Ali A Warsi*, Mr Dr, Alex Wilkins, Dr, Richared Berrisford, Mr, Grant Sanders, Mr, Jo Rahamim, Mr, Tim Wheatley, Mr. Derriford Hospital, Plymouth , Devon, U.K.
Accurate pre-operative staging for oesophago-gastric cancer is essential for consideration of neo-adjuvant therapy, attempted curative resection, prognostication and comparison of results. The role of staging laparoscopy and laparoscopic ultrasound in the management of gastric cancer is well recognised. However, there is limited data regarding the use of staging laparoscopy in the management of oesophago-gastric junctional cancer. It is believed that staging laparoscopy would identify any intra-abdominal metastasis not detectable radiologically, thereby preventing unnecessary laparotomies for incurable disease, allowing better planning of theatre operating time and preventing unexpected bad news for the patient. We have analysed our data in a teaching hospital, over a 2 year period, in an attempt to ascertain the contribution of staging laparoscopy in the algorithm of management of junctional cancer
All oesophagectomies between January 2008 and November 2009 were included in the study. Gastric cancers were excluded. Patients who had junctional cancer on CT scan or EUS and confirmed on retro-flexion during oesophago-gastro-duodenoscopy (OGD) underwent staging laparoscopy provided there were no obvious metastatic disease on PET CT and CT scan (chest abdomen and pelvis). All cancer cases were discussed in the multi-disciplinary team (MDT) meeting to decide best management plan. Data were collected retrospectively from case notes, and computerised cancer database where data was collected prospectively. The type of resection, morbidity and in-patient mortality, duration of stay and final pathological stage were analysed.
There were 33 oesophagectomies, 25 male and 8 females. The median age at resection was 62 years (range 44 to 85). There were 17 oesophageal tumours that were not seen on retro-flexion during OGD and did not undergo staging laparoscopy prior to resection. 10 of these were in the distal third of the oesophagus. There were 16 junctional cancers, all of which underwent staging laparoscopy. None (0%) of junctional cancers that underwent staging laparoscopy showed any evidence of peritoneal or intra-abdominal metastasis. It therefore did not alter further treatment plan, in form of attempted curative resection- with or without a neo-adjuvant chemotherapy. There were two cases that did not come to curative resection following staging laparoscopy- but not dictated by laparoscopic findings. First was a very bulky irresectable tumour with N2 disease on laparatomy. The second had a second primary in the colon on CT-and was eventually considered unfit to undergo 2 major resections. There were 3 squamous cell cancers (SCC) and 29 adenocarcinomas and 1 high grade dysplasia. All distal cancers were adenocarcinomas. 1 patient had laparoscopic assisted oesophagectomy. The remaining 32 patients had 2 phase Ivor-Lewis oesophagectomy. 1 (3%) patient died 12 days after operation. There was 2 (6%) anastomotic leak and 2 (6%) chyle leaks. The median length of stay was 13 days.
Staging laparoscopy for junctional cancers does not detect many irresectable and metastatic disease if patients have had a CT and PET CT. Large prospective studies may provide a more robust evidence to re-evaluate the necessity for a staging laparoscopy prior to resection.
Program Number: P514