Leading articles Br. J. Surg. 1992, Vol. 79, June, 486-487
Laparoscopy and assessment of digestive tract cancer Laparoscopy has been widely used for many years by gynaecologists and some gastroenterologists as a diagnostic and therapeutic tool. Yet, except by a few enthusiasts, it has been little used in general surgery. Now, however, with the explosive development of minimally invasive surgery, it seems that laparoscopic techniques will play an increasingly important role in the diagnosis and treatment of cancer of the digestive tract’. Despite the introduction of ultrasonography, computed tomography (CT), and magnetic resonance imaging, the surgeon dealing with gastrointestinal malignancy is often faced with a wide discrepancy between preoperative and intraoperative staging. There are certain tumours, for example of the stomach and colon, for which the surgeon may be committed to resection at operation even if only palliation may be achieved’. In such instances staging and decision making can take place during laparotomy. However, for patients with cancer of the oesophagus, gastric cardia, pancreas, or liver, surgery is neither the only nor always the best palliative treatment; in such cases more accurate staging before operation should prevent unnecessary laparotomy. Laparoscopy can provide valuable information that should lead to a more accurate staging of gastrointestinal malignancies. It permits inspection and indirect ‘palpation’ of the primary tumour site and the general abdominal cavity (including the lesser sac) to assess both local and peritoneal spread. Furthermore, it allows retrieval of cytological and histological specimens for diagnostic confirmation of the primary tumour, lymph node spread, and hepatic or peritoneal metastases. Watt et ~ 2 demonstrated . ~ the value of laparoscopy by comparing it with ultrasonography and CT for detection of intra-abdominal metastases in cancer of the oesophagus and gastric cardia. They showed prospectively that laparoscopy was significantly more sensitive and accurate than either ultrasonography or CT with respect to hepatic status. Laparoscopy also performed best with respect to nodal metastases, although this was statistically significant only when compared with the sensitivity of ultrasonography. Neither ultrasonography nor CT detected any peritoneal metastases, while laparoscopy detected eight of nine cases. The authors concluded that laparoscopy is a safe and reliable method of determining intra-abdominal tumour status and may obviate the need for surgery in some patients with malignant dysphagia. It is probable that laparoscopy will allow significant advance also in the area of hepatic and pancreatic surgery. Cuschieri4 and colleagues have repeatedly shown that laparoscopy is a useful procedure for diagnosing and staging in patients with pancreatic cancer, by obtaining target biopsies and cytology of the primary tumour or secondary intraperitoneal deposits. Warshaw et af.’ have also demonstrated that, although CT gives useful information about the size of a tumour, it does not successfully detect peritoneal metastases; laparoscopy on the other hand detects peritoneal metastases with 96 per cent sensitivity and provides important information about the resectability of pancreatic cancer. The value of laparoscopy has also been shown in the diagnosis and staging of primary carcinoma of the gallbladder6. The limitations of laparoscopy lie in the evaluation of less obvious hepatic and retroperitoneal malignancies, and it is here that intraoperative ultrasonography, performed during laparotomy, has proven its value. Rifkin et obtained additional information leading to a change in surgical approach in no fewer than 31 per cent of patients with liver tumours. We have found similar results using this technique in screening for liver metastases from colorectal cancer*. Determining the exact diagnosis of hepatic lesions, their number and precise localization, is imperative when considering liver resection or adjuvant therapy; conventional ultrasonography, CT and magnetic resonance imaging all appear to be inferior to intraoperative ultrasonography. It is now technically possible to perform ultrasonography via the laparoscope, enabling exploration of both liver parenchyma and the retroperitoneum using high resolution ultrasonographic probesg. The advantages of combined laparoscopy and ultrasonography are numerous and we believe the technique might even replace other
486
0007-1323/92/060486-02
0 1992 ButterworthbHeinemann Ltd
Leading articles
preoperative radiological investigations. Further refinements of trocars and transducers may allow laparoscopy with ultrasonography to be performed under local anaesthesia on an outpatient basis. In summary, diagnostic laparoscopy, performed immediately before a planned laparotomy, is a safe and reliable technique that provides valuable information needed for the accurate assessment and appropriate management of gastrointestinal malignancies. It is likely to play an increasing role in this context in the future and, with the addition of intraoperative ultrasonography, should prove to be a significant advance.
M. A. Cuesta S. Meijer P. J. Borgstein Department of Surgery Free University Hospital De Boeleluan 1117 1081 H V Amsterdam The Netherlands 1. 2.
3.
4. 5.
Sackier JM, Berci G , Paz-Partlow M . Elective diagnostic laparoscopy. Am J Surg 1991; 161: 326-31. Meijer S, de Bakker OJGB, Hoitsma HFW. Palliative resection in gastric cancer. J Sury Oncol 1983; 23: 77-80. Watt I, Stewart I, Anderson D, Anderson JR. Laparoscopy, ultrasound and computed tomography in cancer of the oesophagus and gastric cardia: a prospective comparison for detecting intra-abdominal metastases. Br J Surg 1989; 76: 1036-9. Cuschieri A. Laparoscopy for pancreatic cancer: does it benefit the patient? Eur J Sury Oncol 1988; 14: 41-4. Warshaw AL, Zhuo-yun-Gu, Wittenberg J, Waltman AC. Preoperative staging and assessment of resectability of pancreatic
Br. J. Surg., Vol. 79, No. 6, June 1992
6.
7.
8.
9.
cancer. Arch Surg 1990; 125: 233-7. Dagnini G , Marin G, Patella M, Zotti S. Laparoscopy in the diagnosis of primary carcinoma of the gallbladder. A study of 98 cases. Gustrointest Endusc 1984; 30: 289-91. Rifkin MD, Rosato FE, Branch HM e l ul. Intraoperative ultrasound of the liver. An important adjunctive tool for decision making in the operating room. Ann Surq 1987; 205: 466-12. Boutkan H, Meijer S, Cuesta MA e / crl. Intra-operative ultrasonography of the liver: a prerequisite for surgery of colorectal cancer? Nelh J Surg 1991; 43: 89-91. Okita K , Kodama T, Oda M , Takemoto T. Laparoscopic ultrasonography. Diagnosis of liver and pancreatic cancer. Scund J Gusfrocwterol 1984; 19(Suppl94): 91-100.
Laparoscopy and assessment of digestive tract cancer Laparoscopy has been widely used for many years by gynaecologists and some gastroenterologists as a diagnostic and therapeutic tool. Yet, except by a few enthusiasts, it has been little used in general surgery. Now, however, with the explosive development of minimally invasive surgery, it seems that laparoscopic techniques will play an increasingly important role in the diagnosis and treatment of cancer of the digestive tract’. Despite the introduction of ultrasonography, computed tomography (CT), and magnetic resonance imaging, the surgeon dealing with gastrointestinal malignancy is often faced with a wide discrepancy between preoperative and intraoperative staging. There are certain tumours, for example of the stomach and colon, for which the surgeon may be committed to resection at operation even if only palliation may be achieved’. In such instances staging and decision making can take place during laparotomy. However, for patients with cancer of the oesophagus, gastric cardia, pancreas, or liver, surgery is neither the only nor always the best palliative treatment; in such cases more accurate staging before operation should prevent unnecessary laparotomy. Laparoscopy can provide valuable information that should lead to a more accurate staging of gastrointestinal malignancies. It permits inspection and indirect ‘palpation’ of the primary tumour site and the general abdominal cavity (including the lesser sac) to assess both local and peritoneal spread. Furthermore, it allows retrieval of cytological and histological specimens for diagnostic confirmation of the primary tumour, lymph node spread, and hepatic or peritoneal metastases. Watt et ~ 2 demonstrated . ~ the value of laparoscopy by comparing it with ultrasonography and CT for detection of intra-abdominal metastases in cancer of the oesophagus and gastric cardia. They showed prospectively that laparoscopy was significantly more sensitive and accurate than either ultrasonography or CT with respect to hepatic status. Laparoscopy also performed best with respect to nodal metastases, although this was statistically significant only when compared with the sensitivity of ultrasonography. Neither ultrasonography nor CT detected any peritoneal metastases, while laparoscopy detected eight of nine cases. The authors concluded that laparoscopy is a safe and reliable method of determining intra-abdominal tumour status and may obviate the need for surgery in some patients with malignant dysphagia. It is probable that laparoscopy will allow significant advance also in the area of hepatic and pancreatic surgery. Cuschieri4 and colleagues have repeatedly shown that laparoscopy is a useful procedure for diagnosing and staging in patients with pancreatic cancer, by obtaining target biopsies and cytology of the primary tumour or secondary intraperitoneal deposits. Warshaw et af.’ have also demonstrated that, although CT gives useful information about the size of a tumour, it does not successfully detect peritoneal metastases; laparoscopy on the other hand detects peritoneal metastases with 96 per cent sensitivity and provides important information about the resectability of pancreatic cancer. The value of laparoscopy has also been shown in the diagnosis and staging of primary carcinoma of the gallbladder6. The limitations of laparoscopy lie in the evaluation of less obvious hepatic and retroperitoneal malignancies, and it is here that intraoperative ultrasonography, performed during laparotomy, has proven its value. Rifkin et obtained additional information leading to a change in surgical approach in no fewer than 31 per cent of patients with liver tumours. We have found similar results using this technique in screening for liver metastases from colorectal cancer*. Determining the exact diagnosis of hepatic lesions, their number and precise localization, is imperative when considering liver resection or adjuvant therapy; conventional ultrasonography, CT and magnetic resonance imaging all appear to be inferior to intraoperative ultrasonography. It is now technically possible to perform ultrasonography via the laparoscope, enabling exploration of both liver parenchyma and the retroperitoneum using high resolution ultrasonographic probesg. The advantages of combined laparoscopy and ultrasonography are numerous and we believe the technique might even replace other
486
0007-1323/92/060486-02
0 1992 ButterworthbHeinemann Ltd
Leading articles
preoperative radiological investigations. Further refinements of trocars and transducers may allow laparoscopy with ultrasonography to be performed under local anaesthesia on an outpatient basis. In summary, diagnostic laparoscopy, performed immediately before a planned laparotomy, is a safe and reliable technique that provides valuable information needed for the accurate assessment and appropriate management of gastrointestinal malignancies. It is likely to play an increasing role in this context in the future and, with the addition of intraoperative ultrasonography, should prove to be a significant advance.
M. A. Cuesta S. Meijer P. J. Borgstein Department of Surgery Free University Hospital De Boeleluan 1117 1081 H V Amsterdam The Netherlands 1. 2.
3.
4. 5.
Sackier JM, Berci G , Paz-Partlow M . Elective diagnostic laparoscopy. Am J Surg 1991; 161: 326-31. Meijer S, de Bakker OJGB, Hoitsma HFW. Palliative resection in gastric cancer. J Sury Oncol 1983; 23: 77-80. Watt I, Stewart I, Anderson D, Anderson JR. Laparoscopy, ultrasound and computed tomography in cancer of the oesophagus and gastric cardia: a prospective comparison for detecting intra-abdominal metastases. Br J Surg 1989; 76: 1036-9. Cuschieri A. Laparoscopy for pancreatic cancer: does it benefit the patient? Eur J Sury Oncol 1988; 14: 41-4. Warshaw AL, Zhuo-yun-Gu, Wittenberg J, Waltman AC. Preoperative staging and assessment of resectability of pancreatic
Br. J. Surg., Vol. 79, No. 6, June 1992
6.
7.
8.
9.
cancer. Arch Surg 1990; 125: 233-7. Dagnini G , Marin G, Patella M, Zotti S. Laparoscopy in the diagnosis of primary carcinoma of the gallbladder. A study of 98 cases. Gustrointest Endusc 1984; 30: 289-91. Rifkin MD, Rosato FE, Branch HM e l ul. Intraoperative ultrasound of the liver. An important adjunctive tool for decision making in the operating room. Ann Surq 1987; 205: 466-12. Boutkan H, Meijer S, Cuesta MA e / crl. Intra-operative ultrasonography of the liver: a prerequisite for surgery of colorectal cancer? Nelh J Surg 1991; 43: 89-91. Okita K , Kodama T, Oda M , Takemoto T. Laparoscopic ultrasonography. Diagnosis of liver and pancreatic cancer. Scund J Gusfrocwterol 1984; 19(Suppl94): 91-100.
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