• Reasoning

    In the primary treatment of colorectal cancer, staging laparoscopy is seldom used since surgical resection and palliation are typically indicated to prevent bleeding, obstruction, and perforation even in patients with advanced disease. However, patients who have liver metastases from a primary colorectal cancer may be candidates for curative resection when there is no other extrahepatic disease, and when all of the disease in the liver is resectable. Thus, staging laparoscopy for these patients can provide more accurate identification of all hepatic lesions, including size,

    number, and location, than non-invasive imaging. Staging laparoscopy may also be indicated in potentially convertible liver metastasis after few cycles of chemotherapy

  • Indications
    • Patients with resectable liver metastases from colorectal cancer but with no evidence of extrahepatic disease on non-invasive imaging
    • Potentially convertible liver metastasis after few cycles of chemotherapy to assess response and operability
  • clinical risk score as indication

    Jarnagin WR et al have developed a Clinical Risk Score (CRS) system to predict which patients will most likely benefit from staging laparoscopy. This system uses five preoperative criteria, which are independent factors of prognosis. Each factor is assigned one point:

    • lymph node-positive colon cancer,
    • disease-free interval less than 12 months (time of discovery of primary colon cancer to discovery of liver metastases),
    • more than one hepatic tumor,
    • CEA greater than 200 ng/mL within 1 month of surgery, and
    • size of largest hepatic tumor greater than 5 cm.

    If the CRS is greater than 2, then the yield of staging laparoscopy is higher.

  • contraindications

    Patients with known extrahepatic metastatic disease or unresectable hepatic disease

  • 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. A standard laparoscopic ultrasound probe is often used to systematically examine the entire liver, identifying all lesions suspected to be malignant. The ultrasound examination should also include the porta hepatitis and celiac lymph nodes. Ultrasound-guided biopsy of peritoneal, lymph node, and unsuspected liver lesions should be obtained.

  • Evidence

    The literature available on staging laparoscopy in colo-rectal cancers is limited. Comparative studies of open intraoperative ultrasound compared with laparoscopic ultrasound and preoperative

    CT scanning for colorectal metastases have shown that the yield is best with open intraoperative ultrasound, followed by laparoscopic ultrasound (98% yield; detected one lesion less than open intraoperative ultrasound), and CT scan 78% yield. Furthermore, staging laparoscopy and laparoscopic ultrasound have better sensitivity than imaging studies in the detection of nodal metastases (94% laparoscopic ultrasound vs. 18% imaging preoperatively). The combination of staging laparoscopy and laparoscopic ultrasound has been reported to detect unresectable disease in 25-42% of patients in whom preoperative radiological testing showed potentially curable disease. The use of laparoscopic ultrasound further identifies unresectable disease, which is not identified with laparoscopic inspection alone. In addition, the findings of the procedure have altered the management in 33-48% of patients.

  • References
    • Milsom JW, Jerby BL, Kessler H, et al. Prospective, blinded comparison of laparoscopic ultrasonography vs. contrast-enhanced computerized tomography for liver assessment in patients undergoing colorectal carcinoma surgery. Dis Colon rectum 2000;43:44-49.
    • Goletti O, Celon G, Galatioto C, et al. Is laparoscopic sonography a reliable and sensitive procedure for staging colorectal cancer? Surg Endosc 1998;12:1236-1241.
    • Jarnagin WR, Conlon K, Bodniewicz J, et al. A clinical scoring system predicts the yield of diagnostic laparoscopy in patients with potentially resectable hepatic colorectal metastases. Cancer 2001;91:1121-1128.
    • Rahusen FD, Cuesta MA, Borgstein PJ, et al. Selection of patients for resection of colorectal metastases to the liver using diagnostic laparoscopy and laparoscopic ultrasonography. Ann Surg 1999;230:31-37.
    • Thaler K, Kanneganti S, Khajanchee Y, et al. The evolving role of staging laparoscopy in the treatment of colorectal hepatic metastasis. Arch Surg 2005;140:727-734.
  • Details on Colon Cancer Surgery Details on Rectal Cancer Surgery

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