Role of laparoscopic ultrasonography in the management of patients with oesophagogastric cancer

The role of staging laparoscopy in complex bariatric surgery

Determining which patients will benefit from bariatric surgery is complex; however, in those who have had previous bariatric surgery or extensive abdominal surgery, this can be particularly challenging. Decisions are often made based on assumptions rather than a complete assessment of all the anatomical and physiological factors. Adopting the approach utilised in gastrointestinal surgery with a diagnostic or staging laparoscopy, it may be possible to more accurately stage disease and determine fitness bariatric surgery. Laparoscopy is relatively low risk and contributes critical information with regard to access, post-operative anatomical changes and response to anaesthetic. Additionally, it allows surgeons to accurately determine the feasibility of undertaking a procedure and facilitates a more precise discussion with patients regarding suitability for surgery. Denying patients bariatric procedures based on an incomplete assessment of risk is unfair. Scenarios in which patients have had previous surgery, particularly bariatric surgery are increasingly common with the numbers requiring revisional surgery steadily rising. Although only applicable in highly selected, very complex cases, diagnostic laparoscopy adds critical information in the preoperative assessment of patients, not only improving care but potentially widening the numbers considered eligible for bariatric surgery. Our limited experience with staging laparoscopy in patients with previous complex abdominal surgery requiring revisional surgery illustrates the potential benefit it offers in determining patient suitability for further bariatric procedures. The adoption of an established technique, applied in a novel setting offers surgeons the opportunity to more thoroughly assess potentially high risk patients as well as the ability to offer personalised care.

Prognostic significance, diagnosis and treatment in patients with gastric cancer and positive peritoneal washings. A review of the literature

Peritoneal dissemination is a common consequence of a relapse following a radical surgical treatment of gastric cancer. The development of the disease in the peritoneum depends not only on its stage, but also on free cancer cells exfoliated from the tumor mass or from involved lymph nodes, and which are capable of being implanted in the peritoneum. According to the latest TNM (7 edition; 2010) classification, patients with free cancer cells in the peritoneal washings qualify for stage IV of the disease. Patients in whom free cancer cells were found during the operation - have a recurrence of gastric cancer - mainly in the peritoneum, and the majority of them die within two years of the diagnosis. To properly assess the prognosis, it is vital to determine the stage of cancer by additionally assessing the washings for the presence of free cancer cells before taking a therapeutic decision. This also allows identifying those patients who require different medical procedures to obtain the best treatment results possible. Medical literature describes various methods of examining peritoneal washings aimed at detecting free cancer cells. The methods apply different cancer cell detection rates, sensitivity and specificity in prediction of a peritoneal relapse. Oncological Departments performing the evaluation of the washings employ non-standard methods of treatment in this group of patients and the results presented are promising.

Multidetector Computed Tomography Versus Staging Laparoscopy for the Detection of Peritoneal Metastases in Esophagogastric Junctional and Gastric Cancer

OBJECTIVE

Staging laparoscopy (SL) is the gold standard investigation for detecting peritoneal metastases (PM) in patients with esophagogastric cancer but computed tomography (CT) has undergone significant improvements in recent years. The aim of this study was to investigate whether CT can replace SL in the detection of PM.

MATERIALS AND METHODS

Patients undergoing SL between January 2008 and December 2009 were identified from a prospectively collected database, operation notes were reviewed for the detection of PM. Corresponding CTs were reassessed by 2 experienced gastrointestinal radiologists, blinded to the SL results.

RESULTS

In total, 74 patients undergoing SL were included. Sensitivity and specificity of SL for PM were 94.1% (95% confidence interval, 69.2-99.7) and 100% (90.7-100). Sensitivity and specificity of CT were 58.8% (33.5-80.6) and 89.6% (76.6-96.1), respectively. Area under the curve of receiver operating characteristic curves for SL and CT were 0.971 (SE, 0.033) and 0.742 (SE, 0.78), respectively.

CONCLUSIONS

CT cannot replace SL for the detection of PM in lower esophageal and gastric cancer.

Diagnostic staging laparoscopy in gastric cancer: a prospective cohort at a cancer institute in Japan

BACKGROUND

There have been many studies that describe the value of diagnostic staging laparoscopy (DSL) in gastric cancer. However, different studies use different indications, making study results difficult to compare. This study aimed to clarify the diagnostic feasibility of DSL for gastric cancer in a prospective manner and investigated the impact of DSL on clinical decision-making in gastric cancer treatment.

METHODS

The study was a prospective cohort study based at a single institution between January 2010 and December 2013. We treated 2213 patients with potentially resectable gastric cancer during this period. DSL was primarily indicated for asymptomatic patients with: (1) large Borrmann type 3 tumours ≥8 cm, (2) Borrmann type 4 tumours (linitis plastica), (3) bulky lymph nodes or paraaortic lymph node swelling, or (4) clinical suspicion of peritoneal disease. The primary outcome is change in treatment strategy, and the secondary outcomes are diagnostic accuracy of the indications and false negative rate of DSL.

RESULTS

DSL was performed on 156 (7%) of 2213 patients. Of these, peritoneal disease was found in 74 (47%) patients: (1) 56% for large type 3, (2) 54% for type 4, (3) 21% for bulky lymph nodes or paraaortic lymph node swelling, and (4) 20% for suspected peritoneal disease. The diagnostic accuracy of our indication for DSL was 92% for all patients and 74% for patients with cT3/T4 tumours. Among 82 patients without peritoneal disease, 66 patients (81%) underwent subsequent radical gastrectomy; peritoneal disease was discovered intraoperatively for 7 patients at laparotomy, indicating a false negative rate of 11%.

CONCLUSION

We confirmed that DSL performed according to our indication, in the context of gastric cancer, possesses diagnostic feasibility. Approximately half of the patients who underwent DSL consequently avoided unnecessary laparotomy and were able to receive appropriate alternative treatment.

Staging Early Esophageal Cancer

Staging esophageal cancer provides a standardized measure of the extent of disease that can be used to inform decisions about therapy and guide prognosis. For esophageal cancer, the treatment pathways vary greatly depending on stage of disease, and accurate staging is therefore crucial in ensuring the optimal therapy for each patient. For early esophageal cancer (T1 lesions), endoscopic resection can be curative and simultaneously gives accurate staging of depth of invasion. For tumors invading the submucosa or more advanced disease, comprehensive investigation is required to accurately stage the tumor and assess suitability for curative resection. A combined imaging approach of computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS) offers complementary diagnostic information and gives the greatest chance of accurate staging. Staging laparoscopy can identify peritoneal disease and small superficial liver lesions that could be missed on CT or PET, and alters management in up to 20 % of patients. Optical diagnostic techniques offer the prospect of further extending the possibilities of endoscopic staging in real time. Optical coherence tomography can image superficial lesions and could provide information on depth of invasion for these lesions. Real-time lymph node analysis using optical diagnostics such as Raman spectroscopy could be used to support immediate endoscopic therapy without waiting for results of cytology or further investigations.

Surgical considerations in the treatment of gastric cancer

Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.

Surgical considerations in the treatment of gastric cancer

Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.

Risk stratification for serosal invasion using preoperative predictors in patients with advanced gastric cancer

Purpose

Although serosal invasion is a critical predisposing factor for peritoneal dissemination in advanced gastric cancer, the accuracy of preoperative assessment using routine imaging studies is unsatisfactory. This study was conducted to identify high-risk group for serosal invasion using preoperative factors in patients with advanced gastric cancer.

Materials and Methods

We retrospectively analyzed clinicopathological features of 3,529 advanced gastric cancer patients with Borrmann type I/II/III who underwent gastrectomy at Korea Cancer Center Hospital between 1991 and 2005. We stratified patients into low- (≤40%), intermediate- (40~70%), and high-risk (>70%) groups, according to the probability of serosal invasion.

Results

Borrmann type, size, longitudinal and circumferential location, and histology of tumors were independent risk factors for serosal invasion. Most tumors of whole stomach location or encircling type had serosal invasion, so they belonged to high-risk group. Patients were subdivided into 12 subgroups in combination of Borrmann type, size, and histology. A subgroup with Borrmann type II, large size (≥7 cm), and undifferentiated histology and 2 subgroups with Borrmann type III, large size, and regardless of histology belonged to high-risk group and corresponded to 25% of eligible patients.

Conclusions

This study have documented high-risk group for serosal invasion using preoperative predictors. And risk stratification for serosal invasion through the combination with imaging studies may collaboratively improve the accuracy of preoperative assessment, reduce the number of eligible patients for further staging laparoscopy, and optimize therapeutic strategy for each individual patient prior to surgery.

A systematic review of the accuracy and indications for diagnostic laparoscopy prior to curative-intent resection of gastric cancer

BACKGROUND

Despite improved preoperative imaging techniques, patients with incurable or unresectable gastric cancer are still subjected to non-therapeutic laparotomy. Diagnostic laparoscopy (DL) has been advocated by some to be essential in decision-making in gastric cancer. We aimed to identify and synthesize findings on the value of DL for patients with gastric cancer, in this era of improved preoperative imaging.

METHODS

Electronic literature searches were conducted using Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from January 1, 1998 to December 31, 2009. We calculated the change in management and avoidance of laparotomy based on the addition of DL and laparoscopic ultrasound (LUS). The accuracy, agreement (kappa), sensitivity, and specificity of DL in assessing tumor extent, nodal involvement, and the presence of metastases with respect to the gold standard (pathology) were also calculated.

RESULTS

Twenty-one articles were included. DL showed moderate to substantial agreement with final pathology for T stage, but only fair agreement for N stage. For M staging, DL had an overall accuracy, sensitivity, and specificity ranging from 85-98.9%, 64.3-94%, and 80-100%, respectively. The use of DL altered treatment in 8.5-59.6% of cases, avoiding laparotomy in 8.5-43.8% of cases. LUS provided additional benefit in 5.8-7.2% of cases.

CONCLUSIONS

Despite evolving preoperative imaging techniques, diagnostic laparoscopy continues to be of substantial value in staging patients with gastric cancer and in avoiding unnecessary laparotomy. The current data support DL for all patients with advanced gastric cancer.

The technique of laparoscopic pelvic ultrasonography for metastatic lymph node

Many reports have provided evidence to support the effective use of diagnostic laparoscopy and laparoscopic ultrasonography (LUS) to determine if patients with upper abdominal malignant diseases are operable so that unnecessary laparotomy can be avoided. LUS is less frequently applied to patients with pelvic malignancies and this is probably related to the technical difficulties. We have developed the LUS technique in examining the pelvic nodes for metastasis systematically and have applied it to 241 cervical cancer patients. The procedure is safe and not associated with any major morbidity. The mean duration of pelvic node assessment by LUS is 14 minutes and the procedure can be satisfactorily completed in 98% of patients. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of LUS in detecting pelvic nodal metastasis were 81.2%, 55.6%, 88.4%, 57.7%, and 87.5%, respectively, in patients scheduled for radical hysterectomy. In this report, we describe the LUS technique in detail and demonstrate important landmarks that provide useful orientation during an LUS examination. The technical limitations and pitfalls are also discussed.

Evaluation of the role of laparoscopic ultrasonography in the staging of oesophagogastric cancers

INTRODUCTION

The role of laparoscopic ultrasound (LUS) during staging laparoscopy for pancreatic cancers is established but remains debatable in evaluating oesophagogastric cancers.

METHODS

A retrospective consecutive case series consisting of patients undergoing staging laparoscopy in two centres (centre A and B) was carried out over a 5-year period (2000-2005). Patients in centre B underwent LUS following laparoscopic assessment using a 7.5-MHz probe. Staging laparoscopy in both centres was performed using a standardised three-port protocol using a 30 degrees laparoscope. All suspicious lesions were sent for histological assessment for confirmation of malignancy.

RESULTS

There were 201 patients in centre A (83 gastric, 138 lower oesophageal/junctional cancers) and 119 patients in centre B (51 and 68, respectively). There were no differences between the two centres for patient demographics and tumour site. There was no difference between the two centres for the detection of metastatic disease using laparoscopic assessment alone (A 13% versus B 20%, p = 0.12). However, there was a significant difference (13% versus 28%, p = 0.001) with the additional use of LUS in centre B. The findings in the additional 8% (n = 9) were para-aortic lymphadenopathy (n = 5), liver metastasis (n = 3) and local extension (n = 1). Five had gastric and four lower oesophageal/junctional cancers. The negative predictive value was 6.4% for centre A and 4.5% for centre B.

CONCLUSION

The addition of LUS increased the detection rate of metastasis by 8% but there was little impact on the false-negative rate. LUS is useful in detecting metastatic lymphadenopathy beyond the limits of curative resection and liver metastasis.

The role of echo-laparoscopy in abdominal surgery: five years' experience in a dedicated center

BACKGROUND

For more than 20 years intraoperative ultrasonography (IOUS) has been considered an important diagnostic tool in abdominal surgery. In the last few years, with the spread of laparoscopic surgery, echo-laparoscopy (LIOUS) has gradually replaced open ultrasonography, aiming to achieve similar results.

METHODS

LIOUS was performed using an ALOKA 5.500 device, provided with a linear flexible laparoscopic probe that was compatible with a 10-mm port. IOUS was performed by means of a linear side-view, T-shaped or microconvex probe. The probes were sterilized with hydrogen peroxide. No water bath was used during the surgical examination, but full contact of the probe with the surface of the involved organ was always attempted. From 2001 to 2005, 36 liver resections, 40 pancreas procedures, 203 procedures for suspected common bile duct calculi, 541 colon and 82 stomach resections, and 82 adrenal surgery procedures were performed. IOUS or LIOUS was performed in 432 patients (43.8%). All livers and pancreases underwent intraoperative ultrasound, while biliary, colonic, gastric, and adrenal pathologies were selectively studied when there were doubts about the location and extension of the disease.

RESULTS

IOUS and LIOUS were valuable diagnostic procedures, supplying relevant clinical information in 65.1% of the patients and modifying the surgical approach in 17.2%. LIOUS was used instead of cholangiography to study bile ducts when lythiasis was suspected, achieving high diagnostic specificity (98%) and accuracy (100%). Surgical anatomy of the bile ducts was correctly identified by LIOUS in every case.

DISCUSSION

In our experience IOUS and LIOUS were of the utmost importance in better defining staging of disease, infiltration of neighboring structures, number and size of nodular lesions, and anatomy of the hepatic pedicle and intrahepatic structures, thus making it possible to more accurately plan surgical procedures.

The role of staging laparoscopy in oesophagogastric cancers

AIMS

Selection of patients for treatment of oesophagogastric cancers rests on accurate staging. Laparoscopy has become a safe and effective staging tool in upper gastrointestinal cancers because of its ability to detect small peritoneal and liver metastases missed by imaging techniques. The aim of this study was to evaluate the role of staging laparoscopy (SL) in determining resectability of oesophagogastric cancers.

METHODS

A review of 511 patients with oesophagogastric cancers referred to our centre during a 7-year period was performed. Four hundred and sixteen of them assessed to have resectable tumours after preoperative staging with CT and/or ultrasound underwent SL. The main outcome measure was the number of patients in whom laparoscopy changed treatment decision.

RESULTS

Staging laparoscopy changed treatment decision in 84 cases (20.2%): locally advanced disease in 17, extensive lymph node disease in four and distant metastases (liver and peritoneum) in 63 cases. The sensitivity of laparoscopy for resectability was 88%. Eighty-one percent of patients who had combined CT scan and EUS were resectable at surgery compared with 65% of those who had CT scan alone (statistically significant with P-value<0.05). Of those patients deemed resectable by SL 8.1% were found to be unresectable at laparotomy, 16 with locally advanced disease and 11 with metastases.

CONCLUSION

Staging laparoscopy avoided unnecessary laparotomy in 20.2% of our patients and was most useful in adenocarcinoma, distal oesophageal, GOJ and gastric cancers and probably not necessary in lesions of the upper two-third of the oesophagus.

The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer

The object of this article is to assess current staging accuracies for individual modalities and to investigate the influence of the multidisciplinary team (MDT) on clinical staging accuracies and treatment selection for patients with gastro-esophageal cancer. Patients newly diagnosed with gastric or esophageal cancer and who were deemed suitable for surgical resection by the MDT were studied. Patients were staged with a combination of computerized tomography (CT), endoscopic ultrasound (EUS) and laparoscopic ultrasound (LUS). Additionally, the MDT determined an overall clinical stage for each patient after discussion at the MDT meeting. Treatments were selected according to this final clinical stage. Final histopathological staging (pTNM) was available for all patients and was used as the gold standard for determining staging accuracy. Suitability of treatment selection was assessed once final pTNM was available. One hundred and eighteen patients were studied. Endoscopic ultrasound was the most accurate individual staging modality for the loco-regional assessment of esophageal tumors (T stage accuracy 78%, N stage accuracy 70%). Laparoscopic ultrasound was the most accurate modality in T staging of gastric cancers (91%). The MDT stage was more accurate than each individual staging modality for T and N staging for both gastric and esophageal cancers (accuracy range: 88-89%) and was better for the assessment of nodal disease than each individual modality (CT P < 0.001, EUS P < 0.01, LUS P < 0.01). Overall staging accuracy as determined at the MDT meeting was increased and resulted in only 2/118 (2%) patients being under-treated. The MDT significantly improves staging accuracy for gastro-esophageal cancer and ensures that correct management decisions are made for the highest number of individual patients.

Combined preoperative endoscopic and laparoscopic ultrasonography for prediction of R0 resection in upper gastrointestinal tract cancer

BACKGROUND

This study evaluated the ability of combined endoscopic and laparoscopic ultrasonography to predict R0 resection and avoid unnecessary surgery in patients with upper gastrointestinal tract cancer (UGIC).

METHODS

A total of 411 consecutive patients with UGIC (182 pancreatic cancers, 134 gastric cancers and 95 oesophageal cancers) treated between January 2002 and May 2004 were analysed prospectively. The allocation of patients into resectability groups by endoscopic ultrasonography (EUS) and laparoscopic ultrasonography (LUS) was compared with the treatment actually undertaken.

RESULTS

The combination of EUS and LUS correctly predicted R0 resection in 90.6 per cent, R1-R2 in 91 per cent and irresectability in 91.4 per cent of patients. Ten patients (2.4 per cent) had explorative laparotomy only. There were no complications associated with the EUS and LUS procedures.

CONCLUSION

The routine use of EUS and LUS before surgery predicted R0 resection in nine of ten patients and reduced the number of unnecessary laparotomies to less than 3 per cent.

Clinical outcomes with laparoscopic stage M1, unresected gastric adenocarcinoma

OBJECTIVE

For patients with laparoscopic stage M1 gastric adenocarcinoma, no resection of the primary tumor, and systemic chemotherapy, this study investigated the incidence of subsequent palliative intervention and survival.

SUMMARY BACKGROUND DATA

Laparoscopy was performed for patients with computed tomography scan stage M0 disease and no significant obstruction or bleeding.

METHODS

A prospectively maintained database for 1993 to 2002 was used to identify 165 patients (median age, 63 years) with laparoscopic M1 disease in the peritoneum (P1, adjacent to stomach, 9%; P2, few distant sites, 35%; or P3, disseminated, 30%) or liver (10%) or both (16%). Functional performance status (FPS, Eastern Cooperative Oncology Group) was 0 to 1 (84%) or 2 (16%).

RESULTS

Subsequent intervention was performed on 50% of patients, at median interval of 4 months (range, 1-35 months) after laparoscopy. Intervention was performed on the stomach for obstruction (33%), bleeding (8%), or perforation (1%) or on a distant site for a metastasis-related complication (20%). More than one intervention (maximum, 4) was performed in 21%. Laparotomy was necessary in 12%; the remainder had endoscopic or radiologic procedures or radiation therapy only. There was one intervention-related death. Median survival was 10 months, with 1-year survival of 39%. On multivariate analysis, better FPS (0-1; odds ratio, 4; P=0.001) and limited peritoneal metastasis (P1 or P2; 2; P=0.01) were independently associated with improved survival.

CONCLUSIONS

The incidence of subsequent intervention was 50%, but few patients had laparotomy. Intervention-related mortality was minimal. The burden of metastatic disease and functional performance status were important prognostic factors.

Advanced esophageal cancer

Although the prognosis for patients with early cancer is good, throughout the world the majority of patients present with advanced disease, and in them, survival is poor. Accurate staging is essential to inform prognosis; to select candidates who may be cured by surgery alone; to select patients requiring neoadjuvant therapy, especially when new protocols are being studied; and to detect patients with advanced disease who would be best served by palliative therapy.

Trends in oesophago-gastric surgery in Scotland

BACKGROUND

The last twenty years have seen significant changes in both the incidence and treatment of gastro-oesophageal disorders as well as a process of subspecialisation in general surgery. The aim of this study is to identify the changes in gastro-oesophageal surgery in Scotland during this period.

METHODS

A retrospective analysis of three years of data, taken over a 20-year period (1977, 1987 and 1997) obtained from the Information and Statistics Division of the Scottish National Health Service, examining the number of patients with oesophageal cancer, gastric cancer and gastro-oesophageal reflux disease (GORD) treated by general and thoracic surgeons.

RESULTS

There was a significant increase (p=0.001, chi2) in the number of patients with oesophageal cancer (2.52-fold) and gastric cancer (1.4-fold) treated by general compared with thoracic surgeons. Since 1977, the overall operability for oesophageal cancer has remained unchanged, while a significant decrease in the overall operability of gastric cancer was noted (p<0.001, chi2). There was a 3-fold increase in the incidence of GORD with a significant increase (p<0.001, chi2) of those treated surgically. Since 1977, there has also been a significant shift of workload from thoracic to general surgical units.

CONCLUSIONS

Scotland has seen a consistent increase in the surgical workload generated by gastro-oesophageal malignancies over the last three decades without any improvement in the operability rate. Surgically treated GORD has also increased, probably due to the introduction of minimally invasive techniques. These trends have implications on healthcare planning, resource allocation and surgical training. Appropriate resources and trainees should follow the patients to those units carrying out this activity. Further centralisation of these services is likely to follow.

The role of staging investigations for oesophago-gastric carcinoma

AIMS

To study the frequency with which unresectable disease was identified on pre-operative staging investigations in patients with oesophago-gastric carcinoma, and to audit whether a staging protocol had reduced the rate of exploratory surgery.

METHODS

Ninety-eight patients with oesophageal carcinoma, 89 patients with adenocarcinoma of the gastro-oesophageal junction (GOJ) and 68 patients with gastric carcinoma were staged according to a protocol of computerised tomography, laparoscopy and endoscopic ultrasound.

RESULTS

The frequency with which each investigation identified unresectable disease was as follows: (a) computerised tomography-oesophagus 12/67, GOJ 13/58, stomach 10/60; (b) laparoscopy-oesophagus 3/22, GOJ 5/45, stomach 8/23; and (c) endoscopic ultrasound-oesophagus 15/55, GOJ 3/30. By tumour location, rates of exploratory surgery were 1/18 for the oesophagus, 12/35 for the GOJ and 4/42 for the stomach. All of the staging failures in patients with GOJ carcinomas related to posterior tumour extension into the lesser sac.

CONCLUSIONS

Staging investigations precluded resection in one-third of patients, the greatest yield being for laparoscopy in gastric carcinoma. In spite of this, 18% of patients undergoing surgical intervention underwent exploratory surgery alone, notably patients with GOJ carcinoma.

Multiport staging laparoscopy in esophageal and cardiac carcinoma

Between February 1993 and September 2000, 320 patients with esophageal cancer were referred to our oesophagogastric unit. One hundred and thirty-three consecutive patients with histologically proven carcinoma of the esophagus were assessed with a view to resection using multiport staging laparoscopy. Multiport staging laparoscopy was performed as a short stay/day case procedure in 133 patients with esophageal and oesophagogastric junctional carcinoma. Multiple ports were used to inspect the liver, omentum, peritoneal surfaces, coeliac/left gastric lymph nodes and obtain biopsies and cytology. Satisfactory assessment was possible in 127 cases (95%). Laparoscopy detected incurable disease in 31 patients (24%), some of whom had more than one contraindication to surgery, including hepatic metastases (n = 10), peritoneal metastases (n = 12) and malignant small volume ascites (n = 5). Lymph node metastases were confirmed histologically by biopsy at laparoscopy in 26 patients (fixed nodes, n = 14; mobile nodes, n = 12). Sensitivity for the detection of liver and peritoneal metastases was 100%, and lymph node metastases were 83%. Specificity for detection of hepatic metastases was 99%, 100% for peritoneal metastases and 82% for lymph node metastases. Ninety-nine patients proceeded to definitive surgery and only two were unresectable. Multiport laparoscopic assessment of metastases in patients with esophageal carcinoma avoids unnecessary surgery and allows for more efficient use of theatre and intensive care time.

Impact of diagnostic laparoscopy on the management of gastric cancer: prospective study of 120 consecutive patients with primary gastric adenocarcinoma

BACKGROUND

Peritoneal seeding or liver metastases found at laparotomy usually preclude curative treatment in patients with gastric adenocarcinoma. Such exploratory laparotomies may be avoided by diagnostic laparoscopy. However, routine diagnostic laparoscopy does not benefit those patients who proceed to laparotomy after negative laparoscopy. The aim of this study was to evaluate prospectively the selective use of laparoscopy in uncertain situations.

METHODS

One hundred and twenty consecutive patients with primary gastric adenocarcinoma were studied prospectively. Diagnostic laparoscopy was performed in patients with clinical T4 tumours or suspected metastases, unless laparotomy was required for symptomatic disease.

RESULTS

Ninety-six of 120 patients were selected for immediate laparotomy with curative intent (n = 81) or for palliation (n = 15). In two of the 81 patients gastrectomy was abandoned because of unexpected peritoneal carcinomatosis. Fifteen patients underwent diagnostic laparoscopy, which identified intra-abdominal metastases in six; the other nine patients proceeded to laparotomy, which revealed peritoneal metastases not detected at laparoscopy in four patients. The remaining nine patients had overt metastases and were referred for systemic chemotherapy without abdominal exploration.

CONCLUSION

Diagnostic laparoscopy in selected patients effectively limits the number of unnecessary invasive staging procedures. Routine use of diagnostic laparoscopy in all patients with gastric adenocarcinoma is not warranted.

Hand-assisted laparoscopic surgery for cancer

Minimally invasive surgical approaches were designed to enhance quality of care and improve patient outcome by minimizing postoperative pain, shortening hospital stay, reducing costs, and facilitating early return to work and presurgical lifestyle. The hand-assisted laparoscopic approach for resection of cancer is still in its formative stage, and this review places it in proper perspective within the context of minimally invasive surgery currently being performed for both benign and malignant disease. The review also outlines the potential advantages and disadvantages, techniques, and site-specific procedures of hand-assisted laparoscopic surgery for cancer.

A comparison of computerised tomography, laparoscopic ultrasound and endoscopic ultrasound in the preoperative staging of oesophago-gastric carcinoma

INTRODUCTION AND OBJECTIVE

Oesophago-gastric carcinoma is associated with a poor prognosis despite advances in diagnosis and treatment. Accurate preoperative staging of gastro-oesophageal carcinoma is, therefore, essential in order to determine patient selection for potentially curative resection. The aim of this study was to evaluate and compare the role of computerised tomography (CT), laparoscopic ultrasound (LapUS) and endoscopic ultrasound (EUS) in the staging of oesophago-gastric carcinoma.

METHODS AND PATIENTS

Thirty-six patients with histologically proven carcinoma of the oesophagus or stomach who were considered fit for surgical resection were identified from a prospectively collected database. All patients underwent spiral CT, LapUS and EUS as part of their preoperative staging investigations. RESULTS from the staging modalities were compared retrospectively with final histopathology where available and to intraoperative findings where the tumour was irresectable.

RESULTS

Locally advanced tumours (T3/T4) were accurately identified by CT in 15/16 (94%) and by EUS in 14/16 (88%). LapUS was unable to detect 11 tumours (of which five were T3/T4) because they were above the diaphragm, but in the locally advanced cases where the tumour could be seen the accuracy was 10/12 (83%). EUS was the best modality for assessing early tumours and locoregional nodal involvement with accuracies of 8/13 (62%) and 21/29 (72%), respectively. EUS accuracies rose to 64, 92 and 83% for T1/T2, T3/T4 and N staging with the exclusion of those patients (n=6) in whom strictures prevented full assessment. LapUS had a specificity of 100%, compared to 90% for CT and was more accurate than CT for assessing distant metastases (accuracy of 26/32 (81%) compared to 23/32 (72%) for CT).

CONCLUSIONS

Although this study is small it has confirmed that CT, EUS and LapUS act in a complimentary manner to provide the most complete preoperative staging for patients with oesophago-gastric cancer.

Evaluation of minimally invasive surgical staging for esophageal cancer

BACKGROUND

Conventional imaging studies (computed tomography and endoscopic esophageal ultrasonography) used for preoperative evaluation of patients with esophageal cancer can be inaccurate for detection of small metastatic deposits. We evaluated the efficacy of minimally invasive surgical (MIS) staging as an additional modality for evaluation of patients with esophageal cancer.

METHODS

Between December 1998 and February 2001, 33 patients with esophageal cancer were evaluated for surgical resection. Conventional imaging studies demonstrated operable disease in 31 patients and equivocal findings in 2 patients. All patients then underwent MIS staging (laparoscopy, bronchoscopy, and ultrasonography of the liver). We compared the results from surgical resection and MIS staging with those from conventional imaging.

RESULTS

MIS staging altered the treatment plan in 12 (36%) of 33 patients; MIS staging upstaged 10 patients with operable disease and downstaged 2 patients with equivocal findings. MIS staging accurately determined resectability in 97% of patients compared with 61% of patients staged by conventional imaging. The specificity and negative predictive value for detection of unsuspected metastatic disease in MIS staging were 100% and 96%, respectively, compared with 91% and 65%, respectively, for conventional imaging studies.

CONCLUSION

In addition to conventional imaging studies, MIS staging should be included routinely in the preoperative work-up of patients with esophageal cancer.

The role of pretherapeutic laparoscopy in the selection of treatment for patients with gastric carcinoma: a proposal for a laparoscopic staging system

BACKGROUND

A pretherapeutic staging system to design nonoperative or neoadjuvant treatments in gastric cancer is required. In this study, a simple staging system based on laparoscopic findings to define a treatment algorithm was developed.

METHODS

A retrospective cohort study was conducted of 151 patients allocated into four stages based on laparoscopic findings. The depth of tumor invasion and the presence of metastasis based on laparoscopic findings were used to construct these stages. Laparoscopic findings were compared with histopathology.

RESULTS

An excellent agreement of the laparoscopy-defined depth of invasion and the surgical pathology standard was found (weighted kappa 0.85). The likelihood ratios for a positive and negative laparoscopic diagnosis of metastasis were 40.4 and 0.015, respectively (98.5% sensitivity, 97.6% specificity). Those for positive and negative diagnosis of resectability were 2.6 and 0.03, respectively (98.4% sensitivity, 62% specificity). The laparoscopic stages presented significant prognostic value. Two-year survival was 93%, 69%, 60%, and 17%, respectively. Surgical resection was possible in 100%, 100%, 49%, and 12%, respectively.

CONCLUSIONS

The proposed laparoscopic staging system is a simple and reproducibLe way for selection of a suitable therapy. It allows for adequate stratification of the main risk factors in the setting of clinical trials evaluating preoperative treatments.

Laparoscopic peritoneal lavage in staging gastric and oesophageal cancer

AIMS

Accurate staging of gastric, oesophageal and oesophagogastric cancer is essential to avoid unnecessary laparotomies in patients where only palliation is appropriate. This requires a multimodal approach utilizing endoscopy, computed tomography and laparoscopy. Previous authors have found that the presence of free peritoneal tumour cells (FPTCs) detected at laparoscopy or laparotomy confers a poorer prognosis. However, various methods of peritoneal lavage are described. The aim of this study was to evaluate the prognostic value of our technique of peritoneal lavage.

MATERIALS AND METHODS

88 staging laparoscopies with peritoneal lavage were carried out between March 1997 and February 1999 on patients eligible for attempted curative resection of a gastric, oesophageal or oesophagogastric cancer. During laparoscopy the pelvis was irrigated with 200 ml of normal saline, with 100 ml aspirated and examined cytologically. Patients were followed-up until September, 1999.

RESULTS

11 patients had FPTC-positive cytology with a median survival following laparoscopy of 122 days (95% CI 82-161) with only a single patient surviving more than one year. In the FPTC-negative group, median survival was 378 days (95% CI 256,-). Log-rank Chi(2)=16.7, P<0.001.

CONCLUSIONS

The presence of FPTCs detected by our technique is a contraindication to attempted curative resection - palliation only (medical or surgical) is appropriate.

One-year survey of carcinoma of the oesophagus and stomach in Wales

BACKGROUND

The aim of the study was to identify all patients who presented with oesophagogastric malignancy within a single National Health Service region (Wales) over 1 year, and to follow the cohort for 5 years. Management and outcome were analysed to identify current practice and draft guidelines for Wales.

METHODS

Patients were identified from hospital records. Details were recorded in structured format for analysis.

RESULTS

Analysable data were obtained for 910 of 916 patients. The overall incidence was 31.4 per 100 000 population. Treatment was by resection 298 (33 per cent), palliation 397 (44 per cent) or no treatment 215 (24 per cent). The 30-day mortality rate was 12 per cent and the in-hospital mortality rate was 13 per cent. Some 226 patients (25 per cent) were alive at 2 years. Resection conferred a significant survival advantage over palliation (P < 0.001) and no treatment. Anastomotic leakage occurred in 16 patients (5 per cent), of whom eight died in hospital. 'Open and close' operations were common (23 per cent), laparoscopy was infrequent (16 per cent), and many surgeons undertook small caseloads. Operating on fewer than six patients per year increased the mortality rate after partial gastrectomy (P < 0.05) and was associated with a trend to a higher mortality rate after mediastinal and cardia surgery. Operating on more than 70 per cent of patients seen resulted in a significantly higher mortality rate (P < 0.01) irrespective of case volume.

CONCLUSION

Tumour resection conferred a survival advantage. Wider use of laparoscopy is advocated. Improved selection for surgery should result in a lower mortality rate.