diagnostic laparoscopy for carcinoma of pancreas dr. david kk tsui department of surgery pamela...

Diagnostic Laparoscopy for

Carcinoma of Pancreas

Dr. David KK Tsui

Department of Surgery

Pamela Youde Nethersole Eastern Hospital

Hong Kong SAR

15 January 2005

Joint Hospital Surgical Grand Round

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL

Operative set-up

Operative set-up

Laparoscopic Guided Biopsy

1970s & 1980s

• Reports from 1970s & 1980s showed the role of laparoscopy in detecting occult metastases, allowing biopsy and avoiding unnecessary laparotomy close to 30 % in Ca pancreas.

• But no satisfactory imagings were available during that period of time and a lot of advanced cases were included in their studies

Cushieri A et al, Gut 1978Ishida H et al, Gastrointest Endosc 1983

Obvious carcinomatosis on laparoscopy and it should not be missed on pre-op. CT

1990s

• Staging laparoscopy has a sensitivity of 60 - 100% and the incidence of metastases at laparoscopy ranges widely from 14 % to 75 %

Catheline JM et al, Chirurgie 1998Van Dijkum EJMN et al, J AM Coll Surg 1999John TG et al, World J Surg 1999

• What is the true benefit from diagnostic laparoscopy nowadays?

• Should we adopt and routine laparoscopy for all the cases?

Limitations of Laparoscopy

• Require general anaesthesia • Prior dissection required for patients with previous

surgery• Increased operative time requirements and equipment

costs• Limited ability to detect retroperitoneal pathologies• Lack of tactile feedback

Laparoscopic USG

Advantages Disadvantages

Identify invisible lesions Highly operator dependent

Better assessment of tumor vessel relationships

Steep learning curve

Help for better localization of guided biopsy

View limited by the port position

Restore part of the lost of tactile feedback

Obscured in case of adhesions by previous surgery

Increase the yield of diagnostic laparoscopy

Laparoscopic USG

Pisters et al, Br J Surg 2001

Laparoscopy with lap USG in Staging of CA pancreas

Peritoneal Cytology

• Can be easily performed during laparoscopy by infusion of 250 – 300 ml normal saline

• 33% of positive peritoneal cytology in periampullary carcinoma was found in some series and the yield is related to any pre-operative biopsy

Bonenkamp JJ et al, Br J surg 1996Rubeiro UJ et al, Surg Laparosc Endosc 1998

Warshaw AL et al, AM J Surg 1991

Factors Affecting the Usefulness of Laparoscopy

1. Pre Operative Imaging

2. Resectability

3. Palliation strategy (surgical versus non-surgical)

4. Tumour Location

5. Cost-benefit consideration

Pre Operative Imaging

• More reliable of “radiographic resectability rate” as a result of improved CT quality, close to 91 % in Memorial Sloan Kettering Cancer Centre

Conlon KC et al Ann Surg 1996

Incidence of occult peritoneal or liver metastasis found after helical CTPisters PWT et al, Br J Surg 2001

Very impressive CT gives you clear image regarding the tumour-vessel relationship

Resectability

• “Resectability” would also vary according to different practice and the type of R resection of the study. The exact pathology and the clearance of tumour are not often mentioned in the those studies evaluating the usefulness of laparoscopy

R0 - gross and microscopic clearR1 - gross clear by microscopic positive marginR2 - both gross and microscopic margin involved

Pisters PWT et al, Br J Surg 2001

Resectability

Pisters PWT et al, Br J Surg 2001Overall and Ro Resection Rates

Palliation Strategy

• Obstructive jaundice is the main symptom and this can be effectively achieved by endoscopy and interventional radiology (surgical vs non-surgical strategy)

Endoscopic guide Stent insertion

Biliary Bypass Surgery – Laparoscopic

Endoscopic Metallic Stenting to relieve biliary obstruction

Carcinoma of pancreas with SMV invasion relieved by metallic stent

Gastric Outflow Obstruction

Carcinoma of body of pancreas causing GOO

Laparoscopic Gastrojejunostomy

Laparoscopic GJ to relieve gastric outflow obstruction

Tumor Location

• 28 out of 171 cases (16.4%) of periampullary carcinoma were found to have metastatic deposits on laparotomy, whereas 9 of 17 cases (52.9%) of pancreatic body and tail were having metastatic deposits

Barreiro CF et al, J Gastrointest Surg 2002

Tumor Location

Vollmer CM et al, Ann Surg 2002

Cost-Benefit Consideration

• Routine diagnostic laparoscopy would need to be seven times cheaper than laparotomy to be justifiable from a cost-effective standpoint

• However diagnostic laparoscopy costs half as much as diagnostic laparotomy, and therefore routine diagnostic laparoscopy could be recommended

• It is not cost effective to use laparoscopy as an alternative to high-quality in a patient who is referred with marginal-quality CT that demonstrate a “resectable” pancreatic tumour

Friess H et al J, Am Coll Surg 1998Pisters PWT et al, Br J Surg 2001

Treatment Algorithm

• Obtain preoperative imaging, preferably high-quality CT

• Review for radiological resectability in multidisplinary session

• Explore options for palliation considering available expertise and patient’s condition

• Proceed to surgery

Routine vs Selective Policy

• Routine diagnostic laparoscopy should not be considered in obviously metastatic disease

• It should not be used to replace high quality CT scan

• In view of the cost consideration, indication would depend on how frequent will unnecessary laparotomy be spared.

Potter MW et al, Surg Oncol 2000

Conclusion

• Diagnostic Laparoscopy for patients with Pancreatic Tumor

optimizes patient selection for tumour resection with curative intent

• Selective use of Laparoscopy after reviewing the Pre Op Imagings

can avoid unnecessary laparotomy

• It is particular pronounced when non-surgical palliation is available

• Ampulla tumor are almost always resectable

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL