Role of Laparoscopy in the Management of Pancreatic Cancer

abstract & commentary Source: Luque-de Leon E, et al. J Gastrointest Surg 1999;3:111-118.

Laparoscopy is commonly used to stage patients with pancreatic cancer and to determine resectability. In a retrospective analysis from the Mayo Clinic presented by Luque-de Leon and colleagues, an argument is presented that the role of laparoscopy be expanded to determine palliative approaches for patients with unresectable lesions.

The clinical series reviewed included those patients treated at the Mayo Clinic between 1985 and 1992 who were felt to have resectable pancreatic cancer on the basis of state-of-the-art imaging techniques, but who were found to have unresectable lesions at surgery. Data were available for 148 such patients. All were considered resectable preoperatively but, at the time of surgery, 29 (20%) were found to have liver metastases (Group I), 22 (15%) had peritoneal dissemination (Group II), 44 (33%) had metastatic lymph nodes (Group III), and 53 (35%) had locally advanced disease with vascular involvement (Group IV). Overall median survival was nine months, but survival varied significantly among the groups. Groups I and II each had a median survival of six months, whereas Groups III and IV each had a median survival of 11 months.

These patients were evaluated by the currently used practice of staging laparoscopy. Luque de-Leon et al discuss the role that laparoscopy could play in addition to determining which patients have resectable cancers. They propose that patients with laparoscopically detected unresectability on the basis of hepatic metastases or peritoneal dissemination have a poor prognosis and might best be treated with nonoperative approaches, such as endoscopically placed endobiliary stents. In contrast, for those patients with metastatic nodes, or locally advanced tumors with vascular invasion (Groups III or IV above) in whom median survival approaches one year, operative palliation with biliary and duodenal bypass combined with operative chemical splanchnicectomy (ablation of splanchnic vessels) might offer better palliation. Thus, they argue that the role of staging laparoscopy should not be just to improve the resectability rate, but to define a group of patients with unresectable lesions who might still benefit from a palliative operative procedure.

COMMENTARY

In the great majority of patients with pancreatic cancer, the tumor is unresectable at the time of presentation. Although laparoscopy is not a new approach, technical advances have allowed for more widespread usage and it is now frequently used in staging evaluation to assist in the determination of resectability. For example, by using an "extended" laparoscopic evaluation, Conlon and colleagues viewed the lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels by laparoscopy before surgery. They reported positive and negative predictive indices of 100% and 91%, respectively, and their resectability rate rose to an impressive 76%.1

Luque-de Leon et al argue that high resectability rates should not be the only goal of staging laparoscopy. Instead, they propose that the procedure be used to define optimal palliative approaches based upon the survival data presented for the different laparoscopically determined reasons for unresectability. The argument is difficult to refute. Nonetheless, endoscopists might point to the rapidly advancing technology in endoprostheses (e.g., self expanding metallic stents) that could allow for more long-lasting palliation, comparable to surgical bypass but without surgical morbidity.2 Also, the developing technique of laparoscopically performed biliary-enteric bypass may provide yet another role for laparoscopy in these patients.3

It should be kept in mind that the data presented in this series were for head of the pancreas lesions alone. For patients with cancers in the body or tail, operative palliation is not usually necessary and laparoscopy remains a procedure used only to establish resectability.

This published report from the Mayo Clinic offers useful guidelines for the evaluation and treatment of patients considered operative candidates based upon a good performance status and a periampullary mass demonstrated by CT and/or endoscopic retrograde cholangiopancreatography (ERCP). If laparoscopy in such patients demonstrates peritoneal dissemination or hepatic metastases, endobiliary stent with or without celiac plexus block would be a reasonable approach. If neither peritoneal dissemination nor hepatic involvement is found, exploration is recommended. For those found to have unresectable lesions, bilioenteric bypass, gastrojejumnostomy, and chemical splanchnicectomy could provide durable palliation for what might be expected to be a median survival of approximately one year.

References

1. Conlon KC, et al. Ann Surg 1996;223:134-140.

2. Lammer J, et al. Radiology 1996;201:167-172.

3. Shimi S, et al. Br J Surg 1992;79:317-319.

With regard to staging laparoscopy for patients with cancers at the head of the pancreas, which of the following statements is true?

a. When used solely to determine resectability, the procedure is very effective at reducing the rate of operative determination of unresectability.

b. The procedure is dangerous in patients with hepatic metastases, and should not be performed in patients with elevated liver function tests.

c. When hepatic peritoneal dissemination is demonstrated, median survival is about one year and surgical palliation is warranted.

d. When vascular invasion is demonstrated, median survival is about six months and endoscopic, but not surgical, palliation is indicated.

e. Laparoscopy is inferior to laparotomy in the performance of palliative biliary bypass procedures.