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Does Staging Laparoscopy Detect a Higher Rate of Occult Metastases in Patients with Resectable Pancreatic Adenocarcinoma?
Carlo M. Contreras*, Robert J. Rettammel, David M. Mahvi, Layton F. Rikkers, Clifford S. Cho, Sharon M. Weber
General Surgery, University of Wisconsin, Madison, WI
Background: Preoperative computed tomography understages pancreatic adenocarcinoma, with occult metastatic disease identified in up to 25% of patients at the time of operation. Because the role of staging laparoscopy continues to be debated, we sought to compare the incidence of occult unresectable disease for patients with radiographically resectable pancreatic adenocarcinoma explored with laparotomy versus laparoscopy, all of whom were evaluated with contemporary imaging over a recent time span.
Methods: Patients with radiographically resectable pancreatic adenocarcinoma were identified from a prospective hepatobiliary database and divided into two groups: those explored initially with laparoscopy versus laparotomy. Preoperatively, all patients were determined to be resectable based on imaging review at a multidisciplinary tumor conference with evaluation by specialists in surgical and medical oncology, gastroenterology, and radiology. Endpoints of resectability, survival, cost, and hospital stay were evaluated.
Results: Between April 2002 and November 2006, 78 patients with pancreatic adenocarcinoma underwent exploration. Twenty-five underwent initial laparoscopic exploration, and 53 underwent immediate laparotomy. There was no difference in the type or number of preoperative imaging tests. Occult metastases were identified in 7/25 (28%) patients undergoing laparoscopy. In addition, 3/25 laparoscopy patients had unresectable disease identified at subsequent laparotomy. Thus, 40% (10/25) of the laparoscopy group had unresectable tumors. In the laparotomy group, only 6/53 (11%) patients were found to have intraoperative evidence of unresectable disease (p = 0.003 vs. laparoscopy). Occult peritoneal disease was identified more frequently in laparoscopy patients (32% vs. 11%, p = 0.03). Median survival for resected patients was 16 months versus 4 months for patients with unresectable tumors (p < 0.0001). Survival for resected patients was not significantly different between the laparoscopy and laparotomy groups. In patients with unresectable disease, there were no differences in length of stay, direct hospital costs, or interval to initiating postoperative chemotherapy between laparoscopy and laparotomy groups.
Conclusions: In patients with apparently resectable pancreatic adenocarcinoma, occult metastatic disease is identified more frequently at the time of staging laparoscopy than at laparotomy. For the first time, this study demonstrates that improved visualization of the abdominal cavity with pneumoperitoneum results in an enhanced ability to detect peritoneal disease in patients evaluated with contemporary imaging.
