Laparoscopic staging for liver, biliary, pancreas, and gastric cancer

Incidental Gallbladder Cancer: A Comprehensive Review

PURPOSE

Patients undergoing cholecystectomy for a presumed benign disease may present with histopathology report revealing carcinoma in the gallbladder specimen, in which case it is referred to as incidental gallbladder cancer (IGBC). This review highlights the approach to evaluation and management of these patients.

METHODS

Available literature from various sources has been reviewed and presented in a narrative format.

RESULTS

Early referral to a tertiary centre for appropriate staging and definitive management is paramount. Once distant metastasis is ruled out, re-resection is indicated in patients with pathological T-stage ≥T1b with the aim to attain R0 resection, and perform complete staging lymphadenectomy, and has been shown to confer survival benefit. Feasibility and safety of minimally invasive approaches have been demonstrated in recent years. Role of peri-operative chemo(radio)-therapy in IGBC remains uncertain and prospective trials are warranted.

CONCLUSION

IGBC is being increasingly diagnosed as the number of cholecystectomies for presumed benign diseases is steadily increasing globally. Overall prognosis depends on the stage and is especially poor in those with residual disease at re-operation.

Mini-laparoscopy is superior in detecting liver cirrhosis and metastases in liver cancer: an over 10-year experience in 1,788 cases

BACKGROUND/AIMS

Mini-laparoscopy has, since its first description in 1998, proven to be a valuable diagnostic method in liver diseases. We re-evaluated the significance of mini-laparoscopy for diagnosis and staging of liver disease and primary liver and bile duct cancer.

PATIENTS AND METHODS

1,788 consecutive patients who received a diagnostic mini-laparoscopy between 10/1998 and 06/2011 were included in this retrospective cohort study.

RESULTS

In chronic liver disease, cirrhosis was detected by mini-laparoscopy in 27% of cases. A comparison of microscopic versus macroscopic diagnosis of cirrhosis revealed a sampling error for histology alone of 21%. Macroscopic inspection of the liver surface contributed to the diagnosis of unknown liver diseases in approximately 38%. In patients with bile duct or liver cancer, mini-laparoscopy led to upstaging of the disease in 33 and 23%, respectively. Major complications (bowel perforation and delayed bleeding) occurred in 0.39% of cases.

CONCLUSIONS

Mini-laparoscopy is a valuable procedure with significant diagnostic impact in known and unknown inflammatory and malignant liver diseases. It can be safely performed even in patients with acute liver failure and severe coagulopathy and the diagnostic value does not differ from diagnostic laparoscopy performed with standard instruments.

Transumbilical single-incision laparoscopic distal pancreatectomy: primary experience and review of the English literature

BACKGROUND

Single-incision laparoscopic surgery (SILS) may represent an improvement over conventional laparoscopic surgery, and has been applied in many surgical procedures. However, for pancreatic surgery, experience is rather limited.

METHODS

The clinical records of 11 cases in which transumbilical single-incision laparoscopic distal pancreatectomy (TUSI-LDP) was performed at our institution since June 2009 were retrospectively analyzed, and all the literatures concerning TUSI-LDP were retrospectively reviewed.

RESULTS

All the 11 patients were female. The ages ranged from 20 to 73 years, with an average age of 38.0 years. The average body mass index (BMI) was 22.67 (18.6-26.2). Most TUSI-LDPs were successfully performed, with only one conversion to multi-incision surgery. Splenic preservation was performed in six cases. The mean operation time was 163.18 ± 63.18 minutes (range 95-300), and the mean intraoperative blood loss was 159.09 ± 181.02 ml (range 10-500 ml). The surgical wounds healed well, with good cosmetic wound healing, and the patients were discharged from hospital in a mean of 7.45 ± 1.44 days (range 5-10). Only one patient developed pancreatic leakage, which ceased spontaneously with only a drain for 61 days. The parameters were comparable with those found in the English literature.

CONCLUSIONS

These recent experiences suggest that SILS in pancreatic surgery is feasible for a select group of patients with relatively small lesions and low BMI, and that, with the gradual accumulation of surgeons' experience with SILS and improvement of laparoscopic instruments, it might become a safe option for some patients.

Outcomes of the patients who were postoperatively diagnosed as malignancy after laparoscopic distal pancreatectomy

PURPOSE

Laparoscopic distal pancreatectomy (LDP) is a reliable and safe operation for selected patients with benign and low-grade malignant lesions in the body and tail of the pancreas. However, its application for malignant disease has been rarely reported. The aim of this study is to analyze postoperative outcomes of the patients with a diagnosis of benign or borderline malignancy, who were postoperatively diagnosed as malignancy after LDP.

METHODS

From January 2005 to March 2011, LDP was performed on 88 patients, and 11 were subsequently diagnosed as malignancy in postoperative pathologic reports. A retrospective analysis of the clinical outcomes of these 11 patients was conducted.

RESULTS

The patients were 4 men and 7 women with a median age of 68 years (range, 29 to 83 y). The postoperative diagnoses were 5 with ductal adenocarcinoma, 3 with invasive intraductal papillary mucinous neoplasm, 1 with mucinous cystadenocarcinoma, 1 with neuroendocrine carcinoma, and 1 with pancreas metastasis from a renal cell carcinoma. The median operation time was 180 minutes (range, 80 to 325 min), and the median estimated blood loss was 200 mL (range, 150 to 500 mL). There were no open conversions. Four (36%) patients experienced complications: intra-abdominal fluid collection (2), spleen infarction (1), and enterocutaneous fistula (1). The median postoperative hospital stay was 11 days (range, 6 to 18 d). All the patients were considered to have curative resection (R0), postoperatively. During the median follow-up period of 30 months (range, 3 to 58 mo), 1 patient was found to have liver metastasis, which had been present and misdiagnosed as benign hemangioma on preoperative diagnostic workup. This patient died 1 year after LDP. Another patient was found to have liver metastasis 30 months after LDP. The patient was treated with radiofrequency ablation, and he was still alive 60 months postoperatively. The remaining patients were alive without any recurrent disease.

CONCLUSIONS

The postoperative outcomes of the patients, who were diagnosed postoperatively as having a malignant pancreatic disease, are acceptable.

The role of laparoscopic staging in patients with incidental gallbladder cancer

BACKGROUND

The role of staging laparoscopy (SL) in patients with incidental gallbladder cancer (IGBC) is ill defined. This study evaluates the utility of SL with the aim of identifying variables associated with disseminated disease (DD).

METHODS

Consecutive patients with IGBC who underwent re-exploration between 1998 and 2009 were identified from a prospective database. The yield and accuracy of SL were calculated. Demographics, tumour- and treatment-related variables were correlated with findings of DD.

RESULTS

Of the 136 patients submitted to re-exploration for possible definitive resection, 19 (14.0%) had DD. Staging laparoscopy was carried out in 46 (33.8%) patients, of whom 10 (21.8%) had DD (peritoneal disease [n = 6], liver metastases [n = 3], retroperitoneal disease [n = 1]). Disseminated disease was identified by SL in two patients (yield = 4.3%), whereas eight were diagnosed after conversion to laparotomy (accuracy = 20.0%). The likelihood of DD correlated closely with T-stage (T1b, n = 0; T2, n = 5 [7.0%], T3, n = 14 [26.0%]; P = 0.004). A positive margin at initial cholecystectomy (odds ratio [OR] 5.44, 95% confidence interval [CI] 1.51-24.37; P = 0.004) and tumour differentiation (OR 7.64, 95% CI 1.1-NA; P= 0.006) were independent predictors of DD on multivariate analysis.

DISCUSSION

Disseminated disease is relatively uncommon in patients with IGBC and SL provides a very low yield. However, patients with poorly differentiated, T3 or positive-margin gallbladder tumours are at high risk for DD and targeting these patients may increase the yield of SL.

Laparoscopic hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) in the management of refractory malignant ascites: A multi-institutional retrospective analysis in 52 patients

Malignant ascites is a debilitating condition affecting cancer patients in their terminal stage of disease. Recently, laparoscopic hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) was introduced as a new approach. From September 2001 to August 2008, 52 patients were treated with this new modality. No treatment-related mortality was observed. Median survival was 98 days. One patient developed a clinical recurrence. Laparoscopic HIPEC is a safe and effective method for palliating malignant ascites.

Outcome of unresected gastric cancer after laparoscopic diagnosis of peritoneal carcinomatosis

BACKGROUND

Most gastric adenocarcinomas in western countries are locally advanced, and these tumours are often associated with metastatic spread at the time of diagnosis. It is controversial whether palliative surgery can improve symptom control in gastric cancer patients with peritoneal carcinomatosis.

OBJECTIVE

To determine the need of palliative procedures and survival in patients affected by gastric cancer with peritoneal carcinomatosis managed without resection. Methods and materials After standard preoperative staging, 160 patients were diagnosed with resectable gastric adenocarcinoma. Laparoscopy was performed in 107 patients (66.9%), finding peritoneal spread in 22 of them (21%). Seventeen of these patients were not submitted to any additional surgical procedure. Data regarding postoperative morbidity and mortality, need of endoscopic, percutaneous or surgical procedures to palliate symptoms, hospital stay and survival were collected. The same data were collected for the 6 non-resected patients who were diagnosed with carcinomatosis by laparotomy.

RESULTS

In the "laparoscopy alone" group, there were 2 minor complications and no postoperative mortality. Mean postoperative stay was 6 days. Eight patients had to be readmitted to hospital for symptoms derived from tumour progression, and 10 palliative endoscopic procedures were performed. Surgical interventions were not needed in any case. Mean survival was 11.5 months. Patients submitted only to laparotomy presented higher morbidity and mortality rates, with a longer postoperative stay and survival of less than 5 months.

CONCLUSIONS

Laparoscopic staging of gastric cancer can help to avoid unnecessary laparotomies. In patients with peritoneal carcinomatosis diagnosed by laparoscopy, nonsurgical treatment has low morbidity and mortality and permits good symptom relief with no shortening of survival.

Clinical outcomes compared between laparoscopic and open distal pancreatectomy

BACKGROUND

Laparoscopic surgery for pancreatic disease has gained increasing popularity. A laparoscopic distal pancreatectomy is technically simple and has been adopted as the preferred method in many centers. However, there is limited information on the outcomes of the laparoscopic surgery compared with open surgery. Therefore, this study aimed to investigate the clinical outcomes of laparoscopic distal pancreatectomy and to evaluate its efficacy compared with open distal pancreatectomy.

METHODS

From February 1995 to March 2006, 31 patients underwent laparoscopic distal pancreatectomy, and 167 patients underwent open distal pancreatectomy at Seoul National University Hospital and Bundang Seoul National University Hospital. A case-control design was used with 2:1 matching to compare laparoscopic surgery with open surgery. Among 167 patients who underwent open distal pancreatectomy, 62 patients whose age, gender, and pathology were similar to those of patients who underwent laparoscopic surgery were selected for this study. The operation time, intraoperative transfusion requirements, duration of postoperative hospitalization, complications, mortality, recurrence, and hospital charges were analyzed.

RESULTS

There were no significant differences in operation time, rate of intraoperative transfusions, complications, recurrence, or mortality between the two groups. Laparoscopic distal pancreatectomy was associated with a statistically significant shorter hospital stay (11.5 days vs 13.5 days; p = 0.049), but with more expensive hospital charges than open distal pancreatectomy (p < 0.01).

CONCLUSION

Laparoscopic distal pancreatectomy is a clinically safe and effective procedure for benign and borderline pancreatic tumors.

What is the role of diagnostic laparoscopy in a gastroenterology unit?

BACKGROUND

Diagnostic laparoscopy is known to be a relatively safe invasive procedure. However, its use has decreased owing to the development of imaging techniques, and fewer gastroenterologists now practice diagnostic laparoscopy. Our aim was to examine the role of diagnostic laparoscopy in a gastroenterology unit in the era of advanced imaging techniques.

METHODS

We retrospectively reviewed 855 diagnostic laparoscopy cases. Its safety and efficacy were evaluated for various indications.

RESULTS

No mortality was observed, and complications were noted in ten patients (1.2%). Among the indications were evaluation of chronic liver disease (n = 673), liver tumor (n = 15), ascites of unknown origin and peritoneal disease (n = 142), and staging of intra-abdominal malignancy (n = 25). In patients with chronic liver disease, 461 were diagnosed as having chronic viral hepatitis, based on clinical data including imaging studies, but the diagnosis was changed to cirrhosis after a laparoscopic exam in 69 patients (15.0%). In patients with ascites of unknown origin and peritoneal disease, the diagnostic yield was 87.2% (123/141). In 24 (19.5%) of the 123 patients, the diagnosis changed or the less probable diagnosis was confirmed after laparoscopic examination. The confirmed diagnoses were mainly primary peritoneal disease, including peritoneal tuberculosis, in 17 patients, peritoneal metastatic carcinoma in five, and mesothelioma in two.

CONCLUSIONS

Diagnostic laparoscopy in a gastroenterology unit is safe and useful, especially for confirmation of liver cirrhosis and primary peritoneal disease evaluation.