Diagnostic Staging Laparoscopy

Diagnostic Staging Laparoscopy
in GI malignancies
Dr. Pranjal Rokaya
Resident General Surgery
KIST MCTH
Moderator
Prof. Dr. Rupesh Mukhiya
13th February, 2023

Outline
• Introduction
• Indication
• Contraindication
• Surgical approach
• Exploratory principles
• Risk and complications
• Laparoscopic ultrasound
• Diagnostic accuracy and yield in
different GI malignancies

Introduction
• Diagnostic staging laparoscopy (DSL) is performed to determine the feasibility of
the proposed cancer operation.
• DSL complements preoperative assessment of radiographic imaging, which has
limitations for identifying regional extension of primary tumor and/or metastatic
disease such as peritoneal involvement. [1,2]
1. Blackshaw GR, Barry JD, Edwards P, Allison MC, Thomas GV, Lewis WG. Laparoscopy significantly improves the perceived preoperative stage of gastric cancer. Gastric
Cancer. 2003;6(4):225-229. doi:10.1007/s10120-003-0257-0.
2. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for diagnostic laparoscopy. Reviewed and approved in April 2010. Available at:
https://www.sages.org/publications/guidelines/guidelines-for-diagnostic-laparoscopy/ (Accessed on Feb 11, 2023).

DSL: Goal
• Identify and disprove the presence of local, regional, and/ or metastatic disease.
• Aids in identifying extra organ disease that would preclude an attempt at a
curative resection.
• Prerequisite: Availability and acceptance of nonoperative palliative treatment for
unresectable tumors.

DSL: Indications[2]
Assessment for resectability with curative intent of primary digestive cancers:
a. Esophageal cancer at GE junction.
b. Gastric cancer
c. Pancreatic and periampullary cancer
d. Biliary tract cancer …Contd

DSL: Indications[2]
Staging prior to administration of neoadjuvant chemotherapy or radiotherapy.
Assessment of equivocal MRI, CT, or PET scan for primary, regional, or distant
disease.
Assessment of inconclusive histology following radiographic guided FNA of
suspicious sites of disease.
Assessment for resectability of liver metastasis in patients with colon or rectal
cancer in combination with a laparoscopic ultrasound.

Contraindications [2]
• Inability to tolerate laparoscopy.
• Previously confirmed metastatic or unresectable disease.

Surgical approach
A. Incision placement
Initial trocar placement should be remote from prior surgical incisions or
suspected metastatic disease.

Surgical approach: Initial access locations
• Umbilicus
• Upper mid-abdomen
• Lateral abdomen: Palmer’s position

Surgical approach: Peritoneal access
Hasson technique Veress needle

Surgical approach
B. Staging procedure
One stage procedure
Perform DSL as sole intended procedure.
Advantage: Identify patients who may be more appropriately treated with
chemo/radiotherapy as first line treatment.
Disadvantage: 2nd definitive procedure required.

Surgical approach
B. Staging procedure
Two-stage procedure
DSL and definite operation in the same setting, if no unresectable /distant disease
is identified.
Advantage : Only one operative setting with one anesthetic administration.
Disadvantage: Possible uncertainty of frozen section report on biopsy.

Surgical approach
C. Collection of fluid for cytology
 Fluid sampled for cytology in patients with ascites.
In patients w/o ascites, peritoneal washing is typically not performed.

Exploratory principles
Access to peritoneal cavity obtained.
General exploration of peritoneal surfaces done.
Surfaces in pelvis, colic gutters are evaluated.

Thorough assessment of local and regional sited performed.
Abnormal lymphadenopathy adequately sampled via
laparoscope.
Single suspicious lymph node resected in entirety if possible.

Complete evaluation of liver surface performed using combination
of altered patient positioning and offsetting angled laparoscope.
Intraoperative laparoscopic ultrasound may be performed to
identify metastatic disease.

Biopsies
• Performed on suspicious lesions.
• In two stages, a frozen section is obtained; otherwise submitted for final
histologic evaluation.
• If metastatic disease is confirmed on the frozen section, operation is concluded.

Risk and Complications
• Morbidity a/w DSL for patients with esophageal, gastric, and pancreatic cancer
ranges from 0-2.5%; no mortality related to DSL [3,4].
• Operative morbidity and mortality of diagnostic laparotomy range from 13-21%
and 10-21% respectively.
• Thus, DSL is safe to perform to identify candidates for primary resection vs other
modalities.
3. Muntean V, Oniu T, Lungoci C, et al. Staging laparoscopy in digestive cancers. J Gastrointestin Liver Dis. 2009;18(4):461-467.
4. Conlon KC, Dougherty E, Klimstra DS, Coit DG, Turnbull AD, Brennan MF. The value of minimal access surgery in the staging of patients with potentially resectable
peripancreatic malignancy. Ann Surg. 1996;223(2):134-140. doi:10.1097/00000658-199602000-00004

a. Port site tumor implantation
• Less than 1 %; median time to occurrence 8 months [5].
• In a review of 1650 procedures, almost all patients who developed port site
recurrence also had local recurrence/distant disease.
• Risk of port site implantation was comparable to that of laparotomy incision [6,7]
.
5. Shoup M, Brennan MF, Karpeh MS, Gillern SM, McMahon RL, Conlon KC. Port site metastasis after diagnostic laparoscopy for upper gastrointestinal tract
malignancies: an uncommon entity. Ann Surg Oncol. 2002;9(7):632-636. doi:10.1007/BF02574478
6. Ziprin P, Ridgway PF, Peck DH, Darzi AW. The theories and realities of port-site metastases: a critical appraisal. J Am Coll Surg. 2002;195(3):395-408.
doi:10.1016/s1072-7515(02)01249-8
7. Curet MJ. Port site metastases. Am J Surg. 2004;187(6):705-712. doi:10.1016/j.amjsurg.2003.10.015

Approaches to reduce port site implantation [7]
• Place trocars perpendicular to the peritoneum.
• Prevent carbon dioxide leakage around trocars.
• Minimize handling of tumor tissue.
• Protect extraction sites.
• Bag specimens intra-abdominally to avoid spillage.
…contd
7. Curet MJ. Port site metastases. Am J Surg. 2004;187(6):705-712. doi:10.1016/j.amjsurg.2003.10.015

Approaches to reduce port site implantation
• Remove the entire lesion rather than a partial biopsy if possible.
• Deflate the abdomen with trocars in place.
• Close the fascia of the trocar port site while avoiding liquid spillage into the
wound.

b. Vascular and organ injury
• May occur at the time of port placement, during organ manipulation, or while
performing biopsies.

Laparoscopic ultrasound (LUS)
• Adjunct to preoperative radiographic imaging and DSL for staging.
• No RCT or systemic review has been done to determine if LUS offers an advantage
over laparoscopy alone for detecting unresectable diseases.

Factors affecting successful DSL
• Patient-related: Presence of intraabdominal adhesions, obesity.
• Prelaparoscopic staging: Advanced tumors are more likely to have a higher yield
at DSL.
• Surgical skill: eg: exploring lesser sac or coeliac nodes and taking biopsies.
• Quality of preoperative imaging
Recent advances in surgery, 40th edition

Laparoscopic ultrasound (LUS)
• In a prospective study of 53 patients with pancreatic cancer, LUS altered
management in 28 patients [8]. The positive predictive value of LUS for
determining resectability was 91 percent [9].
• In a series of 50 consecutive patients with pancreatic cancer, there was no
significant difference in sensitivity, specificity, or overall accuracy between
preoperative CT scan and LUS [10].
8. Taylor AM, Roberts SA, Manson JM. Experience with laparoscopic ultrasonography for defining tumour resectability in carcinoma of the pancreatic head and
periampullary region. Br J Surg. 2001;88(8):1077-1083. doi:10.1046/j.0007-1323.2001.01826.x
9. Viganò L, Ferrero A, Amisano M, Russolillo N, Capussotti L. Comparison of laparoscopic and open intraoperative ultrasonography for staging liver tumours. Br J Surg.
2013;100(4):535-542. doi:10.1002/bjs.9025
10. Pietrabissa A, Caramella D, Di Candio G, et al. Laparoscopy and laparoscopic ultrasonography for staging pancreatic cancer: critical appraisal. World J Surg.
1999;23(10):998-1003. doi:10.1007/s002689900614

Diagnostic accuracy and Yield
• Conventional imaging studies often understate the intraabdominal extent of
cancer. [2]
• Accuracy: Number of unresectable diseases detected by DSL divided by the total
number of unresectable cases
• Yield : No. of unresectable patients detected by DSL divided by a total number of
patients undergoing DSL. [11]
11. Connor S, Barron E, Wigmore SJ, Madhavan KK, Parks RW, Garden OJ. The utility of laparoscopic assessment in the preoperative staging of
suspected hilar cholangiocarcinoma. J Gastrointest Surg. 2005;9(4):476-480. doi:10.1016/j.gassur.2004.10.009

Esophageal cancer
• A review of 195 patients with esophageal cancers found that DSL altered
treatment plans in 29 patients (15%) [33].
• No patients with proximal or middle esophageal cancer had a disease-altering
disease.
• 17% of patients with distal cancer had a regional or metastatic disease that
altered the initial treatment plan.
33. de Graaf GW, Ayantunde AA, Parsons SL, Duffy JP, Welch NT. The role of staging laparoscopy in oesophagogastric cancers. Eur J Surg Oncol.
2007;33(8):988-992. doi:10.1016/j.ejso.2007.01.007

Esophageal cancer
• To limit aggressive t/t in patients with locally
advanced disease, DSL performed in patients
with esophageal and EGJ adenocarcinomas.
• Adenocarcinoma arising from the
intrabdominal segment is prone to develop
intraperitoneal metastasis.
Siewert classification of EGJ tumor

Esophageal cancer: NCCN guidelines [12]
• DSL performed in patients with equivocal radiographic imaging with suspicion of
metastasis but nondiagnostic FNA.
• Patients with EJ cancers but not proximal and mid-esophageal cancer should
routinely undergo DSL.
• During DSL for EGJ cancer, subphrenic and pelvic peritoneal lavage for cytology is
performed.
12. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Esophageal and esophagogastric junction cancers. Version
1.2020 - March 18, 2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf (Accessed on Feb 12 , 2022).

Gastric cancer
• Retrospective and prospective studies on the yield of DSL found that
peritoneal/metastatic disease was found in 30-53% of patients with negative
preoperative CT/MRI evaluation [16,14,15].
• A prospective study of 100 patients undergoing DSL found peritoneal spread/
liver metastasis in 21 patients all of whom had T3/T4 advanced cancers [13].
13. Blackshaw GR, Barry JD, Edwards P, Allison MC, Thomas GV, Lewis WG. Laparoscopy significantly improves the perceived preoperative stage of
gastric cancer. Gastric Cancer. 2003;6(4):225-229. doi:10.1007/s10120-003-0257-0
14. Muntean V, Mihailov A, Iancu C, et al. Staging laparoscopy in gastric cancer. Accuracy and impact on therapy. J Gastrointestin Liver Dis.
2009;18(2):189-195.
15. Yano M, Tsujinaka T, Shiozaki H, et al. Appraisal of treatment strategy by staging laparoscopy for locally advanced gastric cancer. World J Surg.
2000;24(9):1130-1136. doi:10.1007/s002680010183
16. Kapiev A, Rabin I, Lavy R, et al. The role of diagnostic laparoscopy in the management of patients with gastric cancer. Isr Med Assoc J.
2010;12(12):726-728.

Gastric cancer
• Between 20-30% of patients who had disease beyond T1 on EUS; with negative
CT scan had peritoneal metastasis [17,18].
• The risk of occult peritoneal dissemination is even higher for advanced (T4)
tumors or with linitis plastica appearance; where DSL altered mx in up to 50% of
patients [19,20].
17.. Lowy AM, Mansfield PF, Leach SD, Ajani J. Laparoscopic staging for gastric cancer. Surgery. 1996;119(6):611-614. doi:10.1016/s0039-6060(96)80184-x
18. Sarela AI, Lefkowitz R, Brennan MF, Karpeh MS. Selection of patients with gastric adenocarcinoma for laparoscopic staging. Am J Surg. 2006;191(1):134-138.
doi:10.1016/j.amjsurg.2005.10.015
19. Simon M, Mal F, Perniceni T, et al. Accuracy of staging laparoscopy in detecting peritoneal dissemination in patients with gastroesophageal adenocarcinoma. Dis
Esophagus. 2016;29(3):236-240. doi:10.1111/dote.12332
20. Leake PA, Cardoso R, Seevaratnam R, et al. A systematic review of the accuracy and indications for diagnostic laparoscopy prior to curative-intent resection of
gastric cancer. Gastric Cancer. 2012;15 Suppl 1:S38-S47. doi:10.1007/s10120-011-0047-z

Gastric cancer: NCCN guidelines
• Preoperative DSL is recommended for any medically fit patients:
a. Who appears to have more than T1 lesion on EUS.
b. No histologic confirmation of stage IV disease.
c. Who would not otherwise require palliative gastrectomy because of symptoms.

Pancreatic and periampullary cancer
• Many studies evaluating the yield of DSL haven't differentiated between pancreatic
and periampullary cancers.
• Accuracy in predicting resectability:
CT scan: 85-100 %. DSL : >90% [21,22]
• Two meta-analyses have found that 4-21% of patients could have avoided laparotomy
had they undergone DSL following CT imaging [23,24].
21. Holzman MD, Reintgen KL, Tyler DS, Pappas TN. The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies. J
Gastrointest Surg. 1997;1(3):236-244. doi:10.1016/s1091-255x(97)80115-1
22. Stefanidis D, Grove KD, Schwesinger WH, Thomas CR Jr. The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review. Ann Oncol.
2006;17(2):189-199. doi:10.1093/annonc/mdj013
23. Pisters PW, Lee JE, Vauthey JN, Charnsangavej C, Evans DB. Laparoscopy in the staging of pancreatic cancer. Br J Surg. 2001;88(3):325-337.
doi:10.1046/j.1365-2168.2001.01695.x
24. Allen VB, Gurusamy KS, Takwoingi Y, Kalia A, Davidson BR. Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing
the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev. 2016;7(7):CD009323. Published 2016 Jul 6.
doi:10.1002/14651858.CD009323.pub3

• Few studies have suggested that patients with cancers of the body or tail of the
pancreas are more likely to benefit from DSL than those with pancreatic head
involvement [25,26].
• DSL identified occult disease twice as frequently in pancreatic body/tail
compared to pancreatic head cancers.
25. Jimenez RE, Warshaw AL, Rattner DW, Willett CG, McGrath D, Fernandez-del Castillo C. Impact of laparoscopic staging in the treatment of
pancreatic cancer. Arch Surg. 2000;135(4):409-415. doi:10.1001/archsurg.135.4.409
26. Liu RC, Traverso LW. Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by computed tomography. Surg
Endosc. 2005;19(5):638-642. doi:10.1007/s00464-004-8165-x

• Most studies have shown little advantage of DSL for periampullary cancers [22,27].
• Unnecessary laparotomy was avoided in only 2.3% of patients with periampullary
cancer compared to 35% of patients with tumors of the body/tail [28].
22. Stefanidis D, Grove KD, Schwesinger WH, Thomas CR Jr. The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review. Ann
Oncol. 2006;17(2):189-199. doi:10.1093/annonc/mdj013
27. Nieveen van Dijkum EJ, Romijn MG, Terwee CB, et al. Laparoscopic staging and subsequent palliation in patients with peripancreatic carcinoma. Ann
Surg. 2003;237(1):66-73. doi:10.1097/00000658-200301000-00010
28. Barreiro CJ, Lillemoe KD, Koniaris LG, et al. Diagnostic laparoscopy for periampullary and pancreatic cancer: what is the true benefit?. J Gastrointest
Surg. 2002;6(1):75-81. doi:10.1016/s1091-255x(01)00004-x

Pancreatic and periampullary cancer: NCCN guidelines
• DSL is recommended for all patients with pancreatic body or tail cancer.
• Selective use of laparoscopy is recommended for periampullary cancers.

Biliary tract cancer
• The sensitivity and negative predictive value of DSL in identifying peritoneal and
superficial liver metastasis was 60 and 48% [29].
• DSL identified metastasis in 23% of patients who had negative preoperative
imaging.
• The overall yield for detecting unresectable biliary cancer using DSL ranged from
48% [30].
29. Barreiro CJ, Lillemoe KD, Koniaris LG, et al. Diagnostic laparoscopy for periampullary and pancreatic cancer: what is the true benefit?. J Gastrointest Surg.
2002;6(1):75-81. doi:10.1016/s1091-255x(01)00004-x
30. Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients. Ann Surg.
2002;235(3):392-399. doi:10.1097/00000658-200203000-00011

Biliary cancer: NCCN guidelines
• Routine DSL for patients with cholangiocarcinoma of proximal bile duct and gall
bladder cancer but not for distal biliary cancer.

Colorectal cancer
• DSL infrequently used for patients with colon or rectal cancer as resection is
necessary for most patients.
• In a review of 56 patients with liver metastasis from colorectal cancer, DSL
identified only 3 of 8 patients with the unresectable disease [31].
• Additional value of DSL in metastatic disease hasn’t been established [32].
31. Koea J, Rodgers M, Thompson P, Woodfield J, Holden A, McCall J. Laparoscopy in the management of colorectal cancer metastatic to the liver. ANZ
J Surg. 2004;74(12):1056-1059. doi:10.1111/j.1445-1433.2004.03267.x
32. Cotte E, Peyrat P, Piaton E, et al. Lack of prognostic significance of conventional peritoneal cytology in colorectal and gastric cancers: results of
EVOCAPE 2 multicentre prospective study. Eur J Surg Oncol. 2013;39(7):707-714. doi:10.1016/j.ejso.2013.03.021

Hepatocellular cancer (HCC)
• DSL has a theoretical advantage:
Detection of small intrahepatic metastasis.
Safe biopsy of primary and additional lesions.
Assessment of liver remnant and severity of cirrhosis (biopsy).
Detection of extrahepatic disease.
 DSL with EUS leads to upstaging in 16-39% of patients with potentially resectable
HCC and is recommended.
Recent advances in Surgery, 40th edition

Diagnostic Staging Laparoscopy

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