Current Utility of Staging Laparoscopy for Pancreatic and Peripancreatic Neoplasms
ABSTRACT The routine use of staging laparoscopy in patients with radiographically resectable pancreatic and peripancreatic neoplasms remains controversial.
We reviewed a prospective database that identified 1,045 patients who underwent staging laparoscopy for radiographically resectable pancreatic or peripancreatic tumors between 1995 and 2005. Radiographic resectability was determined by review of radiographic reports, surgeons' notes, and cross-sectional imaging studies. Factors were assessed for their association with the laparoscopic identification of radiographically occult unresectable disease. Recursive partitioning was used to build a decision tree, with laparoscopic identification of unresectable disease as the outcomes, including only patients since 1999 (modern imaging) and factors available preoperatively.
Unresectable disease was identified laparoscopically in 145 of the 1,045 radiographically resectable patients (14%). Factors associated with radiographically occult unresectable disease included the time period of the study, whether imaging was performed at our institution (internal versus external imaging), primary site, histology, weight loss, and jaundice. Primary site (pancreatic versus nonpancreatic) was identified as the strongest predictor of yield. In patients with nonpancreatic tumors, the yield of laparoscopy was 4%. In patients with pancreatic tumors, the yield of laparoscopy was 14% overall, but was 8.4% in patients with internal imaging versus 17% in patients with external imaging (p < 0.01). This higher-risk subgroup was partitioned by the presence of weight loss, then by primary site within the pancreas.
During the time period of this study, the yield of staging laparoscopy decreased and exceeded 10% only for patients with pancreatic adenocarcinoma. When high-quality cross-sectional imaging reveals no evidence of unresectable disease, routine staging laparoscopy may not be warranted for pancreatic or peripancreatic tumors other than presumed pancreatic adenocarcinoma.
- SourceAvailable from: Henricus J.M. Handgraaf
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- "We excluded individual patients from the meta-analysis; if patients were diagnosed with unresectable pancreatic cancer during their preoperative workup, but underwent palliative surgery     , patients did not undergo LUS, but only laparoscopy   ; patients declined surgery  ; if patients were diagnosed with other pathology then pancreatic cancer    . In two studies on selective use of LUS, it was not possible to extract the subpopulation of patients that received LUS assessment  . Therefore, these studies were not included. "
ABSTRACT: Prognosis of patients with pancreatic cancer is poor. Even the small minority that undergoes resection with curative intent has low 5-year survival rates. This may partly be explained by the high number of irradical resections, which results in local recurrence and impaired overall survival. Currently, ultrasonography is used during surgery for resectability assessment and frozen-section analysis is used for assessment of resection margins in order to decrease the number of irradical resections. The introduction of minimal invasive techniques in pancreatic surgery has deprived surgeons from direct tactile information. To improve intraoperative assessment of pancreatic tumor extension, enhanced or novel intraoperative imaging technologies accurately visualizing and delineating cancer cells are necessary. Emerging modalities are intraoperative near-infrared fluorescence imaging and freehand nuclear imaging using tumor-specific targeted contrast agents. In this review, we performed a meta-analysis of the literature on laparoscopic ultrasonography and we summarized and discussed current and future intraoperative imaging modalities and their potential for improved tumor demarcation during pancreatic surgery.BioMed Research International 07/2014; 2014. DOI:10.1155/2014/890230 · 2.71 Impact Factor
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ABSTRACT: Pancreatic adenocarcinoma (PC) is the fourth leading cause of cancer-related death in the United States, accounting for over 33,000 deaths in 2008 . The peak incidence occurs in the seventh and eighth decades . Only approximately 15% of patients have resectable disease at the time of presentation  and nearly all patients die from the disease within 7 years of surgery [4, 5], with a median survival of only 6 months in patients with unresectable disease. Surgical resection remains the only hope for cure of this devastating disease.
Article: Pancreatic cancer [J][Show abstract] [Hide abstract]
ABSTRACT: Pancreatic cancer remains a major unsolved health problem, with conventional cancer treatments having little impact on disease course. Almost all patients who have pancreatic cancer develop metastases and die. The main risk factors are smoking, age, and some genetic disorders, although the primary causes are poorly understood. Advances in molecular biology have, however, greatly improved understanding of the pathogenesis of pancreatic cancer. Many patients have mutations of the K-ras oncogene, and various tumour-suppressor genes are also inactivated. Growth factors also play an important part. However, disease prognosis is extremely poor. Around 15-20% of patients have resectable disease, but only around 20% of these survive to 5 years. For locally advanced, unresectable, and metastatic disease, treatment is palliative, although fluorouracil chemoradiation for locally advanced and gemcitabine chemotherapy for metastatic disease can provide palliative benefits. Despite pancreatic cancer's resistance to currently available treatments, new methods are being investigated. Preoperative chemoradiation is being advocated, with seemingly sound reasoning, and a wider role for gemcitabine is being explored. However, new therapeutic strategies based on the molecular biology of pancreatic cancer seem to hold the greatest promise.The Lancet 04/2004; 363(9414):1049-57. DOI:10.1016/S0140-6736(04)15841-8 · 45.22 Impact Factor