Background: Laparoscopy has proven valuable for the identification of radiologically occult advanced disease in patients with potentially resectable pancreatic adenocarcinoma. Its value in other periampullary tumors has not been reported. This study was designed to determine the value of laparoscopy in the management of these tumors.
Methods: One hundred thirty nine patients with radiologically resectable non-pancreatic periampullary tumors were identified were from a prospective peri-pancreatic laparoscopy database of over 1000 procedures performed between 8/1993 and 7/2000. Criteria for radiologic unresectablility were major arterial involvement, long segment portal vein/mesenteric vein involvement, or metastatic disease. Criteria for laparoscopic unresectability included histologically proven peritoneal or hepatic metastases, distant nodal involvement, arterial involvement, and local extension outside the resection field. Univariate analysis was conducted using Chi square for association and log rank analysis for survival.
Results: The median age at operation was 70 years (range 31-87) and 55% were male. An adequate laparoscopy was performed in 127 (91%). Of these patients, laparoscopy identified an additional 10 (8%) with unresectable disease. Laparoscopy identified 4 patients with liver metastases, 4 with peritoneal spread, and 2 with other metastatic disease. Of the 117 patients with laparoscopic resectable disease, 109 (93%) went on to resection. Laparoscopy missed 3 patients with liver metastases, 2 with vascular invasion, 1 with peritoneal spread, 1 with local extension and 1 with benign disease. In the group of patients having inadequate staging laparoscopy, 3 patients (25%) had liver metastases discovered at exploratory laparotomy. Patients with resectable disease were treated by pancreaticoduodenectomy (89, 75%), ampullectomy (12, 10%), duodenal resection (10, 9%), or bile duct excision (7, 6%). Pathologic examination revealed malignancy in 122 patients. Median post operative survival was 48.5 months (38-59) in resected patients and 9.8 months (6-13) in non-resected patients.
Discussion: The addition of diagnostic laparoscopy to dynamic CT scanning results in an 8% decrease in the likelihood of finding unresectable disease at laparotomy. In contrast to patients with pancreatic adenocarcinoma, we believe that laparoscopy should be utilized in a selective fashion for pre-operative staging of patients suspected of having non-pancreatic peri-ampullary tumors.