BACKGROUBD: Optimal management of cancer of the upper gastrointestinal tract requires accurate preoperative staging to facilitate multimodality therapy and to identify those who would benefit from potentially curative surgery. Studies have suggested staging laparoscopy as a useful adjunct, reducing unnecessary laparotomy in those with advanced disease. The aims of our study were: (1) to compare the accuracy of CT scanning with staging laparoscopy in patients with suspected upper gastrointestinal malignancy, (2) to evaluate the extent of re-assignment of pre-operative stage after laparoscopy and (3) to assess the utility of peritoneal washout cytology.
METHODS: All patients undergoing pre-operative staging from 1998 were entered into a database. An analysis was carried over a 2-year period from 1998 to 2000. Patients who had a suspected upper gastrointestinal malignancy and who had both CT and staging laparoscopy were included. From this, 50 patients were identified.
RESULTS: 68% of the study group had gastric cancer or junctional tumours of the cardia. 20% had pancreatic cancer and the remaining 12% had other diagnoses. CT scanning identified ascites in 4 patients, which was confirmed laparoscopically. Laparoscopy detected a further 7 patients with ascites not previously identified by CT. In the assessment of liver metastases, there was concordance between the CT findings and laparoscopy in 91% of cases. Laparoscopy detected a further 2 cases of liver metastases not previously noted on CT. Assessment of nodal status found that there was concordance in 69% of cases. Laparoscopy identified significant lymphadenopathy in an additional 7 cases. In addition to improved accuracy in the detection of a mass lesion, laparoscopy made a further beneficial contribution to staging by identifying the presence of serosal invasion in 9 cases. This information alone led to an upgrading of the disease stage in 5 patients. Laparoscopy identified an additional 5 cases with peritoneal seedlings not detected by CT. Peritoneal washings were positive in 6 out of 18 patients however in this group other features of advanced disease were present at laparoscopy.
CONCLUSIONS: This study demonstrated laparoscopy to be an important adjunct in the staging of upper gastrointestinal malignancy as it identified advanced disease that CT failed to demonstrate, hence altering stage assignment and subsequent management. Positive peritoneal washout cytology did not contribute significantly in the pre-operative staging.