thoracic surgeons have embraced EUS-FNA as the most
accurate locoregional staging modality in esophageal cancer,
this attitude is not fully re ected in utilization patterns due to
25
a lack of quality EUS services in some centers.
Several studies have investigated the detection of the pri-
mary tumor by FDG-PET. Increased uptake of FDG was
26–28
seen in 68–100% of the esophageal tumors.
Undetected
tumors are mostly stages T1 and T2. T1a tumors, remaining
within the submucosa, are especially di cult to detect by
29–30
FDG-PET.
Kato et al 31 found a signi cant relationship
between the intensity of the primary tumor FDG-uptake,
expressed as SUV, and the depth of the tumor invasion. How-
32
ever, Flamen et al
found no correlation between SUV and
pT-stage.
To determine whether FDG-PET could delineate patients
with esophageal cancer who may not bene t from esophagectomy after chemoradiotherapy, Monjazeb et al reviewed 163
patients with histologically con rmed stage I to IVA esophageal cancer receiving chemoradiotherapy with or without
resection with curative intent and found that patients who
achieved a complete response on FDG-PET imaging may not
bene t from added resection given their excellent outcomes
33
without resection.
ese results should be validated in a prospective trial of FDG-PET-directed therapy for esophageal
cancer.
It has been suggested that FDG-PET scanning has a role
for the detection of metastatic disease and for restaging after
neoadjuvant therapy or evaluation of recurrence. In the study
by Flamen and colleagues, FDG-PET scanning had a signi cantly higher rate of detection of stage IV disease compared
with the combination of CT scanning and EUS. It upstaged
disease in 15% and downstaged disease in 7% of patients.
34–36
Other studies have reported similar results.
32
In relation to the role of FDG-PET/CT in tumor delineation for radiotherapy, only three studies have reported a
signi cant positive correlation between FDG-PET-based
tumor lengths and pathological ndings and so the authors
of a systematic review on the role of FDG-PET/CT in
tumor delineation and radiotherapy planning in patients
with esophageal cancer concluded that standard implementation of FDG-PET/CT into the tumor delineation process
for radiation treatment seems unjusti ed and needs further
37
clinical validation rst.
Despite this increasingly sophisticated diagnostic armamentarium, between 15% and 20% of patients will continue
to have radiologically occult peritoneal, nodal, or liver metastases detected at surgical exploration. Laparoscopy has been
suggested as a means to detect such disease and thus exclude
this cohort of patients from potentially ine ective treatment
regimens.
e value of LS in esophageal cancer is accurate abdominal
nodal staging and detection of occult distant mestastases. e
procedure also allows for more detailed assessment of the
tumor looking for serosal involvement, local invasion, or peritoneal cavity, liver, and omental disease. In a comparison of
LS and EUS for esophageal cancer, Kaushik et al found an
overall staging accuracy of EUS compared with LS of 72%.
38
Staging di erences were mostly re ected in distant metastases
detected at LS (17%). e yield of LS appears to be determined at least in part by the site of disease, histologic cell type,
and noninvasive stage. ere are several observational studies
reporting the usefulness of LS in both gastric and oesophageal
cancers, the largest and most recent of which includes 416
39
consecutive patients undergoing staging laparoscopy.
e
80 Part I Introduction
authors report an 88% sensitivity of laparoscopy for resectability, with avoidance of unnecessary laparotomy in 20.2%
of all patients. Staging laparoscopy was most useful in
patients with adenocarcinoma, distal oesophageal, and gastroesophageal cancer, with percentage change in treatment decision of 21.9%, 17.1%, and 17.2%, respectively. No patients
in this study with upper two-third lesions had their treatment
decision changed by staging laparoscopy. is would be in
accordance with the general trend in the literature that the
more distal the tumor in the esophagus, the greater the risk
40,41
and likelihood of intra-abdominal metastases
and this is
likely related to lymphatic anatomy.
In a well-designed study, Samee et al report that the addition of LUS in the staging of esophagogastric cancers increases
the detection rate of metastasis by 8% but that there is little
42
impact on the false-negative rate.
In their retrospective case
series of 320 patients, LUS proved most useful in detecting
metastatic lymphadenopathy beyond the limits of curative
resection and liver metastasis. e main benet appears to be
in the assessment of nodal disease, particularly in the celiac
axis, hepatoduodenal ligament, and para-aortic area as disease in these sites accounts for more than 40% of the positive
ndings at laparoscopy.
e combination of endoscopic and laparoscopic
ultrasonography (EUS-LUS) is accurate for resectability
assessment of patients with esophageal cancer. In a series of
256 consecutive esophageal cancer patients, Mortenson
et al demonstrated a statistically signicant survival dierence (p < 0.01) between the dierent TNM stages and resect-
43
ability groups predicted by a EUS-LUS combination.
e
poor prognosis for the patients with irresectable or disseminated disease was accurately predicted by EUS and LUS.
e yield of LS appears to be determined at least in part
by the site of disease, histologic cell type, and noninvasive
stage. In an earlier review of 369 patients with carcinoma
of the distal esophagus or gastric antrum, Dagnini and colleagues demonstrated occult disease in 33% at laparoscopy
in patients with adenocarcinoma of either the distal esopha-
44
gus or gastric cardia.
However, LS had a minimal impact
for patients with squamous cell cancers in the upper third
of the esophagus, changing management in only 3.5% of
cases. Stein and colleagues reported similar results. At laparoscopy following radiologic staging, they found that 25% of
patients with locally advanced (T3/T4) adenocarcinoma
of the distal esophagus or gastric cardia had peritoneal or liver
45
metastases.
us, for patients with squamous cell carcinoma
of the esophagus, we believe that LS is not indicated in the
absence of suspicious intra-abdominal imaging ndings.
GASTRIC CANCER
e overall incidence of gastric cancers is declining; however,
there has been a relative increase in the incidence of tumors
of the esophagogastric junction (OGJ) and gastric cardia.
e peak incidence is in the seventh decade, and the disease
is approximately twice as common in men as in women.
46
Despite its apparent falling prevalence in the Western world,
gastric cancer remains a signicant public health problem
and one of the leading causes of cancer death worldwide. e
prognosis remains poor, with a current overall 5-year survival
47
of 20%
and 50–90% of patients dying of the disease within
2 years of diagnosis, even in those who have undergone a
48–50
potentially “curative” resection.
e poor outcome may
be related in part to late presentation and inadequate staging
and subsequent poor patient selection for surgery. Historically, following diagnosis and if medically t, patients were
subjected to open exploration for either resection or palliation. In a signicant series of 916 patients in the mid-1990s,
51
Pye and colleagues
reported that 23% of the operations
were exploratory alone in nature. However, with the recent
development of multidisciplinary approaches to the disease,
improved staging, and the establishment of less invasive
palliative algorithms, the need for operative intervention has
been questioned.
52–54
Accurate staging is essential for patient selection. A sophis-
ticated and complex diagnostic armamentarium exists. While
primary diagnostic tools, with multislice contrast-enhanced
CT scanning, EUS, MRI, and CT/PET scanning being used
increasingly for preoperative staging, laparoscopy and LUS
continue to have an important role in the staging algorithm
for selected patients with gastric cancer (Fig. 5-8).
While the literature would suggest that despite currently
available imaging modalities, LS will continue to detect smallvolume metastatic disease in 20–30% of cases, the identication of occult nodal disease remains problematic. EUS
appears somewhat better than CT in this regard. Wakelin and
colleagues have reported an overall accuracy of EUS in nodal
staging for proximal or orogastric junction tumors of 72%.
If tumors that are nontraversable by endoscope are excluded,
its accuracy increases by approximately 10%. Reported accuracy rates for laparoscopy and LUS vary from 60% to 90%.
With LUS, direct biopsy of suspicious nodes can be obtained,
which improves the utility of the modality. In distal gastric
cancer, Finch and colleagues demonstrated an accuracy of
56
82% in T staging with the use of LUS.
is compares favorably with other studies looking at the use of EUS (83%) or
CT scanning (66%) for T staging distal tumors.
57
the authors noted an accuracy rate of 89% for LUS in assessing lymph node status. In contrast, Wakelin noted that 38%
of nodes were understaged. It would appear, therefore, that
as with other ultrasound data, results are operator-dependent
and reect willingness or not to aggressively biopsy suspicious
nodes.
While level I evidence does not exist for the use of LS in
gastric cancer, a number of large single-institution studies have
been carried out that allow us to make a number of conclusions regarding its role in the staging algorithm. As in esophageal cancer, laparoscopy will detect radiologically occult
metastatic disease in a signicant number of patients (Fig.
5-9). Muntean et al reported overall staging laparoscopy sensitivity for distant metastases of 89%, specicity 100%, and
diagnostic accuracy 95.5%. e sensitivity for lymph node
55
In addition,
Chapter 5 Laparoscopic Staging and Approaches to Cancer 81
Endoscopy and MDR-CT EUS
Bleeding of obstruction
Surgical resection or
palliative radiation (for bleeding) or
palliative bypass/stenting (for obstruction)
FIGURE 5-8 Treatment algorithm for gastric cancer.
Early disease
Laparoscopic
or open
resection
metastases was 54.5%, with a specicity 100% and a diagnostic accuracy 64.3%. e positive predictive value for resectability was 96% and the negative predictive value was 50%.
58
Sotiropoulos et al reported that staging laparoscopy resulted
in up staging 51.1% of patients, most commonly in the form
59
of peritoneal seeding.
As a consequence, the therapy
planning was changed and laparotomy was avoided in 14
of these patients as the rst operative procedure. Sensitivity
of clinical staging was especially poor for stage IV tumors
FIGURE 5-9 Peritoneal metastasis in gastric cancer.
T1/T2
N0
Advanced disease
T3/T4
N1/2
Neoadjuvant
chemotherapy
Surgical resection
Adjuvant
chemoradiotherapy
Metastatic disease
M1
Chemotherapy
(5.3%) and for the majority of stage IIIB tumors (42.9%) in
this particular study.
It has been suggested that, with more advanced radiological imaging, the value of staging laparoscopy will somehow
diminish; however, the literature has not borne this out. Kim
et al retrospectively measured the diagnostic performance of
prospective computed tomographic (CT) results obtained by
using 16- or 64-detector row scanners in the detection of
peritoneal metastases (PMs) in patients with advanced gas-
60
tric cancer.
In 498 patients with T2 disease and above in a
retrospective comparison of CT images with operative and
pathological ndings, a sensitivity and a specicity of 28.3%
and 98.9%, respectively, were reported in scans demonstrating denite peritoneal deposits and 50.9% and 96.2%
respectively in scans reported as equivocal. e authors concluded that even with modern CT techniques, the sensitivity for PM detection is limited. Similarly when evaluating
preoperative local staging with 3D multidetector row CT,
Chen et al reported that reconstructions yield signicantly
better overall accuracy than transverse images for tumor
61
staging but not for lymph node staging.
is highlights
the need for a multimodality staging process, including
EUS, LS, and LUS.
As mentioned earlier, we routinely take peritoneal washings
for cytologic examination at the time of LS. Positive cytology
obtained during peritoneal lavage at staging laparoscopy is
information potentially available preoperatively that identies
a patient population at very high risk for early recurrence and
death after curative resection of gastric cancer. Mehzir and colleagues recently reviewed a prospectively maintained database
of 1241 patients with gastric cancer who underwent laparos-
62
copy with peritoneal washings.
Two hundred and ninety-one
(23%) patients had positive cytology. A total of 48 of the 291
cytology-positive patients had repeat staging laparoscopy after
chemotherapy. Compared with patients who had persistently
positive cytology (n = 21), those who converted to negative