Page 18 - Journal of Laparoscopic Surgery

Meenakshi E Yeola et al.
presence of otherwise undetectable peritoneal meta- by preoperative assessment of thoracic and abdominal
stasis. lymph nodes. 19
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• Diagnosis of locally advanced disease (fixed tumor Krasna et al. reported on similar diagnostic accuracy
or vascular invasion) where no evident distant meta- for thoracoscopic and laparoscopic staging procedures
stasis is found. (93% and 94%, respectively). Celiac lymph nodes were
• Development of tailor-suited palliative treatment in missed by standard non-invasive techniques in six of 20
patients with advanced or metastatic disease catering patients, who underwent laparoscopy and thoracoscopy.
to the requirements. Watt et al. comparatively evaluated the accuracies of
21
• For assessment of treatment response or disease pro- laparoscopy, sonography and computerized tomography
gression before a definitive laparotomy. in detection of intra-abdominal metastases in patients
A detailed discussion of the utility of staging laparo- diagnosed with oesophageal cancer and adenocarcinoma
scopy for individual cancer types is beyond the scope of of the cardia. Laparoscopy had a noteworthy higher
this article; however, a brief overview is provided below. significance and accuracy (sensitivity 88%; specificity
100%; accuracy 96%) than sonography or CT, with regard
Esophageal Cancer to hepatic status. Peritoneal masses were not detected by
Presentation of Esophageal cancer is often accompanied sonography or CT, while those were correctly identified
by locally advanced tumors, as well as lymph nodes and by laparoscopy in eight of nine patients before surgery
distant metastases, which is a predictor of a poor prog- with no false-positives and one false-negative result,
nosis. Studies suggest that preoperative chemotherapy giving a sensitivity of 89%, specificity of 100%, and
and radiation followed by surgical resection has been accuracy of 98%.
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shown to improve survival, however, as with other gastro- An additional study by Dagnini et al. supports
intestinal malignancies, preoperative imaging may point laparoscopy as an effective procedure in the staging of
towards a resectable tumor even though a significant esophageal cancer before the therapeutic intervention,
percentage of esophageal cancers (20–65%) are found with false-negative findings estimated at 4.4%.
unresectable at the time of exploratory laparotomy.
There is a significant value of diagnostic laparoscopy Gastric Cancer
in staging oesophageal cancer because of its utility in the
identification of patients who may or may not be likely to Neoadjuvant chemotherapy preceding definitive surgical
benefit from preoperative chemotherapy, therefore avoid- resection has improved survival among gastric cancer
23
ing unnecessary laparotomy or thoracotomy which may patients with tumors (T3-T4N1), as reported by studies.
have eventually yielded negative findings. In those trials, the benefit of survival was derived by
Placement of feeding tubes can be performed at the gastric cancer patients with locally advanced tumors or
same time as the staging laparoscopy, to improve the lymph node metastases; however, the 5-year survival
nutritional status of these patients and to prevent the rate is poor in the presence of unresectable disease or
need for additional, technically difficult procedures like disseminated metastases (<20%). Hence, it is vital to
percutaneous endoscopic gastrostomy (PEG). 4,14 identify patients of gastric cancer who may benefit from
Staging laparoscopy has shown an accuracy of neoadjuvant chemotherapy and those with advanced
75–80% in identification of peritoneal metastasis with or metastatic tumors who are not likely to benefit from
sensitivity and specificity of 64% and 70% compared to therapeutic laparotomy. 24
ultrasonography (40–50%) and computerized tomogra- Several investigators reported that diagnostic lapa-
phy (45–60%). Addition of LUS and video thoracoscopy roscopy has an accuracy of 89 to 100% for staging, aids
has shown to improve the utility of diagnostic laparos- in the identification of occult metastasis or unresectable
copy in oesophageal cancer. 16 disease, and helps to avoid nontherapeutic laparotomy in
Lymph node staging is an important independent 13 to 57% of gastric patients despite a negative preopera-
indicator of prognosis in patients with oesophageal tive imaging workup. 25,26
cancer. Metastasis to thoracic lymph nodes is unvaryingly There has been reported uniquely high sensitivity (90
involved because of lymph node spread, despite the level to 96%) of diagnostic laparoscopy for identifying metas-
17
of the primary tumor. tasis to liver, peritoneum, and lymph nodes as compared
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Hagen et al. showed improved survival for patients with either ultrasonography (23–37%) or CT (28–52%).
undergoing complete lymphadenectomy associated with Diagnostic laparoscopy with the US further improves
oesophagectomy for distal third and gastroesophageal identification of liver metastasis and peritoneal lavage
junction tumors. Appropriate therapy can be determined cytology enhanced identification of occult peritoneal
by actual tumor node metastases (TNM) status, defined metastasis by 10–15% in pancreatic cancer. 26
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