The use of diagnostic laparoscopy supported by laparoscopic ultrasonography in the assessment of pancreatic cancer

The Additional Value of Laparoscopic Ultrasound to Staging Laparoscopy in Patients with Suspected Pancreatic Head Cancer

BACKGROUND

This study aimed to evaluate the additional value of laparoscopic ultrasound (LUS) to staging laparoscopy (SL) for detecting occult liver metastases in patients with potentially resectable pancreatic head cancer.

METHODS

A retrospective cohort study was performed including all patients who underwent SL and LUS between 2005 and 2016. LUS was performed during SL to detect liver metastases not found by preoperative imaging or visual inspection of the liver.

RESULTS

Out of 197 patients, visual inspection during SL detected distant metastases in 29 (14.7%) patients. LUS was performed in 127 patients, revealing 3 additional liver metastases. The proportion of patients with unresectable disease after SL and negative LUS was 32.3%, which was similar to 36.6% of patients with unresectable disease after SL without LUS (difference 4.3%; 95% CI - 13-23%; P = 0.61). Sensitivity, specificity, and positive and negative predictive values of LUS to detect liver metastases were 30, 100, 100, and 94%, respectively. The proportion of patients with distant metastases diagnosed at SL significantly increased over time (P = 0.031).

CONCLUSION

The routine use of LUS during SL for patients with potentially resectable pancreatic head cancer cannot be recommended. Imaging should be repeated when significant delay occurs between index CT and the scheduled surgery.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). This is an update to a previous Cochrane Review published in 2013 evaluating the role of diagnostic laparoscopy in assessing the resectability with curative intent in people with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 15 May 2016), and Science Citation Index Expanded (from 1980 to 15 May 2016).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in people with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. The sensitivities were therefore meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in people who had a negative laparoscopy (post-test probability for people with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies, and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

We included 16 studies with a total of 1146 participants in the meta-analysis. Only one study including 52 participants had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 41.4% (that is 41 out of 100 participants who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 64.4% (95% confidence interval (CI) 50.1% to 76.6%). Assuming a pre-test probability of 41.4%, the post-test probability of unresectable disease for participants with a negative test result was 0.20 (95% CI 0.15 to 0.27). This indicates that if a person is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 20% probability that their cancer will be unresectable compared to a 41% probability for those receiving CT alone.A subgroup analysis of people with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40.0% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in people with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 21 unnecessary laparotomies in 100 people in whom resection of cancer with curative intent is planned.

Several key issues in surgical treatment of distal pancreatic cancer

Distal pancreatic cancer is an aggressive malignancy with insidious and subtle presentation, low radical resection rate and poor prognosis. The effectiveness of treatments for this disease remains to be improved. Radical resection is the only curable treatment. Personalized therapeutic strategy with surgical resection as a core should be the standard mode for these patients, and a professional multidisciplinary team is indispensable. Patients with borderline resectable cancers may benefit from a neoadjuvant approach by initiating chemotherapy and/or chemoradiation prior to the resection. Radical antegrade modular pancreatosplenectomy (RAMPS) is designed to establish an operation with oncologic rationales and should be the standard radical resection mode for distal pancreatic cancer. The use of diagnostic laparoscopy can help find hepatic metastases and peritoneal dissemination to avoid an unnecessary open operation. Laparoscopic distal pancreatectomy has many advantages compared with open operation, but is only applicable to early-stage patients with small tumors. In addition, the long-term oncologic effects of this surgical procedure still need to be verified, and it should be carried out selectively. Radical distal (or left) pancreatectomy with resection of the celiac axis (DP-CAR) is proper for some patients with evidence of celiac arterial invasion and should be conducted meticulously. However, new breakthroughs in early diagnosis and genetically personalized therapy are urgently needed. We still need prospective, randomized studies in multicenter institutions to provide more evidence for the neoadjuvant approach and laparoscopic distal pancreatectomy.

Diagnostic laparoscopy should be performed before definitive resection for pancreatic cancer: a financial argument

OBJECTIVES

Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreatic cancer before curative resection. This study was conducted to test the hypothesis that diagnostic laparoscopy (DL) is cost-effective in patients undergoing curative resection with or without neoadjuvant therapy (NAT).

METHODS

Decision tree modelling compared routine DL with exploratory laparotomy (ExLap) at the time of curative resection in resectable cancer treated with surgery first, (SF) and borderline resectable cancer treated with NAT. Costs (US$) from the payer's perspective, quality-adjusted life months (QALMs) and incremental cost-effectiveness ratios (ICERs) were calculated. Base case estimates and multi-way sensitivity analyses were performed. Willingness to pay (WtP) was US$4166/QALM (or US$50,000/quality-adjusted life year).

RESULTS

Base case costs were US$34,921 for ExLap and US$33,442 for DL in SF patients, and US$39,633 for ExLap and US$39,713 for DL in NAT patients. Routine DL is the dominant (preferred) strategy in both treatment types: it allows for cost reductions of US$10,695/QALM in SF and US$4158/QALM in NAT patients.

CONCLUSIONS

The present analysis supports the cost-effectiveness of routine DL before curative resection in pancreatic cancer patients treated with either SF or NAT.

Role of laparoscopy in patients with peritoneal metastases considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)

BACKGROUND

We hypothesized that diagnostic laparoscopy (DL) was feasible for the evaluation of patients with peritoneal carcinomatosis (PC) undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC).

METHODS

A retrospective review of PC patients treated from January 2010 to April 2013 was conducted. Data on tumor characteristics, treatment details and survival outcomes were extracted and analyzed.

RESULTS

Of the 101 PC patients (mean age 52.9 ± 14.1 years), 73 diagnostic laparoscopies DL (61 concurrent with CRS + HIPEC) were performed in 70 patients whereas 31 patients underwent direct exploratory laparotomy (EL). Complete laparoscopic assessment was possible in 63 cases (86.3%), resulting in 18 exclusions (27.7%) while 10 cases were converted to open due to inadequate laparoscopic visualization. Subsequently, CRS + HIPEC was performed in 85.4% (of 55 selected for HIPEC, DL) versus 74.2% (EL, P value = 0.20). Among those excluded from HIPEC at the initial operation, delayed HIPEC after conversion chemotherapy was achieved in 6 (of 11 with extensive disease, DL). The incidence of grade 3 to 5 complications was 0% DL versus 10% EL (P value = 0.2). There were no port site recurrences at mean follow up of 9.1 ± 8 months.

CONCLUSIONS

Laparoscopy is a feasible technique for selecting patients with PC for CRS + HIPEC, and can help select patients for conversion chemotherapy in the setting of high peritoneal carcinomatosis index (PCI) score.

Current and future intraoperative imaging strategies to increase radical resection rates in pancreatic cancer surgery

Prognosis of patients with pancreatic cancer is poor. Even the small minority that undergoes resection with curative intent has low 5-year survival rates. This may partly be explained by the high number of irradical resections, which results in local recurrence and impaired overall survival. Currently, ultrasonography is used during surgery for resectability assessment and frozen-section analysis is used for assessment of resection margins in order to decrease the number of irradical resections. The introduction of minimal invasive techniques in pancreatic surgery has deprived surgeons from direct tactile information. To improve intraoperative assessment of pancreatic tumor extension, enhanced or novel intraoperative imaging technologies accurately visualizing and delineating cancer cells are necessary. Emerging modalities are intraoperative near-infrared fluorescence imaging and freehand nuclear imaging using tumor-specific targeted contrast agents. In this review, we performed a meta-analysis of the literature on laparoscopic ultrasonography and we summarized and discussed current and future intraoperative imaging modalities and their potential for improved tumor demarcation during pancreatic surgery.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). There has been no systematic review or meta-analysis assessing the role of diagnostic laparoscopy in assessing the resectability with curative intent in patients with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Register of Diagnostic Test Accuracy Studies, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 13 September 2012), and Science Citation Index Expanded (from 1980 to 13 September 2012).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in patients with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. Therefore, the sensitivities were meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in patients who had a negative laparoscopy (post-test probability for patients with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

Fifteen studies with a total of 1015 patients were included in the meta-analysis. Only one study including 52 patients had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 40.3% (that is 40 out of 100 patients who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 68.7% (95% CI 54.3% to 80.2%). Assuming a pre-test probability of 40.3%, the post-test probability of unresectable disease for patients with a negative test result was 0.17 (95% CI 0.12 to 0.24). This indicates that if a patient is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 17% probability that their cancer will be unresectable compared to a 40% probability for those receiving CT alone.A subgroup analysis of patients with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in patients with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 23 unnecessary laparotomies in 100 patients in whom resection of cancer with curative intent is planned.

Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010

Several advances in genetics, diagnosis and palliation of pancreatic cancer (PC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. PC is relatively common as it is the fourth leading cause of cancer related mortality. Most patients present with obstructive jaundice, epigastric or back pain, weight loss and anorexia. Despite improvements in diagnostic modalities, the majority of cases are still detected in advanced stages. The only curative treatment for PC remains surgical resection. No more than 20% of patients are candidates for surgery at the time of diagnosis and survival remains quite poor as adjuvant therapies are not very effective. A small percentage of patients with borderline non-resectable PC might benefit from neo-adjuvant chemoradiation therapy enabling them to undergo resection; however, randomized controlled studies are needed to prove the benefits of this strategy. Patients with unresectable PC benefit from palliative interventions such as biliary decompression and celiac plexus block. Further clinical trials to evaluate new chemo and radiation protocols as well as identification of genetic markers for PC are needed to improve the overall survival of patients affected by PC, as the current overall 5-year survival rate of patients affected by PC is still less than 5%. The aim of this article is to review the most recent high quality literature on this topic.

Novel 3-D laparoscopic magnetic ultrasound image guidance for lesion targeting

OBJECTIVES

Accurate laparoscopic liver lesion targeting for biopsy or ablation depends on the ability to merge laparoscopic and ultrasound images with proprioceptive instrument positioning, a skill that can be acquired only through extensive experience. The aim of this study was to determine whether using magnetic positional tracking to provide three-dimensional, real-time guidance improves accuracy during laparoscopic needle placement.

METHODS

Magnetic sensors were embedded into a needle and laparoscopic ultrasound transducer. These sensors interrupted the magnetic fields produced by an electromagnetic field generator, allowing for real-time, 3-D guidance on a stereoscopic monitor. Targets measuring 5 mm were embedded 3-5 cm deep in agar and placed inside a laparoscopic trainer box. Two novices (a college student and an intern) and two experts (hepatopancreatobiliary surgeons) targeted the lesions out of the ultrasound plane using either traditional or 3-D guidance.

RESULTS

Each subject targeted 22 lesions, 11 with traditional and 11 with the novel guidance (n= 88). Hit rates of 32% (14/44) and 100% (44/44) were observed with the traditional approach and the 3-D magnetic guidance approach, respectively. The novices were essentially unable to hit the targets using the traditional approach, but did not miss using the novel system. The hit rate of experts improved from 59% (13/22) to 100% (22/22) (P < 0.0001).

CONCLUSIONS

The novel magnetic 3-D laparoscopic ultrasound guidance results in perfect targeting of 5-mm lesions, even by surgical novices.

Laparoscopic ultrasound: a survey of its current and future use, requirements, and integration with navigation technology

BACKGROUND

Laparoscopic ultrasound (LUS) increases surgical safety by allowing the surgeon to see beyond the organ surface, by visualizing vascular structures and by improving surgical precision of tumor resection. A questionnaire-based survey was used to investigate the current use and future expectations of LUS technology.

METHODS

A questionnaire consisting of 26 questions was distributed manually at four different conferences (60% at the European Association for Endoscopic Surgery (EAES) conference, Stockholm 2008). The answers were summarized with descriptive statistics and nonparametric tests at a significance level of 0.05.

RESULTS

The questionnaire was answered by 177 surgeons from 40 different countries (85% from Europe). Of these surgeons, 43% use ultrasound during laparoscopic procedures. Generally, more LUS users are found at university hospitals than at general community hospitals. Surgeons use LUS primarily in procedures related to the liver (67% of the surgeons who use LUS), but LUS also is used in other procedures related to the pancreas, biliary tract, and colon. In a 5-year perspective, 82% of surgeons believe in an increased use of LUS, and 79% of surgeons also think that the use of LUS combined with navigation technology will increase and that the most important requirements for such a system are good image quality, easy interpretation, and a high degree of precision.

CONCLUSIONS

Although the surgeons believe LUS has advantages, only 43% of the respondents reported using it. The surveyed surgeons were largely positive toward an increased use of LUS in a 5-year perspective and believe that LUS combined with navigation technology will contribute to improving the surgical precision of tumor resection.

Controversies in the management of borderline resectable proximal pancreatic adenocarcinoma with vascular involvement

Synchronous major vessel resection during pancreaticoduodenectomy (PD) for borderline resectable pancreatic adenocarcinoma remains controversial. In the 1970s, regional pancreatectomy advocated by Fortner was associated with unacceptably high morbidity and mortality rates, with no impact on long-term survival. With the establishment of a multidisciplinary approach, improvements in preoperative staging techniques, surgical expertise, and perioperative care reduced mortality rates and improved 5-year-survival rates are now achieved following resection in high-volume centres. Perioperative morbidity and mortality following PD with portal vein resection are comparable to standard PD, with reported 5-year-survival rates of up to 17%. Segmental resection and reconstruction of the common hepatic artery/proper hepatic artery (CHA/PHA) can be performed to achieve an R0 resection in selected patients with limited involvement of the CHA/PHA at the origin of the gastroduodenal artery (GDA). PD with concomitant major vessel resection for borderline resectable tumours should be performed when a margin-negative resection is anticipated at high-volume centres with expertise in complex pancreatic surgery. Where an incomplete (R1 or R2) resection is likely neoadjuvant treatment with systemic chemotherapy followed by chemoradiation as part of a clinical trial should be offered to all patients.

Evaluation of the role of laparoscopic ultrasonography in the staging of oesophagogastric cancers

INTRODUCTION

The role of laparoscopic ultrasound (LUS) during staging laparoscopy for pancreatic cancers is established but remains debatable in evaluating oesophagogastric cancers.

METHODS

A retrospective consecutive case series consisting of patients undergoing staging laparoscopy in two centres (centre A and B) was carried out over a 5-year period (2000-2005). Patients in centre B underwent LUS following laparoscopic assessment using a 7.5-MHz probe. Staging laparoscopy in both centres was performed using a standardised three-port protocol using a 30 degrees laparoscope. All suspicious lesions were sent for histological assessment for confirmation of malignancy.

RESULTS

There were 201 patients in centre A (83 gastric, 138 lower oesophageal/junctional cancers) and 119 patients in centre B (51 and 68, respectively). There were no differences between the two centres for patient demographics and tumour site. There was no difference between the two centres for the detection of metastatic disease using laparoscopic assessment alone (A 13% versus B 20%, p = 0.12). However, there was a significant difference (13% versus 28%, p = 0.001) with the additional use of LUS in centre B. The findings in the additional 8% (n = 9) were para-aortic lymphadenopathy (n = 5), liver metastasis (n = 3) and local extension (n = 1). Five had gastric and four lower oesophageal/junctional cancers. The negative predictive value was 6.4% for centre A and 4.5% for centre B.

CONCLUSION

The addition of LUS increased the detection rate of metastasis by 8% but there was little impact on the false-negative rate. LUS is useful in detecting metastatic lymphadenopathy beyond the limits of curative resection and liver metastasis.

Carbohydrate antigen 19.9 accurately selects patients for laparoscopic assessment to determine resectability of pancreatic malignancy

BACKGROUND

Laparoscopy with laparoscopic ultrasonography (L-LUS) may be useful in the selection of patients for surgery to resect peripancreatic malignancy in addition to contrast-enhanced computed tomography (CE-CT). The present prospective study assessed the strategy of using carbohydrate antigen 19.9 (CA19.9) levels to select patients for L-LUS.

METHODS

Patients with suspected peripancreatic malignancy that appeared resectable on CE-CT were selected for immediate surgery if CA19.9 was low (up to 150 kU/l, or up to 300 kU/l if serum bilirubin was above 35 micromol/l), or to L-LUS if CA19.9 was high (over 150 kU/l, or over 300 kU/l if serum bilirubin was above 35 micromol/l). Data were assessed to determine the clinical utility of this strategy.

RESULTS

A total of 94 patients went straight to surgery, of whom 65 proved resectable: 63 of 80 with a low CA19.9 level but only two of 14 with a high CA19.9 level and gastric outlet obstruction. From 55 patients with high CA19.9 levels, L-LUS correctly identified 26 of 31 resectable tumours and eight of 24 unresectable tumours.

CONCLUSION

Using CA19.9 levels to help select patients with pancreatic malignancy for immediate surgery or L-LUS for further assessment of resectability effectively increased resection rates and reduced unnecessary laparotomies.

Preoperative prediction of complete resection in pancreatic cancer

BACKGROUND

Accurate preoperative staging is essential in pancreatic cancer to select the 15% of patients who can benefit from surgery and avoid surgery in the 85% with advanced disease. With improvements in computed tomography (CT) scanning, the value of routine laparoscopy for preoperative staging of pancreatic cancer has been questioned because it changes the preoperative plan in less than 20% of unselected cases.

METHODS

We retrospectively reviewed our experience with preoperative staging in 88 consecutive patients with pancreatic cancer. All patients had preoperative CT scans, and selective criteria were used to determine which patients would also undergo preoperative staging laparoscopy. Patients were categorized preoperatively as resectable or not resectable (locally advanced or metastatic). Medical records, operative, and pathology reports were reviewed to determine the accuracy of preoperative predictions.

RESULTS

Thirty patients were deemed resectable based on CT alone and 27 (90%) were resected (25 R0, 2 R1). Two (7%) had metastatic disease discovered at laparotomy and one (3%) had a R2 resection. Only 19 patients (39%) of 49 patients deemed resectable by CT met our selective criteria for preoperative staging laparoscopy. Laparoscopy changed the treatment plan in 11 (58%) of these patients. Eight were still deemed resectable after staging laparoscopy and 7 (88%) were resected (6 R0, 1 R1). One patient (12%) had metastatic disease diagnosed at laparotomy. If selective staging laparoscopy were eliminated from our algorithm, 49 patients would have been deemed potentially resectable based on CT alone, 34 (69%) would have been found to be resectable at laparotomy (31 R0, 3 R1), and 15 (31%) would have been found to be unresectable at laparotomy (positive predictive value of 69%). The addition of selective staging laparoscopy avoided unnecessary laparotomy in 11 patients and increased the positive predictive value to (34/38) 89%.

CONCLUSION

Selective use of laparoscopy increases the positive predictive value of preoperative staging in pancreatic cancer and avoids unnecessary laparoscopy in the majority of patients.

Intraoperative ultrasonography in open and laparoscopic abdominal surgery: an overview

This article reviews the current state of intraoperative ultrasonography in open surgery (IOUS) and laparoscopic surgery (LUS). The review is based on extensive study of data published (Pubmed search) and on 25 years of personal experience with intraoperative ultrasonography. The main application areas of IOUS and LUS and its use during liver, biliary tract, and pancreatic surgery are discussed. The benefits and limitations as well as future expectations with regard to the existing and emerging applications also are discussed. New developments in ultrasound technology and the increasing experience of surgeons in ultrasonography secure the future for IOUS and LUS.

The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review

In the absence of metastatic disease patients with localized or locally advanced pancreatic cancer can benefit from surgical resection or chemoradiation. Despite the advances of imaging technology, however, noninvasive staging modalities are still inaccurate in identifying small volume metastatic disease leading potentially to inappropriate treatment and avoidable morbidity in a subgroup of patients. Staging laparoscopy may identify those patients with unsuspected metastatic disease on preoperative imaging and prevent unnecessary laparotomy or chemoradiation. A controversy exists, however, as to whether the procedure should be used routinely or selectively in pancreatic cancer patients with no evidence of metastasis on noninvasive staging. This review aims to assess the current role of staging laparoscopy by examining its diagnostic accuracy and ability to prevent unnecessary treatment as well as its morbidity, oncologic effect and cost-effectiveness. The available literature will be evaluated critically, its limitations identified and exisiting controversies addressed.

Computed tomography, endoscopic, laparoscopic, and intra-operative sonography for assessing resectability of pancreatic cancer

Pancreas cancer is the fourth leading cancer killer in adults. Cure of pancreas cancer is dependent on the complete surgical removal of localized tumor. A complete surgical resection is dependent on accurate preoperative and intra-operative imaging of tumor and its relationship to vital structures. Imaging of pancreatic tumors preoperatively and intra-operatively is achieved by pancreatic protocol computed tomography (CT), endoscopic ultrasound (EUS), laparoscopic ultrasound (LUS), and intra-operative ultrasound (IOUS). Multi-detector CT with three-dimensional (3-D) reconstruction of images is the most useful preoperative modality to assess resectability. It has a sensitivity and specificity of 90 and 99%, respectively. It is not observer dependent. The images predict operative findings. EUS and LUS have sensitivities of 77 and 78%, respectively. They both have a very high specificity. Further, EUS has the ability to biopsy tumor and obtain a definitive tissue diagnosis. IOUS is a very sensitive (93%) method to assess tumor resectability during surgery. It adds little time and no morbidity to the operation. It greatly facilitates the intra-operative decision-making. In reality, each of these methods adds some information to help in determining the extent of tumor and the surgeon's ability to remove it. We rely on pancreatic protocol CT with 3-D reconstruction and either EUS or IOUS depending on the tumor location and operability of the tumor and patient. With these modern imaging modalities, it is now possible to avoid major operations that only determine an inoperable tumor. With proper preoperative selection, surgery is able to remove tumor in the majority of patients.

New approaches to the minimally invasive treatment of pancreatic cancer

Advances in minimally invasive surgery have revolutionized the field of surgery. Despite the great strides in equipment and experience, operative conduct remains confined by the limits of exposure. Retroperitoneal fat can be abundant and can contribute greatly to difficulty in exposure. Visceral organs ventral to the retroperitoneum preclude direct access and require optimal patient positioning to operate. Additionally, the major vascular pedicles all originate in the retroperitoneum off of the abdominal aorta or enter the inferior vena cava. The pancreas, in particular, is surrounded by the portal vein, celiac axis, superior mesenteric vein and artery, and splenic vein and artery. If injured during surgery, these vessels can present a life-threatening emergency. The issues related to the vasculature, coupled with the difficulty in resecting portions of the pancreas and the relative paucity of pancreatic procedures, have greatly concentrated these cases at tertiary care centers staffed by experienced laparoscopists. However, as surgical technology improves and fellowships train more surgeons with advanced laparoscopic skills, minimally invasive pancreatic surgery may diffuse with more community-based health care networks.

Impact of taurolidin and octreotide on liver metastasis and lipid peroxidation after laparoscopy in chemical induced ductal pancreatic cancer

BACKGROUND

There is controversial discussion whether metastasis initiated by laparoscopy with carbon dioxide might be prevented by instillation of taurolidin or radical scavengers like the somatostatin analogue Octreotide. Therefore we evaluated the effects of laparoscopic lavage with taurolidin and Octreotide on liver metastasis after staging laparoscopy in ductal pancreatic cancer.

METHODS

In 60 Syrian hamsters pancreatic adenocarcinoma was induced by weekly subcutanous injection of 10 mg N-nitrosobis-2-oxopropylamin/kg body weight for 10 weeks. In the 16th week laparoscopic staging biopsy by use of carbon dioxide was performed. Finally animals underwent abdominal irrigation with saline (gr.1, n = 20), taurolidin (0.5%) (gr.2, n = 20) or Octreotide (gr.3, n = 20). In week 25 animals were sacrificed, pancreas and liver were analysed.

RESULTS

Size of pancreatic carcinomas was decreased in the taurolidin gr. compared to the other two groups. Furthermore the number of liver metastasis per animal was reduced after lavage with taurolidin (2 +/- 2) and Octreotide (2.5 +/- 2) compared to saline irrigation (4 +/- 4) (p < 0.05). Additionally the incidence of port site metastases was significantly reduced in the taurolidin group. Activity of antioxidative enzyme superoxide dismutase (SOD) was increased while concentration of products of lipidperoxidation was decreased in non-metastatic liver after taurolidin irrigation compared to saline or Octreotide irrigation.

CONCLUSIONS

Taurolidin irrigation during laparoscopy might be a new concept to reduce the number of liver metastasis and port site metastases in pancreatic cancer.

Limitation of diagnostic laparoscopy for patients with a periampullary carcinoma

BACKGROUND

Diagnostic laparoscopy has been generally accepted in staging of patients with a periampullary malignancy. In our institution diagnostic laparoscopy was routinely used since 1992. However, in 1998 it was eliminated from the protocol since in a prospective study a yield of only 13% was found with a histologically proven accuracy of 60% for distant metastases. The effect of implementation of the new protocol on the occurrence of unnecessary laparotomies and the outcome after bypass surgery was assessed.

METHODS

Between January 1999 and December 2001, 186 consecutive patients with a potentially resectable periampullary carcinoma after radiological staging without diagnostic laparoscopy underwent explorative laparotomy with the intention to perform a curative pancreatoduodenectomy. Incidence of unresectability and outcome of palliative surgery were assessed.

RESULTS

Resection could not be performed in 65 patients who underwent laparotomy because of metastatic disease (29 patients) and loco-regional tumour ingrowth (34 patients). These patients underwent a bypass procedure with a median survival of 216 days.

CONCLUSION

At laparotomy distant metastases were detected in 16% of the patients. Considering the fact that the detection rate of diagnostic laparoscopy is lower than 100%, the use of staging laparotomy is too limited to justify it as a routine procedure.

A new visualization technique for laparoscopic ultrasonography

BACKGROUND

Using laparoscopic ultrasonography (LUS) is challenging for both novice and experienced ultrasonographers. The major difficulty surgeons experience is understanding the orientation of the ultrasonography image. The purpose of this study was to assess whether providing surgeons with orientation information improves their ability to interpret LUS images.

METHODS

We performed a LUS examination on a 25-kg pig and simultaneously digitized video from the laparoscopic camera, the LUS, and a novel orientation system. From the video recordings, 12 different clips of intra-abdominal anatomy were prepared. Twenty surgeons (18 staff, 2 fellows) volunteered to participate in an experimental crossover study. Test subjects reviewed the LUS clips along with the laparoscopic video images and the orientation display. Controls reviewed the LUS clips with only the laparoscopic video images. Diagnostic accuracy was compared by using the odds ratio.

RESULTS

For all vessels, the orientation display improved the odds ratio for correctly identifying structures from 3.7 to 8.9 (P=.02). For arteries, the orientation display improved the odds ratio from 2.4 to 9.6 (P=.01). For veins, the orientation display improved the odds ratio from 4.4 to 13.6 (P=.04).

CONCLUSIONS

Providing orientation information significantly improves a surgeon's ability to interpret LUS images.

Staging of pancreatic head adenocarcinoma with spiral CT and endoscopic ultrasonography: an indirect evaluation of the usefulness of laparoscopy

BACKGROUND

The interest of laparoscopy in the preoperative staging of pancreatic head adenocarcinoma before curative pancreaticoduodenectomy is a matter of controversy and depends on the accuracy of preoperative imaging techniques.

AIM

To assess the potential value of laparoscopy when a standardised and optimal preoperative staging is performed, including spiral computed tomography (CT) and endoscopic ultrasonography (EUS).

METHODS

All consecutive patients operated on with a view to curative pancreaticoduodenectomy for pancreatic head or ampullary adenocarcinoma in our centre from January 1998 to August 2000 were retrospectively studied. All of them had preoperative spiral CT and EUS. Tumour resectability was considered as highly probable (HP) or uncertain (U) according to well-defined criteria. Operative records of patients were reviewed to indirectly assess the effective resectability rate and the criteria responsible for unresectability and which of them would have been identified by laparoscopy if initially performed.

RESULTS

69 consecutive patients were studied. Resectability was HP (n = 56) or U (n = 13) after preoperative staging. Curative pancreatoduodenectomy was performed in 53 patients (77%) (48 HP, 5 U). Positive predictive value of preoperative imaging for highly probable resectability was 86% (48/56). Among the 16 unresectable tumours (8 HP, 8 U), the cause of non-resection would have been found at laparoscopy in 9 patients (56%) (6 HP, 3 U). Finally, if initially performed, laparoscopy would have avoided laparotomy in 9/69 patients (13%) (6/56 HP (11%); 3/13 U (23%)).

CONCLUSIONS

With accurate preoperative staging using spiral CT and EUS, laparoscopy would detect tumours which were unresectable in 13% of patients with pancreatic head cancer. Laparoscopy remains useful in selected patients, such as those with preoperative uncertain resectability, in whom it can prevent unnecessary laparotomy in one fourth of patients.

Suprapancreatic and periportal lymph nodes are normally larger than 1 cm by laparoscopic ultrasound evaluation

BACKGROUND

Laparoscopic and endoscopic ultrasound is used to assess resectability of gastrointestinal malignancies. Lymph node size greater than 1 cm is a criterion used to identify suspicious nodes. We define size and echo characteristics of suprapancreatic and periportal nodes to determine if this criterion is reliable for suprapancreatic and periportal lymph nodes.

METHODS

A prospective study of 21 patients with nonacute gallbladder disease was performed. Each underwent laparoscopic cholecystectomy with intraoperative ultrasound. The suprapancreatic and periportal nodes were evaluated in a transverse and longitudinal axis. Length and width measurements were taken in both orientations. Length-to-width ratios were calculated. Shape and echo textures were characterized.

RESULTS

The mean size of both nodes was greater than 1 cm in the transverse and longitudinal orientation. Two nodes were "round." Remaining nodes were "oblong." All nodes had a hyperechoic center with a hypoechoic rim.

CONCLUSION

In suprapancreatic and periportal lymph nodes, size greater than 1 cm should not be used as criterion for malignancy.

Effects of taurolidine and octreotide on tumor growth and lipid peroxidation after staging-laparoscopy in ductal pancreatic cancer

Irrigation with taurolidine after laparoscopy decreases tumor growth in colon carcinoma. In pancreatic cancer subcutaneous therapy with octreotide decreases oxidative stress and carcinogenesis as well. However, it is still unclear, whether irrigation with taurolidine or octreotide after laparoscopic pancreatic biopsy reduces tumor growth in pancreatic cancer as well. In 60 Syrian hamsters ductal pancreatic adenocarcinoma was induced by weekly injection of 10mg/kg body weight N-nitrosobis-2-oxopropylamine s.c. for 10 weeks. In week 16 laparoscopic pancreatic biopsy by use of carbon dioxide was performed (gr. 1, n = 20) with subsequent laparoscopic irrigation with taurolidine (gr. 2, n = 20) or octreotide (gr. 3, n = 20). In week 25 hamsters were sacrificed. Our results show that macroscopic visible primary tumors were found in only one animal of the taurolidine group (5.9%), compared to 42.1% in the saline and 62.5% in the octreotide group (P<0.05). Carcinomas were smaller after saline (6+/-23 mm(2)) than after octreotide irrigation (70+/-120 mm(2), P<0.05). In conclusion this study showed that laparoscopic irrigation with taurolidine after pancreatic biopsy inhibited tumor growth in ductal pancreatic adenocarcinoma.

Abdominal malignancies missed during laparoscopic cholecystectomy

BACKGROUND

We present our experience with intra-abdominal malignancies different from gallbladder cancer not diagnosed preoperatively and undiscovered during laparoscopic cholecystectomy

METHODS

This study involved retrospective analysis of 10 patients hospitalized in the Second Department of General Surgery between 1993 and 2000. In all of them, laparoscopic cholecystectomy had been performed between one week and 21 months earlier.

RESULTS

Primary or metastatic neoplasms were diagnosed in five men and five women patients ages 38 to 79 years. In three patients with colorectal cancer, a radical resection was possible. Nonresectable pancreatic cancer was found in three patients. In one of two patients with gastric cancer, palliative, distal gastrectomy was performed. In a patient who had small bowel cancer with metastasis to the ovary, a radical operation was possible. In one patient, liver metastasis from lung cancer was found.

CONCLUSIONS

In patients with atypical symptoms of gallbladder lithiasis, a thorough workup before laparoscopic cholecystectomy should be performed. During the laparoscopic procedure, a detailed examination of the whole peritoneal cavity is essential. In cases of prolonged convalescence after laparoscopic cholecystectomy, a source of symptoms different from cholelithiasis should be suspected.

Experience with laparoscopic ultrasonography for defining tumour resectability in carcinoma of the pancreatic head and periampullary region

BACKGROUND

Computed tomography (CT) is currently the most widely available staging investigation for pancreatic tumours. However, the accuracy of CT for determining tumour resectability is variable and can be poor. Laparoscopic ultrasonography (LUS) is potentially a more accurate method for disease staging. The authors' experience of LUS for staging carcinoma of the pancreatic head and periampullary region is described.

METHODS

Fifty-one patients with potentially resectable pancreatic tumours defined at CT underwent further investigation with LUS. Twenty-seven patients subsequently had an open laparotomy. The evaluations of tumour resectability at CT and LUS were compared with the operative findings.

RESULTS

At LUS, 24 patients were considered to have resectable tumours, 21 non-resectable tumours and six patients were shown to have no pancreatic tumour mass. Twenty-two patients deemed to have a resectable tumour at LUS underwent surgery. Twenty patients were confirmed to have resectable disease and two patients had non-resectable disease. A further five patients underwent surgery. In all five the ultrasonographic diagnosis was confirmed at surgery (four patients with non-resectable disease and no pancreatic tumour in one patient). LUS prevented unnecessary extensive surgery in 53 per cent of patients. For the 22 patients who underwent surgery for potentially resectable disease, the positive predictive value of LUS for defining tumour resectability was 91 per cent.

CONCLUSION

LUS is an accurate additional investigation for defining tumour resectability and directing management in patients with potentially resectable carcinoma of the pancreatic head or periampullary region.

Diagnostic and interventional laparoscopy and intraoperative ultrasonography in the management of pancreatic disease

The laparoscopic management of pancreatic disorders has evolved dramatically from its inception in 1911 and its rediscovery in the 1970s. Although investigators once proclaimed that "it seems unlikely that laparoscopy will have any more than an extremely limited use in the investigation of pancreatic disorders," laparoscopy and LUS now have a well-recognized role in the staging of pancreatic cancer and an increasing part in the management of benign pancreatic disease at many institutions. Although the appropriate role of LS and LUS is debatable, the development and refinement of laparoscopic techniques and instrumentation and the improvement of noninvasive diagnostic modalities will provide new data, increase the rate of resection at laparotomy, and allow surgeons to treat a broader range of pancreatic disease by minimally invasive methods. The value of LS and LUS for benign and malignant pancreatic disorders has been clearly demonstrated, but the inevitable issues of hospital resource, operative expertise, and surgical philosophy will ultimately determine the role of laparoscopy and LUS in clinical practice.

[Surgical treatment of pancreatic cancer: curative resections]

Curative resection of pancreatic adenocarcinoma can only be performed in 10% of patients. This review article reports resectability rates and criteria, results of pancreatic resection and prognostic factors. Lymph node and/or vascular involvement and retroperitoneal tissue invasion constitute very poor prognostic factors; however, lymph node involvement limited to the first draining nodes and limited invasion of the mesenteric-portal vein do not constitute contraindications to surgical resection. Cephalic pancreaticoduodenectomy is still the reference procedure and its postoperative mortality has greatly decreased. The risk of pancreatic fistula mainly depends on the friability of the pancreatic stump. Median survival rate after tumour resection is usually limited between 12 and 18 months. Five-year actuarial survival rate is no more than 5%, but after curative resection (RO), it may be as high as 20 to 25% in recent surgical series. Concomitant or neoadjuvant chemotherapy-radiotherapy, currently under evaluation, may increase resection and survival rates.