Laparoscopic assessment of the jaundiced patient: a review of 53 patients

[Evaluation of pancreatic cancer by combined laparoscopy and echolaparoscopy]

STUDY AIM

This prospective study was undertaken to evaluate the efficiency of staging laparoscopy associated with laparoscopic ultrasonography in the assessment of tumoural extension and surgical resectability in patients with carcinoma of the pancreatic head.

PATIENTS AND METHODS

From June 1995 to March 1997, 26 consecutive patients (11 male and 15 female patients), with a mean age of 62.5 years, were included in this study. The lesion was located in the pancreatic head with jaundice. Four staging methods were used: percutaneous ultrasonography (n = 26) computed tomography (n = 26), endoscopic ultrasonography (n = 26). The assessment of resectability by each procedure was verified by surgical exploration and histologic examination.

RESULTS

Results of percutaneous ultrasonography and computed tomography were similar, predicting unresectability in 50% of the patients. Endoscopic ultrasonography performed in the 16 patients without visible metastases according to the previous procedures predicted surgical resectability in seven patients only. With staging laparoscopy associated with laparoscopic ultrasonography, undiscovered metastases were found and unresectability was predicted in 21 patients out of 26; the sensitivity was 100% for liver metastases, peritoneal metastases and vascular involvement, 90% for lymph node involvement and 88% for diagnosis of the primitive lesion. A Whipple procedure was performed in five patients and a palliative bypass in all the other patients except one. An unnecessary laparotomy was avoided in 12 patients.

CONCLUSIONS

Staging laparoscopy associated with laparoscopic ultrasonography is superior to all other staging methods. It should be the first step of a potentially curative surgical treatment (five cases only in this series) or of a palliative bypass. Laparotomy was avoided in 12 cases.

Port-site metastases in patients undergoing laparoscopy for gastrointestinal malignancy

Laparoscopic colonic resection and laparoscopy for the assessment of malignant disease have been advocated. Metastatic deposits at port sites are recognized but the incidence of these is poorly defined. Forty-six patients, of median age 65 (range 19-90) years, with gastrointestinal malignancy underwent laparoscopy. Eighteen patients died a median of 4 (range 1-28) months after laparoscopy, four following colonic resection and 14 with gastro-oesophageal malignancy; ten had undergone resection. Median follow-up of the 28 survivors is 8 (range 2-39) months. Five of the 46 patients developed port-site recurrence giving an early incidence of port-site recurrence in this cohort of patients of 11 per cent. Five of 20 patients with tumour involving serosal surfaces developed port-site recurrence compared with none of 26 without serosal involvement (P = 0.022, Fisher's exact test). Port-site recurrence may be related to serosal involvement with tumour.

Laparoscopy in the management of patients with cancer of the gastric cardia and oesophagus

The role of laparoscopy in determining suitability for resection was prospectively evaluated in 244 patients with cancer of the gastric cardia and oesophagus. Laparoscopy enabled detection of inoperable disease in 92 patients (38 per cent), several of whom had more than one contraindication to surgery. Hepatic metastases (n = 75, 31 per cent), extensive peritoneal (n = 25, 10 per cent) or lymph node involvement (n = 5, 2 per cent) and direct invasion of the liver or colon (n = 5, 2 per cent) were considered contraindications to surgery. Laparoscopy was poorly tolerated in a further 11 (5 per cent) patients, who were not considered suitable for resection. Extra-abdominal metastatic disease was detected in 17 patients who appeared normal at laparoscopy, and a further six patients refused surgery. The remaining 118 patients underwent laparotomy with a view to resection which was successful in 85 (72 per cent). Laparoscopy thus prevented ill-advised laparotomy in 103 patients (42 per cent), either because of extensive intra-abdominal disease or poor tolerance to anaesthesia. Laparoscopy may be a valuable investigation when used to assess the feasibility of resection.

Diagnostic yield and management benefit of laparoscopy: a prospective audit

A prospective audit of the diagnostic yield and management benefit of laparoscopy was undertaken in 220 consecutive patients. The procedure was performed electively in 180 patients and as an emergency in 40. The indications for laparoscopy in the elective group were suspected hepatic disease, staging of intra-abdominal malignancy, diagnostic problems, and chronic abdominal pain. Emergency laparoscopy was performed in patients admitted with acute abdominal pain. Diagnostic benefit varied with the indication for the procedure: liver disease 71%, tumour staging 87%, uncertain diagnosis 74%, acute abdominal pain 100%, and chronic abdominal pain 41%. Clinical management was significantly influenced by laparoscopy in 15 of 21 (71%) patients with liver disease, 10 of 30 (33%) with intra-abdominal malignancy, 5 of 19 (26%) with uncertain diagnosis, 32 of 40 (80%) with acute abdominal pain, and 15 of 110 (23%) patients with chronic abdominal pain. A wrong assessment of the nature or stage of the disease was made by laparoscopy in 3 of 220 (1.0%). There was no morbidity or mortality attributed to laparoscopy in the study.

Laparoscopy in the management of pancreatic cancer: endoscopic cholecystojejunostomy for advanced disease

Following a period of animal experimentation in pigs, a laparoscopic technique for sutured gastrointestinal and bilioenteric anastomoses was developed and its safety and efficacy tested in chronic experiments. The method involves the construction of a preformed external jamming loop knot and continuous suturing using a specially developed Endoski needle. The technique was used to construct a cholecystojejunostomy in five patients with advanced cancer of the pancreas (four hand-sutured and one stapled/sutured). Four of the patients recovered from the procedure with no complications, minimal postoperative discomfort and complete relief of their jaundice. In one patient relief of jaundice was slow due to blockage of the anastomosis by debris and blood clot; this resolved following removal of the inspissated material. This minimally invasive procedure has the potential for complete palliation with short hospital stay and avoids the hazards of endoscopic stenting such as encrustation and cholangitis.

Laparoscopy, ultrasound and computed tomography in cancer of the oesophagus and gastric cardia: a prospective comparison for detecting intra-abdominal metastases

We have evaluated the sensitivity, specificity and accuracy of laparoscopy under general anaesthesia, ultrasound and computed tomography (CT) in detecting intra-abdominal metastases in 90 consecutive patients with carcinoma of the oesophagus or cardia. Metastases were histologically confirmed as hepatic in 25 patients, nodal in 35 and peritoneal in nine. All investigations had high specificity (86-100 per cent) for each type of metastasis. Laparoscopy was found to be significantly more sensitive (P less than 0.01; P less than 0.02) and more accurate (P less than 0.01; P less than 0.01) than either ultrasound or CT, respectively, with regard to hepatic status. Although laparoscopy performed best with regard to nodal metastases, this reached statistical significance only when sensitivity of ultrasound was compared (P less than 0.01). Neither ultrasound nor CT detected any peritoneal metastases, although laparoscopy detected eight out of nine, giving a sensitivity of 89 per cent and an accuracy of 98 per cent. There was no morbidity or mortality associated with laparoscopy, which offers a safe, reliable method of determining intra-abdominal status and may obviate the need for surgery in some patients with malignant dysphagia.

Laparoscopy or scanning in oesophageal and gastric carcinoma?

A prospective study was undertaken of the accuracy in diagnosing intra-abdominal metastatic disease of the liver by scintigraphy, ultrasound scanning and laparoscopy. The effect of laparoscopy on management was also studied. Fifty patients were studied: 23 oesophageal carcinoma, 14 gastric carcinoma and 13 with suspected intra-abdominal metastatic spread. Accuracy was determined by laparoscopic biopsy, laparotomy and autopsy. The accuracy was 72 per cent for scintigraphy, 75 per cent for ultrasound and 96 per cent for laparoscopy (with 10 per cent failed ultrasound due to intra-abdominal gas). There was no morbidity or mortality associated with laparoscopy, with one failure due to adhesions. Thirteen patients without hepatic metastases had nodal and/or peritoneal spread diagnosed only by laparoscopy. Laparotomy was avoided in 58 per cent, and 74 per cent died in the 18 month follow-up period. Laparoscopy can obviate the need for laparotomy in inoperable cases of oesophageal carcinoma and allow better planning for potentially curable surgery. In gastric carcinoma the value of laparoscopy is doubtful as a high percentage require at least palliative surgery.

Laparoscopy in general surgery

The results of diagnostic laparoscopy under general anaesthetic in 81 general surgical patients have been reviewed. A tissue diagnosis was achieved in 25 of 42 patients (60 per cent) suspected to have widespread intra-abdominal malignancy with minimal preoperative investigation. Extensive investigation, excluding only computerized tomography, failed to achieve a diagnosis in 25 patients with an intra-abdominal mass. Subsequent laparoscopy allowed diagnosis of 22 of these patients (92 per cent). Severe persistent and unexplained abdominal pain in 14 patients was diagnosed at laparoscopy in only one patient (7 per cent) and the procedure did not influence the subsequent course of events in the remainder. There was no mortality and the morbidity (4.9 per cent) compares well with that of laparotomy in similar patients. Laparoscopy failed in 5 patients (6.2 per cent) due to the presence of dense intraperitoneal adhesions.

Radiographic contribution to diagnosis and treatment of complications from peritoneoscopy

Peritoneoscopy is a valuable nonsurgical procedure for evaluating patients with malignant disease. Directed biopsies of suspected tumor masses may be obtained, and peritoneoscopy can frequently obviate the need for laparotomy. Although the complication rate is low, the radiologist must be aware of potential problems. Radiologists may participate not only in the diagnosis and localization of these complications but also in their therapy by interventional techniques. The radiographic findings in four patients with complications of peritoneoscopy are presented.

The value of laparoscopy under local anaesthesia in 250 medical and surgical patients

This study reports our experience of laparoscopy under local anaesthesia in 250 patients; the procedure was safe, quick and easy to perform with minimal inconvenience to the patient. We advocate the early use of laparoscopy in patients with ascites and when there is difficulty in the diagnosis of patients with jaundice and hepatomegaly, an accurate histological diagnosis being obtained in the majority. In patients with intra-abdominal malignancy, in whom surgery is planned, laparoscopy can detect disseminated disease and so avoid an unnecessary laparotomy. Laparoscopy may also provide a diagnosis in patients presenting with a variety of vague symptoms such as abdominal pain, weight loss, lethargy etc. We have found laparoscopy an excellent investigation if positive but, as if only allows the surface inspection of viscera, when negative, we recommend caution in its interpretation.