Page 19 - Journal of Laparoscopic Surgery

WJOLS

Diagnostic Laparoscopy as an Effective Tool in Evaluation of Intra-abdominal Malignancies
Therefore, laparoscopy can now play a pivotal role in Diagnostic laparoscopy has a median sensitivity
the management of gastric cancer by accurately defining (range), specificity, and accuracy of (93–100%), 88%
those patients who are suitable for immediate gastric (80–100%), and 89% (87–98%) respectively in the iden-
resection and lymphadenectomy or patients with the tification of unresectable, imaging-occult pancreatic
advanced local disease who may benefit from preopera- adenocarcinoma. Total 5–7% of patients assumed to
tive neoadjuvant chemotherapy. Gastric serosal infiltra- have resectable tumors on diagnostic laparoscopy are
tion, metastases in lymph nodes, adherence to adjacent found to have unresectable tumors on open exploration,
structures, peritoneal carcinomatosis, ascites and the which may be ascribed to the occult vascular invasion,
presence of liver metastases are the inherent character- fixed tumors or presence of lymph node metastasis.
istics to evaluate in the staging of gastric cancer. Laparotomy with negative findings can avoid 4 to 36%
The distinction between local and disseminated patients, but not all cases. 33
disease is essential, and knowledge of these parameters On combining with LUS, the diagnostic accuracy of
dictates the most appropriate intervention. 27 diagnostic laparoscopy increases by 12–14%; albeit few
28
Possik et al. reported from a cohort of 360 patients surgeons and centers have the equipment and the skills
that laparoscopic examination assessed tumor fixity in necessary for the interpretation of LUS images. Identifica-
255 patients and had a sensitivity of 87% for the detec- tion of occult metastasis can be further improved with
tion of hepatic metastases and 83% for peritoneal dis- peritoneal lavage cytology in 7–15% of patients, but it is
semination. hindered due to the time constraints and unavailability
Kriplani and Kapur et al. 29 found a comparable of expert cytopathologists. 34
35
laparoscopic staging accuracy of 92%, with laparoscopy John et al. in their prospective trial of 40 patients,
predicting resectability in 87% of patients studied. Several demonstrated that Staging laparoscopy is essential in
investigators have identified the usefulness of staging the detection of occult intra-abdominal metastases and
Laparoscopy as a necessary adjunct to radiography and that LUS improves the accuracy of laparoscopic staging
sonography. The results suggest that laparoscopic staging with potentially resectable pancreatic and periampul-
may obviate exploratory surgery in a significant group lary cancer.
of patients. 30 Jiminez et al. found that laparoscopy diagnosed
36
31
Burke et al. published their study of 111 gastric unsuspected metastases in 31.2% of patients with pan-
cancer patients who were judged to be free of metastatic creas cancer, thus avoiding nontherapeutic Laparotomy.
37
disease by pre-operative CT underwent laparoscopy, Reddy et al. suggested that unresectable disease can be
which diagnosed metastatic disease in 32 patients with detected by staging laparoscopy in 20–48% of patients felt
an overall accuracy of 94%. to be resectable by CT scan.
32
Ribeiro et al. demonstrated a utility of peritoneal Conlon et al. have reported an accuracy rate of 98%
39
lavage with laparoscopy while staging gastric cancer in for staging laparoscopy in pancreatic cancer. In a series of
patients since the data is easily available and enhances the 115 patients, they delineated good results in detection of
accuracy of laparoscopy. They also showed that peritoneal extrapancreatic tumor extension where only six patients
cytology is useful in the identification of patients at high (9%) were deemed unresectable on laparotomy out of 67
risk for peritoneal recurrence since it is of great value patients with resectable disease on laparoscopy.
in detecting the microscopic intra-abdominal spread of The need for a prophylactic bypass is an additional
gastric cancer. consideration regarding staging laparoscopy for pancre-
atic cancer. On examination of a prospective cohort of 155
Pancreatic Adenocarcinoma patients with unresectable pancreatic adenocarcinomas
Fifteen to forty percent patients with pancreatic cancer who did not undergo enteric or biliary bypass at the time
39
where tumors are reckoned resectable are found to of laparoscopic staging, Espat et al. identified only three
have unresectable tumors because of extension of local patients who required surgical bypass. Endoscopically
tumor or presence of metastasis, despite advances in placed stents achieved biliary decompression in these
pre-operative imaging [including CT, endoscopic ultra- patients. They proposed advocating surgical biliary
sonography (EUS), MRI, positron emission technology bypass just for patients with obstructive jaundice who
(PET)]. Findings associated with metastatic cancer at fail endoscopic stent placement and open gastroenter-
the time of staging laparoscopy are large size of the ostomy in patients who have a confirmed gastric outlet
tumor, adenocarcinoma of the pancreas as opposed to obstruction.
periampullary cancer or duodenal cancer, body and tail Laparoscopy has a significant contribution to the
location, and preoperative serum levels of CA 19-9 higher proper management of patients with pancreatic cancer,
33
than 150 U/Ml. by abolishing nontherapeutic laparotomy and redirection
World Journal of Laparoscopic Surgery, May-August 2018;11(2):68-75 71