Gastric cancer very often presents with locally advanced or metastatic disease. Accurate staging of gastric cancer aids in the appropriate treatment selection for both cure and palliation. Palliative resection may be indicated for gastric cancer causing obstruction, hemorrhage, or perforation; however, surgical resection alone for patients with advanced disease has not been shown to improve survival. Studies regarding neoadjuvant protocols for locally advanced gastric cancers are ongoing which makes accurate staging imperative. Moreover, even after many preoperative radiologic tests (CT scan, endoscopic and transabdominal ultrasound, and PET scan) for staging of gastric tumors, a proportion of patients are found to have unsuspected, unresectable disease at exploration. Thus, staging laparoscopy may aid in the more accurate staging of gastric cancers and guide appropriate treatment without the morbidity associated with exploratory laparotomy.
Reasoning For Staging Laparoscopy
Patients with T3 or T4 gastric cancer without evidence of lymph node or distant metastases on high quality preoperative imaging
Severe upper abdominal adhesions from prior surgery that may preclude the procedure
When the plan is to proceed for definitive procedure by open technique, then the following are also contraindications for staging laparoscopy.
- Obstruction, hemorrhage, or perforation in need of palliative surgery
- Patients with early stage gastric cancer (T1 or T2).
However, if the plan is to do laparoscopic gastrectomy or gastrojejunostomy then it can start with staging laparoscopy.
The patient is placed in the supine position, and pneumoperitoneum is established. If present, ascitic fluid is aspirated and sent for cytology. In the absence of ascites, 200 cc of normal saline can be instilled into the peritoneal cavity and aspirated from the pelvis and bilateral subdiaphragmatic spaces for cytologic examination. Full inspection of the peritoneal cavity helps evaluate for peritoneal or liver metastases. Laparoscopic ultrasound may aid in the detection of deep hepatic lesions. If no metastatic disease is discovered, then the left lateral lobe of the liver is elevated to expose the entire stomach. The perigastric nodes along the greater and lesser curvature are inspected and biopsied if needed. In addition, the portahepatic and gastrohepatic ligaments are inspected carefully. Next, the gastric tumor itself is inspected for extra-serosal invasion and infiltration into surrounding structures. If the tumor is posterior, then the lesser sac must be accessed to gain appropriate visualization.
The results of various studies have shown that staging laparoscopy can identify unsuspected metastatic disease in 13-57% of patients despite negative preoperative imaging studies. Accuracy has been reported to range from 89-100% in different series. In addition, exploratory laparotomy has been avoided in 17-40% of cases. Compared with CT scan and ultrasound, staging laparoscopy is more sensitive (96%) for detecting hepatic metastasis compared with both CT (52%) and ultrasound (37%). Similarly, sensitivity is also better for detecting peritoneal metastasis (laparoscopy 69%, ultrasound 23%, CT 8%). The additional value of laparoscopic ultrasound has not yet been determined. Peritoneal washings positive for cancer cells have been demonstrated to correlate with the extent of disease (T1/T2: 0%, T3/T4: 10%, and M+: 59%).
Details On Gastric Cancer Surgery
- D’Ugo DM, Pende V, Persiani R, Rausei S, Picciocchi A. Laparoscopic staging of gastric cancer: an overview. J Am Coll Surg 2003; 196:965-974.
- Gross E, Bancewicz J, Ingram G. Assessment of gastric cancer by laparoscopy. Br Med J 1984; 288:1577.
- Possik RA, Franco EL, Pires DR, et al. Sensitivity, specificity, and predictive value of laparoscopy for the staging of gastric cancer and for the detection of liver metastases. Cancer 1986; 58:1-6.
- Kriplani AK, Kapur BML. Laparoscopy for the pre-operative staging and assessment of operability in gastric carcinoma. Gastrointest Endosc 1991; 37:441-443.
- Lowy AM, Mansfield PF, Steven D, et al. Laparoscopic staging for gastric cancer. Surg 1996; 119:611-614.
- Burke EC, Karpeh MS, Conlon KC, et al. Laparoscopy in the management of gastric adenocarcinoma. Ann Surg 1997; 225:262-267.
- Stell DA, Carter CR, Stewart I, et al. Prospective comparison of laparoscopy, ultrasonography and computed tomography in the staging of gastric cancer. Br J Surg 1996; 86:1260-1262.
- Asencio F, Aguilo J, Salvador JL, et al. Video-laparoscopic staging of gastric cancer. Surg Endo 1997; 11:1153-1158.
- Conlon KC. Staging laparoscopy for gastric cancer. Ann Ital Chir 2001; 72:33-37.
- Hulscher JBF, Nieveen van Dijkum EJ, de Wit LT, et al. Laparoscopy and laparoscopic ultrasonography in staging carcinoma of the gastric cardia. Eur J Surg 1000; 166:862-865