Staging Laparoscopy in Pancreatic Cancer: A Potential Role for Advanced Laparoscopic Techniques Thomas Schnelldorfer, MD, FACS, Andrew I Gagnon, MD, Richard T Birkett, Kristen M Murphy, MBA, Roger L Jenkins, MD, FACS
MD,
Gail Reynolds,
MS,
The role of staging laparoscopy in pancreatic cancer in the age of high-resolution CT scans is under debate. This study’s aim is to evaluate the efficacy of staging laparoscopy in this disease. STUDY DESIGN: A retrospective cohort study was conducted evaluating patients who underwent operative treatment for radiographic stage I to III pancreatic cancer between July 2003 and October 2012. Radiographic follow-up was 94% at 6 months. RESULTS: Of 274 patients who met inclusion criteria, 136 underwent staging laparoscopy, which identified radiographic occult distant metastases in 2% (3 of 136). However, subsequent laparotomy identified an additional 9% (12 of 136) harboring distant metastases in regions not visualized on standard staging laparoscopy; specifically, the posterior liver surface, paraduodenal retroperitoneum, proximal jejunal mesentery, and lesser sac. The remaining 138 patients underwent initial staging laparotomy, which showed similar results identifying radiographic occult distant disease in 11% (15 of 138). Within 6 months after the operation, peritoneal or subcapsular liver metastases developed in an additional 6% (15 of 257)ddisease that potentially could have been diagnosed at the time of operationdproviding a false-negative rate of 88% for staging laparoscopy compared with 36% for staging laparotomy. CONCLUSIONS: Despite the availability of high-resolution CT scans, occult distant metastases can still be found in 11% of patients during the operation. In the absence of reliable risk factors to predict distant metastases, staging laparoscopy should be offered to all patients with radiographic localized disease. However, the results favor extended laparoscopic staging with evaluation of the posterior liver surface, mobilization of the duodenum, evaluation of the proximal jejunal mesentery, and visualization of the lesser sac. (J Am Coll Surg 2014;218: 1201e1206. 2014 by the American College of Surgeons)
BACKGROUND:
Staging laparoscopy, as a less-invasive approach for detection of peritoneal metastases compared with traditional open exploration, became a commonly accepted practice for treating patients with presumed resectable pancreatic cancer in the 1990s.1 A decade later, with the introduction of highresolution CT scans, a selective approach became common
CME questions for this article available at http://jacscme.facs.org Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Presented at the New England Surgical Society 94th Annual Meeting, Hartford, CT, September 2013. Received October 18, 2013; Accepted February 10, 2014. From the Department of General Surgery (Schnelldorfer, Gagnon, Birkett), Sophia Gordon Cancer Center (Reynolds), Department of Operating Room (Murphy), and Department of Transplantation (Jenkins), Lahey Hospital and Medical Center, Burlington, MA. Correspondence address: Thomas Schnelldorfer, MD, FACS, Department of General Surgery, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
practice.2 Laparoscopy was considered in what were deemed “high-risk” patients without ever determining reliable selection criteria; resulting in laparotomy without therapeutic benefit in 6% to 26% of all patients who undergo operative evaluation.3,4 Today, with the introduction of high-resolution laparoscopes, the indication for staging laparoscopy in pancreatic cancer is evolving and remains under debate. The aim of this retrospective single-institutional cohort study is to evaluate the efficacy of staging laparoscopy compared with laparotomy in pancreatic cancer, with the goal of identifying an optimal operative staging strategy for this patient group.
METHODS All adult patients (18 years and older) who underwent operative treatment for a diagnosis of pancreatic neoplasm between July 1, 2003 and October 31, 2012 at Lahey Hospital and Medical Center were evaluated. Patients were retrospectively identified through an administrative database using CPT and ICD-9 codes.
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ISSN 1072-7515/14/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2014.02.018
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Schnelldorfer et al
Staging Laparoscopy in Pancreatic Cancer
There were 436 patients who met these criteria. After review of the clinical charts, the cohort was limited to 282 patients with pancreatic carcinoma, ampullary carcinoma, and invasive pancreatic cystic neoplasms. One hundred and fifty-four patients were excluded with noninvasive cystic neoplasm, neuroendocrine neoplasm, ampullary adenoma, metastases to the pancreas, and pancreatic intraepithelial neoplasia. Eight additional patients with preoperative radiographic stage IV pancreatic malignancy were also excluded, leaving a study cohort of 274 patients. All patients meeting the eligibility criteria were assigned to a laparoscopic staging group or open staging group (ie, staging laparotomy) according to the initial method of operative staging, determined by the clinical judgment of the operating surgeon. Any follow-up radiographic abdominal cross-sectional imaging studies were reviewed if conducted within 6 months of initial operative treatment. A cost-analysis model was created using data from the hospital’s finance department electronic information system. To calculate the post-anesthesia recovery and daily in-hospital care costs, available data for the actual cost of postoperative care for the most recent consecutive patients who underwent pancreatoduodenectomy (n ¼ 10) and distal pancreatectomy with splenectomy (n ¼ 10) were obtained. Although the actual cost for services provided was measured, the time necessary to perform the operative staging and resection was estimated according to our experience, representing a hypothetical model. The study was approved by the Lahey Clinic Institutional Review Board. Descriptive statistics were reported as percentage or median with range unless specified otherwise. Twosample t-test and chi-square test (or Fisher’s exact test) were used for univariate analyses. A p value
MD,
Gail Reynolds,
MS,
The role of staging laparoscopy in pancreatic cancer in the age of high-resolution CT scans is under debate. This study’s aim is to evaluate the efficacy of staging laparoscopy in this disease. STUDY DESIGN: A retrospective cohort study was conducted evaluating patients who underwent operative treatment for radiographic stage I to III pancreatic cancer between July 2003 and October 2012. Radiographic follow-up was 94% at 6 months. RESULTS: Of 274 patients who met inclusion criteria, 136 underwent staging laparoscopy, which identified radiographic occult distant metastases in 2% (3 of 136). However, subsequent laparotomy identified an additional 9% (12 of 136) harboring distant metastases in regions not visualized on standard staging laparoscopy; specifically, the posterior liver surface, paraduodenal retroperitoneum, proximal jejunal mesentery, and lesser sac. The remaining 138 patients underwent initial staging laparotomy, which showed similar results identifying radiographic occult distant disease in 11% (15 of 138). Within 6 months after the operation, peritoneal or subcapsular liver metastases developed in an additional 6% (15 of 257)ddisease that potentially could have been diagnosed at the time of operationdproviding a false-negative rate of 88% for staging laparoscopy compared with 36% for staging laparotomy. CONCLUSIONS: Despite the availability of high-resolution CT scans, occult distant metastases can still be found in 11% of patients during the operation. In the absence of reliable risk factors to predict distant metastases, staging laparoscopy should be offered to all patients with radiographic localized disease. However, the results favor extended laparoscopic staging with evaluation of the posterior liver surface, mobilization of the duodenum, evaluation of the proximal jejunal mesentery, and visualization of the lesser sac. (J Am Coll Surg 2014;218: 1201e1206. 2014 by the American College of Surgeons)
BACKGROUND:
Staging laparoscopy, as a less-invasive approach for detection of peritoneal metastases compared with traditional open exploration, became a commonly accepted practice for treating patients with presumed resectable pancreatic cancer in the 1990s.1 A decade later, with the introduction of highresolution CT scans, a selective approach became common
CME questions for this article available at http://jacscme.facs.org Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Presented at the New England Surgical Society 94th Annual Meeting, Hartford, CT, September 2013. Received October 18, 2013; Accepted February 10, 2014. From the Department of General Surgery (Schnelldorfer, Gagnon, Birkett), Sophia Gordon Cancer Center (Reynolds), Department of Operating Room (Murphy), and Department of Transplantation (Jenkins), Lahey Hospital and Medical Center, Burlington, MA. Correspondence address: Thomas Schnelldorfer, MD, FACS, Department of General Surgery, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
practice.2 Laparoscopy was considered in what were deemed “high-risk” patients without ever determining reliable selection criteria; resulting in laparotomy without therapeutic benefit in 6% to 26% of all patients who undergo operative evaluation.3,4 Today, with the introduction of high-resolution laparoscopes, the indication for staging laparoscopy in pancreatic cancer is evolving and remains under debate. The aim of this retrospective single-institutional cohort study is to evaluate the efficacy of staging laparoscopy compared with laparotomy in pancreatic cancer, with the goal of identifying an optimal operative staging strategy for this patient group.
METHODS All adult patients (18 years and older) who underwent operative treatment for a diagnosis of pancreatic neoplasm between July 1, 2003 and October 31, 2012 at Lahey Hospital and Medical Center were evaluated. Patients were retrospectively identified through an administrative database using CPT and ICD-9 codes.
1201
ISSN 1072-7515/14/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2014.02.018
1202
Schnelldorfer et al
Staging Laparoscopy in Pancreatic Cancer
There were 436 patients who met these criteria. After review of the clinical charts, the cohort was limited to 282 patients with pancreatic carcinoma, ampullary carcinoma, and invasive pancreatic cystic neoplasms. One hundred and fifty-four patients were excluded with noninvasive cystic neoplasm, neuroendocrine neoplasm, ampullary adenoma, metastases to the pancreas, and pancreatic intraepithelial neoplasia. Eight additional patients with preoperative radiographic stage IV pancreatic malignancy were also excluded, leaving a study cohort of 274 patients. All patients meeting the eligibility criteria were assigned to a laparoscopic staging group or open staging group (ie, staging laparotomy) according to the initial method of operative staging, determined by the clinical judgment of the operating surgeon. Any follow-up radiographic abdominal cross-sectional imaging studies were reviewed if conducted within 6 months of initial operative treatment. A cost-analysis model was created using data from the hospital’s finance department electronic information system. To calculate the post-anesthesia recovery and daily in-hospital care costs, available data for the actual cost of postoperative care for the most recent consecutive patients who underwent pancreatoduodenectomy (n ¼ 10) and distal pancreatectomy with splenectomy (n ¼ 10) were obtained. Although the actual cost for services provided was measured, the time necessary to perform the operative staging and resection was estimated according to our experience, representing a hypothetical model. The study was approved by the Lahey Clinic Institutional Review Board. Descriptive statistics were reported as percentage or median with range unless specified otherwise. Twosample t-test and chi-square test (or Fisher’s exact test) were used for univariate analyses. A p value
