Staging Laparoscopy: A Peek May Save a Cut

Abdominal malignancies comprise some of the most common causes of cancer and account for significant morbidity and mortality throughout the world. Despite a continuing worldwide decline in its prevalence, gastric cancer remains the second most common malignancy in the world [1]. Pancreatic adenocarcinoma is the fifth leading cause of cancer death in men [2], with 25 000 cancer-related deaths annually in the United States alone [3] and a dismal 3 % 5-year survival rate after diagnosis [4]. Esophageal squamous cell carcinoma accounts for 5 - 7 % of all gastrointestinal malignancies and the incidence of esophageal adenocarcinoma is rapidly rising among white North American males and Europeans [5]. Less frequently encountered malignancies such as nonpancreatic periampullary tumors and gallbladder cancer are also associated with high rates of morbidity and mortality [6] [7].

Despite utilization of newer and more aggressive surgical and chemotherapeutic interventions, currently available therapeutic modalities yield poor overall results with the best outcomes seen with early stage disease. Unfortunately, outside of high prevalence areas where mass screening is performed, most patients present with late stage disease not amenable to current therapeutic measures. Furthermore, despite advances in imaging techniques and introduction of new modalities such as endoscopic ultrasound, in 10 - 40 % of patients tumors which are felt to be resectable prior to laparotomy are found to be unresectable because of the presence of small intra-abdominal metastases or local tumor ingrowth [8] [9] [10] [11] [12]. Consequently, techniques which would enhance staging of abdominal malignancies would avoid unnecessary surgical intervention and potential morbidity and mortality. In addition, they would allow for more appropriate stratification and enrollment of patients in research protocols designed to determine the efficacy of new therapeutic modalities.

The initial imaging study for staging of abdominal malignancies is typically a new-generation computed tomography (CT) scan of the abdomen, which detects up to 85 % of distant metastases but may miss gastric lesions of < 5 mm in size [1] or pancreatic lesions < 1.5 - 2.0 cm [13] [14]. Poor delineation of depth of invasion and lymph node involvement contribute to an overall staging accuracy of approximately 50 % for gastric tumors, and a reported false-positive rate of up to 15 % [1].

Although angiography is highly accurate in detecting vascular invasion (up to 95 % in pancreatic malignancies), its accuracy in predicting overall resectability is more limited (54 %) because of the presence of concurrent metastases [10] The role of angiography in preoperative staging is diminishing, not only because helical CT scanning, magnetic resonance (MR) angiography and CT angiography provide similar information, but because they do so without invasiveness and with minimal potential complications [13]. In addition, recent experience with pancreatic cancer indicates that endoscopic ultrasound is slightly more sensitive than angiography in detecting portal and splenic vein invasion, but less sensitive for diagnosing superior mesenteric vein involvement [15].

The introduction of endoscopic ultrasound has been especially helpful because it is excellent for identifying the depth of invasion and presence of lymph node involvement. Use of a 7.5 - 12-MHz transducer in the stomach allows for a depth of view of up to 5 cm and provides good resolution for detecting depth of invasion (67 - 91 %) and regional lymph node involvement (50 - 87 %) [16]. Not surprisingly the limited depth of view does not allow for detection of distant lymph nodes, hepatic involvement or distant metastases. In esophageal cancer, endoscopic ultrasound is more accurate than CT scan in detecting depth of invasion (84 % vs. 20 %) and regional lymph node involvement [5]. The characteristics of malignant compared with benign lymph nodes are not yet well standardized, however [17]. In addition, endoscopic ultrasound requires considerable expertise which may not be widely available. The combination of new-generation CT scans and endoscopic ultrasound does yield an overall staging accuracy of up to 80 % in gastric cancer [1]. However, this means that approximately 20 % of patients may be subjected to unnecessary surgical intervention, with various groups reporting unexpected peritoneal or hepatic metastases, local tumor growth or lymph node involvement at the time of explorative laparotomy [8] [9] [10] [11] [12].

As far back as the turn of the century, laparoscopy has been used as a diagnostic tool [18] [19]. The recent proliferation of noninvasive surgery has in part rekindled interest in the use of laparoscopy in the preoperative staging of intra-abdominal malignancies. Laparoscopy allows for direct inspection of the tumor bed, evaluation of the abdominal cavity, including the lesser sac, for metastatic spread or lymph node involvement, the biopsy of questionable lesions, and achievement of prompt hemostasis. Laparoscopy is able to detect hepatic or peritoneal lesions as small as 1 - 2 mm in diameter [20], and considering that 40 % of liver metastases are surface lesions [21], laparoscopy is particularly well suited for staging purposes. The ability of staging laparoscopy to demonstrate heretofore undetected metastases, thus precluding unnecessary laparotomies, has been well documented in pancreatic cancer [8] [10] [22], periampullary tumors [23], esophageal cancer [5], gallbladder carcinoma and gastric cancer [7] [24] [25] [26] [27] [28], with more recent experience indicating a 20 - 25 % rate of detection of intra-abdominal metastases in patients with negative results from imaging studies. The concomitant use of other staging modalities, such as laparoscopic ultrasound and peritoneal washings, has further enhanced the diagnostic accuracy of staging laparoscopy [13].

Laparoscopy is typically performed under general anesthesia and thus exposes patients to certain risks. Staging laparoscopy has also been performed under conscious sedation, which avoids the risks and expense of general anesthesia but limits extensive manipulation, particularly blunt dissection into the lesser sac, and the use of laparoscopic ultrasound, because of the discomfort to the patient.

In our own experience in 109 patients with pancreatic cancer, 29 additional cases of metastatic disease were identified using laparoscopy where CT scanning did not detect metastases [22].

The role of staging laparoscopy in gastric cancer has been evaluated by a number of authors. In 1985, Shandall and Johnson questioned the utility of staging laparoscopy, because of the high rate of surgical palliative procedures which were required in their series (10/14 or 70 %) [7]. Several subsequent studies, however, have reported significantly lower requirements for surgical palliation and have established the utility of staging laparoscopy, emphasizing the importance of appropriate patient selection, for example of patients who do not require impending surgical palliation [24] [25] [26] [27] [28] [29] [30]. The two most recent studies reported a 24 - 27 % rate of avoidance of unnecessary laparotomy with only a 1 - 2 % rate of need for subsequent surgical intervention [29] [30].

The article by Feussner et al. [31] in this issue of Endoscopy is an important contribution to the field and emphasizes another important role of staging laparoscopy: the proper staging of patients for enrollment in appropriate preresection multimodality protocols. In 111 consecutive patients with advanced gastric cancer (stages T3 and T4), who were felt to be suitable for chemotherapy prior to surgical therapy, preoperative evaluation was carried out with endoscopy, endoscopic ultrasound, ultrasound and CT scanning. In addition, laparoscopy including a thorough inspection of the lesser sac was done, along with laparoscopic ultrasound when indicated. The prospective nature of the study, the extensive evaluation of the lesser sac, the use of endoscopic ultrasound, and the incorporation of laparoscopic ultrasound, lend strength to the study. Of particular interest is that in 17/111 (15.3 %) patients, the results of laparoscopy and biopsy actually downgraded the tumor stage, indicating a significant false-positive rate with the other modalities.

Staging laparoscopy is a powerful tool in complementing the role of CT imaging and endoscopic ultrasound in the preoperative staging of gastric cancer. It is minimally invasive, can be carried out under conscious sedation if necessary, and provides meaningful information which directly influences patient care by reducing the number of unnecessary laparotomies, avoiding potential morbidity and a lengthened hospital stay.

With the development of nonsurgical palliative measures, such as placement of endobiliary prostheses, the number of patients who do not require surgical palliation continues to grow. Thus the argument that many of these patients would require a surgical intervention in any case is not valid.

All patients with abdominal malignancies who do not need palliative surgical procedures and are being considered for surgical resection, should undergo a new-generation CT scan, followed by endoscopic ultrasound and then, again if no metastases are discovered, diagnostic laparoscopy prior to exploratory laparotomy. Further studies are needed to evaluate the role of laparoscopic ultrasound and peritoneal washings. In patients with suspected peritoneal metastases, a group in which false-positivity by CT scans has been reported, laparoscopy should also be done, since a subset of these patients may have resectable tumors or be eligible for multimodality therapy. Finally, in experimental protocols evaluating the efficacy of new treatment modalities, staging laparoscopy ensures proper stratification of participants.

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