Page 20 - Journal of Laparoscopic Surgery

Meenakshi E Yeola et al.
of treatment plans and therefore, increased efficiency of Colorectal Cancer
resource utilization.
Diagnostic laparoscopy may infrequently benefit patients
with primary colorectal cancer without any evidence of
HEPATOBILIARY MALIGNANCIES
systemic metastasis, essentially because of its low yield
Primary Liver Tumors in the identification of occult or subclinical metastasis
In patients with primary liver tumors, staging laparoscopy but also because of a preference to undergo colectomy
is indicated when pre-operative imaging is suggestive of (laparoscopic or open) with intent for cure or alleviation
resectable disease and an adequate hepatic reserve. Diag- of bleeding, obstruction or perforation.
nostic laparoscopy with LUS permits evaluation of entire Diagnostic laparoscopy with intraoperative ultraso-
hepatic parenchyma and permits identification of the nography can be of paramount utility for the identifica-
size, location, and some liver tumors along with potential tion of the number and location of hepatic metastases and
vascular invasion, even though the incidence of peritoneal to rule out peritoneal or extrahepatic disease in patients
metastasis in uncommon among these patients. of colorectal cancer with isolated liver metastases and
Nontherapeutic laparotomy can be avoided in 25–40% no evidence of extrahepatic disease. A nontherapeutic
of patients by combining diagnostic laparoscopy and LUS laparo tomy can be avoided in 25–45% if a staging lapa-
since it has a sensitivity of 63–67% for the identification roscopy is performed for these indications.
of unresectable disease in patients with liver cancer. For Diagnostic laparoscopy with LUS has a higher sensi-
lesions larger than 2 cm, diagnostic laparoscopy with LUS tivity and specificity of 98–99% to identify occult hepatic
has a sensitivity of 96–100% over triphasic CT which is metastasis and to evaluate the porta hepatic and celiac
35–40% sensitive. Although on diagnostic laparoscopy, lymph nodes with other GI cancers. 13,14
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there can be false negatives in 5 to15% of primary liver In a study by Jarnagin et al., out of 104 patients
tumors. 13,14 underwent MIS staging, 25% of patients with the poten-
tially resectable disease were found to have a disease at
Biliary Tract Tumors laparoscopy which precluded resection. Laparoscopy
predicted an overall resectability in 68% of patients and
In nearly all patients with gallbladder cancer, hilar chol- avoided unnecessary laparotomy in 54%. An increased
angiocarcinoma, or extrahepatic bile duct tumors without rate of resectability and reduced cost of hospitalization
substantiation of unresectability or metastatic disease was observed in the group of patients who underwent
on preoperative imaging, staging laparoscopy may be laparoscopic staging.
indicated. The utility of diagnostic laparoscopy may be Rahusen et al. reported a 38% yield of staging lapa-
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limited to those with T2–T3 cholangiocarcinoma due to roscopy showing unresectability. Later, those results were
the increased availability of EUS, since most patients with confirmed by Thaler et al. that identified a 25% yield of
45
T1 cancers have a resectable disease.
In patients with gallbladder cancer and cholangiocar- SL in identifying radiographically occult disease which
cinoma, diagnostic laparoscopy has a diagnostic accuracy led to the decision of resection or no resection.
of 48–60% and 53–60%, respectively. 13,14 An enhancement LYMPHOMA
in the overall yield and accuracy may be achieved by
combining diagnostic laparoscopy with LUS. 40 Since the last 1960s, staging laparotomy was recom-
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A study by D’angelica et al. of 410 patients with mended for patients with Hodgkin’s disease and some
radiographically resectable hepatobiliary malignancies patients with Non-Hodgkins lymphoma to identify the
was completed in 73% of patients and, in 84 (55%) of patients who were potentially curable with radiotherapy,
the 153 evaluated patients, SL identified the disease that and to precisely plan the fields of radiotherapy. 46
precluded resection. With the introduction of CT scan and CT-directed
42
Hemming et al. studied 168 patients who under- percutaneous biopsy, development of combination
went laparoscopic staging for malignant tumors (chiefly chemotherapy, progressive use of combined modality
hepatobiliary tumors) in the abdomen and reported 1.8% therapy, recognition of morbidity due to laparotomy
overall complication rate and no mortality. Several studies and an emerging role of laparoscopy in new and recur-
suggest that laparotomy can be avoided in a significant rent lymphadenopathy, in staging of patients with
number of patients with hepatobiliary cancer when the histologically confirmed lymphoma and assessment of
disease is non-resectable on diagnostic laparoscopy. the response to treatment, the role of laparotomy has
In-patient stay can be reduced by avoiding laparotomy, been reduced. A particular indication for laparotomy is
which may normally average 5–6 days post-laparotomy where the percutaneous biopsy has yielded inadequate
when compared with 1.5 days after laparoscopy. information.
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