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

Background Significant disparity often exists between the findings of preoperative imagings and exploratory laparotomy Unnecessary laparotomy would increase patient’s morbidity both physically and psychologically

Diagnostic Laparoscopy Minimally invasive procedure Quick and safe Direct visualization of organs and the peritoneal cavity Surface of organs only Allow biopsy and cytology examination

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 1978 Ishida 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 % and the incidence of metastases at laparoscopy ranges widely from 14 % to 75 % Catheline JM et al, Chirurgie 1998 Van Dijkum EJMN et al, J AM Coll Surg 1999 John 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

Adjuncts to Laparoscopy Laparoscopic USG Laparoscopic Guided Biopsy Peritoneal Washing Cytology

Laparoscopic USG Flexible laparoscopic USG probe, comprising a 9-mm diameter, 7.5-MHz linear-array probe

Laparoscopic USG AdvantagesDisadvantages Identify invisible lesionsHighly 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 1996 Rubeiro 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 CT Pisters 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 R 0 - gross and microscopic clear R 1 - gross clear by microscopic positive margin R 2 - both gross and microscopic margin involved Pisters PWT et al, Br J Surg 2001

Resectability Pisters PWT et al, Br J Surg 2001 Overall 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

Location of Tumor Carcinoma of Ampulla are 100% resectable both in Barreiro and Vollmer’s series Palliative procedures (biliary bypass, gastrojejunostomy) are often required for advanced pancreatic head/neck tumor compared with pancreatic body / tail tumor John TG et al, World J Surg 1999

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 1998 Pisters 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