Abstracts
1998 Digestive Disease Week

#2318

STAGING LAPAROSCOPY FOR PANCREATIC CANCER SHOULD BE USED TO SELECT THE BEST PALLIATION, NOT TO INCREASE RESECTION RATE. E Luque-de León, GG Tsiotos, BM Balsiger, J Barnwell, L Burgart, MG Sarr. Dept of Surg, Mayo Clinic, Rochester, MN.

Preoperative laparoscopy has been suggested as an appropriate staging procedure based on the assumption that non-operative biliary stenting is the best palliation and will save an "unnecessary" laparotomy in pts with incurable pancreatic cancer. HYPOTHESIS: Patients with clinically resectable cancer of the pancreatic head found to be unresectable only at operation, have different survivals depending on cause of unresectability; optimal palliation (stent vs operative biliary bypass/gastroenterostomy) may differ accordingly. AIM: To determine survival of such pts and infer appropriate use and extent of staging laparoscopy. METHODS: We reviewed charts of 150 consecutive pts with pancreatic head cancer (1985-92). Follow-up was complete in 148 (99%). All underwent exploration for potential resection (ie good risk pts with clinically resectable lesion based on current imaging techniques), but were unresectable intraoperatively because of I) liver mets (29), II) peritoneal mets (22), III) nodal mets (44) or IV) venous or arterial invasion (53). When more than one site was present, pts were included in the group of more advanced disease. Results: 99 men and 49 women (mean age 65 yr; range: 32-90) had a median survival of 9 months (range: 1-53). Survival by group was I) 6 months with liver mets (range: 1-34), II) 7 months with peritoneal mets (range: 2-36), III) 11 months with distant nodal mets (range: 1-53) and IV) 11 months with vascular involvement (3-30); differences were significant (ANOVA, p<0.001). Survival (corrected Mann-Whitman U-tests) was longer for pts with distant nodal mets or with vascular involvement than those with liver or peritoneal mets (each p<0.03). SUMMARY: Patients with clinically resectable pancreatic head cancer found unresectable at laparotomy, live significantly longer if unresectability is 2° to distant nodal or vascular involvement compared to peritoneal or liver mets. CONCLUSIONS: Staging laparoscopy should aim at identifying pts with liver or peritoneal mets to avoid laparotomy because their expected survival is short (~6 months); short-term endoscopic palliation in this group is satisfactory. Extended laparoscopy to identify nodal or vascular involvement (longer expected survival) is contingent upon which palliative measure (operative vs endoscopic) is considered most appropriate. We avoid extended laparoscopy because we believe operative bypass provides a better, more durable palliation in this specific group of pts (less recurrent jaundice, prevents duodenal obstruction).

Copyright 1996 - 1998, SSAT, Inc. Revised 29 June 1998.