|Year : 2012 | Volume
| Issue : 2 | Page : 45-49
Role of diagnostic laparoscopy in assessing operability in borderline resectable gastrointestinal cancers
Chandramohan K Nair1, Kiran C Kothari2
1 Department of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat; Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, Kerala, India
2 Department of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
|Date of Submission||06-Dec-2010|
|Date of Acceptance||23-Mar-2011|
|Date of Web Publication||2-May-2012|
Chandramohan K Nair
Division of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala
Background: Diagnostic laparoscopy helps in diagnosing and staging Gastrointestinal (GI) cancers. Routine laparoscopy before laparotomy, especially in cancers that have equivocal operability, helps to avoid unnecessary laparotomies. Present study evaluates utility of laparoscopy in diagnosing and staging GI cancers. Materials and Methods: Diagnostic laparoscopy was done in 41 patients with gastrointestinal (GI) cancers who were thought to have equivocal operability. Patients with suspected or known non-metastatic GI cancers, in whom resectability was found doubtful by clinical assessment and pre-operative imaging, were included. Patients with non-GI cancers (lymphoma, gynaecologic cancers, genitourinary cancers, retroperitoneal sarcoma, sarcoma and abdominal metastasis of non-GI cancers) and metastatic cancers which were beyond the scope of curative surgery were excluded from the study. Results: After diagnostic laparoscopy (DL) five patients had benign diagnosis. Out of 36 patients with malignant diagnosis, after DL, 22 patients (61.1%) were inoperable, 11 patients (30.6%) were operable, and three (8.3%) patients were of equivocal operability. Sensitivity, specificity, positive predictive value, and negative predictive value of laparoscopy in detecting operability were 100%, 91.7%, 81.8%, and 100%, respectively. Conclusions: Laparoscopy helped in a significant number of patients with advanced GI cancers to avoid laparotomy. The morbidity of DL was acceptable.
Keywords: Diagnostic laparoscopy, gastrointestinal cancer, operability, staging
|How to cite this article:|
Nair CK, Kothari KC. Role of diagnostic laparoscopy in assessing operability in borderline resectable gastrointestinal cancers. J Min Access Surg 2012;8:45-9
|How to cite this URL:|
Nair CK, Kothari KC. Role of diagnostic laparoscopy in assessing operability in borderline resectable gastrointestinal cancers. J Min Access Surg [serial online] 2012 [cited 2013 Jun 19];8:45-9. Available from: http://www.journalofmas.com/text.asp?2012/8/2/45/95533
| ¤ Introduction|| |
The word 'Laparoscopy' comes from words 'Lapara' which means 'soft part of body between the rib margins and hips' or more simply 'flank or loin'. The other Greek root is 'Skopein' which means 'to see or view or examine'. Skopein has become scope in English. Laparoscopy has gained a very important role in armamentarium of Surgical Oncologist. Laparoscopy is exalted as king of all surgical procedures, thanks to the popularity gained by acceptance of laparoscopic procedures like cholecyctectomy. The main advantages of laparoscopy are short length of hospitalization, increased comfort and well being of the patients and their rapid return to normal activities.
Main advantages of laparoscopy over laparotomy include avoidance of larger incision, undue tissue handling, and retraction, which contribute to well being of the patient. Murine and human experiments showed that carbon dioxide (CO 2) in peritoneum can reduce inflammatory mediators from leucocytes and macrophages by marked acidification of cytosol. , This, acidification produced, reduces local inflammatory response. Production of leukocyte superoxides and cytokines (TNF-α, inlerturkin 1, IL6, IL8, and mitochondrial dehydrogenases) decreases. This causes less pain and inflammation after laparoscopy. , Even though the local peritoneal inflammatory response is reduced, the systemic immunity is better preserved in laparoscopic surgery group. Vallina and Velasco showed that there is no decrease in absolute CD4, CD8 counts after laparoscopic cholecyctectomy.  In a prospective animal and human study comparing laparotomy and laparoscopy, cell mediated immunity was better preserved in laparoscopy. 
By definition port site metastases are recurrence of tumour at the small wounds created by trans-abdominal placement of ports to pass instruments and retrieve specimen. Various early reports showed the rate of port site metastases in laparoscopic surgeries are up to 21% as reported by Berends et al.  This has tempered initial enthusiasm for minimally invasive surgery, because in comparison to laparoscopy laparotomy wound recurrence was 6-8%. , But fortunately recent laparoscopy series show port site metastases in less than 1% cases. , Usually post site metastasis is also a surrogate marker of advanced and aggressive malignancy.
Diagnostic laparoscopy (DL) helps in diagnosing and staging GI cancers. Routine laparoscopy before laparotomy, especially in cancers which have equivocal operability helps to avoid unnecessary laparotomies. Our study is to find out how helpful is laparoscopy in diagnosing and staging GI cancers.
| ¤ Materials and Methods|| |
Forty-one patients with GI malignancies who had undergone DL in our unit during the period 2003-2005 were studied. During these period 312 patients presented with GI cancers, of which 152 had undergone laparotomy for cancer while 109 were diagnosed with inoperable disease. In the study group, clinical, imaging and perioperative parameters were recorded. The primary aim of study was to find out sensitivity, specificity, positive predictive value, and negative predictive value of DL in assessing operability. The secondary aim was to document morbidity and mortality of DL.
The patients with suspected or known non-metastatic GI cancers in which resectability was found doubtful by clinical assessment and pre-operative imaging were included. The tumours with doubtful fixity to adjacent structures, especially organs that cannot be salvaged such as main arteries and pelvic walls, on imaging and tumours with a poor natural history with high propensity for peritoneal or distant spread are included in the study and selected for DL.
Patients with non-GIT cancers (lymphoma, gynaecologic cancers, genitourinary cancers, retroperitoneal sarcoma, sarcoma and abdominal metastasis of non-GI cancers) and metastatic cancers which were beyond the scope of curative surgery were excluded from the study.
Pre-operative work-up and operative technique
Pre-operative investigations included ultrasound scan (USS) of the abdomen, computerized axial tomography (CT) scan of abdomen (also of the chest in case of carcinoma oesophagus), chest x-ray, haemogram, renal function tests (RFT) and liver function tests (LFT). Preparation for surgery included antibiotic prophylaxis and pre-operative bowel preparation.
In laparoscopic surgery midline camera port is put near umbilicus and two working ports are put in right and left lumbar regions with additional port are put as and when required. General inspection of peritoneal cavity and liver surface was done first. We did not use intraopeative ultrasound. Then the area of primary tumour and lymphatic drainage area are examined in detail. Any suspicious lesions anywhere including para-aortic nodes are biopsied. Frozen section is used, if needed .In case of upper abdomen, lesser sac is entered routinely.
All patients received standard postoperative care which included antibiotics, IV fluids, chest physiotherapy, deep vein thrombosis (DVT) prophylaxis and analgesics.
Study was approved by Institutional Review Board and Human Ethics Committee of the institute . All statistical analyses were performed with SPSS software, version 17.
| ¤ Results|| |
A total of 41 patients had undergone DL. Among them the average age was observed to be 50 years (20 to 75 years). Twenty-two (53.70%) patients were males, and the remaining 19 (46.30%) were females. [Table 1] shows pre-operative and post-operative diagnoses.
In 22 patients (53.65%) there was no confirmed diagnosis of malignancy (five had pancreatic masses, 16 had gall bladder masses while one had mass in liver) where in 19 (43.35%) patients malignancy was confirmed.
After DL, out of the total 41 patients, five (12.20%) had benign diseases while 36 (87.80%) had malignancy. [Table 2] gives information regarding the final pre- and post-operative stage grouping in malignant cases.
Nine patients had undergone laparotomy in the same sitting.Two had carcinoma (ca) gall bladder (gb), two had carcinoma stomach, two had carcinoma rectum, one had carcinoma sigmoid colon, one had carcinoma head of pancreas and one had periampullary carcinoma. Two cases of ca gb were operable, and both were operated in the same sitting by doing laparotomy. One case of ca rectum was operable on laparoscopy and also on subsequent laparotomy. Operability of the second case of carcinoma rectum was equivocal after laparoscopy and laparotomy; it was inoperable due to local infiltration to urinary bladder and lateral and posterior pelvic walls. Sigmoid colon was showing doubtful operability in laparoscopy and on laparotomy there was extensive nodal infiltration of sigmoid mesentery, creating frozen pelvis, making it unresectable. A mass in the head of pancreas showed equivocal operability in laparoscopy, but it was inoperable on laparotomy owing to encasement of superior mesenteric artery near the uncinate process of the pancreas. Periampullary carcinoma was operable on laparoscopy as well as on laparotomy. Two cases of carcinoma distal stomach were inoperable by laparoscopy owing to peritoneal metastases, where open gastrojejunostomy was done to palliate gastric outlet obstruction.
Details of operability by DL are given in [Table 3]. The table also gives final operability. Reasons for inoperability and number of cases in which inoperability diagnosed by laparoscopy are given in [Table 4].
After laparoscopy, five (12.2%) patients had benign diagnoses (two cases of chronic cholecystitis, one case each of pseudo pancreatic cyst, haemangioma liver and chronic pancreatitis). Out of 36 patients with malignant diagnosis, after DL 22 patients (61.1%) were inoperable, 11 patients (30.6%) were operable and three (8.3%) (ca rectum, ca head of pancreas and ca sigmoid) had equivocal operability. Finally 10 (27.8%) patients were operable while 26 (72.2%) were inoperable. Carcinoma of body of pancreas which showed operability on laparoscopy turned inoperable on laparotomy due to encasement of superior mesenteric artery by disease.
Sensitivity, specificity, positive predictive value, and negative predictive value of laparoscopy in detecting operability were 100%, 91.7%, 81.8%, and 100%, respectively.
When perioperative outcome was analysed, out of 41 patients, nine patients who had undergone open laparotomy on same day were excluded from analysis. The average duration of laparoscopic surgery was observed to be 55.78 min (30 to 180 min). Average time taken till post-operative oral intake was 1.34 days (1 to 3 days). It took average of 2.97 days (1 to 5 days) for restoration of bowel movements. Average duration of hospitalization was 3.97 days (2 to 7 days).
Out of 32 of the total patients who had undergone laparoscopy (those nine patients who have undergone open surgery in same setting were excluded), and eight patients (25%) developed some or other complication subsequent to the procedure. In none of patients, the morbidity was major. Two patients had developed pneumonic consolidation (radilogic), urinary retention, and prolonged ileus and wound infection. All were managed conservatively.
| ¤ Discussion|| |
Our study evaluated laparoscopy as a diagnostic and staging tool for cancers. Out of 41 patients who had undergone DL, after pre-operative staging workout, malignancies were diagnosed in 36 cases. Out of 36 patients, only 11 were operable after DL. DL avoided unnecessary laparotomy in 20 patients, who were found to be inoperable on laparoscopy.
Second-generation helical CT machines were used in our institute. According to pre-operative imaging only six (16.7%) patients had stage IV disease but after laparoscopy 21 (58.3%) patients had stage IV disease. DL has best utility in detecting peritoneal nodules and liver metastasis, especially if the resources are scarce to provide state-of-the-art imaging equipments. In this sudy, all the peritoneal and liver metastases were detected by laparoscopy. We have to acknowledge the limitations as well. Laparoscopy failed to detect local infiltration and nodal disease.
According to study by Muntean et al., for staging laparoscopy sensitivity for distant metastases varied between 66% and 100% and the diagnostic accuracy between 87% for the lower oesophageal cancer and 100% for the biliary tract tumours.  According to Krasna et al., accuracy for thoracoscopic staging for mediastinal and abdominal metastasis were 58% and 68%, respectively, for imaging and 91% and 96% for thoracolaparocopic staging.  In one prospective multi-institutional study by National cancer Institute, USS, CT, magnetic resonance imaging and endoscopic ultrasound failed to identify 25% of metastatic disease identified by laparoscopy. 
Among different malignancies we have observed that the utility of laparoscopy in evaluating gall bladder masses was significant. There were 16 patients with gall bladder disease. After DL, 14 were found to have malignancies, among which 11 cases were inoperable and three were operable.. Hence, ca gall bladder is a disease where laparoscopy has the maximum potential as a diagnosing and staging tool.
In one of the early studies undetected metastasis disease was found in 13% to 57% of patients with gastric cancers initially staged by conventional modalities.  Thus, exploratory laparotomy was avoided in over 20% patients. These prospective studies showed staging accuracy of laparoscopy is 90% vs 70-80% in conventional imaging.
In our series, three cases where DL failed to detect operability were ca head of pancreas, ca body of pancreas and ca rectum. In these cases laparoscopy showed equivocal operability, but all turned inoperable after laparotomy. In case of pancreatic cancer, unfortunately, there are no strict guidelines for resectability. Even portal vein involvement can be managed by resection and vascular grafting by some authors. In two cases of pancreatic cancers in our series, laparoscopy failed to detect operability. Similarly, one study in John Hopkins showed that laparoscopy has identified only 2.3% of patients undergoing unnecessary laparotomy.  Moreover in the last few years, advancement of imagelogy resulted in a reduction of negative laparotomy from 13% to 4%.  As it stands today, routine laparoscopy cannot be recommended as a standard of care for pancreatic head malignancy, but in case of pancreatic body and tail masses laparoscopy may be useful in evaluation before considering surgery. However, many authors still recommend laparoscopic staging for all pancreatic cancers. ,,
Accurate staging for hepatobilary cancer is important as there is no role for laparotomy or palliative surgery in the presence of metastatic disease. Thus, staging laparoscopy is a clear cut winner among the investigational modalities. In one prospective study involving 60 cases, laparoscopic procedure detected additional tumour nodule in 11 out of 15 patients, and this changed the plan of management. 
One study of hilar cholangio ca and ca GB done in Memorial Sloan Kettering Cancer Centre, laparoscopy identified 84 inpoerable cases out of 153, increasing resectability from 62% to 78%. 
Different cancers of GI tract also have different biological behaviour so applying same modality to study various cancers may be questionable. We know that our sample size is small so each subtype is not evaluated separately. Moreover AJCC (American Joint Committee on Cancer) TNM (Tumour Node Metastasis) staging calls for generalization of malignancies based on staging across different organs and pathologic types.
However, the complication rate of DL was also noted to be quite low (25%, only minor morbidities) which included pneumonic consolidation, prolonged ileus, urinary retention and wound infection. It is notable that patients remained in hospital for an average of 3.97 days only. Most of the patients began oral intake next day itself. Even though spectra of modalities available to diagnose and stage intra-abdominal malignancies, laparoscopy holds a unique place in the array of modalities. The main area where laparoscopy scores over imagelogy is in identifying peritoneal and surface lesions of various organs inside the peritoneal cavity and provision for taking biopsy under vision. Different types of biopsies such as trucut biopsy, wedge biopsy and cup forceps biopsy can be done with laparoscopic instruments. Cytologic washing can also be done. Introduction of laparoscopic ultrasound in the armamentarium of minimally invasive surgery resulted in identification of otherwise occult metastasis in liver, peritoneum and other solid organs which is difficult to visualize. Using laparoscopic technique, lesions even smaller than 1 cm can be identified, biopsied and ablated. Laparoscopy has been suggested to prevent 10-44% of patients from having an unnecessary laparotomy by identifying those with unresectable disease not identified by imaging. ,,
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[Table 1], [Table 2], [Table 3], [Table 4]