In Brief

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Over the last decade, laparoscopic evaluation has been used increasingly to stage many types of gastrointestinal cancers, including liver (primary and metastatic), biliary, pancreas, and stomach tumors. It is clear that direct examination of the abdominal cavity with laparoscopy is the most accurate way to detect occult peritoneal metastases. In addition, laparoscopic ultrasound allows surgeons to assess for vascular involvement and evaluate the liver for intrahepatic metastases.

In the recent past, there has clearly been an evolution in the approach to staging cancer patients with laparoscopy. Early in our experience with laparoscopy, there was little downside to using the technique, since other attempts at staging the disease often underestimated the amount of disease present, leading to a high rate of unresectability at the time of surgery. The traditional role of staging laparoscopy, therefore, has been primarily to prevent patients from undergoing unnecessary laparotomy. Recently, however, there have been several changes that have improved our ability to care for cancer patients. These include modern improvements in imaging, including thin-section helical computed tomography (CT) scanning and positron emission tomography (PET), which have greatly contributed to our ability to accurately stage patients preoperatively and therefore decrease the rate of unresectability. Improvements in imaging also affect the yield of staging laparoscopy. Demonstrating this fact, the percentage of patients with unresectable disease found at diagnostic laparoscopy has decreased over time as the sensitivity of CT scanning has improved. Because the yield of laparoscopy is dependent on the quality of preoperative imaging, it is particularly important to assess outcomes after staging laparoscopy in patients who were evaluated with contemporary radiographic studies.

At the same time, the use of laparoscopy has expanded, such that many operations are now performed completely laparoscopically. In addition, the indications for surgical resections for some diseases are expanding based on new, much more effective chemotherapy (eg, colorectal liver metastases). Clearly, all of these recent changes add to the complexity of the discussion regarding which patients benefit from staging laparoscopy. As a result, there is a need to re-address the indications for staging laparoscopy for liver, biliary, pancreas, and gastric cancers.

It is useful to consider the terms used to define the role of laparoscopy. The benefit of staging laparoscopy can be evaluated in several ways, which will affect the perception of how beneficial it is to patients. Both the overall yield for the entire patient group (in which the denominator equals all patients) and the accuracy of detection of unresectable disease (in which the denominator includes only patients with unresectable disease) are commonly presented in studies evaluating the results from staging laparoscopy. In all cases, the accuracy for detection of unresectable disease will be higher than the overall yield. This distinction in evaluating the results is important because, depending on the pattern of spread of the tumor being evaluated, the accuracy of detecting unresectable disease may be high, but the overall yield may be low. One example is a tumor that is infrequently associated with peritoneal metastases in patients who are determined to be resectable on preoperative imaging, such as ampullary cancer, where laparoscopy could lead to a high accuracy of detection of unresectable disease, but a very low overall yield. Thus, many patients would be evaluated with staging laparoscopy but only a small number would benefit. For surgeons defining the role of staging laparoscopy in their practice, the data must be analyzed by evaluating not only the number of cases of unresectable disease detected by laparoscopy, but perhaps more importantly, the total percentage of patients benefiting from the procedure.

The issue of palliation in patients with unresectable disease is an important one because there is no benefit in performing laparoscopy if an open palliative surgery is required. This is an area in which there are significant institutional biases toward palliating either with surgery or with minimally invasive techniques, particularly for patients with pancreas cancer. Nonetheless, this issue needs to be addressed at the time of preoperative treatment planning for these patients, since it is clear that unresectable disease discovered at the time of laparoscopy results in a decreased length of stay and earlier initiation of chemotherapy for patients than when unresectable disease is found at the time of laparotomy.

To maximize scarce resources and enhance patient care, the trend in use of laparoscopy is moving toward evaluating patient factors that could improve the selection of patients submitted to staging laparoscopy and improve the yield. Although we have made great strides in some tumor types, such as hepatic colorectal metastases, this still remains to be defined for other tumor types.

Regarding the technique of laparoscopy, it is clear that direct examination of the peritoneal cavity is simple to perform and results in finding occult metastatic disease in the majority of patients. Laparoscopic ultrasound adds a small incremental increase in the number of patients with unresectable disease, and should therefore be used selectively depending on the tumor type. The issue of timing of laparoscopy (ie, whether to perform staging laparoscopy immediately before laparotomy or during a separate operating room visit) is dependent on 2 factors: surgeon preference and whether peritoneal cytology is required. In tumors such as gastric cancer, in which the significance of positive peritoneal cytology is clear, laparoscopy should be performed on a separate visit, since this requires processing of the specimen. For the majority of tumors, laparoscopy can reasonably be performed immediately before laparotomy, saving the patient an additional anesthetic.

Many studies have now shown that finding occult metastatic disease at the time of staging laparoscopy can reduce hospital stay, hospital charges, and perioperative morbidity, and result in earlier initiation of chemotherapy compared with patients undergoing laparotomy. The detractors of staging laparoscopy, however, point out that in the majority of patients who are found to have resectable disease, laparoscopy unnecessarily increases operative time and cost. Clearly, in identifying factors that can improve patient selection for staging laparoscopy and increase the overall yield, we will continue to improve quality outcomes for patients while minimizing cost.