The value of minimal access surgery in the staging of patients with potentially resectable peripancreatic malignancy.
Academic Article
Overview
abstract
OBJECTIVE: The purpose of this study was to determine if an endosurgical approach that mimics open exploration would improve the accuracy of simple diagnostic laparoscopy. SUMMARY BACKGROUND DATA; Most patients with peripancreatic malignancy are found at exploration to be unable to undergo resection. Laparoscopy has been suggested as a sensitive method for detecting metastatic disease in this group of patients. However, the ability to assess resectability with simple diagnostic laparoscopy remains relatively low (<40%). METHODS: Between December 1992 and August 1994, 115 patients with radiologically resectable peripancreatic tumors underwent extended laparoscopy before undergoing a planned curative resection. This technique required assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels. RESULTS: Sixty male and 55 female patients were included in the current study. The pancreatic head was involved in 74 patients (64%), followed by the body in 21 (18%), tail in 8 (7%), ampulla in 8 (7%), duodenum in 3 (3%), and distal bile duct in 1 (1%). An abdominal computed tomography (CT) scan was performed for all patients before laparoscopy, ultrasonography for 74 patients (64%), endoscopic retrograde choleangiopancreatography for 59 patients (51%), and mesenteric angiography for 9 patients (8%). Pneumoperitoneum was established successfully in all but 2 cases (98%). A complete examination of 108 patients was performed. Sixty-seven patients were considered to have resectable disease, and 61 resections were performed. Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient. Unresectable disease was identified in 41 patients. Hepatic metastases were observed in 20 patients, mesenteric vascular encasement in 14, extrapancreatic/peritoneal involvement in 16, and celiac or portal lymphatic metastases in 8. There were no intraoperative or postoperative complications related to the laparoscopic procedure. The positive predictive index, negative predictive index, and accuracy of laparoscopy were 100%, 91%, and 94%, respectively. CONCLUSIONS: This study demonstrates that extended laparoscopy is accurate and safe and makes exploration unnecessary in many patients with potentially resectable peripancreatic malignancy. In this series, 76% of patients explored were resected, compared with the authors' experience between 1983 and 1993 of 35%. The authors believe that laparoscopy is an important component in the staging of this group of patients and should be performed before exploration.
