BACKGROUBD: To determine the usefulness of laproscopic assessment of suspected ampullary neoplasms, prior to exploratory laparotomy.
METHODS: Between January 1990 and August 1999, 63 patients with a suspected ampullary neoplasm were referred for possible resection. Two practice patterns were prevalent during this time period: patients proceeded directly to resection prior to 1994 but underwent laparoscopic evaluation prior to attempted resection (after 1994). Information gathered from laparoscopy included presence of metastasis, local resectability as judged by laproscopic ultrasound and tumor size - patients with positive findings avoided laparotomy, and underwent ERCP stent placement. Standard work-up consisted of triple-phase, helical CT scanning and ERCP as well appropriate testing to rule out distant disease in all cases.
RESULTS: 24 patients proceeded directly to laparotomy without laparoscopic staging. 22 were resected (92%) - 2 had liver metastasis and underwent operative bypass. Of 39 patients who underwent laparoscopic evaluation, 5 patients (13%) were found to have either metastasis or portal vein involvement and were referred for palliative ERCP and stent placement. 5 patients (15%) who underwent laparotomy were found at surgery to be unresectable, despite laproscopic evaluation and underwent palliative biliary and gastric bypass. Two patients, who had undergone previous laparoscopic evaluation, underwent late laparatomy for duodenal obstruction.
CONCLUSIONS: Unnecessary laparotomy was prevented by laparoscopic findings in 13% of patients, however an additional 15% of patients were found to be unresectable at the time of surgery. In the group that proceeded directly to surgery, 92% of patients were resected. Lastly, two patients who were denied laparotomy because of laparoscopic findings underwent a late laparotomy for duodenal obstruction. Laparoscopic staging of suspected ampullary cancer does not appear to prevent unnecessary laparotomy, and may indeed deny patients operative palliation of potential duodenal obstruction.
