Diagnostic laparoscopy for periampullary and pancreatic cancer: what is the true benefit?

[Primary pancreatic lymphoma clinically mimicking carcinoma. An important differential diagnostic problem due to the different therapeutic implications]

Primary pancreatic lymphoma is very rare; the most commonly described subtype is diffuse large B-cell lymphoma. Although it is morphologically similar to lymphoproliferative lesions found in other locations, clinically it can mimic an epithelial neoplasm. The differential diagnosis is important due to the different therapeutic implications of each entity. We present a case of primary pancreatic lymphoma in a 77-year-old woman and describe its characteristic features.

Reappraisal of Staging Laparoscopy for Patients with Pancreatic Adenocarcinoma: A Contemporary Analysis of 1001 Patients

BACKGROUND

Recent advances in imaging and the increasing use of neoadjuvant therapy puts the contemporary utility of staging laparoscopy for patients with pancreatic adenocarcinoma (PDAC) into question. This study aimed to develop a prognostic score to optimize prevention of an unnecessary laparotomy and minimize the rate for unnecessary laparoscopy.

METHODS

Clinicopathologic data were evaluated for all patients undergoing surgical intervention for PDAC between 2001 and 2015, who were stratified into group 1 (2001-2008) and group 2 (2009-2014).

RESULTS

The study identified 1001 patients eligible for analysis, 331 (33%) of whom underwent a staging laparoscopy before exploration. An unnecessary laparotomy was prevented for 44.4% of the patients in period 1 and for 24% of the patients in period 2 (p < 0.001). Male gender [odds ratio (OR), 1.8; p < 0.05], preoperative resectability (borderline resectable OR 2.1; p < 0.019; locally advanced OR 7.6; p < 0.001), CA 19-9 levels higher than 394 U/L (OR 3.1; p < 0.001), no neoadjuvant chemotherapy (OR 2.7; p = 0.012), and pancreatic body or tail lesions (OR 1.8; p = 0.063) were predictive of occult metastatic disease. The developed scoring index demonstrated a c-statistic of 0.729. The observed-to-expected ratio for the index at every score level validated the index's model. A score cutoff at 4 was able to detect 76.1% of radiographically occult metastatic disease.

CONCLUSION

The rate for unnecessary laparotomy among patients with PDAC has decreased in contemporary times, but unnecessary laparotomy still occurs for 1 in 4 patients. Using our scoring system, a cutoff of 4 allows 76% of radiographically occult metastases to be predicted, thereby selecting high-risk patients for laparoscopic biopsy and potentially avoiding a non-therapeutic laparotomy.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). This is an update to a previous Cochrane Review published in 2013 evaluating the role of diagnostic laparoscopy in assessing the resectability with curative intent in people with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 15 May 2016), and Science Citation Index Expanded (from 1980 to 15 May 2016).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in people with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. The sensitivities were therefore meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in people who had a negative laparoscopy (post-test probability for people with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies, and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

We included 16 studies with a total of 1146 participants in the meta-analysis. Only one study including 52 participants had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 41.4% (that is 41 out of 100 participants who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 64.4% (95% confidence interval (CI) 50.1% to 76.6%). Assuming a pre-test probability of 41.4%, the post-test probability of unresectable disease for participants with a negative test result was 0.20 (95% CI 0.15 to 0.27). This indicates that if a person is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 20% probability that their cancer will be unresectable compared to a 41% probability for those receiving CT alone.A subgroup analysis of people with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40.0% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in people with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 21 unnecessary laparotomies in 100 people in whom resection of cancer with curative intent is planned.

Value of Intraoperative Sonography in Pancreatic Surgery

The utility of intraoperative sonography for pancreatic disease has been well described for detection and evaluation of neoplastic and inflammatory pancreatic disease. Intraoperative sonography can help substantially reduce surgical time as well as decrease potential injury to tissues and major structures. Imaging with sonography literally at the point of care--the surgeon's scalpel--can precisely define the location of pancreatic lesions and their direct relationship with surrounding structures in real time during surgery. This article highlights our experience with intraoperative sonography at multiple institutional sites for both open and laparoscopic surgical procedures. We use intraoperative sonography for a wide range of pancreatic disease to provide accurate localization and staging of disease, provide guidance for enucleation of nonpalpable, nonvisible tumors, and in planning the most direct and least invasive surgical approach, avoiding injury to the pancreatic duct or other vital structures.

Skeletal muscle metastases from pancreatic carcinoma-a case report and review of literature

With an overall mortality approaching nearly 100 %, pancreatic cancer is still a challenging disease. A major proportion of pancreatic cancers are still diagnosed at the locally advanced or metastatic stage. Tumors originating from tail region present very late due to the absence of specific symptoms and signs. The usual sites of metastases are the liver, peritoneum and lungs, with occasional reports of metastases in other sites. There are very few documented cases of gastrointestinal cancers manifesting as metastases to muscle. This is a report on a case of pancreatic cancer presenting as metastases to skeletal muscle and multiple other viscera and review of literature for pancreatic cancer metastases.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). There has been no systematic review or meta-analysis assessing the role of diagnostic laparoscopy in assessing the resectability with curative intent in patients with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Register of Diagnostic Test Accuracy Studies, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 13 September 2012), and Science Citation Index Expanded (from 1980 to 13 September 2012).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in patients with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. Therefore, the sensitivities were meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in patients who had a negative laparoscopy (post-test probability for patients with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

Fifteen studies with a total of 1015 patients were included in the meta-analysis. Only one study including 52 patients had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 40.3% (that is 40 out of 100 patients who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 68.7% (95% CI 54.3% to 80.2%). Assuming a pre-test probability of 40.3%, the post-test probability of unresectable disease for patients with a negative test result was 0.17 (95% CI 0.12 to 0.24). This indicates that if a patient is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 17% probability that their cancer will be unresectable compared to a 40% probability for those receiving CT alone.A subgroup analysis of patients with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in patients with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 23 unnecessary laparotomies in 100 patients in whom resection of cancer with curative intent is planned.

Role of diagnostic laparoscopy in assessing operability in borderline resectable gastrointestinal cancers

BACKGROUND:

Diagnostic laparoscopy helps in diagnosing and staging Gastrointestinal (GI) cancers. Routine laparoscopy before laparotomy, especially in cancers that have equivocal operability, helps to avoid unnecessary laparotomies. Present study evaluates utility of laparoscopy in diagnosing and staging GI cancers.

MATERIALS AND METHODS:

Diagnostic laparoscopy was done in 41 patients with gastrointestinal (GI) cancers who were thought to have equivocal operability. Patients with suspected or known non-metastatic GI cancers, in whom resectability was found doubtful by clinical assessment and pre-operative imaging, were included. Patients with non-GI cancers (lymphoma, gynaecologic cancers, genitourinary cancers, retroperitoneal sarcoma, sarcoma and abdominal metastasis of non-GI cancers) and metastatic cancers which were beyond the scope of curative surgery were excluded from the study.

RESULTS:

After diagnostic laparoscopy (DL) five patients had benign diagnosis. Out of 36 patients with malignant diagnosis, after DL, 22 patients (61.1%) were inoperable, 11 patients (30.6%) were operable, and three (8.3%) patients were of equivocal operability. Sensitivity, specificity, positive predictive value, and negative predictive value of laparoscopy in detecting operability were 100%, 91.7%, 81.8%, and 100%, respectively.

CONCLUSIONS:

Laparoscopy helped in a significant number of patients with advanced GI cancers to avoid laparotomy. The morbidity of DL was acceptable.

Ductal adenocarcinoma of the pancreatic head: A focus on current diagnostic and surgical concepts

Complete surgical resection still remains the only possibility of curing pancreatic cancer, however, only 10% of patients undergo curative surgery. Pancreatic resection currently remains the only method of curing patients, and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer. Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques. Nevertheless, even in experienced hands, perioperative morbidity rates (delayed gastric emptying, pancreatic fistula etc.) are as high as 50%. Different strategies to reduce postoperative morbidity, such as different techniques of gastroenteric reconstruction (pancreatico-jejunostomy vs pancreatico-gastrostomy), intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome. The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct (< 3 mm). The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying, respectively. Currently, the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity, but without any positive impact on overall survival. However, there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.

Mini-laparoscopy in the endoscopy unit: Safety and outcomes in over one thousand patients

AIM: To investigate the safety of consecutive mini-laparoscopy guided liver biopsies for the diagnosis and staging of liver diseases.

METHODS: In this study we retrospectively analyzed the safety of mini-laparoscopic liver biopsy performed in an endoscopy unit in 1071 patients. We measured the incidence of bleeding and evaluated the management and outcome of bleeding interventions.

RESULTS: The most common etiologies of liver injury were viral hepatitis and autoimmune liver disease. 250 patients had macroscopically and histologically proven cirrhosis. 13 patients had no pathological findings. 33% of all patients had bleeding that required argon plasma coagulation of the puncture site during laparoscopy. Significant bleeding occurred more often in patients with liver cirrhosis compared to non-cirrhotic liver diseases but was effectively treated with laparoscopic coagulation.

CONCLUSION: In conclusion, mini-laparoscopy liver biopsy can be performed safely and effectively in high risk patients with advanced liver disease; mini-laparoscopy with liver biopsy can be done safely in an endoscopy unit.

Alternative port site selection (APSS) for improved cosmesis in laparoscopic surgery

The use of laparoscopy can be associated with improved cosmesis following a variety of gastrointestinal procedures versus standard open surgery. The placement of laparoscopic ports in less visible areas of the body such as the bikini line, termed alternative port site selection (APSS), may result in further improved cosmesis. Performance of laparoscopic procedures from such alternative port placement areas may be associated with increased technical challenge. This manuscript discusses APSS approaches for two common laparoscopic procedures, cholecystectomy and gastric banding. Familiarity and implementation of these techniques can allow select patients to undergo procedures with less visible scarring and is less challenging than laparoscopic single site approaches.

Escalating computed tomography angiogram (CTA) grade predicts unresectability and margin status for pancreaticobiliary neoplasms

BACKGROUND AND AIMS

The Raptopoulos computed tomography (CT) grading system of pancreaticobiliary cancers was conceived to predict resectability based on tumour involvement of critical vasculature. The aim of the present study was to investigate the relationship between CT grade, resectability, margin status and survival after pancreatic resection.

METHODS

Patients with presumed pancreaticobiliary malignancy and a pancreas protocol computed tomography angiogram (CTA) who underwent attempted curative resection from October 2001 and August 2008 were identified. The relationship between radiographical involvement of critical vasculature, according to a five-point scale, and ultimate resectability, margin status and survival was assessed.

RESULTS

Overall, 276 (70.2%) out of 393 patients were resectable. The proportion of patients who were unresectable at laparotomy increased as CT grade escalated; 41/250 (16.4%) CT Grade 0, 16/55 (29.1%) CT Grade 1, 33/55 (60%) CT Grade 2, 27/33 CT Grade 3, P < 0.001. Local invasion or vascular involvement was the reason for unresectability in 14/41, 12/16, 23/33, 16/27 patients with CT Grade 0-3, respectively. A R0 resection was achieved in 84/131 patients with pancreatic adenocarcinoma and varied significantly by CT grade, P= 0.021. Significant predictors of survival were age (P < 0.0001), resectability (P < 0.0001) and diagnosis (P < 0.009).

CONCLUSIONS

Escalating Raptopoulos CT grade is correlated with increasing probability of unresectability and R1 resection.

Vascular invasion in pancreatic cancer: Imaging modalities, preoperative diagnosis and surgical management

Pancreatic cancer is associated with a poor prognosis, and surgical resection remains the only chance for curative therapy. In the absence of metastatic disease, which would preclude resection, assessment of vascular invasion is an important parameter for determining resectability of pancreatic cancer. A frequent error is to misdiagnose an involved major vessel. Obviously, surgical exploration with pathological examination remains the “gold standard” in terms of evaluation of resectability, especially from the point of view of vascular involvement. However, current imaging modalities have improved and allow detection of vascular invasion with more accuracy. A venous resection in pancreatic cancer is a feasible technique and relatively reliable. Nevertheless, a survival benefit is not achieved by curative resection in patients with pancreatic cancer and vascular invasion. Although the discovery of an arterial invasion during the operation might require an aggressive management, discovery before the operation should be considered as a contraindication. Detection of vascular invasion remains one of the most important challenges in pancreatic surgery. The aim of this article is to provide a complete review of the different imaging modalities in the detection of vascular invasion in pancreatic cancer.

Patients with pancreatic adenocarcinoma benefit from staging laparoscopy

BACKGROUND

Unnecessary laparotomy in patients with advanced pancreatic cancer may both compromise the quality of life and delay the initiation of more appropriate therapy. Very often, peritoneal small liver metastases and true local status cannot be fully determined without surgery. Laparoscopy may spare laparotomy and decrease morbidity for patients with nonresectable advanced disease. The aim of this study was to determine the impact of laparoscopy in patients with potentially resectable adenocarcinoma of the pancreas.

MATERIALS AND METHODS

We reviewed the records of patients undergoing pancreatic surgery at the University of Nebraska Medical Center from October 2001 to April 2005. A total of 59 patients were included in the study. All patients were staged radiographically with a high resolution helical computed tomography scan and their tumors were considered resectable. Thirty-seven patients underwent staging laparoscopy while 22 proceeded directly to laparotomy.

RESULTS

Of the 37 patients who underwent laparoscopic staging, 9 (24.3%) were detected to have metastatic disease or advanced tumor; the remaining 28 (75.7%) patients with negative laparoscopy proceeded to laparotomy. Of those, 24 patients (85.7%) underwent pancreatic resection with curative intent, while 4 patients had metastatic or locally advanced disease at subsequent laparotomy which was missed on staging laparoscopy (false negative rate of 14.3%). Of the 22 patients who proceeded directly to laparotomy, 16 (72.7%) received curative Whipple resection and 6 (27.3%) were found to have advanced disease and received bypass procedures or biopsy alone.

CONCLUSION

These findings suggest that staging laparoscopy is beneficial in a significant proportion of patients deemed resectable by routine noninvasive preoperative studies. We plan to add intraoperative laparoscopic ultrasound to our staging protocol in order to decrease the false negative rate.

Evolving preoperative evaluation of patients with pancreatic cancer: does laparoscopy have a role in the current era?

BACKGROUND

Recent years have brought important developments in preoperative imaging and use of laparoscopic staging of patients with pancreatic adenocarcinoma (PAC). There are few data about the optimal combination of preoperative studies to accurately identify resectable patients.

STUDY DESIGN

We conducted a statewide review of all patients with surgically managed PAC from 1996 to 2003 using data from the Oregon State Cancer Registry, augmented with clinical information from primary medical record review. We documented the use of all staging modalities, including CT, endoscopic ultrasonography, and laparoscopy. Primary outcomes included resection with curative intent. The association between staging modalities, clinical features, and resection was measured using a multivariate logistic regression model.

RESULTS

There were 298 patients from 24 hospitals who met the eligibility criteria. Patients were staged using a combination of CT (98%), laparoscopy (29%), and endoscopic ultrasonography (32%). The overall proportion of patients who went to surgical exploration and were resected was 87%. Of patients undergoing diagnostic laparoscopy, metastatic disease that precluded resection was discovered in 24 (27.6%). For patients who underwent diagnostic laparoscopy and were not resected, vascular invasion was the most common determinant of unresectability (56.6%). In multivariate analysis, preoperative weight loss and surgeon decision to use laparoscopy predicted unresectability at laparotomy.

CONCLUSIONS

This population-based study demonstrates that surgeons appear to use laparoscopy in a subset of patients at high risk for metastatic disease. The combination of current staging techniques is associated with a high proportion of resectability for patients taken to surgical exploration. With current imaging modalities, selective application of laparoscopy with a dual-phase CT scan as the cornerstone of staging is a sound clinical approach to evaluate pancreatic cancer patients for potential resectability.

The role of staging laparoscopy for intraabdominal cancers: an evidence-based review

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for the staging of intraabdominal cancers. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. The search identified and reviewed seven main categories that have received attention in the literature: esophageal cancer, gastric cancer, pancreatic cancer, hepatocellular carcinoma, biliary tract cancer, colorectal cancer, and lymphoma. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.

Improving outcomes for operable pancreatic cancer: is access to safer surgery the problem?

Despite advances in the understanding and treatment of pancreatic cancer in the last two decades, there is a persisting nihilistic attitude among clinicians. An alarmingly high rate of under-utilization of surgical management for operable pancreatic cancer was recently reported in the USA, where more than half of patients with stage 1 operable disease and no other contraindications were not offered surgery as therapy, denying this group of patients a 20% chance of long-term survival. These data indicate that a nihilistic attitude among clinicians may be a significant and reversible cause of the persisting high mortality of patients with pancreatic cancer. This article examines the modern management of pancreatic cancer, in particular, the advances in surgical care that have reduced the mortality of pancreatectomy to almost that of colonic resection, and outlines a strategy for improving outcomes for patients with pancreatic cancer now and in the future.

Current utility of staging laparoscopy for pancreatic and peripancreatic neoplasms

BACKGROUND

The routine use of staging laparoscopy in patients with radiographically resectable pancreatic and peripancreatic neoplasms remains controversial.

STUDY DESIGN

We reviewed a prospective database that identified 1,045 patients who underwent staging laparoscopy for radiographically resectable pancreatic or peripancreatic tumors between 1995 and 2005. Radiographic resectability was determined by review of radiographic reports, surgeons' notes, and cross-sectional imaging studies. Factors were assessed for their association with the laparoscopic identification of radiographically occult unresectable disease. Recursive partitioning was used to build a decision tree, with laparoscopic identification of unresectable disease as the outcomes, including only patients since 1999 (modern imaging) and factors available preoperatively.

RESULTS

Unresectable disease was identified laparoscopically in 145 of the 1,045 radiographically resectable patients (14%). Factors associated with radiographically occult unresectable disease included the time period of the study, whether imaging was performed at our institution (internal versus external imaging), primary site, histology, weight loss, and jaundice. Primary site (pancreatic versus nonpancreatic) was identified as the strongest predictor of yield. In patients with nonpancreatic tumors, the yield of laparoscopy was 4%. In patients with pancreatic tumors, the yield of laparoscopy was 14% overall, but was 8.4% in patients with internal imaging versus 17% in patients with external imaging (p < 0.01). This higher-risk subgroup was partitioned by the presence of weight loss, then by primary site within the pancreas.

CONCLUSIONS

During the time period of this study, the yield of staging laparoscopy decreased and exceeded 10% only for patients with pancreatic adenocarcinoma. When high-quality cross-sectional imaging reveals no evidence of unresectable disease, routine staging laparoscopy may not be warranted for pancreatic or peripancreatic tumors other than presumed pancreatic adenocarcinoma.

Guidelines for the Surgical Management of Pancreatic Adenocarcinoma

Pancreaticoduodenectomy remains the most formidable operative procedure for the surgical treatment of gastrointestinal malignancy. Improved outcomes after the Whipple procedure have been attributed to better preoperative patient selection, advances in three-dimensional radiographic imaging, and regionalization of referrals to high-volume, tertiary care centers. Despite these advances, morbidity and mortality after pancreaticoduodenectomy are not insignificant and the overall prognosis following resection for adenocarcinoma of the pancreas remains poor. Improvements in endoscopic decompression of malignant biliary obstruction have decreased the need for palliative bypass operations and have focused current surgical issues on ways to improve clinical outcomes following potentially curative resections. Controversies such as whether or not to perform extended lymph node dissections, and standard versus pylorus-preserving resections have been addressed by randomized, prospective clinical trials. Major venous resections secondary to local tumor extension are now performed without an increase in morbidity or mortality and with survival rates comparable to standard resections. This has led to even more aggressive resections following neoadjuvant therapy for lesions previously considered unresectable and now perhaps better categorized as borderline resectable. The impact of surgical specialization and regionalization of referrals to tertiary care centers is evident in markedly improved perioperative mortality rates. This article will attempt to describe current guidelines for the preoperative, intraoperative, and postoperative management of patients with localized pancreatic adenocarcinoma.

Minimally invasive treatment of pancreatic disease

Although open surgical procedures remain the standard for both benign and malignant diseases of the pancreas, in recent years a wide variety of surgical procedures performed on the pancreas have been completed laparoscopically. This article reviews the application of minimally invasive surgery to the management of both benign and malignant diseases of the pancreas.

Assessment of pancreatic malignancy with laparoscopy and intraoperative ultrasound

BACKGROUND

Staging laparoscopy for pancreatic malignancy is controversial. This study aimed to assess the efficacy of laparoscopy with intraoperative ultrasound in the management of patients with pancreatic carcinoma.

METHODS

The study involved patients undergoing laparoscopy and intraoperative ultrasound over a period of 42 months. The entry criteria specified radiologic (computed tomography) diagnosis of pancreatic carcinoma and no evidence of metastases.

RESULTS

The study enrolled 100 patients (52 men and 48 women) ages 21 to 83 years (mean, 63 years). On the basis of imaging, 75 patients had lesions judged to be operable, and 25 patients had a pancreatic head lesion larger than 4 cm radiologically, considered to be unresectable, but with no evidence of metastatic disease. At laparoscopy, three patients had a normal examination, with no evidence of a pancreatic mass, and an additional seven patients had other pathology including one lymphoma, one ampullary tumor, two cases of chronic pancreatitis, and three sarcomas. Of the patients with radiologically inoperable disease, 16% had previously undetected metastases, but 24% were judged to be suitable for curative resection. Half of these patients underwent successful resection. Of the patients with radiologically operable disease, undetected liver or peritoneal metastases were found in 20% of the body or tail lesions and in 26% of the pancreatic head lesions. Of the pancreatic head tumors, 12% were found to be larger than 4 cm and therefore unsuitable for curative resection. Consequently, only 53% were confirmed to be suitable for resection. Of the patients explored with a view to curative resection, 42% actually underwent resection, with clearance of resection margins achieved in 77.8%.

CONCLUSION

Of the patients thought to have a resectable tumor on the basis of good quality preoperative imaging, 44% had their management approach altered after laparoscopy and avoided an open procedure. Laparoscopy should therefore be used in the preoperative staging of pancreatic tumors.

Locally advanced pancreatic cancer: current therapeutic approach

Even though pancreatic cancer accounts for only 2% of all cancer diagnoses in the U.S., it is the fourth-leading cause of cancer death and one of the most difficult malignancies to manage. Because of the usually late onset of symptoms, only 10%-15% of patients present with resectable disease, whereas the remaining 85%-90% present with locally advanced unresectable or metastatic disease. Despite a lack of consistent evidence from previous clinical trials, chemotherapy in addition to radiation therapy is the most commonly used approach in treating locally advanced pancreatic cancer. The most appropriate chemotherapy in combination with radiation is still debatable between 5-fluorouracil and gemcitabine, and novel trends to prevent resistance and enhance efficacy incorporate biologically targeted agents. This paper reviews the current management options, controversies, and ongoing and future directions for the treatment of locally advanced adenocarcinoma of the pancreas.

Impact of Regional Lymph Node Evaluation in Staging Patients With Periampullary Tumors

BACKGROUND

Two distinct lymph nodes reproducibly assessed by computed tomography for the evaluation of periampullary tumors are the common bile duct (CBD) node and the gastroduodenal artery (GDA) node. We examined whether radiographical enlargement of either lymph node predicts tumor resectability, nodal metastasis, or patient survival.

METHODS

Ninety-four consecutive patients underwent attempted curative resection of periampullary tumors between September 2001 and June 2003. A single radiologist recorded in a retrospective, blinded fashion the short- and long-axis measurements of the CBD and GDA nodes.

RESULTS

Sixty-one percent (n = 57) of tumors were resectable by pancreaticoduodenectomy. Overall, actual 6-, 12-, and 18-month survival was 87%, 68%, and 63%, respectively. Enlarged radiographical nodal size by either axis was not associated with the presence of metastasis to these lymph nodes or with reduced overall patient survival. Only a CBD node short-axis size >10 mm predicted unresectability (odds ratio, 3.2; P = .036). Liver metastasis and/or carcinomatosis were present in 43% of unresectable patients, and this was associated with decreased survival at both 1 year (25% vs. 77%; P < .001) and 18 months (19% vs. 72%; P <.001). A pathologic diagnosis of metastasis to the GDA node, but not the CBD node, was associated with a similarly decreased survival (1 year: 33% vs. 78%, P = .028; 18 months: 22% vs. 70%, P = .023).

CONCLUSIONS

For presumed periampullary malignancy, a CBD node short-axis size >10 mm predicts tumor unresectability. Metastatic disease to the GDA node, particularly for pancreatic adenocarcinoma, portends a poor prognosis equivalent to that of hepatic or peritoneal spread. Given these findings, radiographical CBD lymph node measurements may guide selection for performing laparoscopic staging with or without ultrasonography in conjunction with GDA nodal biopsy in patients with periampullary malignancy.

Staginglaparoskopie in der Onkologie

The availability of more treatment options for gastrointestinal cancer requires precise and reliable pretherapeutic staging. Despite impressive technical progress in modern imaging procedures, this high level of staging quality is not yet warranted in all instances. Visual exploration of the abdominal cavity in extended diagnostic laparoscopy (EDL), including surgical dissection of areas which are primarily inaccessible, biopsy retrieval, and laparoscopic ultrasound, is superior in the diagnostic workup of early peritoneal carcinomatosis and (small) liver metastases. It is helpful to evaluate lymph node infliction and local resectability. In esophageal carcinoma, pretherapeutic EDL is valuable in case of advanced adenocarcinoma of the distal esophagus (AEG I according to Siewert), whereas the incidence of abdominal tumor manifestations in squamous cell carcinoma is too low to perform staging laparoscopy. In advanced gastric cancer, EDL yields relevant additional information in up to 20% of cases. If a multimodal therapeutic strategy is considered, EDL should be obligatory at least in prospective therapeutic studies. In carcinoma of the pancreas, EDL is in general not recommended by the majority of centers. Selective use (in particular in advanced cancer with a high probability of local irresectability) is gaining importance. In hepatobiliary malignancy including colorectal metastases, the high yield of additional information by EDL was confirmed in recent studies.

Pancreatic cancer mortality in Egypt: comparison to the United States pancreatic cancer mortality rates

OBJECTIVES

Little is known about the descriptive epidemiology of pancreatic cancer in many developing countries, such as Egypt. It is believed to be rare in developing countries, but this may reflect lack of systematic cancer registration. Mortality may serve as a surrogate for incidence, since the disease is lethal. Because of availability of reliable mortality registration in Egypt, we used the national mortality data to estimate pancreatic cancer mortality in 2765 deaths from 2000 to 2004, and to gain insights into the disease incidence.

METHODS

Mortality data in Egypt was obtained from the electronic national mortality records of the Ministry of Health. We calculated population-based age-specific and age-standardized pancreatic cancer mortality rates for Egypt, and compared them with the Surveillance, Epidemiology, and End Results (SEER) mortality data of the United States.

RESULTS

Comparisons of age-specific mortality demonstrated higher rates in Egypt compared to the United States for subjects under age 20 years (relative risks (RR) of 7.7 and 4.2, for the age groups 0-15 and 15-20, respectively), and significantly higher rates in the United States compared to Egypt for subjects 40 years and older (RR 1.8-80.5 for the age groups of 40-45 to 75+). For the majority of age groups in Egypt and the United States, mortality in males was higher than in females. Analysis of regional distribution of pancreatic cancer mortality in Egypt showed significant variations in rates among provinces (p<0.0001) with Northern provinces having average rate that is 2.85 times the rate of Southern provinces. The highest mortality rates were observed in the Nile Delta compared to southern Egypt and the oasis.

CONCLUSIONS

The findings of this study demonstrate both international and regional variation in pancreatic cancer mortality, and highlight the importance of further investigation to explore the possible factors that may contribute to the observed epidemiological patterns.

Hepatectomy enables prolonged survival in select patients with isolated noncolorectal liver metastasis

OBJECTIVE

This study was done to determine the benefit of undergoing liver resection for noncolorectal metastasis.

METHODS

A single-institution retrospective review of all patients (n = 95) who underwent hepatic resection for a noncolorectal liver metastasis from 1990 to 2005 was performed. Primary outcomes measure was months of patient survival after liver resection.

RESULTS

Median patient age was 58 years (range 19 to 83 years). There were 37 men (38.9%) and 58 women (61.1%). The 30-day postoperative mortality rate was 2.1%, and postoperative complications developed in 15.8% of patients. Mean hospital stay was 7 days (range 4 to 25 days). Median time of survival from date of liver resection was 36 months, and 5-year survival rate was 34.9%. Primary tumor sites were identified as foregut or gastrointestinal in 16.8% and nongastrointestinal in 83.2%. Patients with a nonforegut primary tumor had a median survival time twice as long as those with foregut primaries (49 months versus 20 months, p < 0.001). Multiple liver metastases were an independent prognostic factor for worse outcomes with a hazard ratio of 3.3 (p = 0.007). No treatment-dependent variables (initial treatment modality, extent of liver resection, margins, complications) were found on multivariable analysis to be important prognostic factors.

CONCLUSIONS

In select patients with any of a variety of malignancies metastatic to the liver, prolonged survival can result from liver resection, especially in those with a single, resectable tumor from a nongastrointestinal primary site.

Is adjuvant 5-FU-based chemoradiotherapy for resectable pancreatic adenocarcinoma beneficial? A meta-analysis of an unanswered question

The objective of this study was to determine the effect, if any, on survival of adjuvant 5-FU-based chemoradiotherapy following pancreaticoduodenectomy for pancreatic carcinoma. A systematic review of the published literature was undertaken. Survival estimates were derived from published reports. Five prospective studies (4 level I, 1 level II) with a total of 607 (229 surgery only; 378 surgery-adjuvant) patients followed for survival met selection criteria. Two-year survival ranged from 15%-37% in the surgery only group and 37%-43% in the surgery and adjuvant groups. The survival advantage (absolute difference) ranged from 3%-27% and no individual study achieved statistical significance (5%). Although clinical heterogeneity existed in surgery-alone control groups with regard to trial date, no statistical heterogeneity was detected (P = 0.459, chi2 test), allowing pooling of survival data. Using a fixed effects model, the summary estimate showed an absolute 2-year survival benefit with adjuvant therapy of 12% (95% CI, 3%-21%, P = 0.011). Trials after 1997 (n = 3) indicated a survival benefit of 8% to patients receiving adjuvant therapy (95% CI, -3-18%, P = 0.145). The result was not statistically significant, and there was no evidence of heterogeneity (P = 0.626, chi2 test). Summary estimates were unchanged when the analysis was performed with a random effects model. 5-FU based chemotherapy with radiotherapy given after resection imparts a small overall survival benefit of 2 years. The benefit of 5-FU-based adjuvant therapy, however, has declined in recent years, and its significance remains unproven in the context of current diagnostic and surgical practice.

¿Cuáles son los principales errors que cometemos los cirujanos en el tratamiento del cáncer de páncreas?

The present review identifies two major conceptual errors. Therapeutic nihilism, which should be discounted in view of the results currently achieved by surgery, and noncentralization, since better results have been demonstrated, both in terms of morbidity and mortality and in survival, in high-volume centers than in low volume centers. The present review also identifies errors in management, the most important of which are: undervaluing the medical record, which is of great utility and continues to be the pillar on which the entire diagnostic process is based; the systematic use of preoperative biliary drainage, which used to be considered mandatory but should be used highly selectively in patients with severe jaundice or biliary tract infections, and viewing preoperative imaging tests as unreliable, when current radiological techniques, particularly helical computed tomography (CT), are highly reliable in establishing tumor resectability and consequently they should be used in all treatment planning. Moreover, because radiological tests are highly reliable, laparoscopic staging has lost diagnostic value; obtaining a preoperative histological diagnosis, which is not mandatory except when neoadjuvant therapy is planned or when tumors requiring nonsurgical treatment are suspected; undervaluing the use of surgical palliation, since this technique provides better long-term results than nonsurgical palliation, and consequently still plays a role in patients with good general health status and prolonged life expectancy; systematically performing gastrojejunostomy with bilio-enteric bypass, as this procedure should only be performed in tumors of the uncus or when there is imminent biliary or gastroduodenal obstruction; the use of supraradical surgical techniques such as regional, total or extensive pancreatectomy, since these techniques do not prolong survival after resection. Furthermore, the use of vascular resections would only be justified if resection with disease-free margins could be performed; undervaluing close postoperative monitoring within specialized units since this is the key to reducing morbidity and mortality rates in this type of surgery; and lastly when an intraoperative pancreatic incidentaloma is present, performing diagnostic maneuvers such as biopsy or pancreatic mobilization, since these procedures hamper subsequent radiological interpretation and possible surgical intervention.

The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review

In the absence of metastatic disease patients with localized or locally advanced pancreatic cancer can benefit from surgical resection or chemoradiation. Despite the advances of imaging technology, however, noninvasive staging modalities are still inaccurate in identifying small volume metastatic disease leading potentially to inappropriate treatment and avoidable morbidity in a subgroup of patients. Staging laparoscopy may identify those patients with unsuspected metastatic disease on preoperative imaging and prevent unnecessary laparotomy or chemoradiation. A controversy exists, however, as to whether the procedure should be used routinely or selectively in pancreatic cancer patients with no evidence of metastasis on noninvasive staging. This review aims to assess the current role of staging laparoscopy by examining its diagnostic accuracy and ability to prevent unnecessary treatment as well as its morbidity, oncologic effect and cost-effectiveness. The available literature will be evaluated critically, its limitations identified and exisiting controversies addressed.

The role of minimally invasive surgery for pancreatic pathology

The last decade has seen an increase in the application of minimally invasive surgical procedures to the management of pancreatic disease. The role of the minimally invasive surgical procedure in the staging of pancreatic malignancies appears to be one of selective use in patients at high risk of occult metastatic disease based on high-resolution CT imaging and clinical presentation. These patients can be spared the morbidity of a nontherapeutic laparotomy. Laparoscopic pancreatic surgery is an advanced laparoscopic procedure with a significant learning curve. It should be considered only by surgeons with extensive experience in open pancreatic surgery who possess advanced laparoscopic skills. Early reports suggest that laparoscopic pancreatic surgery can be accomplished with acceptable morbidity and mortality rates for the resection of small benign and low-grade malignant lesions in the body and tail of the pancreas, as well as for the internal drainage of pancreatic pseudocysts. Its role in the management of lesions in the head, neck, and uncinate process of the pancreas has yet to be determined.

Pancreaticoduodenectomy in the presence of superior mesenteric venous obstruction

The study goal was to determine the technical feasibility and outcomes associated with pancreaticoduodenectomy for periampullary malignancies with near (>80%) or complete (100%) superior mesenteric venous (SMV) obstruction. A retrospective examination of 11 patients with high-grade or complete SMV obstruction who underwent pancreaticoduodenectomy at five academic medical centers is reviewed. Pancreaticoduodenectomy for locally advanced periampullary malignancies causing high-grade or complete SMV obstruction is technically feasible. Operative approaches and outcomes are presented. One 30-day death was observed. Median survival of the cohort is 18 months. Survivals exceeding 2 years post-resection have been observed. In a number of cases, significant palliation of pain and of biliary and duodenal obstruction were achieved. Based on this initial series, pancreaticoduodenectomy in the presence of near or total SMV obstruction is feasible, may result in an R0 resection, and may be beneficial in select patients with a periampullary malignancy. We suggest such an approach be considered particularly following completion of neoadjuvant therapy without systemic progression. Further studies and more long-term follow-up at high-volume centers are required, however, to better determine the indications and potential benefit of such an undertaking.

Laparoscopic spleen-preserving distal pancreatectomy

Distal pancreatectomy with spleen preservation may be the preferred procedure for certain benign tumors and cystic lesions of the pancreatic body or tail. Alternatively, laparoscopic removal including either distal pancreatectomy with splenectomy or splenic-preservation with ligation of the splenic vessels have also been described. We describe, herein, our method to perform spleen-preserving laparoscopic distal pancreatectomy that preserves the splenic vessels and hence splenic function. The described technique of spleen-preserving distal pancreatectomy has been used in two patients with favorable results. Both patients underwent laparoscopic distal pancreatectomy with splenic conservation for an oligocystic serous cystadenoma and serous cystadenoma. Operative time was 3-6 hours with total blood loss of less than 200 cc in both cases. The length of stay in the hospital was 4-8 days and both patients returned to work within 3 weeks. Laparoscopic spleen-preserving distal pancreatectomy should be considered for younger patients with select body or tail lesions that are not candidates for less extensive procedures.

Survival of patients with periampullary carcinoma is predicted by lymph node 8a but not by lymph node 16b1 status

BACKGROUND

The aim of this study was to assess the impact of metastatic disease in lymph nodes 8a and 16b1 (as defined by the Japanese Pancreas Society) on survival in patients with periampullary malignancy.

METHODS

Patients undergoing resection for primary pancreatic ductal adenocarcinoma or intrapancreatic bile duct adenocarcinoma were identified from a prospective database (September 1997-May 2003).

RESULTS

Thirteen of 54 and ten of 44 evaluable patients had metastatic involvement of lymph nodes 8a and 16b1 respectively. Metastatic involvement of lymph node 8a was associated with a significantly shorter median survival (197 versus 470 days; P = 0.003) but metastatic involvement of lymph node 16b1 did not affect survival (457 versus 503 days; P = 0.185). Multivariate analysis showed lymph node 8a status to be the strongest predictor of outcome (P = 0.006). Median survival of those with metastatic lymph node 8a was not significantly different from that of 81 patients with overt metastatic periampullary cancer at the time of diagnosis (98 days; P = 0.072)

CONCLUSION

Lymph node 8a was an independent prognostic factor in patients with periampullary malignancy, but lymph node 16b1 was not. Survival in those with metastatic lymph node 8a was not significantly different from that in patients with metastatic disease at presentation. Preoperative determination of lymph node 8a status may have important implications in selecting patients for treatment.

Neoadjuvant therapy for resectable pancreatic cancer

The length and quality of life of patients with localized pancreatic cancer will be maximized by accurate preoperative assessment of resectability, a standardized technique of tumor resection, and the routine use of protocol-based adjuvant or neoadjuvant therapy. Continued efforts to enroll patients with localized and advanced pancreatic cancer into well-designed clinical trials should remain a high priority for oncologists across all disciplines. At present, preoperative therapy remains investigational but has a sound clinical basis and remains a reasonable alternative to up front surgery. Future clinical trials for resectable pancreatic cancer will lead to progress only if the principles of multidisciplinary cancer care and quality assurance are incorporated into their design and conduct.

Current standards of surgery for pancreatic cancer

Background

Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.

Methods

An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.

Results

Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.

Conclusion

The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.

Limitation of diagnostic laparoscopy for patients with a periampullary carcinoma

BACKGROUND

Diagnostic laparoscopy has been generally accepted in staging of patients with a periampullary malignancy. In our institution diagnostic laparoscopy was routinely used since 1992. However, in 1998 it was eliminated from the protocol since in a prospective study a yield of only 13% was found with a histologically proven accuracy of 60% for distant metastases. The effect of implementation of the new protocol on the occurrence of unnecessary laparotomies and the outcome after bypass surgery was assessed.

METHODS

Between January 1999 and December 2001, 186 consecutive patients with a potentially resectable periampullary carcinoma after radiological staging without diagnostic laparoscopy underwent explorative laparotomy with the intention to perform a curative pancreatoduodenectomy. Incidence of unresectability and outcome of palliative surgery were assessed.

RESULTS

Resection could not be performed in 65 patients who underwent laparotomy because of metastatic disease (29 patients) and loco-regional tumour ingrowth (34 patients). These patients underwent a bypass procedure with a median survival of 216 days.

CONCLUSION

At laparotomy distant metastases were detected in 16% of the patients. Considering the fact that the detection rate of diagnostic laparoscopy is lower than 100%, the use of staging laparotomy is too limited to justify it as a routine procedure.

Staging of pancreatic head adenocarcinoma with spiral CT and endoscopic ultrasonography: an indirect evaluation of the usefulness of laparoscopy

BACKGROUND

The interest of laparoscopy in the preoperative staging of pancreatic head adenocarcinoma before curative pancreaticoduodenectomy is a matter of controversy and depends on the accuracy of preoperative imaging techniques.

AIM

To assess the potential value of laparoscopy when a standardised and optimal preoperative staging is performed, including spiral computed tomography (CT) and endoscopic ultrasonography (EUS).

METHODS

All consecutive patients operated on with a view to curative pancreaticoduodenectomy for pancreatic head or ampullary adenocarcinoma in our centre from January 1998 to August 2000 were retrospectively studied. All of them had preoperative spiral CT and EUS. Tumour resectability was considered as highly probable (HP) or uncertain (U) according to well-defined criteria. Operative records of patients were reviewed to indirectly assess the effective resectability rate and the criteria responsible for unresectability and which of them would have been identified by laparoscopy if initially performed.

RESULTS

69 consecutive patients were studied. Resectability was HP (n = 56) or U (n = 13) after preoperative staging. Curative pancreatoduodenectomy was performed in 53 patients (77%) (48 HP, 5 U). Positive predictive value of preoperative imaging for highly probable resectability was 86% (48/56). Among the 16 unresectable tumours (8 HP, 8 U), the cause of non-resection would have been found at laparoscopy in 9 patients (56%) (6 HP, 3 U). Finally, if initially performed, laparoscopy would have avoided laparotomy in 9/69 patients (13%) (6/56 HP (11%); 3/13 U (23%)).

CONCLUSIONS

With accurate preoperative staging using spiral CT and EUS, laparoscopy would detect tumours which were unresectable in 13% of patients with pancreatic head cancer. Laparoscopy remains useful in selected patients, such as those with preoperative uncertain resectability, in whom it can prevent unnecessary laparotomy in one fourth of patients.

Prospective evaluation of ultrasound and colour duplex imaging for the assessment of surgical resectability of pancreatic tumours

BACKGROUND

This study was performed to evaluate colour duplex imaging (CDI) for the assessment of resectability of pancreatic tumours (PTs).

METHOD

From October 1998 to December 2001, 182 patients consecutively having surgery for a PT were enrolled in this prospective study. Extension of the tumour to large blood vessels and retroperitoneum, the detection of liver metastases, enlarged lymph nodes and peritoneal carcinomatosis were defined as criteria for assessment. The patients were grouped into three classes of resectability: US-TU 1 = resectable/potentially curable, US-TU 2 = questionably resectable/curable, and US-TU 3 = non-resectable/not curable. CDI was performed by five different examiners. Results were compared with intra-operative findings.

RESULTS

Using CDI, we classified 85 (46.7%) tumours as resectable, 64 (35.2%) as non-resectable, and 33 (18.1%) as questionably resectable. Overall, 46.2% ( n=84) were found to be resectable, and 53.8% ( n=98) to be non-resectable, intra-operatively. A correlation between CDI classification and intra-operative findings was found in 138 of 149 cases (92.6%) (sensitivity 88.4%, specificity 96.3%). With regard to the complete oncological status (local extension, metastases, lymph-node staging and peritoneal carcinomatosis), a sensitivity of 77.2% and specificity of 95.7% were found. Non-correlated findings were likely attributed to missing small liver metastases, peritoneal carcinomatosis without ascites, and on difficulties in the assessment of enlarged lymph nodes concerning tumour infiltration.

CONCLUSION

The use of CDI in evaluation of PTs may provide valuable pre-operative assessment of surgical resectability and may be performed in the clinical setting.