The ability of staging laparoscopy (SL) to change the surgical decision in esophageal cancer patients in the era of EUS and PET/CT scanning: when should it be performed?

M Aboul Enein, MBChB,, MSc,, MRCS, M Khalil, MBChB, A Hamouda, MD, FRCS, A Nisar, FRCS, FRCSI, H Ali, MD, FRCS. Maidstone and Tunbridge Wells hospitals NHS trust.

INTRODUCTION – To assess whether staging laparoscopy changes the surgical decision making in resectable esophageal cancer patients who were staged as T3 M0 after EUS and PET/CT scanning.

METHODS AND PROCEDURES – The notes of 109 patients who were considered for curative esophageal cancer resections were reviewed retrospectively. All patients had maximum of T3 M0 disease staging on EUS and PET CT. Staging laparoscopy was carried out in a separate session even if the esophageal resection was performed laparoscopically. The following data was collected; patients demographics, TNM staging based on EUS, PET/CT. The findings on staging laparoscopy in terms of fixation of tumour, liver, peritoneal and omental spread. Complications after SL were also recorded.

RESULTS – 107 (98.1%) out of 109 patients underwent curative resection for their esophageal cancers. Forty six (42.2%) by open surgical technique and 63 (57.8%) by the laparoscopic/assisted or laparoscopic methods. All patients had an initial T3 / T4, M0 status, based on EUS and PET/CT. Staging Laparoscopy was able to detect metastasis that precluded resection in 2 patients (1.84%). The causes found for changing the decision to operate, in the two patients were solitary peritoneal nodules, which came back as malignant in one of the patient. While in the second patient, the biopsy showed an enlarged celiac lymph node, which showed metastatic disease on histology. During SL, biopsies were obtained from liver and peritoneum in 12 (11%) patients, and feeding jejunostomies were inserted in 7 (6.4%) patients. Neither of these altered whether patients underwent resections.

CONCLUSIONS – 98% negative laparoscopies need to be done to pick up 2% of avoidable resections. In the era of uniform chemotherapy and abdominal laparoscopic resectional techniques, the merits of staging laparoscopy are probably in doubt. And require a prospective clinical trial.

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