• Reasoning

    Pancreatic adenocarcinoma is diagnosed in just over 30,000 patients every year in the United States and has a dismal prognosis, with an almost identical yearly death rate. Surgery is the only modality that can lead to cure; however, most patients present with inoperable disease. The overall 5-year survival is <5%. Patients with localized disease have a 15% 5-year survival after curative resection. In a disease with such a poor prognosis even after curative resection, it is not only important to identify patients with resectable disease but also to spare patients with incurable disease the morbidity, inconvenience, and expense of an unnecessary operation. Thus, accurate staging of pancreatic adenocarcinoma is of paramount importance. A high quality CT scan of the pancreas is considered the best initial diagnostic modality for this disease. Nevertheless, even after appropriate preoperative imaging, 11-48% of patients are found to have unresectable disease during laparotomy. For this reason, many authors have introduced staging laparoscopy in the treatment algorithm of pancreatic adenocarcinoma patients in an effort to decrease the number of unnecessary laparotomies

  • Indications
    • As a staging procedure for pancreatic adenocarcinoma
    • For detection of imaging occult metastatic disease or unsuspected locally advanced disease in patients with resectable disease based on preoperative imaging prior to laparotomy
    • For assessment prior to administration of neo-adjuvant chemoradiation
    • For selection of palliative treatments in patients with locally advanced disease without evidence of metastatic disease on preoperative imaging
  • contraindications
    • Known metastatic disease
    • Inability to tolerate pneumoperitoneum or general anesthesia
    • Multiple adhesions/prior operations
  • Technique

    The procedure is usually performed under general anesthesia, and the majority of reports have used 15 mm Hg insufflation pressures. A thorough evaluation of peritoneal surfaces is performed. The suprahepatic and infrahepatic spaces, the surface of the bowel, the lesser sac, the root of the transverse mesocolon and small bowel, the ligament of Treitz, the paracolic gutters, and pelvis are inspected with frequent bed position changes as necessary. In addition to visual inspection, peritoneal washings can be performed, ascitic fluid, if present, sent for cytology, and biopsy specimens of lesions suspected to be malignant obtained. When no metastatic disease is identified on inspection, a detailed laparoscopic ultrasound examination can be employed during which the

    deep hepatic parenchyma, the portal vein, mesenteric vessels, celiac trunk, hepatic artery, the entire pancreas, and even pathologic periportal and paraaortic nodes can be evaluated and biopsied. The addition of color flow Doppler can further assist in the assessment of vascular patency. A controversy exists in the literature about the extent of staging laparoscopy for pancreatic adenocarcinoma patients. Advocates of a short duration procedure that is based only on inspection of abdominal organ surfaces argue that the procedure can be performed quickly (usually within 10–20 min), can be done through one port, does not require significant expertise, minimizes the risk of potential complications by the dissection near vascular structures, and has good diagnostic accuracy. On the other hand, advocates of a more extensive procedure that includes opening the lesser sac and assessment of the vessels argue that the diagnostic accuracy of the procedure can be enhanced by detecting metastatic lesions in the lesser sac, vascular invasion by the tumor, or deep hepatic metastasis, often missed by visual inspection alone, and that it can be performed safely without a significant increase in morbidity and within a reasonable time. It is very important, therefore, to consider these differences in technique when evaluating reports of the diagnostic yield of this procedure in patients with pancreatic adenocarcinoma.

  • Evidence

    The feasibility of staging laparoscopy has been demonstrated in multiple studies with success rates ranging from 94-100%. Dense adhesions that impair inspection and examination with the ultrasound probe are the main reason for technical failures. Nevertheless, even patients with adhesions can be examined; however, the extent and yield of the examination may be compromised. Conversions to open surgery are uncommon and have been reported to occur in <2% of patients in a large series.

    The reported median (range) sensitivity, specificity, and accuracy in detecting imaging-occult, unresectable pancreatic adenocarcinoma in the literature is 94% (range, 93-100%), 88% (range, 80-100%), and 89% (range, 87-98%), respectively. However, the procedure misses 6% (range, 5-25) of patients whose disease is identified as unresectable during an ensuing laparotomy. Overall, in 4-36% of patients, an unnecessary laparotomy can be avoided.

    A number of studies have also evaluated the added benefit of laparoscopic ultrasound at the time of laparoscopic staging indicating that the diagnostic accuracy of the procedure can be improved by 12-14%. In addition, peritoneal washings have been reported to augment the yield of the procedure. Reports on the sensitivity of peritoneal washings have ranged widely (25-100%). The highest sensitivity for peritoneal cytology has been reported in patients with a disrupted ventral pancreatic margin (when peripancreatic fatty tissue cannot be differentiated from the tumor by helical CT scan). In addition, locally advanced pancreatic cancers have a higher incidence of positive cytology. Importantly, studies have reported a 7-14% incidence of positive peritoneal washings in the absence of other findings of metastatic disease during preoperative imaging and scopy. This incidence seems to be lower in studies that include a variety of periampullary tumors. The diagnostic yield of the procedure also depends on the histology, stage of disease, tumor size, and location. There is convincing evidence that the yield of staging laparoscopy is significantly higher in patients with pancreatic cancer compared with other types of periampullary tumors. Furthermore, staging laparoscopy appears to have a higher yield in patients with locally advanced cancer compared with patients with localized disease. Identification of metastatic disease by staging laparoscopy in patients with locally advanced disease by high quality imaging studies has been reported in 34-37% of cases, which compares favorably with the identification rates of metastatic disease in patients with localized disease. Tumors of the pancreas body and tail are associated with a higher chance for unsuspected metastasis found at laparoscopy. Larger tumors appear to be associated with a higher incidence of imaging occult metastatic disease. Although the tumor size at which the risk of occult metastatic disease justifies the added time and cost of laparoscopy is currently unknown, some studies have suggested that tumors > 3 cm are more likely to be associated with metastatic disease at exploration. Moreover, a Ca19-9 level <150 has been associated with a lower chance for metastatic disease and consequently a lower yield for staging laparoscopy.

  • Further reading
    • Luque-de Leon, E., Tsiotos, G. G., Balsiger, B., Barnwell, J., Burgart, L. J., and Sarr, M. G. Staging Laparoscopy for Pancreatic Cancer Should Be Used to Select the Best Means of Palliation and Not Only to Maximize the Resectability Rate. Journal of Gastrointestinal Surgery 1999;3(2):111-7.
    • Jimenez, R. E., Warshaw, A. L., Rattner, D. W., Willett, C. G., McGrath, D., and Fernandez-Del Castillo, C. Impact of Laparoscopic Staging in the Treatment of Pancreatic Cancer. Archives of Surgery 2000;135(4):409-14.
    • Schachter, P. P., Avni, Y., Shimonov, M., Gvirtz, G., Rosen, A., and Czerniak, A. The Impact of Laparoscopy and Laparoscopic Ultrasonography on the Management of Pancreatic Cancer. Archives of Surgery 2000;135(11):1303-7.
    • Minnard, E. A., Conlon, K. C., Hoos, A., Dougherty, E. C., Hann, L. E., and Brennan, M. F. Laparoscopic Ultrasound Enhances Standard Laparoscopy in the Staging of Pancreatic Cancer. Annals of Surgery 1998;228(2):182-7.
    • Hunerbein, M., Rau, B., Hohenberger, P., and Schlag, P. M. The Role of Staging Laparoscopy for Multimodal Therapy of Gastrointestinal Cancer. Surgical Endoscopy 1998;12(7):921-5.
    • Durup Scheel-Hincke, J., Mortensen, M. B., Qvist, N., and Hovendal, C. P. TNM Staging and Assessment of Resectability of Pancreatic Cancer by Laparoscopic Ultrasonography. Surgical Endoscopy 1999;13(10):967-71.
    • Doran HE, Bosonnet L, Connor S et al. Laparoscopy and laparoscopic ultrasound in the evaluation of pancreatic and periampullary tumours. Dig Surg 2004; 21: 305–313.
    • Pietrabissa, A., Caramella, D., Di Candio, G., Carobbi, A., Boggi, U., Rossi, G., and Mosca, F. Laparoscopy and Laparoscopic Ultrasonography for Staging Pancreatic Cancer: Critical Appraisal. World Journal of Surgery 1999;23(10):998-1002
    • Awad, S. S., Colletti, L., Mulholland, M., Knol, J., Rothman, E. D., Scheiman, J., and Eckhauser, F. E. Multimodality Staging Optimizes Resectability in Patients With Pancreatic and Ampullary Cancer. American Surgeon 1997;63(7):634-8.
    • Conlon, K. C., Dougherty, E., Klimstra, D. S., Coit, D. G., Turnbull, A. D., and Brennan, M. F. The Value of Minimal Access Surgery in the Staging of Patients With Potentially Resectable Peripancreatic Malignancy. Annals of Surgery 1996;223(2):134-40
    • Vollmer CM, Drebin JA, Middleton WD et al. Utility of staging laparoscopy in subsets of peripancreatic and biliary malignancies. Ann Surg 2002; 235: 1–7.
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    • Friess, H., Kleeff, J., Silva, J. C., Sadowski, C., Baer, H. U., and Buchler, M. W. The Role of Diagnostic Laparoscopy in Pancreatic and Periampullary Malignancies. Journal of the American College of Surgeons 1998;186(6):675-82.
    • Barreiro, C. J., Lillemoe, K. D., Koniaris, L. G., Sohn, T. A., Yeo, C. J., Coleman, J., Fishman, E. K., and Cameron, J. L. Diagnostic Laparoscopy for Periampullary and Pancreatic Cancer: What Is the True Benefit? Journal of Gastrointestinal Surgery 2002;6(1):75-81.
    • Liu RC, Traverso LW. Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by computed tomography. Surg Endosc. 2005;19(5):638-42.
    • Holzman MD, Reintgen KL, Tyler DS, Pappas TN. The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies. J Gastrointest Surg. 1997;1(3):236-43.
    • Tilleman, E. H., de Castro, S. M., Busch, O. R., Bemelman, W. A., van Gulik, T. M., Obertop, H., and Gouma, D. J. Diagnostic Laparoscopy and Laparoscopic Ultrasound for Staging of Patients With Malignant Proximal Bile Duct Obstruction. Journal of Gastrointestinal Surgery 2002;6(3):426-30.
    • John, T. G., Wright, A., Allan, P. L., Redhead, D. N., Paterson-Brown, S., Carter, D. C., and Garden, O. J. Laparoscopy With Laparoscopic Ultrasonography in the TNM Staging of Pancreatic Carcinoma. World Journal of Surgery 1999;23(9):870-81.
    • Callery, M. P., Strasberg, S. M., Doherty, G. M., Soper, N. J., and Norton, J. A. Staging Laparoscopy With Laparoscopic Ultrasonography: Optimizing Resectability in Hepatobiliary and Pancreatic Malignancy. Journal of the American College of Surgeons 1997;185(1):33-9.
    • Bemelman, W. A., de Wit, L. T., van Delden, O. M., Smits, N. J., Obertop, H., Rauws, E. J., and Gouma, D. J. Diagnostic Laparoscopy Combined With Laparoscopic Ultrasonography in Staging of Cancer of the Pancreatic Head Region.[See Comment]. British Journal of Surgery 1995;82(6):820-4.
    • Stefanidis D, Grove KD, Schwesinger WH, Thomas CR Jr. The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review. Ann Oncol. 2006 Feb;17(2):189-99.
    • Fernandez-del Castillo, C. L. and Warshaw, A. L. Pancreatic Cancer. Laparoscopic Staging and Peritoneal Cytology. Surgical Oncology Clinics of North America 1998;7(1):135-42.
    • Fernandez-Del Castillo, C., Rattner, D. W., and Warshaw, A. L. Further Experience With Laparoscopy and Peritoneal Cytology in the Staging of Pancreatic Cancer. British Journal of Surgery 1995;82(8):1127-9.
    • Schmidt J, Fraunhofer S, Fleisch M, Zirngibl H. Is peritoneal cytology a predictor of unresectability in pancreatic carcinoma? Hepatogastroenterology 2004; 51: 1827–1831.
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