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82 Part I Introduction
cytology (n = 27) had a signicant improvement in diseasespecic survival (2.5 years vs 1.4 years, p = 0.0003). In an earlier
publication by the same group on a lesser number of patients
in this database, multivariate analysis identied preoperative
T stage, preoperative N stage, site, and cytology as signicant
predictors of outcome. Positive cytology was the preoperative
factor most predictive of death from gastric cancer (RR 2.7,
63
p < 0.001).
reported similar results in their cohort of 64 patients.
Although evaluated at laparotomy, La Torre et al
64
Eightysix percent of patients with positive peritoneal lavage cytology
had a pT3/pT4 tumor and 100% of those positive had an
N-positive tumor (p < 0.001). e median survival of patients
presenting with positive cytology was signicantly lower than
that of patients with negative peritoneal cytology (19 and 38
months respectively, p = 0.0001). Multivariate analysis of this
group of patients also identied cytology as a signicant predictor of outcome (p = 0.018). Looking at the value of staging
laparoscopy in advanced gastric cancer, Shimitzu et al stratied
34 patients into groups according to the presence of peritoneal
65
deposits and/or positive peritoneal lavage cytology.
ose
who were positive for both did not receive any operative intervention and were shown to do signicantly worse over all, thus
validating the argument for LS.
Taking the concept of intraperitoneal disease and its consequences even further, novel methods are being evaluated
to increase the sensitivity of peritoneal lavage cytology.
Wong et al have recently described a novel and very interesting method of detecting free peritoneal cancer cells in gastric
cancer using cancer-specic Newcastle disease virus (NDV).
66
e green uorescent protein of NDV appears to specically
infect and detect peritoneal gastric cancer cells and oers a
more sensitive method compared with conventional cytology.
Results were particularly impressive in advanced disease. Of
patients with M1 disease discovered during laparoscopy, only
50% were cytology positive. All, however, were NDV-GFP
positive. Cytology was positive in 9% of patients with T3
disease, 8% with N1 disease, and 50% with N2 disease. In
contrast, NDV-GFP was positive in 95% of T3 patients and
100% of patients with N1 or N2 disease. is novel modality may oer enhanced detection of intraperitoneal cancer
spread and provide important prognostic information. e
same group has also looked at reverse transcriptase polymer
chain reaction to detect micrometastases in peritoneal wash-
67
ings with promising results
and this reects a growing area
of research in gastric cancer staging today.
In this chapter, we have concentrated on the role of LS in
determining unresectability. However, the advent of minimally invasive techniques applied to early gastric cancer has
raised the possibility that LS may have an increasing role in
treating that spectrum of the disease. It has been argued that
gastric cancer is one of the most suitable targets for minimally invasive surgery (MIS) based on sentinel node status.
Staging laparoscopy combined with sentinel node mapping
may become a very important adjunct to laparoscopic local
resection for curative treatment of sentinel-node-negative
68
early gastric cancer.
More work is required before the true
utility of this approach is understood.
LIVER AND GALLBLADDER CANCER
At present, surgical resection remains the most eective
therapy for primary and metastatic disease of the liver. While
there are no denitive criteria that dene what constitutes
resectable disease in part owing to diering therapeutic
philosophies and surgical experience, most surgeons would
consider extrahepatic disease, extensive bilobar disease, or the
presence of extensive cirrhosis as the major factors that would
preclude a potentially curative resection.
As with the other gastrointestinal malignancies, imaging
modalities such as multidetector CT scanning, MRI, and CT/
PET scanning are available for preoperative staging. Despite
the use of these modalities, a signicant number of patients
continue to have exploration without resection.
aroscopy, therefore, can serve to improve curative resection
rates and decrease unnecessary laparotomy with its associated
morbidity and quality-of-life issues.
Laparoscopic staging detects subradiologic disease in
72,73
10–60% of cases.
As with other anatomical sites, variability in part relates to the completeness and quality of preoperative imaging. Jarnagin and colleagues from Memorial
Sloan-Kettering Cancer Center (MSKCC) reviewed their
experience with 186 patients who had either primary or secondary hepatic malignancies who underwent surgery at their
70
institution.
Laparoscopy was attempted in 104 patients and
completed successfully in 85%. Overall, 26 (25%) of these
patients were noted to have unresectable disease at the time
of LS, and although nine patients had subsequent laparotomy
for palliation, 17 patients were spared a laparotomy. More
extensive hepatic disease, peritoneal disease, and extensive
cirrhosis were the main laparoscopic ndings that precluded
resection. Diculties were encountered determining the true
extent of tumor vascular invasion or extensive biliary involvement. In addition, ndings at laparoscopy had an impact on
the type of resection performed in a further 10%. e authors
also compared the patients undergoing LS with a similar
nonrandomized cohort of 82 patients who did not receive LS
but went directly to operation during the same time period.
At open laparotomy, 28 (34%) of this group were noted to
have unresectable disease. Although nine patients had a palliative procedure, 19 patients had only an exploratory procedure, which the authors suggested potentially could have
been avoided with laparoscopy. Comparing the two groups,
LS was associated with increased resectability rates (83% vs
63%), shorter hospital stay (8.6 vs 11.9 days), and reduced
hospital charges. A subsequent study from the same institution analyzed experience with 401 patients.
did not preclude staging because a complete laparoscopic
examination was performed in 291 (73%) cases. Despite a
false-negative rate of 22%, LS improved the overall resectability rate from 62% to 78%.
In an attempt to dene the patients who would benet from
LS, the same group created a clinical risk score (CRS) based on
ve factors related to the primary tumor and the hepatic dis-
75,76
(Table 5-2). Each criterion was assigned one point. us,
ease
42% of patients with a CRS score of greater than 2 had unre-
48–50,69–71
74
Prior surgery
Lap-
Chapter 5 Laparoscopic Staging and Approaches to Cancer 83
TABLE 5-2: CLINICAL RISK SCORE FOR THE
DETERMINATION OF RESPECTABILITY IN
HEPATIC COLORECTAL DISEASE
Lymph node–positive tumor
Disease-free interval between primary colonic surgery and detection
of metastatic disease <12 months
Number of hepatic tumors greater than one (based on
pre-operative staging)
CEA greater than 200ng/mL within one month of surgery
Size of the largest hepatic tumor greater than 5 cm
sectable disease detected at laparoscopy versus 0% of patients
with CRS scores of 0–1. erefore, targeting laparoscopy to
high-risk patients should avoid unnecessary LS in low-risk
patients, whereas performing it in the high-risk group should
prevent needless staging laparotomies and overall improve the
yield from laparoscopy. is scoring scheme has recently been
validated by a number of groups. Mann and coworkers noted
that an increasing CRS correlated with the likelihood of detecting incurable disease. Management was altered in 0%, 14%,
and 53% of cases if the CRS was 0–1, 2–3, or 4–5, respec-
77
Shah and colleagues reported that in patients with a
tively.
CRS ≤2 laparoscopy and LUS prevented an operation in only
78
7% compared to 24% in those with a CRS >2.
gests that a focused use of LS is warranted.
Others have argued that improved imaging, particularly
is data sug-
FIGURE 5-10 Isolated metastasis in a patient with gallbladder can-
cer as demonstrated by LUS.
the increased availability of preoperative CT/PET, coupled
with a more aggressive surgical approach have reduced the
potential yield of LS in patients with colorectal metastases to the liver. However, data to support this hypothesis is
lacking and in the main relies on review of the ndings at
open exploration, which were noted to preclude resection
and potentially would have been detected by laparoscopy if
it had been performed.
e history of a prior colectomy does not preclude
accurate LS. Rahusen and colleagues performed laparoscopy
in 50 patients with colorectal metastases, laparoscopy completing the examination in 94% and demonstrating unre-
79
sectable disease in 38%.
80,
by others.
81 Failure to accurately stage patients may occur
Similar results have been reported
due to adhesions from the prior open surgery in up to 20%
80,
of patients.
81
aler and colleagues have suggested that the addition of
intraoperative ultrasonography (IUS) improves the yield of
LS ( Fig. 5-10 ). In a review of 136 patients, LS/IUS changed
the treatment plan in 48% of patients. Surgically untreatable
disease was noted in 25% owing to PMs, nodal involvement,
82
or di use hepatic disease.
added value of LUS to LS.
Others have also noted the
73,
79,
83,
84 Foroutani and colleagues
reported their experience with LUS and biopsy in 310
patients with 1080 primary and metastatic liver lesions.
Using a linear side-viewing transducer, core needle biopsies
were taken using an 18-gauge spring-loaded biopsy gun.
Histologic con rmation was obtained in all patients, with no
bleeding complications or visceral injuries. A recent report
has suggested that the combined use of laparoscopic and
LUS-guided biopsies changed patient management in 27%
of patients with upper gastrointestinal cancers (including
primary and secondary liver tumors). LUS–guided biopsies
were supplementary to laparoscopic biopsies and accounted
for 44% of the clinical impact, suggesting that LUS should
be an integral component of the staging procedure.
ley and colleagues reported that LUS was equivalent to MRI
in determining resectability, particularly for primary hepatic
87
tumors.
However, they and others also have noted that
determining the extent of vascular and biliary involvement
83
was problematic.
For primary hepatocellular disease, experience is similar.
Lo and colleagues performed staging laparoscopy with
LUS in 91 patients with primary hepatocellular carcinoma
(HCC), identifying unresectable disease in 16%, two-thirds
of whom avoided any further surgical intervention and
commenced nonoperative treatment earlier.
71
laparoscopic resection and radiofrequency ablation for HCC
has increased, it has been suggested that the role of LS has
also expanded to not only identify unresectable disease but
85
also aid selection of the optimal therapy. Lai and coworkers
described a cohort of 122 patients with potentially resectable
HCC who underwent LS prior to planned open laparotomy.
Laparoscopic staging was performed in 119 patients, 44 of
86
Hart-
88,
As the use of
89
84 Part I Introduction
whom were noted to have unresectable disease. Overall 25%
of patients had their therapy delivered laparoscopically (22
curative resection, 8 palliative ablation/resection) with a signicant reduction in median hospital stay compared to those
90
who underwent open surgery.
In an interesting publication,
Casaccia et al noted that, while laparoscopic ultrasonography
accurately staged HCC in patients with advanced cirrhosis,
it also allowed for laparoscopic radiofrequency ablation to be
safely performed.
91
e role of LS in the evaluation of noncolorectal nonneu-
roendocrine tumors was studied by D’Angelica and colleagues
92
from MSKCC.
Following preoperative staging, 30 patients
considered to have resectable disease underwent laparoscopy.
Staging was completed in 80% and correctly identied six
patients of the nine nally found to have unresectable disease.
ere has been little work specically directed to determining the utility of LS for gallbladder cancer. Agrawal and
colleagues reported on a cohort of 91 patients with apparent resectable disease who underwent staging laparoscopy.
Laparoscopic ndings of either locally advanced or dissemi-
93
nated disease avoided open exploration in 35 cases.
Similar
results were reported by Goere and coworkers from France
who noted that LS detected unresectable disease in 36% of
patients with potentially resectable biliary cholangiocarcinoma or gallbladder cancers. Peritoneal and liver metastases
were detected but vascular and lymphatic extension was not
diagnosed leading the authors to suggest that laparoscopy
was more useful in extrahepatic cholangiocarcinomas and
gallbladder cancer and should only be considered in selected
cases with hilar cholangiocarcinomas.
94
PANCREAS CANCER
Adenocarcinoma of the pancreas remains a lethal disease.95
Despite increased awareness and improved diagnostic
modalities, most patients continue to present with advanced
disease at the time of diagnosis. Actual 5-year survival is
between 3% and 5%, with surgical resection oering the only
chance of cure. However, resection is only appropriate for a
minority of patients. For the majority, the need for surgical
intervention is controversial. In common with esophagogastric cancers, the notion that all patients require an operative
procedure for accurate staging or palliation no longer is true.
Our increased understanding of the natural history of the
disease, coupled with the improvements in nonoperative palliative techniques, suggests that eective palliation does not
require an open surgical procedure. Proponents of LS argue
that the combination of dynamic contrast-enhanced CT
scanning and/or MRI with laparoscopy remains the most
eective means of staging, preventing needless open surgery
for those who would not benet, while not precluding resection for those who would benet. Avoidance of unnecessary
open procedures potentially will result in reduced perioperative morbidity and mortality, decreased hospital stay, shorter
time to appropriate therapy, improved quality of life, and
overall reduced treatment costs.
Laparoscopic staging for pancreatic cancer is not a new
concept. In fact, the rst published case in the United
States of a minimally invasive approach to cancer staging
was in a patient with pancreatic cancer. Bernheim in 1911
staged a patient of W. S. Halstead with presumed pancreatic
96
cancer prior to laparotomy.
He stated that the procedure
he termed organoscopy “may reveal general metastases or a
secondary nodule in the liver, thus rendering further procedures unnecessary and saving the patient a rather prolonged
convalescence.” e use of laparoscopy was sporadic and not
widespread until the seminal works of Alfred Cuschieri from
Scotland and Andrew Warshaw from the United States.
97–100
Both used the technique before the laparoscopic revolution
and began to dene the role it would have in the staging
algorithm.
e yield of positive laparoscopy that avoids unnecessary
laparotomy is highly dependent on the quality of the preoperative radiologic studies. e yield of laparoscopy cannot be assessed from studies that have not included state-of-
101
the-art CT scans.
Currently, the standard protocol should
include a contrast-enhanced thin-cut dynamic CT scan
of the pancreas. Initial reports from MSKCC concerning
LS of peripancreatic malignancy reported an improvement
in resectability from 50% based on standard CT scanning
alone to 92% when staging laparoscopy was performed.
73,102
Compared with previous reports, improvements in technology and better patient selection have reduced the benet of
laparoscopy. However, laparoscopy continues to consistently
upstage approximately 15–20% of patients with radiologically resectable disease.
73,97,102–107
An early study at MSKCC examined 577 patients who
following contrast-enhanced CT scans were considered to
have potentially resectable disease and underwent staging
108
laparoscopy.
Unresectability was determined at laparos-
copy if histologic proof was obtained of:
1. Metastasis (hepatic, serosal, and/or peritoneal) (Fig. 5-11)
2. Extrapancreatic extension of the tumor (ie, mesocolic
involvement)
FIGURE 5-11 Hepatic metastases in pancreas cancer.
Chapter 5 Laparoscopic Staging and Approaches to Cancer 85
3. Celiac or high portal node involvement
4. Invasion or encasement of the celiac or hepatic artery
5. Involvement by tumor of the superior mesenteric artery
Portal or superior mesenteric venous involvement was
considered a relative contraindication to resection depending
on the degree and extent of involvement.
In the MSKCC series, 366 patients were considered to
have resectable disease after LS and subsequently underwent
open exploration, with 92% (338 patients) being resected.
e predominant sites for metastases were the liver and the
peritoneal cavity. e resectability rate was compared with
results from the decade before the introduction of LS, during which 1135 patients at MSKCC were explored but
only 35% were resected. In a recent update from the same
group examining 1045 patients with radiographically resectable disease who underwent LS between 1995 and 2005, it
was reported that the yield of LS had decreased to 14% for
patients with pancreatic adenocarcinoma. e predominant
reason for unresectability at lapaproscopy was metastatic liver
disease. Only seven patients were noted to have locoregional
disease highlighting the improvements in CT imaging. Of the
patients considered resectable at laparoscopy 99% were sub-
109
sequently resected.
A similar yield was reported by Doran
and colleagues; 239 patients with suspected periampullary cancer underwent staging laparoscopy following dual-phase heli-
110
cal CT scanning.
CT “resectable” disease was noted in 190
patients, of whom laparoscopy correctly identi ed unresectable
disease in 28 patients. Overall, owing to ndings at laparoscopy, 15% of patients were spared a further procedure, leading
the authors to conclude that when added to CT scanning, LS
provides valuable information that improves the selection of
patients for surgical or nonsurgical treatment signi cantly.
Many other authors have reported similar results ( Table 5-3 ).
TABLE 5-3: DETECTION OF INTRA-
ABDOMINAL METASTASES AT
LAPAROSCOPY
Author Year
John 1995 40 14 (35%)
Fernandez-del
Castello 1995 114 27 (24%)
Conlon 1996 108 28 (26%)
Holzman 1997 28 14 (50%)
Jiminez 2000 125 30 (24%)
White 2001 45 8 (18%)
Vollmer 2002 72 16 (22%)
Doran 2004 45 8 (18%)
Karachristos 2005 63 63 (19%)
Ahmed 2006 37 9 (24%)
Ferrone 2006 297 68 (23%)
Number of
patients Yield (%)
Carbohydrate Antigen 19-9
e use of tumor markers such as the carbohydrate antigen 19-9 (CA-19-9) to further select patients for staging
laparoscopy has been proposed. Halloran and colleagues
used a cut o value for CA-19-9 of 150 kU/L improving
resectability levels and reducing nontherapeutic laparoto-
111
Using a receiver operating characteristics (ROC)
mies.
curve for preoperative CA-19-9 values and tumor respectability, Maithel and coworkers demonstrated a statistically
optimal cuto of 130 U/mL. Unresectable disease was identi ed in 38 of 144 patients (26%) with a preoperative level
≥130 U/mL compared to 13 of 118 patients (11%) with a
112
value <130 U/mL.
We believe that this added information does allow for better selection of patients. Figure 5-12
details a recommended clinical algorithm. e use of such
a strategy is supported by the analyses of population-based
administrative databases. Mayo and colleagues reviewed
the experience in Oregon and noted that the majority of
113
patients did not undergo LS.
However, in the subset that
did undergo LS metastatic disease, which precluded resection, was noted in 27.6%. ese patients were spared an
unnecessary laparotomy.
Laparoscopic Ultrasonography
To further increase the added value, we use LUS. LUS has been
used by a number of groups in an attempt to increase the yield
114,
115
of LS.
onstrated unsuspected metastatic disease in 14 of 40 patients
considered to have resectable disease.
had only 50% sensitivity in predicting tumor resectability. e
accuracy in predicting resectability increased to 89% with the
addition of LUS. Several other studies have demonstrated that
the added value of LUS to standard laparoscopy is on the order
of 14–25%.
of routine implementation of laparoscopy with LUS, determining that the addition of LUS improved staging by identifying an additional 22% of patients with unresectable disease.
Minnard and colleagues reported the bene t of LUS over laparoscopy alone in evaluating the primary tumor and the presence of vascular involvement.
change in surgical treatment in 14% of patients in whom standard laparoscopic examination was equivocal. A further study
by Schachter and colleagues demonstrated a change in surgical
intervention in 36% of patients, with avoidance of unnecessary laparotomy in 31%.
that LUS altered therapy in 41% of cases, avoiding open
exploration in 46%.
for assessing positive nodal disease and 100% for hepatic and
peritoneal disease. Vollmer and colleagues similarly reported
an improvement in resection rates using LUS (84% with LS
vs 58% without)
the addition of LUS during LS enhances the ability of laparoscopy to determine resectability and approaches the accuracy
of open exploration without increasing morbidity or mortality
John and colleagues showed that laparoscopy dem-
103
However, laparoscopy
73,
116–119
Callery and colleagues analyzed the e ect
117
LUS ndings resulted in a
120
Catheline and colleagues reported
121
is group reported a 90% sensitivity
122
. Merchant and colleagues concluded that
73
86 Part I Introduction
Clinical suspicion of pancreas cancer
MDR-CT scan, EUS, MRCP CA 19-9,
Resectable
(Neoadjuvant tx)
Head <2 cm
CA 19-9 <150 ku/L
Laparotomy
Resectable
Resection
FIGURE 5-12 Treatment algorithm for pancreas cancer.
Head >2 cm
All body/tail
CA 19-9 >150 ku/L
Laparoscopy Laparoscopy
Unresectable
biological markers
Locally advanced
disease
Combined
modality therapy
Metastastic diseaseLocalized disease
Symptomatic
therapy
chemotherapy best
supportive care
signicantly.
123
As clinical experience has developed it appears
that the main utility remains in assessment of the liver or vascular involvement (Fig. 5-13). In patients with portal/superior
mesenteric vein involvement, determining (i) resectability and/
or if resectable (ii) the amount of venous resection required to
obtain clear margins. is approach is supported by omson
and colleagues using the widely accepted CT classication of
vascular involvement, which examined the relationship between
the tumor and the major vasculature and grades the involve-
124
ment between A and F.
Tumors graded A to D were generally
resectable while those graded E and F were invariably unre-
125
sectable.
e authors suggest that, using these criteria, the
selective use of LUS in LS is indicated. A meta-analysis examining the role of laparoscopy and LUS was performed by Hari-
126
haran and coworkers.
ey identied 29 studies in which
3305 patients underwent LS. e true yield was 25% (95% CI
24–27). e authors suggested that this represents a signicant
benet to patients with potentially resectable adenocarcinoma
of the pancreas in avoiding nontherapeutic laparotomy.
Peritoneal Cytology
Cytologic examination of peritoneal washing obtained at the
time of laparoscopy has also been suggested to enhance the
sensitivity of staging laparoscopy.
with peritoneal cytology is reported to upstage approximately
123,128
10% of patients.
Peritoneal recurrence is a signicant
127
Laparoscopy combined
SpA
CA
Tumor
FIGURE 5-13 LUS examination demonstrating inltration of the
celiac axis (CA) and splenic artery (SpA).
Chapter 5 Laparoscopic Staging and Approaches to Cancer 87
site of failure following a potentially curative pancreaticoduodenectomy. Leach and colleagues studied a consecutive series
of patients with suspected or biopsy-proven radiologically
129
resectable adenocarcinoma of the pancreatic head.
Peritoneal washings were obtained at the time of staging laparoscopy and/or at subsequent laparotomy. Positive peritoneal
cytology (PPC) was noted in 7% of patients, all of whom had
overt metastatic disease at a median of 4.8 months. Merchant
and colleagues examined 228 patients with radiographically
resectable pancreatic adenocarcinoma who underwent LS.
123
Peritoneal washings were taken from both upper quadrants
at the beginning of laparoscopy. Overall survival was signicantly higher in patients with negative peritoneal cytology.
e authors determined that PPC had a positive predictive
value of 94.1%, a specicity of 98.1%, and a sensitivity of
25.6% for determining unresectability. Quantitative real
time-polymerase chain reaction (RT-PCR) assay was used by
Dalal and coworkers to detect tumor cells in a cohort of 35
130
patients undergoing staging laparoscopy.
Positive cytology
was noted in eight cases and appeared to be stage-related.
this methodology could represent a more sensitive method
for the detection of subclinical disease and enable improved
selection for operative therapies and clinical trials. is
intriguing pilot study requires further conrmation.
Despite the above, there is no consensus around the value
of LS. Critics argue that conning laparoscopy to the setting of
determination of resectability overestimates the usefulness of
laparoscopy because it fails to account for patients who require
open procedures for palliation of unresectable disease.
101
Pisters and colleagues from the MD Anderson Cancer
Center reported resectability rates of 80% using high- quality
101
CT scanning alone.
Based on these data, the authors proposed that the maximum positive yield of routine staging
laparoscopy in patients with potentially resectable disease on
high-quality CT scanning would be 20%, assuming a falsenegative result of zero. is group did not perform routine
staging laparoscopy but rather used selective laparoscopy at
the time of planned laparotomy for tumor resection in patients
with localized disease on CT scan and patients at high risk for
131,132
occult M1 disease.
cated by others.
is is a strategy that has been advo-
133
Gouma and colleagues from Amsterdam
assessed the role of LS in patients with periampullary tumors
compared with standard radiologic staging with helical CT
134
scanning.
Laparoscopic staging identied biopsy-proven
unresectable disease in only 13% of 297 patients, with a detection rate of 35%. Based on the ndings, the authors proposed
that LS should be performed selectively. Since their practice
is to recommend a surgical bypass as palliation for patients
with locally advanced unresectable disease, they believe that
LS only adds value in the presence of metastatic disease.
Locally Advanced Disease
Recent reports have focused on the role of LS in patients with
locally advanced unresectable disease who were considered for
adjuvant chemoradiotherapy. Shoup and colleagues reviewed
100 consecutive patients with locally advanced disease who
135
underwent LS.
Contemporary imaging studies failed to
detect metastatic disease in 37% of cases. Peritoneal disease
was noted in 12 cases, liver metastases in 18, and 7 patients
had both. Similar results were reported by Liu and Traverso,
who described their experience with 74 patients, all of whom
had undergone high-quality pancreas protocol CT exami-
136
nation prior to LS.
patients. e authors reported that tumors situated in the
Occult tumor was found in 34% of
body and tail of the gland were more likely than head lesions
to have unsuspected metastases (53% vs 28%). Morak and
coworkers in a prospective cohort study reported that 24 of
68 (35%) patients with locally advanced disease on CT had
137
metastatic disease at laparoscopy.
ese studies emphasize
that despite the improvements in imaging modalities, LS
should be performed in patients considered to have locally
advanced disease prior to the start of combined modality
therapy.
e studies cited earlier focus on invasive ductal adenocarcinoma of the pancreas. For other cell types, including
neuroendocrine tumors, intraductal papillary mucinous
neoplasms, and cystadenocarcinomas, the data are sparse. A
review of the MSKCC experience with laparoscopy in nonfunctioning islet cell tumors by Hochwald and colleagues
found a high incidence of occult metastases at laparoscopy.
CT scan followed by laparoscopy was signicantly more sensitive than CT scan alone in predicting resectability (93%
vs 50%; p = 0.03). is resulted from a high false-negative
rate on CT scan for small-volume metastatic disease, hepatic
disease being the most common site. e predictive value
for tumor resectability also was much higher for CT scan
followed by laparoscopy than for CT scan alone (95% vs
74%). Brooks and colleagues examined the role of LS in
144 patients with ampullary, duodenal, and distal bile duct
139
tumors.
Patients with distal bile duct tumors also appeared
to benet from LS in terms of both determining resectability
and avoiding unnecessary surgery. In contrast, patients with
known duodenal or ampullary tumors gained little added
value from LS.
COMPLICATIONS OF STAGING
LAPAROSCOPY
In experienced hands, the procedure is safe and well tolerated as a day case procedure. Complications are low with
few specic reports in the literature. Of those, only one
identies a series of complications directly attributable
to the LS procedure.
Rodgers et al report a complication rate of 2.8% (3/106
patients), one of which was unrecognized at laparoscopy
and which eventually contributed directly to the patients’
death. In general, major morbidity such as hemorrhage,
visceral perforation, and intra-abdominal infection may
occur in 1–2% of cases.
140
In their series published in 2003,
138
88 Part I Introduction
As the use of laparoscopy in malignant disease increased,
concern was expressed regarding the potential risk of disseminating disease at the time of pneumoperitoneum. An initial
case report in 1978 by Dobronte and colleagues described a
“port site” tumor implant in a patient with malignant ascites
141
2 weeks following laparoscopy.
A number of similar reports
followed, again involving patients who had disseminated disease at the time of their laparoscopic examination. Nieveen
van Dijkum and colleagues from Amsterdam demonstrated
an overall 2% port-site recurrence, with all cases having
advanced peritoneal disease.
142
Clinical experience over the last two decades appears to
support the hypothesis that LS is safe from the oncologic
standpoint. Pearlstone and colleagues from the MD Anderson
Cancer Center described their experience with laparoscopy in
533 patients with nongynecologic intra-abdominal cancer,
339 of whom had laparoscopic procedures for upper gastro-
143
intestinal malignancies.
ey reported port-site recurrences
in four patients (0.88%), three of whom had advanced disease
at the time of initial laparoscopy. Similar results were noted
in a report from MSKCC, which reviewed a prospective database of 1650 diagnostic laparoscopic procedures performed
in 1548 patients with upper gastrointestinal malignancies, in
144
which a total of 4299 trocars were inserted.
e most frequent diagnosis was pancreatic cancer (51.2%). At a median
follow-up of 18 months, a port-site recurrence was noted in
13 patients (0.8%). An open operation was performed in
1040 patients, of whom 9 (0.9%) developed a wound recurrence. is latter gure is similar to the 0.8% incisional recurrence rate noted by Hughes and colleagues in a review of 1600
145
open laparotomies for colon cancer.
Median time for the
development of the port-site recurrence in the MSKCC study
was 8.2 months. Eight occurred in patients with documented
metastatic disease at the time of laparoscopy, and the remaining ve had local or distant disease at the time of diagnosis of
the port-site implant, and therefore, the recurrence did not
appear to be an isolated event but rather a marker for more
advanced disease. e authors concluded that LS appeared
safe from an oncologic standpoint. is is further supported
by a retrospective review of 235 patients who had laparoscopy
to stage pancreatic cancer. is study demonstrated a portsite recurrence rate of 3% versus a 3.9% incisional recurrence
rate in those patients who had an exploratory laparotomy
146
alone.
A number of hypotheses have been suggested to explain
port-site implantation. Tumor seeding has been associated
with carbon dioxide pneumoperitoneum in animal studies;
however, reports that tumor growth is established more easily
after open laparotomy would appear to refute this theory.
147–149
Other mechanisms, such as tissue manipulation, direct wound
contamination, poor surgical technique, or immunologic
eects such as changes in host immune responses, also have
150
been suggested.
It appears so far, however, in most studies
that port-site implantation is uncommon, diers little from
open surgical incision recurrence, and is more likely to reect
the underlying biologic behavior of the disease rather than the
type of surgery.
LAPAROSCOPIC BILIARY
AND GASTRIC BYPASS
Since the majority of patients with pancreatic cancer have
unresectable disease at the time of presentation, palliation to
minimize symptoms and maximize quality of life has a major
role in the care of these patients. Palliation most commonly
is required for one of three problems: biliary obstruction, gastric outlet obstruction (GOO), and relief of pain.
While both cholecystoenteric and choledochoenteric
bypasses have been performed laparoscopically, the latter
is much more dicult technically, requiring a high level
of laparoscopic skills. A sucient length of common duct
needs to be exposed, and a dicult intracorporeal anastomosis between the small bowel and the common duct must be
performed. Cholecystojejunostomy is the more commonly
performed laparoscopic procedure (Fig. 5-14). Patient selection is critical. A low insertion of the cystic duct into the
common bile duct or tumor impingement within 1 cm of the
duct is a predictor of early technical failure. e anastomosis
can be performed with either a stapled or hand-sewn technique. In patients who have experienced a prior cholecystectomy or who have a diseased gallbladder, blocked cystic duct,
low insertion of the cystic duct, or tumor encroachment on
the cystic duct or gallbladder, a cholecystojejunostomy is not
possible; therefore, either a laparoscopic cholodochojejunostomy is performed, or the procedure is converted to open and
a standard surgical bypass is performed.
Rhodes and colleagues presented in 1995 one of the rst
series of patients who underwent laparoscopic palliation for
advanced pancreatic carcinoma. From the 16 patients, 7
underwent laparoscopic cholecystojejunostomy, 5 had laparoscopic gastroenterostomy, 3 had both procedures, and in 1
patient laparoscopic palliation failed. e median operating
time was 75 minutes, the hospital stay was 4 days, the morbidity was 13%, and the median survival in 10 patients was
201 days, with the rest of the patients remaining alive at the
FIGURE 5-14 Laparoscopic cholecystojejunostomy.
Chapter 5 Laparoscopic Staging and Approaches to Cancer 89
time of the publication.
151
In 1999, Rothlin and colleagues
published a case-controlled study of 28 patients with pancreatic cancer divided in two groups; in one group, laparoscopic
palliation was performed, and the other group underwent
152
conventional surgical palliation.
Of the 14 patients in the
laparoscopic group, 7 had laparoscopic gastroenterostomy, 3
had gastoenterostomy and hepaticojejunostomy, and 4 had
staging laparoscopy only.
Postoperative morbidity was 7% for the laparoscopic
group compared with 43% for the open palliation group.
ere were no deaths in the laparoscopic group versus 29%
mortality in the open group. Average postoperative hospital
stay was 9 days for the laparoscopic group versus 21 days
for the open group. Finally, the laparoscopic group required
signicantly less analgesia postoperatively. Choi presented
a series of 78 gastrojejunostomies, 45 open and 33 laparoscopic, performed for palliation of gastric outow obstruction caused by advanced gastric, duodenal, ampullary, and
153
pancreatic cancers.
In the laparoscopic group, there was less
suppression of immune function, lower morbidity, and ear-
by Navarra and colleagues demonstrated that patients undergoing a laparoscopic gastrojejunostomy had signicantly less
intraoperative blood loss and resumed oral intake sooner
than those patients undergoing an open palliative antecolic
gastrojejunostomy.
154
e technique for a transumbilical single-incision laparoscopic gastrojejunostomy has recently been reported.
155
While this is technically feasible, the benets compared
to the conventional laparoscopic approach remain to be
determined.
e true incidence of symptomatic GOO in pancreatic
cancer remains unclear. Historically, it was considered that
more than 25% of patients would develop GOO during
the course of their illness, and therefore, prophylaxic gastric bypass was recommended at the time of exploratory
laparotomy. However, as the need for open exploration for
staging purposes has decreased, the need for prophylaxic
bypass for the majority of patients has been questioned.
GOO is a late complication of advanced pancreatic cancer aecting 10–20% of patients who survive more than
156–158
15 months.
who develop GOO require surgical bypass.
However, fewer than 3% of the patients
156,159,160
Most
important, 60% of patients with advanced pancreatic cancer have delayed gastric emptying with no evidence of gastric or duodenal invasion. is may be explained by tumor
inltration of the celiac plexus causing gastric stasis, nausea,
and vomiting.
161
Espat and colleagues examined in a prospective but non-
156
random study of 155 patients undergoing LS.
Following
laparoscopy, 40 patients had locally advanced unresectable disease, and the remainder had metastatic disease. In follow-up,
only 3% of patients required a subsequent open operation for
biliary drainage or GOO. A subsequent update of this experience has conrmed the results, with over 90% of patients dead
of disease. is low incidence of patients requiring operation
for symptomatic GOO is consistent with the data seen from
the nonoperative control groups in randomized trials of endoscopic biliary drainage versus surgery.
A laparoscopic gastroenterostomy is a relatively straight-
forward procedure. Nagy and colleagues reported a series
162
of laparoscopic gastrojejunostomies.
Nine of 10 patients
in this series had GOO from pancreatic malignancy. e
laparoscopic method was successful in 90%. ere was no
postoperative morbidity or mortality associated with the
surgical technique.
Surgical Technique for Biliary
and Gastric Bypass
e patient is placed supine on the operating table in 10
degrees of reverse Tredelenberg position with 10 degrees of
left lateral tilt. e placement of trocars is similar to that for
a standard staging procedure. However, in order to accommodate a linear stapler, the right upper quadrant 10-mm
trocar is converted into a 12- to 15-mm size. Following
exploration, the ligament of Trietz is identied, and a loop
of jejunum approximately 30 cm distal to the ligament of
Treitz is brought in an antecolic position to the gallbladder (Fig. 5-15). Using an intracorporeal suturing technique,
the jejunum is approximated to the gallbladder by two 3-0
coated, braided lactomer sutures (Polysorb, US Surgical,
Norwalk, CT). e distended gallbladder may be decompressed using a Veress needle attached to a suction device.
ere is usually minimal biliary spillage owing to the raised
intra-abdominal pressure consequent on the pneumoperitoneum. Small enterotomy incisions (10 mm) are made in the
gallbladder and jejunum using either scissors or a device such
as the ultrasonic shears (Fig. 5-16). Hemostasis is achieved
with electrocautery. Any spillage can be dealt with by suction device placed through the left upper quadrant port.
An endoscopic 30-mm linear stapler using 3.5-mm staples
is introduced through the right upper quadrant port, and
the “jaws” are manipulated into the gallbladder and jejunum
in a standard fashion. Often, this is dicult because of the
proximity of the port site to the gallbladder. A reticulating stapler facilitates this maneuver. e stapler heads are
approximated, and the instrument is red (Fig. 5-17). After
removing the stapler, the anastomosis is inspected, hemostasis is conrmed, and the gallbladder interior is aspirated and
irrigated with saline.
e resulting enterotomy can be closed by using either
a completely intracorporeal or laparoscopically assisted
approach. Using an intracorporeal technique, the defect is
closed with a continuous seromuscular 3-0 coated, braided
lactomer suture, with knots tied using an intracorporeal
technique (Fig. 5-18).
An alternative method is to create a completely hand-sewn
anastomosis using 3-0 coated, braided lactomer suture. If a
running suture is used, the assistant should maintain tension
on the suture with an atraumatic grasping forceps following
placement of each stitch. Knots can be tied either using an
intracorporeal or extracorporeal technique.
90 Part I Introduction
Liver
Gallbladder
Grasping
forceps
Small bowel
FIGURE 5-15 Laparoscopic cholecystojejunostomy.
Stomach
Stay suture
Laparoscopic
scissors
Grasping
forceps
Small bowel
FIGURE 5-16 Approximation of small bowel to gallbladder, creation of enterostomy.
Stomach
Chapter 5 Laparoscopic Staging and Approaches to Cancer 91
Stay suture
Laparoscopic
linear stapler
Laparoscopic
suction device
Small bowel
Stomach
FIGURE 5-17 Stapled anastomosis.
Grasping
forceps
Laparoscopic
needle holder
FIGURE 5-18 Closure of enterotomy.