• Reasoning

    The overall prognosis for patients with esophageal cancer is poor. Many patients with esophageal cancer present at an advanced stage with lymph node or even distant metastases. Patients with advanced cancer commonly undergo preoperative chemotherapy and radiation in an attempt to improve survival. Thus, the value of precise staging is important to separate patients with an early stage tumor who are candidates for immediate curative resection from those who need neoadjuvant therapy. The most common radiologic tests used to confirm the stage of the tumor are CT scan, endoscopic ultrasound, and PET scan. Staging laparoscopy may aid in more accurate staging of esophageal cancers to guide the most appropriate treatment and avoid non-therapeutic laparotomy.

  • Indications

    Staging laparoscopy should be used for patients with esophageal cancer who are potential candidates for curative surgical resection based on a negative preoperative staging for lymph node or distant metastases. Furthermore, the procedure can be used for the placement of enteral feeding access in patients when a percutaneous endoscopic gastrostomy cannot be undertaken, and the patients are candidates for neoadjuvant chemotherapy.

  • Contraindications

    The primary contraindication is known metastatic disease. In addition, dense intra-abdominal adhesions, particularly in the upper abdomen, from prior surgery may be a relative contraindication.

  • Technique

    The patient is placed in the supine position, and pneumoperitoneum is established. Additional ports in the left upper quadrant and epigastric area can be placed as needed. Full inspection of the peritoneal cavity helps evaluate for peritoneal or liver metastases. If no distant disease is discovered, then the left lateral lobe of the liver is elevated to expose the gastroesophageal junction, and the patient is placed in steep reverse Trendelenburg position. The tumor is inspected for extension into the surrounding area. Lymph nodes in the gastrohepatic ligament or celiac axis suspected to be malignant are biopsied. An optional laparoscopic feeding jejunostomy can be placed when neoadjuvant therapy is planned.

    In addition, combined thoracoscopic/laparoscopic staging has been described to improve staging for esophageal cancer by increasing the number of positive lymph nodes identified compared with conventional staging. Specifically for the thoracoscopic evaluation, the patient is placed in prone position (authors preference) or left lateral decubitus position with single-lung ventilation. Two to three thoracic trocars are placed, and the mediastinal pleura overlying the esophagus is incised to identify and biopsy lymph nodes as needed.

  • Problems
    • Procedure and anesthesia related complication
    • False negative studies that lead to unnecessary laparotomy and thoracotomy
    • Delay in definitive treatment when the procedure does not coincide with planned laparotomy
    • Unnecessary cost if procedure has a very low yield
    • Potential adverse oncologic effects of the procedure
  • Benefits
    • Accurate preoperative staging can identify patients with an early stage cancer in whom curative resection is possible.
    • The patients with distant or lymph node metastasis are best treated with chemotherapy and radiation as neoadjuvant therapy or even palliation.
    • Since patients undergoing staging laparoscopy will usually have a faster postoperative recovery than those undergoing exploratory laparotomy, the time interval to adjuvant therapy may be shorter.
    • In addition, laparoscopic feeding jejunostomy can be placed during SL when neoadjuvant therapy is anticipated.
  • Evidence

    At present the data is limited to provide firm recommendations. There are no large randamised trials to which could provide clear guidelines. The study by Bonavina L et al has shown that when all preoperative imaging indicates no metastatic disease, staging laparoscopy with or without laparoscopic ultrasound has a sensitivity of 71% in finding peritoneal metastases, 78% for nodal metastases, and 86% for liver metastases. This compares with ultrasound sensitivities of 14%, 11%, 86%, respectively, and CT scan sensitivities of 14%, 55%, 71%, respectively. Heath EI Et al have reported an accuracy of 75-80%. However, several reports indicate that only 0.08-10% of patients actually had a change in their management based on the results of laparoscopy. In the hands of a skilled thoracic surgeon, combined thoracoscopic and laparoscopic staging can be performed over 70% of the time. Krasna MJ et al have shown that when compared with final pathologic staging, thoracoscopic and laparoscopic staging has a sensitivity of 64%, specificity of 60%, and accuracy of 60%.

  • References
    • Krasna MJ, Reed CE, Nedzwiecki D, et al. CALGB 9380: A prospective trial of the feasibility of thoracoscopy/laparoscopy in staging esophageal cancer. Ann Thorac Surg 2001;71:1073-1079.
    • Bonavina L, Incarvone R, Lattuada E, et al. Preoperative laparoscopy in management of patients with carcinoma of the esophagus and of the esophagogastric junction. J Surg Onc 1997; 65:171-174.
    • Heath EI, Kaufman HS, Talamini MA, et al. The role of laparoscopy in preoperative staging of esophageal cancer. Surg Endo 2000;14:495-499.
    • Romijn MG, van Overhagen H, Spillenaar Bilgen EJ, et al. Laparoscopy and laparoscopic ultrasonography in the staging of oesophageal and cardial carcinoma. Br J Surg 1998;85:1010-1012.
    • Krasna MJ, Jiao X, Mao YS, et al. Thoracosopy/laparoscopy in the staging of esophageal cancer. Surg Laparosc Endosc Percutan Tech 2002;12: 213-218.
    • Wallace MB, Nietert PJ, Earle C, et al. An analysis of multiple staging management strategies for carcinoma of the esophagus: computed tomography, endoscopic ultrasound, positron emission tomography, and thoracoscopy/laparoscopy. Ann Thorac Surg 2002;74:1026-1032.
  • Details on Esophageal Cancer Surgery

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