0016-5107/91/3704-0441$03.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1991 by the American Society for Gastrointestinal Endoscopy
Laparoscopy for pre-operative staging and assessment of operability in gastric carcinoma Ajay K. Kriplani, MS, Brij M. L. Kapur, MS, FRCS New Delhi, India
Laparoscopy was performed in 40 patients with gastric carcinoma, whose lesions were otherwise considered amenable to operation, in order to more accurately stage the disease and ascertain the prospect of resectability. Laparoscopy disclosed hitherto unrecognized distant metastases in 5 cases (12.5%) and locally advanced, unresectable neoplasia in 11 cases (27.5%). Thus, laparoscopy served as a basis for avoiding the burden of futile laparotomy in 16 patients (40%). Laparoscopy confirmed the feasibility of resection in 24 patients, and this finding was borne out in 20 of 23 patients surgically explored (87%). The overall diagnostic accuracy of laparoscopy was 91.6%. Laparoscopy was performed in these patients with no mortality or morbidity. We conclude that laparoscopy is an effective means of evaluating resectability of gastric carcinomas and can provide valuable help in planning surgical approach. (Gastrointest Endosc 1991;37:441443)
When far-advanced or metastatic disease is not evident by conventional diagnostic procedures, exploratory laparotomy has been the traditional means of ascertaining resectability of gastric carcinoma. However, it has been found that, due to advanced disease, the lesions of nearly 25% of patients who undergo exploratory laparotomy are amenable to no procedure other than open biopsy (15.8 to 34.3%).1,2 In patients found with unresectable lesions, complications of laparotomy are reported in 13 to 23%, and mortality has ranged from 10 to 21.2%.1,3,4 More accurate pre-operative staging, thus avoiding unnecessary laparotomy, will be a significant advance toward improved management of these patients. Laparoscopy has proved useful in the management of various malignant disorders. 5-1o The utility of laparoscopy has been limited, for the most part, to evaluation of visceral and serosal surfaces and detection of visible hepatic or peritoneal metastases,5,n while certain reports have shown its usefulness also in extrahepatic abdominal disease. 8,9 In patients with gastric carcinoma, laparoscopy has yielded valuable Received September 19, 1990, For revision November 1, 1990. Accepted February 5, 1991. From the Department of Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. Reprint requests: A. K. Kriplani, MS, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
VOLUME 37, NO.4, 1991
information pertaining to local extent and regional spread of the disease,8, 10, 12 thus significantly influencing management. Herein we describe our technique and report our experience with laparoscopy in the evaluation of resectability in patients with gastric carcinomas. PATIENTS AND METHODS
From October 1987 to June 1990, we performed laparoscopy in 40 patients with gastric carcinoma in order to accurately stage their lesions and ascertain resectability. Twenty-three of these patients were older than 50 years. Patients in whom conventional examination had disclosed obviously unresectable lesions (e.g., those with palpably nodular livers, distant lymphadenopathy, ascites, pelvic deposits, or clearly evident metastases by ultrasonography or CT scanning) were excluded from our protocol. Patients with carcinoma obstructing the gastric outlet also were not considered for laparoscopy inasmuch as they required palliative bypass procedures despite distant disease. Laparoscopy was performed under local anesthesia with light premedication. The sites for the pneumoperitoneum needle and trocar were selected, when possible, below the umbilicus. Both forward-viewing and side-viewing telescopes were used according to a technique described in a previous publication. 8 The visible surfaces of the liver, diaphragm, omentum, and parietal and serosal peritoneum were carefully examined for evidence of malignant deposits and ascites. Most of the 441
anterior wall of the stomach could be inspected without manipulation. However, a second puncture to the left of the midline permitted introduction of a probe with which the viscera could be moved and palpated so as to determine the extent of infiltration of the entire stomach wall and its adjacent structures. The normal stomach wall is soft and yielding, and the anterior wall can be readily moved over the posterior wall. Areas infiltrated by tumor feel hard and fixed. Combined inspection and probing provide a fairly accurate estimate of the extent of disease within the gastric wall. Enlarged lymph nodes along the greater curve of the stomach usually can be seen. By elevating the left lobe of the liver with the probe, the undersurface can be inspected by means of the side-viewing telescope for evidence of metastases. Rotating the telescope 180 degrees brings into view the lesser curve of the stomach, the lesser omentum, and the caudate lobe of the liver. The gastrohepatic omentum can be similarly examined. 13 If the patient is not obese, the lobular architecture of the pancreas can be seen through the translucent gastrohepatic ligament. Infiltration by tumor of the lesser omentum is reflected in neovascularization and a loss of its normally smooth, glistening appearance. Inspection and manipulation are aided by elevating the head end of the table. Biopsy can be performed, with proper caution, where needed, including areas of the lesser omentum and celiac nodes. To assess resectability of the posterior wall tumor, the palpating probe is inserted behind the stomach, through an avascular area of the greater omentum, and an attempt is made to lift the tumor mass with the probe. In thin patients, mobility of the tumor can be thus predicted, although the procedure may be difficult in the presence of a fat-laden omentum. Mobility of tumors involving the gastric fundus also can be assessed by probing. Biopsy of the liver, peritoneum, or lymph nodes is deferred until inspection and probing is complete, as blood trickling from a biopsy site may hamper proper visualization. Finally, the pelvic cavity is examined by elevating the foot end of the table, and the procedure is terminated. Oral fluids can be given immediately, and intravenous fluids, when needed, are continued for several hours, after which the patient can be discharged. In our hands, the entire procedure can be accomplished in about 15 min.
RESULTS
Laparoscopy, as described, was undertaken as an outpatient procedure in 22 of the 40 cases. Early in
the series, patients were regularly admitted to the hospital for laparoscopy, but it soon became evident that the procedure was well tolerated, even by elderly patients, and thereafter outpatient laparoscopy became our routine. We encountered no complication or mortality. Laparoscopic diagnosis and final outcome are shown in Table 1. In five patients, previously unrecognized distant spread of tumor was found by laparoscopy and confirmed by biopsy in all. In 11 patients, local spread and fixation of tumor were found, as evident by infiltration of the lesser omentum, posterior rigidity, or enlarged, fixed celiac nodes. In five of these patients, biopsy documented the spread of tumor and in three it was confirmed at subsequent laparotomy. In the remaining three patients, the laparoscopic evidence of bulky tumor growth and regional lymphadenopathy was so obvious as to preclude laparotomy. Laparoscopic examination indicated resectability of tumor in 24 patients. One patient refused operation. The remaining 23 underwent surgery, and resection was accomplished in 20. In the remaining three patients, local or distant spread of disease, unappreciated at laparoscopy, precluded resection; palliative gastrojejunostomy was performed in two. Excluding the four patients in whom laparoscopic findings could not be confirmed, the diagnostic accuracy of laparoscopy in this series can be calculated as 91.6% (33 of 36). Laparoscopic assessment of unresectable tumor proved consistently correct. The assessed accuracy of resectable disease was 87% (20 of 23 patients surgically explored). The overall resectability rate in this series was 50% (20 to 40) and 77% (20 of 26) for those who underwent laparotomy. Eleven positive, laparoscopically targeted, biopsy specimens were taken in 10 patients. Sites with positive biopsy included liver (4), lymph nodes (3), lesser omentum (2), greater omentum (1), and parietal peritoneum (1). Laparoscopy disclosed otherwise unrecognized neoplastic spread or metastasis in 16 patients (40%) who were thus spared the burden and risk of laparotomy. On the other hand, laparoscopy disclosed no evidence of suspected liver involvement in three patients with elevated serum alkaline phosphatase activity, thus
Table 1. Results of laparoscopic examination Final diagnosis Laparoscopic findings
Correct
N
Laparoscopic biopsy Unresectable Distant disease Loco-regional fixation Resectable Total
442
5 11
5 5
24 40
10
Wrong
Unconfirmed
Surgery
3
3
20
3
23
3
1
4
GASTROINTESTINAL ENDOSCOPY
permitting resection of primary lesions which otherwise might have been considered inoperable. DISCUSSION
Gastric carcinoma has been marked by a relatively low rate of resectability (nearly 50% )3,4 and a generally poor prognosis. Results of palliative surgery are also disappointing, while morbidity and mortality remain high. 1-4 Hepatic metastases can be detected preoperatively by ultrasonography6. 10, 14 or computed tomography.14 However, local extension of tumor growth, often found only at laparotomy in ordinary circumstances, remains a frequent cause of unresectability (in as many as 32% of operated patients 2). It has been suggested that laparoscopy cannot permit an accurate evaluation of tumor growth in the area of the gastrohepatic omentum and celiac nodes5 or of local extension and fixation by gastric carcinoma. l l A paucity of reports describing the utilization of laparoscopy for preoperative evaluation of gastric carcinoma supports this belief. However, in our experience, using the technique described in this report, we find that a fairly accurate assessment of the extent of gastric carcinoma can be made by laparoscopy in a majority of patients. By selecting appropriate candidates for operation, solely on the basis of laparoscopic evaluation, the resectability rate among our patients was 87%, an appreciable improvement when compared with rates of approximately 50% when patients are selected by other means. 3. 4 Thus, laparoscopy can influence therapy in a large percentage of patients. For staging gastric carcinoma, laparoscopy offers additional advantages. It is superior to ultrasonography and CT scanning in identifying hepatic metastases of small size (1 to 3 cm).5,14 Laparoscopic visualization of the liver surface is an effective means of differentiating hepatic metastases and cirrhosis. 5. 9 Detection of cirrhosis, and its complication by portal hypertension, can influence the choice of management. In terms of hepatic metastases from gastric carcinoma, falsely positive results of 20 to 26.7% have been reported for ultrasonography1o,12 and 16% for CT scanning. 14 Accurate diagnosis of hepatic involvement requires histologic confirmation before a patient is denied potentially curative treatment. Guided biopsy by laparoscopy has an advantage of safety insofar as visible vessels can be avoided, and undue bleeding can be detected and controlled. Laparoscopy also affords an opportunity to identify small omental and
VOLUME 37, NO.4, 1991
peritoneal implants which imaging modalities may not detect. The presence of such nodules, reported in as many as 14% of patients,2 or their absence significantly alters the management and outcome of patients with gastric carcinoma. From these considerations, we recommend that laparoscopy be employed in the staging of all presumably operable gastric carcinomas. Excepted from this rule, of course, are those patients with gastric outlet obstruction who require surgical palliation despite the presence of advanced disease. Also, if evidence of inoperability is equivocal, the patient should not be denied a rightful chance of cure by exploratory laparotomy. We believe that preoperative laparoscopy in selected patients, leading to a more discriminating selection of candidates for operation, can reduce the operative risk and increase the rate of resectability of gastric carcinoma.
REFERENCES 1. Viste A, Haugstvedt T, Eide E, Soreide 0. Postoperative com-
plications and mortality after surgery for gastric cancer. Ann Surg 1988;207:7-13. 2. Hallissey MT, Allum WH, Roginski C, Fielding JWL. Palliative surgery for gastric cancer. Cancer 1988;62:440-4. 3. Valen B, Viste A, Haugstvedt T, Elide GE, Soreido 0. Treatment of stomach cancer, a national experience. Br J Surg 1988;75:708-12. 4. Irvin TT, Bridger JE. Gastric cancer: an audit of 122 consecu-
tive cases and the results of rt gastrectomy. Br J Surg 1988;75:106-9.
5. Lightdale CJ. Clinical applications of laparoscopy in patients with malignant neoplasms. Gastrointest Endosc 1982;28:99102.
6. Cuschieri A. Value of laparoscopy in hepatobiliary disease. Ann R CoIl Surg Engl 1975;57:33-8. 7. Bhargava DK, Sarin S, Verma K, Kapur BML. Laparoscopy in carcinoma of the gallbladder. Gastrointest Endosc 1983;29:212.
8. Kriplani AK, Sharma LK. Peritoneoscopy in extrahepatic abdominal diseases. Arch Surg 1986;121:818-20. 9. Dagnini G, Caldironi MW, Marin G, Buzzacarini 0, Tremolda C, Ruol A. Laparoscopy in abdominal staging of esophageal carcinoma. Report of 369 cases. Gastrointest Endosc 1986;32:400-2. 10. Possik RA, Franco EL, Pires DR, Wohnrath DR, Ferreira EB.
Sensitivity, specificity and predictive value of laparoscopy for the staging of gastric cancer and for the detection of liver metastasis. Cancer 1986;58:1-6. 11. Gross E, Bancewicz J, Ingram G. Assessment of gastric cancer by laparoscopy. Br Med J 1984;288:1577. 12. Shandall A, Johnson C. Laparoscopy or scanning in oesophageal and gastric carcinoma. Br J Surg 1985;72:449-51. 13. Meyer-Burg J, Ziegler U. The intra-abdominal inspection and biopsy of lymph nodes during peritoneoscopy. Endoscopy 1978;10:41-3. 14. Smith TJ, Kemeny MM, Sugarbaker PH, et al. A prospective
study of hepatic imaging in the detection of metastatic disease. Ann Surg 1982;195:486-91.
443
Laparoscopy for pre-operative staging and assessment of operability in gastric carcinoma Ajay K. Kriplani, MS, Brij M. L. Kapur, MS, FRCS New Delhi, India
Laparoscopy was performed in 40 patients with gastric carcinoma, whose lesions were otherwise considered amenable to operation, in order to more accurately stage the disease and ascertain the prospect of resectability. Laparoscopy disclosed hitherto unrecognized distant metastases in 5 cases (12.5%) and locally advanced, unresectable neoplasia in 11 cases (27.5%). Thus, laparoscopy served as a basis for avoiding the burden of futile laparotomy in 16 patients (40%). Laparoscopy confirmed the feasibility of resection in 24 patients, and this finding was borne out in 20 of 23 patients surgically explored (87%). The overall diagnostic accuracy of laparoscopy was 91.6%. Laparoscopy was performed in these patients with no mortality or morbidity. We conclude that laparoscopy is an effective means of evaluating resectability of gastric carcinomas and can provide valuable help in planning surgical approach. (Gastrointest Endosc 1991;37:441443)
When far-advanced or metastatic disease is not evident by conventional diagnostic procedures, exploratory laparotomy has been the traditional means of ascertaining resectability of gastric carcinoma. However, it has been found that, due to advanced disease, the lesions of nearly 25% of patients who undergo exploratory laparotomy are amenable to no procedure other than open biopsy (15.8 to 34.3%).1,2 In patients found with unresectable lesions, complications of laparotomy are reported in 13 to 23%, and mortality has ranged from 10 to 21.2%.1,3,4 More accurate pre-operative staging, thus avoiding unnecessary laparotomy, will be a significant advance toward improved management of these patients. Laparoscopy has proved useful in the management of various malignant disorders. 5-1o The utility of laparoscopy has been limited, for the most part, to evaluation of visceral and serosal surfaces and detection of visible hepatic or peritoneal metastases,5,n while certain reports have shown its usefulness also in extrahepatic abdominal disease. 8,9 In patients with gastric carcinoma, laparoscopy has yielded valuable Received September 19, 1990, For revision November 1, 1990. Accepted February 5, 1991. From the Department of Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. Reprint requests: A. K. Kriplani, MS, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
VOLUME 37, NO.4, 1991
information pertaining to local extent and regional spread of the disease,8, 10, 12 thus significantly influencing management. Herein we describe our technique and report our experience with laparoscopy in the evaluation of resectability in patients with gastric carcinomas. PATIENTS AND METHODS
From October 1987 to June 1990, we performed laparoscopy in 40 patients with gastric carcinoma in order to accurately stage their lesions and ascertain resectability. Twenty-three of these patients were older than 50 years. Patients in whom conventional examination had disclosed obviously unresectable lesions (e.g., those with palpably nodular livers, distant lymphadenopathy, ascites, pelvic deposits, or clearly evident metastases by ultrasonography or CT scanning) were excluded from our protocol. Patients with carcinoma obstructing the gastric outlet also were not considered for laparoscopy inasmuch as they required palliative bypass procedures despite distant disease. Laparoscopy was performed under local anesthesia with light premedication. The sites for the pneumoperitoneum needle and trocar were selected, when possible, below the umbilicus. Both forward-viewing and side-viewing telescopes were used according to a technique described in a previous publication. 8 The visible surfaces of the liver, diaphragm, omentum, and parietal and serosal peritoneum were carefully examined for evidence of malignant deposits and ascites. Most of the 441
anterior wall of the stomach could be inspected without manipulation. However, a second puncture to the left of the midline permitted introduction of a probe with which the viscera could be moved and palpated so as to determine the extent of infiltration of the entire stomach wall and its adjacent structures. The normal stomach wall is soft and yielding, and the anterior wall can be readily moved over the posterior wall. Areas infiltrated by tumor feel hard and fixed. Combined inspection and probing provide a fairly accurate estimate of the extent of disease within the gastric wall. Enlarged lymph nodes along the greater curve of the stomach usually can be seen. By elevating the left lobe of the liver with the probe, the undersurface can be inspected by means of the side-viewing telescope for evidence of metastases. Rotating the telescope 180 degrees brings into view the lesser curve of the stomach, the lesser omentum, and the caudate lobe of the liver. The gastrohepatic omentum can be similarly examined. 13 If the patient is not obese, the lobular architecture of the pancreas can be seen through the translucent gastrohepatic ligament. Infiltration by tumor of the lesser omentum is reflected in neovascularization and a loss of its normally smooth, glistening appearance. Inspection and manipulation are aided by elevating the head end of the table. Biopsy can be performed, with proper caution, where needed, including areas of the lesser omentum and celiac nodes. To assess resectability of the posterior wall tumor, the palpating probe is inserted behind the stomach, through an avascular area of the greater omentum, and an attempt is made to lift the tumor mass with the probe. In thin patients, mobility of the tumor can be thus predicted, although the procedure may be difficult in the presence of a fat-laden omentum. Mobility of tumors involving the gastric fundus also can be assessed by probing. Biopsy of the liver, peritoneum, or lymph nodes is deferred until inspection and probing is complete, as blood trickling from a biopsy site may hamper proper visualization. Finally, the pelvic cavity is examined by elevating the foot end of the table, and the procedure is terminated. Oral fluids can be given immediately, and intravenous fluids, when needed, are continued for several hours, after which the patient can be discharged. In our hands, the entire procedure can be accomplished in about 15 min.
RESULTS
Laparoscopy, as described, was undertaken as an outpatient procedure in 22 of the 40 cases. Early in
the series, patients were regularly admitted to the hospital for laparoscopy, but it soon became evident that the procedure was well tolerated, even by elderly patients, and thereafter outpatient laparoscopy became our routine. We encountered no complication or mortality. Laparoscopic diagnosis and final outcome are shown in Table 1. In five patients, previously unrecognized distant spread of tumor was found by laparoscopy and confirmed by biopsy in all. In 11 patients, local spread and fixation of tumor were found, as evident by infiltration of the lesser omentum, posterior rigidity, or enlarged, fixed celiac nodes. In five of these patients, biopsy documented the spread of tumor and in three it was confirmed at subsequent laparotomy. In the remaining three patients, the laparoscopic evidence of bulky tumor growth and regional lymphadenopathy was so obvious as to preclude laparotomy. Laparoscopic examination indicated resectability of tumor in 24 patients. One patient refused operation. The remaining 23 underwent surgery, and resection was accomplished in 20. In the remaining three patients, local or distant spread of disease, unappreciated at laparoscopy, precluded resection; palliative gastrojejunostomy was performed in two. Excluding the four patients in whom laparoscopic findings could not be confirmed, the diagnostic accuracy of laparoscopy in this series can be calculated as 91.6% (33 of 36). Laparoscopic assessment of unresectable tumor proved consistently correct. The assessed accuracy of resectable disease was 87% (20 of 23 patients surgically explored). The overall resectability rate in this series was 50% (20 to 40) and 77% (20 of 26) for those who underwent laparotomy. Eleven positive, laparoscopically targeted, biopsy specimens were taken in 10 patients. Sites with positive biopsy included liver (4), lymph nodes (3), lesser omentum (2), greater omentum (1), and parietal peritoneum (1). Laparoscopy disclosed otherwise unrecognized neoplastic spread or metastasis in 16 patients (40%) who were thus spared the burden and risk of laparotomy. On the other hand, laparoscopy disclosed no evidence of suspected liver involvement in three patients with elevated serum alkaline phosphatase activity, thus
Table 1. Results of laparoscopic examination Final diagnosis Laparoscopic findings
Correct
N
Laparoscopic biopsy Unresectable Distant disease Loco-regional fixation Resectable Total
442
5 11
5 5
24 40
10
Wrong
Unconfirmed
Surgery
3
3
20
3
23
3
1
4
GASTROINTESTINAL ENDOSCOPY
permitting resection of primary lesions which otherwise might have been considered inoperable. DISCUSSION
Gastric carcinoma has been marked by a relatively low rate of resectability (nearly 50% )3,4 and a generally poor prognosis. Results of palliative surgery are also disappointing, while morbidity and mortality remain high. 1-4 Hepatic metastases can be detected preoperatively by ultrasonography6. 10, 14 or computed tomography.14 However, local extension of tumor growth, often found only at laparotomy in ordinary circumstances, remains a frequent cause of unresectability (in as many as 32% of operated patients 2). It has been suggested that laparoscopy cannot permit an accurate evaluation of tumor growth in the area of the gastrohepatic omentum and celiac nodes5 or of local extension and fixation by gastric carcinoma. l l A paucity of reports describing the utilization of laparoscopy for preoperative evaluation of gastric carcinoma supports this belief. However, in our experience, using the technique described in this report, we find that a fairly accurate assessment of the extent of gastric carcinoma can be made by laparoscopy in a majority of patients. By selecting appropriate candidates for operation, solely on the basis of laparoscopic evaluation, the resectability rate among our patients was 87%, an appreciable improvement when compared with rates of approximately 50% when patients are selected by other means. 3. 4 Thus, laparoscopy can influence therapy in a large percentage of patients. For staging gastric carcinoma, laparoscopy offers additional advantages. It is superior to ultrasonography and CT scanning in identifying hepatic metastases of small size (1 to 3 cm).5,14 Laparoscopic visualization of the liver surface is an effective means of differentiating hepatic metastases and cirrhosis. 5. 9 Detection of cirrhosis, and its complication by portal hypertension, can influence the choice of management. In terms of hepatic metastases from gastric carcinoma, falsely positive results of 20 to 26.7% have been reported for ultrasonography1o,12 and 16% for CT scanning. 14 Accurate diagnosis of hepatic involvement requires histologic confirmation before a patient is denied potentially curative treatment. Guided biopsy by laparoscopy has an advantage of safety insofar as visible vessels can be avoided, and undue bleeding can be detected and controlled. Laparoscopy also affords an opportunity to identify small omental and
VOLUME 37, NO.4, 1991
peritoneal implants which imaging modalities may not detect. The presence of such nodules, reported in as many as 14% of patients,2 or their absence significantly alters the management and outcome of patients with gastric carcinoma. From these considerations, we recommend that laparoscopy be employed in the staging of all presumably operable gastric carcinomas. Excepted from this rule, of course, are those patients with gastric outlet obstruction who require surgical palliation despite the presence of advanced disease. Also, if evidence of inoperability is equivocal, the patient should not be denied a rightful chance of cure by exploratory laparotomy. We believe that preoperative laparoscopy in selected patients, leading to a more discriminating selection of candidates for operation, can reduce the operative risk and increase the rate of resectability of gastric carcinoma.
REFERENCES 1. Viste A, Haugstvedt T, Eide E, Soreide 0. Postoperative com-
plications and mortality after surgery for gastric cancer. Ann Surg 1988;207:7-13. 2. Hallissey MT, Allum WH, Roginski C, Fielding JWL. Palliative surgery for gastric cancer. Cancer 1988;62:440-4. 3. Valen B, Viste A, Haugstvedt T, Elide GE, Soreido 0. Treatment of stomach cancer, a national experience. Br J Surg 1988;75:708-12. 4. Irvin TT, Bridger JE. Gastric cancer: an audit of 122 consecu-
tive cases and the results of rt gastrectomy. Br J Surg 1988;75:106-9.
5. Lightdale CJ. Clinical applications of laparoscopy in patients with malignant neoplasms. Gastrointest Endosc 1982;28:99102.
6. Cuschieri A. Value of laparoscopy in hepatobiliary disease. Ann R CoIl Surg Engl 1975;57:33-8. 7. Bhargava DK, Sarin S, Verma K, Kapur BML. Laparoscopy in carcinoma of the gallbladder. Gastrointest Endosc 1983;29:212.
8. Kriplani AK, Sharma LK. Peritoneoscopy in extrahepatic abdominal diseases. Arch Surg 1986;121:818-20. 9. Dagnini G, Caldironi MW, Marin G, Buzzacarini 0, Tremolda C, Ruol A. Laparoscopy in abdominal staging of esophageal carcinoma. Report of 369 cases. Gastrointest Endosc 1986;32:400-2. 10. Possik RA, Franco EL, Pires DR, Wohnrath DR, Ferreira EB.
Sensitivity, specificity and predictive value of laparoscopy for the staging of gastric cancer and for the detection of liver metastasis. Cancer 1986;58:1-6. 11. Gross E, Bancewicz J, Ingram G. Assessment of gastric cancer by laparoscopy. Br Med J 1984;288:1577. 12. Shandall A, Johnson C. Laparoscopy or scanning in oesophageal and gastric carcinoma. Br J Surg 1985;72:449-51. 13. Meyer-Burg J, Ziegler U. The intra-abdominal inspection and biopsy of lymph nodes during peritoneoscopy. Endoscopy 1978;10:41-3. 14. Smith TJ, Kemeny MM, Sugarbaker PH, et al. A prospective
study of hepatic imaging in the detection of metastatic disease. Ann Surg 1982;195:486-91.
443
