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Technical aspects of laparoscopy and laparoscopic sonography in preoperative staging of cancer of the pancreatic head region
A448
AGA ABSTRACTS
GASTROENTEROLOGY, Vol. 108, No. 4
• EVALUATIONOF SC"RRlgI~rlNGCOLONOSCOPYIN FIRSTDEGREERELATIVES OF COLORECTALCANCERPATIENTS.R.M Bashir, AM Axelrad, PK Gupta, JI-ILewis, CC Ngnyen, DE Fleischer, SB Benjamin. Georgetown University Medical Center, Washington, D.C. Objective: The majority of familial colon cancer is seen in first degree relatives of eoloreetal cancer patients (FDR-CRCPs). Prevalence data on adenomas in this population is very limited. Our aim was to evaluate the yield of adenomas and celoreetal cancer with screening colonosoopy in FDR-CRCPs and potentially identify subgroups who are at particularly increased risk. Methods: All FDRCRCPs who were referred for celonoscepy were prospectively identified over a 12-month period. All eolonoscopi¢ and histologic data were reviewed to assess the yield of adenomatous polyps or cancer in each patient: Additional retrospective evaluation of four years was performed through chart review, endoscopic report review, and histopathologieal assessment. Associated symptoms, including stool hemoeeult status, were recorded for all patients. Patients with a previous history of coloreetal cancer or polyps, inflammatory bowel disease, or familial polyposis s)mdromaswere excluded. Results: Yield of sercera~ cel0noscopy i~ shown:.~ . PATIENT CHARACTERISTICS TOTAL PATIENTS SCREENED PROSPECTIVE • ~.I'.,R.OSP..E~. .
NO. , POLYPS (R-sided) CA 149 25.5%(38) 1 2 . 1 % ( 1 8 ) 0 29 17.3% (5) 10.3% (3) 0 !..2..0.....2..7...5..°/.o.!,.3..3.).. !.2.5%(!5) 0 .
NORMAL '74.5% (111)82.8% (24) 72.5%(87): ,
AGE>_S0Yns 86 35.7%(30) 15.5%(13) 0 64.3%(54) ..A...GE.<....~..y...gS... . 63 ......./..2.:..7°../.o.(8) - 6.5%(4). 0 . 87:3%(55)...... ASYMPTOMAT!C 116 26.7%(31) 13.8%(16) 0 73.2%(84) SYMPTOMATIC 33 21.2%(7) 9.1%(3) 0' 7S.7%.(26) Of 149 patients screened (66 nml"e,83 female), 38 (25.5%) had adenomatous polyps and none had cancer. Of all adenomas, 47.4% (18) were proximal tothe splenic flexure (R-sided). Yield of all adenomas and R-sided adenomas in'the prospective group and retrospective groups was not significantly different. Among patients over 50 years of age (n=86), 35.7% had adenomatous polyps (43.3% R-sided). Of patients under 50 years of age (n=63), only 12.7% (8 patients) had adenomas (50% R-sided). There was no significant difference in yield between patients with symptoms (rectal bleeding (10), altered bowel habits (9), abdominal pain (8), heme positive stool (5)) and asymptomatic patients. Conclusions: 1) Screening celonescepy in FDR-CRCPs appears to yield adenomas most oommonly in patients over age 50.2) Right-sided adenomas aeeoant for 47.4% of all polyps, demonstrating the importance of full eolonoscopy in this population. 2) Additional symptomatology, such as heine positive stool or rectal bleeding, does not appear to increase the yield of celonoscepy in FDR-CRCPs.
GUIDELINES FOR LAPAROSCOPY AND LAPAROSCOPIC SONOGRAPHY IN
PREOPERATIVESTAGINGOF ESOPHAGEALCANCER. W.A. Bemelman a, O.M. van Delden 2, J.J.B. van Lanschot1, L.Th. de Wit ~, N.J. Smits ~, P.Fockens 3, D.J. Gouma~, H. ObertopL
Departments of Surgery1, Radiology 2 and Gastroenterology~, Academic Medical Center, University of Amsterdam. The objective of this prospective study was to assess the additional role of diagnostic laparoscopy combined with laparoscopic ultrasonography in the preoperative staging of patients with cancer of the esophagus and cardia. Preoperative laparoseopy and laparoseopic ultrasonography was performed in 56 patients who were selected for curative resection of cancer of the esophagus (n=36) or gastric cardia with involvement of the distal esophagus (n= 18) after routine preoperative work-up. The peritoneal cavity was scrutinized for metastatic disease and ultrasonography of liver and coeliac axis was performed All patients without histologically proven metastases proceeded to laparotomy. Morbidity of the procedure was 3.5 % (two superficial wound infections). In three of the 56 (5%) patients laparotomy was avoided because of intraabdominal metastatic disease. In three Other patients laparotomy was necessary to confirm the suspected liver and/or peritoneal metastases because histologic proof was not obtained at laparoseopy. In one patient laparoscopic ultrasonography failed to detect a small liver metastasis in segment VII. Preoperative stage was altered by laparoseopy in 9 (17%) patients (M~ 6x, T, 3x). Laparotomy was avoided and preoperative stage changed in 2 (11%) and in 7 patients (41%) with cancer of the gastie cardia, and in 1 (3%) and 2 (5 %) patients with middle and distal esophageal cancer respectively. Preoperative staging by laparoscopy combined with laparoseopic ultrasonography can be considered in patients with cancers of the gastric cardia infiltrating the lower esophagus, but its application in patients with middle and lower esophageal cancer is of little value.
• ,/~IEEDFOR TOTAL COLONOSCOPY SCREENING IN ASYMPTOMATIC SUBJECTS WITH SIMPLE PRIMARY FAMILY I~STORY OF COLORECTAL CANCER. F.Bazzoli, S.Fossi, S.Sottili, P.Pozzato, R.M.Zagnri and E.Roda. Cattedra di Gastroenterologia. University of BaloDaa. Bologna. Italy. This study was undertaken to clarify whiner having only one first-degree relative with colorectal cancer increases the risk of developing premalignant lesions such :as adenomatous polyps, and whether total celonosc0py is an appropriate screening measure in these subjects~ Methods. The frequency of simple primary family history of colorectal cancer (only one first-degree relative affected) was evaluated by personal interview in 397 consecutive asymptomatie subjects who successfully underwent total celonoscepy. Of these, !55 wore found to have colorectal polyps (95 males; 60 females; mean age+SE=58.2_+0.9 yrs); the remaining 242,were free of polypoid lesions (! 12 males; 130 females; mean agn+__SE=52.7:t:l.3 yrs). Subjects with signs or symptoms of, or any factor predisposing to, coloreetal cancer had been excluded. For the purposes of this study, those with two or more first-degree relatives affected had also been excluded. Polyps were considered proximal or distal accerding to their location above or below the junction deseending-sigmoid colon. Results. Among patients with adenomatous polyps, 27/155 (17.4%) had a positive simple primary family history of colorectal cancer; among those with a normal examination,12/242 (5.0%). The risk of developing adenomatous polyps associated with simple primary family history, calculated as the estimated Odds Ratio adjusted for age and sex (multiple logistic regression model), was 19 with 95% Confidence Interval from 13 to 2.8. Among the cases with adenomatous polyps, 51:9% (14/27) of those with a positive family history and 25.0% (32/128) of those with a negative history had proximal polyps with no distal index lesions (Z2test p=0.006; OR 3.2 with 95%CL=1 4-76); in the same two groups, the frequency of high-grade dysplasia was 29.6% (8/27) and 12.5% (16/128), respectively ( z test p=0.04; OR 2.9 with 95%CL=1.0-7.8). Conclusions. Asymptomatic subjects with only one first-degree relative affected with colorectal cancer had nearly double the risk of developing adenomatous polyps relative to those with no family history; they also had a greater frequency of severely dysplastic lesions and a significantly higher frequency of proximal location of the polyps. For these reasons, total celonoscopy screening shoud be performed in these subjects.
TECHNICAL ASPECTSOF LAPAROSCOPYAND LAPAROSCOPIC SONOGRAPHYIN PREOPERATIVESTAGINGOF CANCEROF THE PANCREATICHEAD REGION. W.A.Bemelman ~ L.Th.de Wit!, O.M.van Delden 2, N.J. Stairs2, H. Obertop 1, E.J.A. Rauws3 and D.J. Gouma 1.
Departments of Surgerfl, Radiology 2 and Gastroenterology 3 Academic Medical Center, University of Amsterdam. Since the revival of minimally invasive surgery, diagnostic laparoscopy gained ground in the preoperative staging of pancreatic cancer, Small liver metastases and peritoneal can be detected with a high accuracy rate. The development of a laparoscopic ultrasonography probe made it possible to evaluate the solid organs and retroperitoneal space during the same procedure without disturbance of overlying bowel gas or thick abdominal wall. This video will show the technique of laparoscopy combined with ultrasound in the preoperative staging of pancreatic cancer. Using a three 10/11-mm trocar approach the abdominal cavity is investigated for peritoneal and hepatic deposits and malignant infiltration of mesocolon and Treitz ligament. Laparoscopic exploration of the lesser sac and biopsy of :lymph nodes around the coeliac axis will be demonstrated. Laparoscopic ultrasound of the liver and of the tumor With regards to vascular involvement (local unresectability) will be shown. Biopsies of suspicious lesions are taken: under direct laparoscopic or ultrasound guidance using biopsy forceps or Tru-cut and Rotex biopsy needles. In 70 patients with a presumed Stage I tumor of the pancreatic head region local vascular involvement was correctly predicted in 93% and laparotomy was avoided in 19%.
AGA ABSTRACTS
GASTROENTEROLOGY, Vol. 108, No. 4
• EVALUATIONOF SC"RRlgI~rlNGCOLONOSCOPYIN FIRSTDEGREERELATIVES OF COLORECTALCANCERPATIENTS.R.M Bashir, AM Axelrad, PK Gupta, JI-ILewis, CC Ngnyen, DE Fleischer, SB Benjamin. Georgetown University Medical Center, Washington, D.C. Objective: The majority of familial colon cancer is seen in first degree relatives of eoloreetal cancer patients (FDR-CRCPs). Prevalence data on adenomas in this population is very limited. Our aim was to evaluate the yield of adenomas and celoreetal cancer with screening colonosoopy in FDR-CRCPs and potentially identify subgroups who are at particularly increased risk. Methods: All FDRCRCPs who were referred for celonoscepy were prospectively identified over a 12-month period. All eolonoscopi¢ and histologic data were reviewed to assess the yield of adenomatous polyps or cancer in each patient: Additional retrospective evaluation of four years was performed through chart review, endoscopic report review, and histopathologieal assessment. Associated symptoms, including stool hemoeeult status, were recorded for all patients. Patients with a previous history of coloreetal cancer or polyps, inflammatory bowel disease, or familial polyposis s)mdromaswere excluded. Results: Yield of sercera~ cel0noscopy i~ shown:.~ . PATIENT CHARACTERISTICS TOTAL PATIENTS SCREENED PROSPECTIVE • ~.I'.,R.OSP..E~. .
NO. , POLYPS (R-sided) CA 149 25.5%(38) 1 2 . 1 % ( 1 8 ) 0 29 17.3% (5) 10.3% (3) 0 !..2..0.....2..7...5..°/.o.!,.3..3.).. !.2.5%(!5) 0 .
NORMAL '74.5% (111)82.8% (24) 72.5%(87): ,
AGE>_S0Yns 86 35.7%(30) 15.5%(13) 0 64.3%(54) ..A...GE.<....~..y...gS... . 63 ......./..2.:..7°../.o.(8) - 6.5%(4). 0 . 87:3%(55)...... ASYMPTOMAT!C 116 26.7%(31) 13.8%(16) 0 73.2%(84) SYMPTOMATIC 33 21.2%(7) 9.1%(3) 0' 7S.7%.(26) Of 149 patients screened (66 nml"e,83 female), 38 (25.5%) had adenomatous polyps and none had cancer. Of all adenomas, 47.4% (18) were proximal tothe splenic flexure (R-sided). Yield of all adenomas and R-sided adenomas in'the prospective group and retrospective groups was not significantly different. Among patients over 50 years of age (n=86), 35.7% had adenomatous polyps (43.3% R-sided). Of patients under 50 years of age (n=63), only 12.7% (8 patients) had adenomas (50% R-sided). There was no significant difference in yield between patients with symptoms (rectal bleeding (10), altered bowel habits (9), abdominal pain (8), heme positive stool (5)) and asymptomatic patients. Conclusions: 1) Screening celonescepy in FDR-CRCPs appears to yield adenomas most oommonly in patients over age 50.2) Right-sided adenomas aeeoant for 47.4% of all polyps, demonstrating the importance of full eolonoscopy in this population. 2) Additional symptomatology, such as heine positive stool or rectal bleeding, does not appear to increase the yield of celonoscepy in FDR-CRCPs.
GUIDELINES FOR LAPAROSCOPY AND LAPAROSCOPIC SONOGRAPHY IN
PREOPERATIVESTAGINGOF ESOPHAGEALCANCER. W.A. Bemelman a, O.M. van Delden 2, J.J.B. van Lanschot1, L.Th. de Wit ~, N.J. Smits ~, P.Fockens 3, D.J. Gouma~, H. ObertopL
Departments of Surgery1, Radiology 2 and Gastroenterology~, Academic Medical Center, University of Amsterdam. The objective of this prospective study was to assess the additional role of diagnostic laparoscopy combined with laparoscopic ultrasonography in the preoperative staging of patients with cancer of the esophagus and cardia. Preoperative laparoseopy and laparoseopic ultrasonography was performed in 56 patients who were selected for curative resection of cancer of the esophagus (n=36) or gastric cardia with involvement of the distal esophagus (n= 18) after routine preoperative work-up. The peritoneal cavity was scrutinized for metastatic disease and ultrasonography of liver and coeliac axis was performed All patients without histologically proven metastases proceeded to laparotomy. Morbidity of the procedure was 3.5 % (two superficial wound infections). In three of the 56 (5%) patients laparotomy was avoided because of intraabdominal metastatic disease. In three Other patients laparotomy was necessary to confirm the suspected liver and/or peritoneal metastases because histologic proof was not obtained at laparoseopy. In one patient laparoscopic ultrasonography failed to detect a small liver metastasis in segment VII. Preoperative stage was altered by laparoseopy in 9 (17%) patients (M~ 6x, T, 3x). Laparotomy was avoided and preoperative stage changed in 2 (11%) and in 7 patients (41%) with cancer of the gastie cardia, and in 1 (3%) and 2 (5 %) patients with middle and distal esophageal cancer respectively. Preoperative staging by laparoscopy combined with laparoseopic ultrasonography can be considered in patients with cancers of the gastric cardia infiltrating the lower esophagus, but its application in patients with middle and lower esophageal cancer is of little value.
• ,/~IEEDFOR TOTAL COLONOSCOPY SCREENING IN ASYMPTOMATIC SUBJECTS WITH SIMPLE PRIMARY FAMILY I~STORY OF COLORECTAL CANCER. F.Bazzoli, S.Fossi, S.Sottili, P.Pozzato, R.M.Zagnri and E.Roda. Cattedra di Gastroenterologia. University of BaloDaa. Bologna. Italy. This study was undertaken to clarify whiner having only one first-degree relative with colorectal cancer increases the risk of developing premalignant lesions such :as adenomatous polyps, and whether total celonosc0py is an appropriate screening measure in these subjects~ Methods. The frequency of simple primary family history of colorectal cancer (only one first-degree relative affected) was evaluated by personal interview in 397 consecutive asymptomatie subjects who successfully underwent total celonoscepy. Of these, !55 wore found to have colorectal polyps (95 males; 60 females; mean age+SE=58.2_+0.9 yrs); the remaining 242,were free of polypoid lesions (! 12 males; 130 females; mean agn+__SE=52.7:t:l.3 yrs). Subjects with signs or symptoms of, or any factor predisposing to, coloreetal cancer had been excluded. For the purposes of this study, those with two or more first-degree relatives affected had also been excluded. Polyps were considered proximal or distal accerding to their location above or below the junction deseending-sigmoid colon. Results. Among patients with adenomatous polyps, 27/155 (17.4%) had a positive simple primary family history of colorectal cancer; among those with a normal examination,12/242 (5.0%). The risk of developing adenomatous polyps associated with simple primary family history, calculated as the estimated Odds Ratio adjusted for age and sex (multiple logistic regression model), was 19 with 95% Confidence Interval from 13 to 2.8. Among the cases with adenomatous polyps, 51:9% (14/27) of those with a positive family history and 25.0% (32/128) of those with a negative history had proximal polyps with no distal index lesions (Z2test p=0.006; OR 3.2 with 95%CL=1 4-76); in the same two groups, the frequency of high-grade dysplasia was 29.6% (8/27) and 12.5% (16/128), respectively ( z test p=0.04; OR 2.9 with 95%CL=1.0-7.8). Conclusions. Asymptomatic subjects with only one first-degree relative affected with colorectal cancer had nearly double the risk of developing adenomatous polyps relative to those with no family history; they also had a greater frequency of severely dysplastic lesions and a significantly higher frequency of proximal location of the polyps. For these reasons, total celonoscopy screening shoud be performed in these subjects.
TECHNICAL ASPECTSOF LAPAROSCOPYAND LAPAROSCOPIC SONOGRAPHYIN PREOPERATIVESTAGINGOF CANCEROF THE PANCREATICHEAD REGION. W.A.Bemelman ~ L.Th.de Wit!, O.M.van Delden 2, N.J. Stairs2, H. Obertop 1, E.J.A. Rauws3 and D.J. Gouma 1.
Departments of Surgerfl, Radiology 2 and Gastroenterology 3 Academic Medical Center, University of Amsterdam. Since the revival of minimally invasive surgery, diagnostic laparoscopy gained ground in the preoperative staging of pancreatic cancer, Small liver metastases and peritoneal can be detected with a high accuracy rate. The development of a laparoscopic ultrasonography probe made it possible to evaluate the solid organs and retroperitoneal space during the same procedure without disturbance of overlying bowel gas or thick abdominal wall. This video will show the technique of laparoscopy combined with ultrasound in the preoperative staging of pancreatic cancer. Using a three 10/11-mm trocar approach the abdominal cavity is investigated for peritoneal and hepatic deposits and malignant infiltration of mesocolon and Treitz ligament. Laparoscopic exploration of the lesser sac and biopsy of :lymph nodes around the coeliac axis will be demonstrated. Laparoscopic ultrasound of the liver and of the tumor With regards to vascular involvement (local unresectability) will be shown. Biopsies of suspicious lesions are taken: under direct laparoscopic or ultrasound guidance using biopsy forceps or Tru-cut and Rotex biopsy needles. In 70 patients with a presumed Stage I tumor of the pancreatic head region local vascular involvement was correctly predicted in 93% and laparotomy was avoided in 19%.