The current role of laparoscopy in staging upper gastrointestinal malignancies

Feasibility of transgastric and transcolonic natural orifice transluminal endoscopic surgery peritoneoscopy combined with intraperitoneal EUS

BACKGROUND

If natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy is to become an alternative to diagnostic laparoscopy, NOTES peritoneoscopy must be comparable to laparoscopy in its diagnostic accuracy.

OBJECTIVE

To assess the feasibility of transgastric (TG) and transcolonic (TC) NOTES peritoneoscopy combined with intraperitoneal EUS.

DESIGN

Twelve nonsurvival experiments on 6 female pigs.

SETTING

Animal laboratory.

PATIENTS

Six 35- to 40-kg female pigs.

INTERVENTIONS

Randomization was performed to determine the order of approach (TG or TC as first procedure). After peritoneal access, systematic peritoneoscopy was performed according to a preassessed list of 12 locations considered clinically important. For each visualized location, 1 point was scored and 1 point added if it was touched as well, leading to a maximum score of 24 points. Subsequently, the endoscope was exchanged for a linear EUS-scope. The percentage of visualization of the 4 sections of the liver was recorded (0, not visible; 1, 33%; 2, 66%; 3, 100%; maximum score, 12 points). After withdrawal, the protocol was repeated by using the second natural orifice (TG or TC).

MAIN OUTCOME MEASUREMENTS

Extent of adequate visualization of diagnostic peritoneoscopy and intraperitoneal EUS measured by a preassessed record form.

RESULTS

Access was achieved without difficulties at all 12 sites. TG peritoneoscopy resulted in a median of 23 points (range 20-24) via the TC approach. A maximum of 24 points was recorded in all pigs (P = .102). TG-EUS resulted in a median of 11 points (range 6-12) and TC-EUS in a median of 12 points (range 8-12) (P = .317).

LIMITATION

Lack of objective landmarks for EUS.

CONCLUSIONS

TG and TC NOTES peritoneoscopy combined with intraperitoneal EUS is technically feasible. Furthermore, NOTES peritoneoscopy and intraperitoneal EUS seem to result in adequate visualization of the peritoneal cavity and liver, respectively.

Outcome of unresected gastric cancer after laparoscopic diagnosis of peritoneal carcinomatosis

BACKGROUND

Most gastric adenocarcinomas in western countries are locally advanced, and these tumours are often associated with metastatic spread at the time of diagnosis. It is controversial whether palliative surgery can improve symptom control in gastric cancer patients with peritoneal carcinomatosis.

OBJECTIVE

To determine the need of palliative procedures and survival in patients affected by gastric cancer with peritoneal carcinomatosis managed without resection. Methods and materials After standard preoperative staging, 160 patients were diagnosed with resectable gastric adenocarcinoma. Laparoscopy was performed in 107 patients (66.9%), finding peritoneal spread in 22 of them (21%). Seventeen of these patients were not submitted to any additional surgical procedure. Data regarding postoperative morbidity and mortality, need of endoscopic, percutaneous or surgical procedures to palliate symptoms, hospital stay and survival were collected. The same data were collected for the 6 non-resected patients who were diagnosed with carcinomatosis by laparotomy.

RESULTS

In the "laparoscopy alone" group, there were 2 minor complications and no postoperative mortality. Mean postoperative stay was 6 days. Eight patients had to be readmitted to hospital for symptoms derived from tumour progression, and 10 palliative endoscopic procedures were performed. Surgical interventions were not needed in any case. Mean survival was 11.5 months. Patients submitted only to laparotomy presented higher morbidity and mortality rates, with a longer postoperative stay and survival of less than 5 months.

CONCLUSIONS

Laparoscopic staging of gastric cancer can help to avoid unnecessary laparotomies. In patients with peritoneal carcinomatosis diagnosed by laparoscopy, nonsurgical treatment has low morbidity and mortality and permits good symptom relief with no shortening of survival.

What is the role of diagnostic laparoscopy in a gastroenterology unit?

BACKGROUND

Diagnostic laparoscopy is known to be a relatively safe invasive procedure. However, its use has decreased owing to the development of imaging techniques, and fewer gastroenterologists now practice diagnostic laparoscopy. Our aim was to examine the role of diagnostic laparoscopy in a gastroenterology unit in the era of advanced imaging techniques.

METHODS

We retrospectively reviewed 855 diagnostic laparoscopy cases. Its safety and efficacy were evaluated for various indications.

RESULTS

No mortality was observed, and complications were noted in ten patients (1.2%). Among the indications were evaluation of chronic liver disease (n = 673), liver tumor (n = 15), ascites of unknown origin and peritoneal disease (n = 142), and staging of intra-abdominal malignancy (n = 25). In patients with chronic liver disease, 461 were diagnosed as having chronic viral hepatitis, based on clinical data including imaging studies, but the diagnosis was changed to cirrhosis after a laparoscopic exam in 69 patients (15.0%). In patients with ascites of unknown origin and peritoneal disease, the diagnostic yield was 87.2% (123/141). In 24 (19.5%) of the 123 patients, the diagnosis changed or the less probable diagnosis was confirmed after laparoscopic examination. The confirmed diagnoses were mainly primary peritoneal disease, including peritoneal tuberculosis, in 17 patients, peritoneal metastatic carcinoma in five, and mesothelioma in two.

CONCLUSIONS

Diagnostic laparoscopy in a gastroenterology unit is safe and useful, especially for confirmation of liver cirrhosis and primary peritoneal disease evaluation.