Minilaparoscopy in the diagnosis of peritoneal tumor spread: prospective controlled comparison with computed tomography.

Abstract

Early diagnosis of peritoneal spread in malignant disease prevents unnecessary laparotomies. Minimally invasive laparoscopy with the patient under conscious sedation is a new, easily feasible diagnostic technique. This study compares prospective and controlled diagnostic minilaparoscopy with computed tomography (CT) scan for the diagnosis of peritoneal metastases.
In this study, 56 patients with malignant disease were prospectively investigated with diagnostic minilaparoscopy and CT scan.
The study criteria were fulfilled by 54 patients. Minilaparoscopy detected peritoneal carcinosis in 28 of 54 cases, whereas CT detected the disease in 14 of 54 cases. For 36 patients, the diagnosis could be verified by histologic examination of peritoneal biopsies or laparotomy. In this group, minilaparoscopy detected peritoneal carcinosis in 25 of 36 cases, whereas CT detected the disease in 12 of 36 cases.
Minilaparoscopy was more sensitive than CT in detecting peritoneal carcinosis (100% vs 47.8%; p < 0.01). Considering its low grade of invasiveness and superior sensitivity, minilaparoscopy should be regarded as the procedure of choice for the early detection of peritoneal carcinosis.

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Minilaparoscopy in the diagnosis of peritoneal tumor spread
Prospective controlled comparison with computed tomography
U. Denzer,1S. Hoffmann,2I. Helmreich-Becker,1H. U. Kauczor,2M. Thelen,2S. Kanzler,1P. R. Galle,1
A. W. Lohse1
1Department of Medicine, Johannes Gutenberg University, Langenbeckstrasse 1, D-55131 Mainz, Germany
2Department of Radiology, Johannes Gutenberg University, Langenbeckstrasse 1, D-55131 Mainz, Germany
Received: 30 May 2003/Accepted: 10 January 2004/Online publication: 27 May 2004
Abstract
Background: Early diagnosis of peritoneal spread in
malignant disease prevents unnecessary laparotomies.
Minimally invasive laparoscopy with the patient under
conscious sedation is a new, easily feasible diagnostic
technique. This study compares prospective and con-
trolled diagnostic minilaparoscopy with computed to-
mography (CT) scan for the diagnosis of peritoneal
metastases.
Methods: In this study, 56 patients with malignant dis-
ease were prospectively investigated with diagnostic
minilaparoscopy and CT scan.
Results: The study criteria were fulfilled by 54 patients.
Minilaparoscopy detected peritoneal carcinosis in 28 of
54 cases, whereas CT detected the disease in 14 of 54
cases. For 36 patients, the diagnosis could be verified by
histologic examination of peritoneal biopsies or lapar-
otomy. In this group, minilaparoscopy detected perito-
neal carcinosis in 25 of 36 cases, whereas CT detected
the dispose in 12 of 36 cases.
Conclusions: Minilaparoscopy was more sensitive than
CT in detecting peritoneal carcinosis (100% vs 47.8%;
p < 0.01). Considering its low grade of invasiveness and
superior sensitivity, minilaparoscopy should be regarded
as the procedure of choice for the early detection of
peritoneal carcinosis.
Key words: Minilaparoscopy — Peritoneal metastases
— Computed tomography
Adequatestagingoftumorsinthegastrointestinaltractis
crucial in the choice of appropriate medical or surgical
therapy. However, 10% to 40% of gastrointestinal ma-
lignancies remain understaged despite modern imaging
methods [8]. This occurs because local tumor invasion,
vascular invasion, small and superficial hepatic meta-
stases, and peritoneal metastases can be missed by
standard imaging procedures. Since the introduction of
minimally invasive surgery, diagnostic laparoscopy [13]
has regained importance in the preoperative staging of
gastrointestinal malignancies. The main goal of laparo-
scopic staging for patients with gastrointestinal malig-
nanciesistoavoidexplorativelaparotomyinpatientswith
incurable diseases. In particular, small superficial hepatic
and small peritoneal lesions can be detected with high
accuracy.Findings haveshownstaginglaparoscopytobe
of superior diagnostic accuracy, as compared with imag-
ing procedures (computed tomography [CT] scan, ultra-
sound) [12].
With the development of a small laparoscope (di-
ameter, 1.9 mm) [4], a minimally invasive and easily
feasible method for diagnostic laparoscopy with the
patient under conscious sedation has become available.
The goal of this study was to investigate whether diag-
nostic minilaparoscopy is comparable with or even more
accurate than modern CT scan in the diagnosis of
peritoneal metastases.
Patients and methods
Staging for peritoneal metastases was performed by minilaparoscopy
and CT scan. Consecutive patients were recruited from the in- and out-
patient clinics of the First Department of Medicine at the University of
Mainz (Mainz, Germany). The identified patients and their primary
care physicians were invited to participate in the study, and informed
consent was obtained. The study was approved by the local ethic
committee in Rheinland Pfalz, Germany (837.277.97 [1416]).
The main inclusion criteria for participation in the study required a
histologically proven malignant disease. Minilaparoscopy and CT scan
were performed less than 1 month apart. The results of the examination
were blinded, so the investigators were unaware of the previous results.
All CT scans were evaluated by two experienced radiologists. All the
minilaparoscopies were performed by four experienced investigators.
The exclusion criteria for study participation specified age less than
18 years, New York Heart Association (NYHA) heart insufficiency
Correspondence to: U. Denzer
Surg Endosc (2004) 18: 1067–1070
DOI: 10.1007/s00464-003-9139-0
? Springer-Verlag New York, LLC 2004

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grade III–IV, acute coronary syndrome, respiratory insufficiency, me-
chanical or paralytic ileus, pregnancy, and creatinine levels exceeding
1.5 mg/dl.
Between 1999 and 2001, 56 patients ages 36 to 89 years with his-
tologically proven malignant disease were investigated with diagnostic
minilaparoscopy and CT scan. Information about the primary tumors
of the patients is summarized in Table 1.
Technique
Minilaparoscopy was performed with the patient under conscious se-
dation using pethidin and midazolam, as previously described by
Helmreich-Becker et al. [4]. The normal puncture site for the Veress
needle (diameter, 2.3 mm) enclosed by a 2.75-mm shaft was 2 cm cra-
nially and 2 cm laterally from the umbilicus. In cases of marked
splenomegalyorpriormedianlaparotomy,othersiteswereused(mostly
the lower border of the umbilicus).
After a pneumoperitoneum had been formed with approximately
1.5 I of nitrous oxide (N2O), the Veress needle was exchanged for
insertion of the optical instrument (diameter, 1.9 mm; Richard Wolf,
GmbH, Knittlingen, Germany). Thus, only a single abdominal punc-
ture site was required. Intraabdominal organs, especially the perito-
neum and omentum, were examined macroscopically. White-colored
focal lesions of the peritoneum and omentum were judged macro-
scopically as positive for peritoneal spread. Biopsies of these lesions
usually were performed with the forceps under visual guidance.
Patients were monitored by continuous measurement of heart rate,
blood pressure, electrocardiogram, and oxygen saturation. The pa-
tients were monitored by measurement of heart rate and blood pres-
sure within the next 4 h after the investigation. They remained in the
hospital for the following 20 h.
Computed tomography scans (helical CT scan, 5-mm slice thick-
ness increment, Siemens Somatom plus 4) were performed with oral
and intravenous contrast medium and intravenous N-butylscopolam-
in. Peritoneal cancer spread was diagnosed if at least two of the four
following criteria were present: presence of ascites or thickening of the
peritoneum, intestinal wall, or mesentery. The CT scans were per-
formed on an outpatient or inpatient basis.
Results were analyzed systematically only when a definitive final
diagnosis could be made by histologic proof of peritoneal metastases or
demonstrationofmetastasesabsencebyopenlaparotomy.Inthisgroup
of 36 patients, the sensitivity and specificity were calculated using the
StatXact 4.0.1 test. The sensitivity of an investigation is the proportion
of positive tests in all the patients with proven disease, whereas the
specificity is the proportion of negative tests in all the patients proven to
be disease free. The 95% confidence intervals (CI) are stated.
Results
Of the 56 patients, 54 fulfilled the study criteria. The CT
quality was not of sufficient for the two patients who
Table 1. Comparison of minilaparoscopy and computed tomography used to diagnose peritoneal metastasis: Results for patients with a proven
positive or negative diagnosis
ML diagnosis of PM
No. Age (years) Gender Primary tumor Macroscopy Biopsy Overall CT diagnosis of PM Surgery after CT/ML PM
1
2
3
4
5
6
7
8
9
10
11
12
13
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
58
77
34
60
65
63
57
74
66
33
46
58
62
37
63
51
42
61
87
60
41
71
71
42
59
89
41
72
69
57
77
70
55
70
55
63
M
F
F
F
M
M
M
M
M
M
F
F
M
F
F
F
F
M
F
F
F
F
F
M
M
F
M
M
F
M
F
F
F
F
F
M
Pancreas
Gallbladder
Sigmaa
Sigma
Biliary system
Liver
Esophagus
Stomach
Stomach
Stomach
Liver
Pancreas
Biliary system
Stomachb
Stomachb
Stomachb
Stomach
CUP
CUP
CUP
Rectum
Ovarial
Colon
Colon
Stomach
Stomach
Stomachb
Stomachb
Stomach
Stomachb
Esophagus
Gallbladder
Mamma
Uterus
Kidney
Prostata
)
)
)
)
)
)
)
)
)
)
)
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
ø
ø
ø
ø
ø
ø
ø
ø
ø
ø
ø
)
)
Unspecified +
+
+
ø
ø
+
+
+
+
ø
+
+
+
+
+
ø
ø
+
+
+
+
+
+
)
)
)
)
)
)
)
)
)
)
)
+
+
)
)
)
)
)
)
)
)
)
)
+
)
)
+
+
+
+
+
+
+
+
+
+
+
)
)
)
)
)
)
)
)
)
)
)
)
Whipple operation
Hemihepatectomy
Hemihepatecomy with liver metastasis )
Resection of the sigma
Hemihepatecomy
Liver transplantation
Esophagectomy
Gastrectomy
Gastrectomy
Gastrectomy
Hemihepatectomy
Whipple operation
Hemihepatectomy
Palliative bowel resection with PM
ø
ø
Palliative lleostomy with ileus and PM +
Explorative laparotomy
ø
ø
Explorative laparotomy
ø
Hemicolectomy
Explorative laparotomy
ø
ø
ø
ø
Explorative laparotomy
Explorative laparotomy
ø
ø
ø
ø
ø
ø
)
)
)
)
)
)
)
)
)
)
)
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
ML, minilaparoscopy; PM, peritoneal metastasis; CT, computed tomography;
aSigmaresection in the past, actually single liver metastasis ø, not done; CUP, Cancer of unknown primary
bGastrectomy in the past
1068

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dropped out the study (Fig. 1). Diagnostic minilapar-
oscopy detected peritoneal carcinosis in 28 of 54 cases,
whereas CT detected the disease in 14 of 54 cases.
For 36 patients, the final diagnosis was verified by
histologic examination of peritoneal biopsies (n = 15),
operative laparotomy (n = 17) or both (n = 4) after
diagnostic examination. Histologic examination of
peritoneal biopsies or laparotomy excision probes de-
fined the results for 13 of 36 patients as negative for
peritoneal metastases, and the results for 23 of 36 pa-
tients as positive for peritoneal metastases (Table 1).
Minilaparoscopy detected peritoneal spread in 25 of 36
cases, whereas CT detected spread in 12 of 36 cases.
Minilaparoscopy macroscopically suspected peritoneal
spread false-positively in two cases (peritoneal biopsy
and laparotomy results were histologically negative),
and the histology showed fatty or fibrinous peritoneal
lesions. Computed tomography showed one false-posi-
tive result (laparotomy results were negative). Genuine
false-negative diagnoses were not observed by minila-
paroscopy. However, CT gave false-negative results in
12 cases. Diagnostic minilaparoscopy was thus much
more sensitive in detecting peritoneal spread than CT:
minilaparoscopy, 100%; 95% CI, 85.2–100% versus CT,
47.8%; 95% CI, 26.8–69.4% (p = 0.0025). The specifi-
cities for both procedures were comparable: minilapar-
oscopy, 84.8%; 95% CI, 64–99.8% versus CT, 92.3%;
95% CI, 64–99.8% (n = 0.85).
In the subgroup of 17 patients evaluated with mi-
nilaparoscopy and CT scan whose peritoneal metastases
was proven by laparoscopic biopsy, CT scan detected
peritoneal spread only in 7 patients. The diagnosis was
not verified definitively in 18 patients. For various rea-
sons, these patients did not undergo surgery after the
diagnostic procedure, and for three patients with mac-
roscopically suspected peritoneal metastasis, no biopsies
of the lesions had been performed minilaparoscopically.
Minilaparoscopy diagnosed peritoneal metastases mac-
rosopically in 3 of these 18 cases, whereas CT diagnosed
the condition in 2 of the 18 cases. In view of the missing
histologic confirmation, these patients were excluded
from the statistical analysis. No serious peri- or post-
interventional complications occurred.
Discussion
The prognosis of gastrointestinal malignancies, espe-
cially gastroesophageal and pancreatic cancer, cancer of
the biliary tract, and hepatocellular cancer, still is poor.
Surgical resection offers the only chance of cure. How-
ever 20% to 40% of the patients present with incurable
disease at the time of the first diagnosis, primarily be-
cause of liver metastases or peritoneal spread. Preoper-
ative assessment of tumor stage is therefore crucial in
the selection of patients for potentially curative resection
to avoid unnecessary laparotomies in those with meta-
stases [12]. Studies have shown surgical staging lapar-
oscopy, including exploration of the omental bursa or
further invesigation of the periaortal or pericaval lymph
nodes, to be of superior diagnostic accuracy, as com-
pared with imaging procedures (CT, ultrasound), for
gastroesophageal cancer, pancreatic cancer, and cancer
of the biliary tract and the liver [2, 6, 7, 10, 14]. Rates of
prevented laparotomies after laparoscopy in these
studies ranged from 18% to 38%. Besides staging for
tumor invasion, nodal infiltration, and liver metastases,
the superiority of staging laparoscopy was attributable
to the low sensitivity of imaging methods for detecting
peritoneal seeding in the absence of ascites [5]. The
confirmed superior diagnostic accuracy of surgical la-
paroscopy staging, as compared with that of modern
CT, has been confirmed in more recent studies [3, 9, 11].
Diagnostic laparoscopy focuses on the detection of
liver and peritoneal metastases. This procedure does not
include the exploration of the bursa omentalis. Minila-
paroscopy, as a further development of diagnostic la-
paroscopy with even less invasiviness, is a safe and easy-
to-handle technique, performed with the patient under
conscious sedation. The diagnostic procedure can be
performed even in an outpatient setting.
Minilaparoscopy allows inspection of about 70% of
the liver surface as well as superficial exploration of the
small bowel, omentum, and peritoneum. In our series of
1,500 consecutive up-to-date minilaparoscopies, the
overall complication rate with this technique has proved
to be very low (<0.9%) [1]. Adhesions attributable to
previous abdominal surgery or peritoneal tumor spread
are not considered a contraindication for minilaparos-
copy because the laparoscopic instrument can be pushed
through adhesions without risks and a path can be
tunneled through thin transparent adhesions to gain
access to the stomach or jejunum. Even accidental bowel
perforation with the 2.75-mm instrument in patients
with adhesions can be managed conservatively because
of the minilaparoscopic instrument’s thin diameter [1].
In this prospective study comparing minilaparosco-
py with CT scan in the diagnosis of peritoneal meta-
stases, minilaparoscopy detected peritoneal seeding with
a statistically significant higher sensitivity. The specific-
ity of the two diagnostic methods was comparable. The
results for minilaparoscopically diagnosed peritoneal
metastases are comparable with those for conventional
diagnostic laparoscopy with the patient under conscious
sedation.
However, a few limitations of the current study must
be kept in mind. First, the study size was small.
Fig. 1. Study data.
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Minilaparoscopy missed only one case of local perito-
neal cancer spread that was diagnosed only by surgical
exploration. This high sensitivity of minilaparoscopy as
compared with CT scan is expected to be reduced with
higher study numbers. Second, the study group was not
homogeneous. It included patients with various under-
lying malignancies and patients receiving palliative
chemotherapy with a history of prior tumor resection.
Therefore, surgical intervention after diagnostic mi-
nilaparoscopy was not performed for every patient
staged negative for peritoneal seeding.
Nevertheless, the results of our study demonstrate
that minilaparoscopy is a highly sensitive and specific
diagnostic tool that clearly is superior to modern CT
scanning for diagnosing peritoneal spread. Especially
for patients with newly diagnosed gastrointestinal ma-
lignancies that have a high tendency for cancer spread-
ing (i.e., gastroesophageal, pancreatic, and biliary
cancers), minilaparoscopy is an easily feasible and
minimally invasive staging procedure of high efficacy
that reduces the number of unnecessary laparotomies.
Its exact place between noninvasive diagnostic imaging
procedures and surgical explorative laparotomy needs to
be defined more clearly in future studies.
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