• Reasoning

    Biliary tract tumors can be divided into two main categories: gallbladder cancers and cholangiocarcinomas. The two groups differ in their patterns of spread and in prognosis. Gallbladder cancer tends grow more rapidly and has earlier dissemination which makes staging laparoscopy a more useful tool in this setting. In contrast, cholangiocarcinomas tend to be more locally invasive, decreasing the yield of staging laparoscopy. Preoperative imaging to determine resectability of biliary tract cancers often includes ultrasound, CT scan, direct cholangiography (PTC or ERCP), and/or MRCP. These radiologic preoperative studies are used to evaluate the extent of tumor within the biliary tree, vascular invasion, hepatic lobar atrophy, and metastatic disease.

    Many gallbladder cancers are incidental findings during or after laparoscopic cholecystectomy. For patients with T2 lesions or greater, liver resection along regional lymphadenectomy is indicated as a secondary procedure, therefore obviating the need for staging laparoscopy .

  • Indications
    • Known or suspected gallbladder cancer without evidence of unresectable or metastatic disease
    • Stage T2 or T3 hilar cholangiocarcinoma without evidence of unresectable or metastatic disease determined by preoperative imaging
  • contraindications
    • Known metastatic or unresectable disease
    • Known stage T1 disease found incidentally may potentially be treated with cholecystectomy alone.
  • Technique

    The patient is placed in the supine position, and pneumoperitoneum is established. A 30-degree laparoscope through an umbilical port is recommended for optimal visualization of the entire abdominal cavity. Additional ports can be placed in the right anterior axillary line and epigastric area as needed. Careful and thorough inspection of the peritoneum, pelvis, liver surfaces, porta hepatitis, gastrohepatic ligament, and omentum should be made. A standard laparoscopic ultrasound probe may improve the yield of finding lesions in the liver and lymph node metastasis in the porta and celiac nodal areas. Biopsy specimens of peritoneal metastases, nodes suspected to be malignant, or hepatic lesions should be obtained to determine the extent of disease.

  • Evidence

    Staging laparoscopy can detect peritoneal or superficial liver metastases (23%), which are often not detected by preoperative imaging. For gallbladder cancer, the overall yield for detecting unresectable disease using staging laparoscopy as been reported to be 48%, with a diagnostic accuracy of 58%. In cholangiocarcinoma, as many as 9-42% patients may avoid laparotomy with an accuracy of 42-53%. The sensitivity and negative predictive value of staging laparoscopy for detecting unresectable disease have been reported to be 60% and 52%, respectively. The yield of staging laparoscopy for gallbladder cancer is slightly higher than for cancers of the biliary tree because of the higher incidence of peritoneal and liver metastases associated with gallbladder cancer. One study suggests that the yield for cholangiocarcinoma may be improved if staging laparoscopyis limited to patients with higher stage primary tumors on preoperative imaging (T2 and T3), since there are few patients with stage T1 disease who are deemed unresectable (9%) by laparoscopy. The added benefit of laparoscopic ultrasound in improving the diagnostic yield of the procedure has been inconsistent.

  • References
    • van Delden OM, de Wit LT, Nieveen van Dijkum EJM, et al. Value of laparoscopic ultrasonography in staging of proximal bile duct tumors. J Ultrasound Med 1997;16:7-12.
    • Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Staging laparoscopy in patients withextrahepatic biliary carcinoma. Ann Surg 2002; 235:392-399.
    • Connor S, Barron E, Wigmore SJ, Madhavan KK, Parks RW, Garden OJ. The utility of laparoscopic assessment in the preoperative staging of suspected hilar cholangiocarcinoma. J Gastroint Surg 2005;9:476-480.
    • Tilleman EHBM, de Castro SMM, Busch ORC, et al. Diagnostic laparoscopy and laparoscopic ultrasound for staging of patients with malignant proximal bile duct obstruction. J Gastroint Surg 2002;6:426-430
  • Details on Biliary Tract Cancer Surgery

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