Accurate staging plays a primary role in determining the appropriate treatment of gastrointestinal malignancies. Recently, laparoscopy has emerged as a staging modality that is more sensitive and specific in staging most
Laparoscopy is a technology that is looking for a purpose. The development of microchips and video cameras, which allow for a team approach to the use of laparoscopic instrumentation, might be valuable in treating intra-abdominal pathology.
Laparoscopy remains controversial in the treatment of gastrointestinal malignancies, however, because of anecdotal reports suggesting that it may increase or change the patterns of recurrent disease. Until this issue is resolved by ongoing prospective, randomized trials, the use of laparoscopy as a diagnostic or therapeutic alternative should be subject to careful scrutiny.
Role as a Staging Modality
There are two fundamental circumstances in which laparoscopy can be used. One is as a perioperative or pretherapeutic staging modality. In this role, it needs to be compared to other techniques, such as computed tomographic (CT) scanning and ultrasound, which the authors discuss. They also refer, in a limited way, to monoclonal antibody imaging. Newer monoclonal antibody techniques, as well as positron emission tomography (PET), should also be included in this comparison.
All of these techniques are increasingly sensitive and specific in evaluating patients preoperatively. The vast majority of patients will be accurately staged by these techniques, and only the relatively few patients who show no evidence of malignancy would be candidates for further laparoscopic evaluation.
Role in Treatment
Laparoscopy also has a potential role in the treatment of gastrointestinal malignancies. Hollow organ malignancies are generally best removed whenever possible to obviate the risk of bleeding and/or obstruction. Laparoscopy, therefore, may offer little advantage in these situations. Most patients with these malignancies will undergo surgical exploration, and the use of laparoscopy as a purely diagnostic tool only adds to the cost of their management. Liver, pancreatic, and, perhaps, biliary disease, on the other hand, can be managed with nonopen techniques, and any staging modality that would obviate an open celiotomy is, therefore, attractive.
Similar to the authors, our experience has shown that intraoperative ultrasound scans are effective. However, the inability to position the instrument appropriately for some liver and/or retroperitoneal disease remains a limitation. It is expected that this will be resolved as the technology becomes more sophisticated. Evaluation of the retroperitoneum continues to be a problem. Nevertheless, if retroperitoneal disease is found, as most series have suggested, a celiotomy can be avoided.
The role of peritoneal cytology remains unclear. Although positive cytology is meaningful for the pancreas and stomach, it is less so for colon cancer.
Clearly, laparoscopy should be a tool in the armamentarium of surgeons who perform intra-abdominal procedures. The authors have nicely summarized our current understanding of the role of laparoscopy in the staging of gastrointestinal malignancies.
If used inappropriately, laparoscopy can substantively increase the cost of a work-up. With the increasing sensitivity and specificity of various other diagnostic modalities, laparoscopy will have a very specific, limited role in the staging of gastrointestinal malignancies.