Diagnostic staging laparoscopy for digestive system cancers

INTRODUCTION — Diagnostic staging laparoscopy (DSL) is performed to determine the feasibility of the proposed curative cancer operation. DSL complements the preoperative assessment of radiographic imaging, which has limitations for identifying regional extension of the primary tumor and/or metastatic disease, such as peritoneal involvement [1,2].

The general principles and approach for performing a DSL for patients with a digestive malignancy are reviewed here. Laparoscopic assessment and/or resection of other malignant and benign diseases are discussed in separate topics.

●(See "Minimally invasive esophagectomy".)

●(See "Laparoscopic gastrectomy for cancer".)

●(See "Minimally invasive pancreatectomy (MIP)".)

●(See "Minimally invasive liver resection (MILR)".)

INDICATIONS — The goal of diagnostic staging laparoscopy (DSL) for primary digestive malignancies is to identify and/or disprove the presence of local, regional, and/or metastatic disease. DSL aids in identifying extra-organ disease that would preclude an attempt at an intended curative resection.

Indications for DSL include [1]:

●Assessment for resectability with curative intent of the following digestive cancers:

•Esophageal cancer at the gastroesophageal junction or advanced (>T1) gastric cancer (routinely) (see 'Esophagogastric junction and gastric cancer' below)

•Pancreatic cancer located in the body or tail of the pancreas (routinely) (see 'Pancreatic cancer' below)

•Biliary tract cancer located in the proximal bile duct (intrahepatic or hilar cholangiocarcinoma, both selectively) or gallbladder (routinely) (see 'Biliary tract cancer' below)

•Colorectal liver metastasis (selectively)

●Staging prior to administration of neoadjuvant chemotherapy or radiation therapy [3]

●Assessment of equivocal magnetic resonance imaging (MRI), computed tomography (CT) scan, or positron emission tomography (PET) scan findings for primary, regional, or distant disease

●Assessment of inconclusive histology following radiographic-guided fine needle aspiration of suspicious sites of disease

For certain conditions, selective rather than routine use of DSL is warranted. DSL is cost effective if unresectable disease is identified and the patient is spared a laparotomy [1]. However, DSL performed routinely increases the overall cost of the operative procedure. Patient selection is based on primary tumor site and is discussed below. (See 'Diagnostic yield for specific digestive system cancers' below.)

CONTRAINDICATIONS — Diagnostic staging laparoscopy (DSL) is not a debulking procedure and should not be used for that purpose. It is not performed unless the treatment plan will be altered. Other contraindications include inability to tolerate laparoscopy and previously confirmed metastatic or unresectable disease [1].

DSL is not recommended for proximal or midesophageal cancer, periampullary cancer/distal bile duct cancer, or hepatocellular carcinoma. The yield of DSL in these patients is not sufficiently high enough to justify the procedure. (See 'Diagnostic yield for specific digestive system cancers' below.)

SURGICAL APPROACH — This section reviews the basic surgical principles for performing a diagnostic staging laparoscopy (DSL).

Incision placement — The access point for the initial trocar placement should be remote from prior surgical incisions or suspected metastatic disease. Open techniques, Veress needle insufflation, and/or optical ports can be utilized at the discretion of the surgeon. An overview of the techniques for laparoscopic surgery is reviewed elsewhere. (See "Abdominal access techniques used in laparoscopic surgery".)

Staging procedure

One- versus two-stage approach — There are two approaches to utilizing DSL. The first is to perform DSL as the sole intended procedure. The advantage of this approach includes identifying patients who may be more appropriately treated with chemotherapy or radiation therapy as the first cancer treatment. The disadvantage is that a second procedure will be required for the definitive cancer operation.

The second approach involves performing DSL first, in the same setting where the definitive cancer operation will be performed if no unresectable and/or distant disease is identified. The advantage of this approach includes there being only one operative setting with one anesthetic administration. The disadvantages include the possible uncertainty of a frozen section report on a biopsy, need for final pathology to confirm a suspicious finding, and operating room time scheduling.

A two-stage approach is common for esophagogastric junction (EGJ) cancer and gastric cancer, while a one-stage approach is typically used for hepatopancreatobiliary cancers [2].

Exploratory principles — Laparoscopic exploration should be performed in an orderly fashion, evaluating for distant, regional, and local disease as follows:

●After obtaining access into the peritoneal cavity, a generalized exploration of the peritoneal surfaces of the abdominal cavity is performed. An angled 30° or 45° laparoscope will aid in evaluation of surfaces in the pelvis, colic gutters, and the initial survey of the surface of the liver. (See "Instruments and devices used in laparoscopic surgery" and "Imaging studies after bariatric surgery".)

●A thorough assessment of the local and regional sites should be performed next. For example, the gastrocolic ligament is divided in order to obtain entry into the lesser sac for evaluation of primary pancreatic and gastric malignancies. Abnormal lymphadenopathy should be adequately sampled via the laparoscope. A single suspicious lymph node should be resected in its entirety if technically possible.

●Finally, a complete evaluation of the liver surface is performed using a combination of altered patient positioning and offsetting the angled laparoscope. Intraoperative laparoscopic ultrasound of the liver can be performed expeditiously to aid in identification of metastatic disease (see 'Laparoscopic ultrasound' below). Alteration in patient positioning and port placement will assist with the ultrasound evaluation. (See "Instruments and devices used in laparoscopic surgery" and "Imaging studies after bariatric surgery".)

●For any patient with a suspicion for metastatic or otherwise unresectable disease that cannot be confirmed with laparoscopy, conversion to an open laparotomy should be performed.

Peritoneal washing — In patients with ascites, fluid is sampled for cytologic analysis. Peritoneal washing in patients with digestive malignancy without ascites is typically not performed, except for patients with EGJ cancers or gastric cancers [4,5]. Peritoneal washing is performed before any biopsy is taken. (See 'Esophagogastric junction and gastric cancer' below.)

Biopsies — Biopsies are performed on suspicious lesions. If DSL is performed immediately before the planned definitive resection, a frozen section is obtained. Otherwise, the biopsy tissue is submitted for a final histologic evaluation.

Minimizing the use of electrocautery at the time of the biopsy will minimize thermal artifact effect. Laparoscopic graspers, cup biopsy forceps, and/or scissors can be used to aid in sampling of tissue. If metastatic disease is confirmed on the frozen section and no palliative procedure is indicated, the operation is concluded.

If the frozen section results are uncertain, ideally, histologic confirmation with permanent hematoxylin and eosin staining of tissue or other special stains will be obtained, as needed, before proceeding with a definitive operative procedure. For those patients with inconclusive results from laparoscopic biopsies, several options are available, including a second pathologist evaluation, repeat laparoscopy, or proceeding to an open laparotomy with the intent for treatment if no metastatic disease is subsequently identified.

Laparoscopic ultrasound — Laparoscopic ultrasound (LUS) serves as an adjunct to preoperative radiographic imaging studies and DSL for staging of select cancers. The utility of LUS may be in identifying patients who are not candidates for a primary resection, because of misdiagnosis or misinterpretation of radiographic imaging.

We suggest performing LUS with DSL for planning a resection of primary and metastatic liver cancer. LUS can correctly identify unresectable disease and prevent unnecessary laparotomy in about one-third of patients with both primary and secondary hepatic malignancies [6]. (See 'Liver cancer' below.)

Risks and complications — There are few additional risks associated with DSL other than the general risks of laparoscopy. (See "Complications of laparoscopic surgery".)

Morbidity and mortality — The overall morbidity and mortality rates of DSL for patients with primary digestive cancers are low in comparison with an open laparotomy. The morbidity associated with DSL for esophageal, gastric, and pancreatic cancer patients ranges from 0 to 2.5 percent [7,8], while no mortality was related to DSL. In comparison, the operative morbidity and mortality rates of a diagnostic laparotomy for patients with unresectable gastric cancer range from 13 to 23 percent and 10 to 21 percent, respectively [9-11]. Therefore, DSL can be performed safely to identify patients who are candidates for a primary resection and permit the rest to recover quickly before the initiation of systemic therapy [12,13].

Port site tumor implantation — Port site tumor implantation following laparoscopic intervention for upper gastrointestinal malignancy is less than 1 percent, with a median time to occurrence of eight months [14]. In a review of 1650 procedures, almost all patients who developed a port site recurrence also had developed a local recurrence and/or distant disease [15]. The contemporary risk of port site implantation is comparable to that of a laparotomy incision as the site of tumor implantation. (See "Complications of laparoscopic surgery", section on 'Trocar site metastasis'.)

Approaches suggested to reduce the risk of port site implantation include [16]:

●Place trocars perpendicular to the peritoneum

●Prevent carbon dioxide leakage around trocars

●Minimize handling of tumor tissue

●Protect extraction sites

●Bag specimens intra-abdominally to avoid spillage

●Remove entire lesion rather than an excisional biopsy if possible

●Drain the peritoneal cavity before deflating

●Deflate the abdomen with trocars in place

●Close the fascia of the trocar port site while avoiding liquid spillage into the wound

DIAGNOSTIC YIELD FOR SPECIFIC DIGESTIVE SYSTEM CANCERS — Conventional imaging studies (eg, MRI, CT scan) often understage the intra-abdominal extent of cancer [1]. In the setting of a negative high-quality radiographic preoperative evaluation, diagnostic staging laparoscopy (DSL) performed prior to a planned major resection may spare the patient an unnecessary laparotomy and decrease the time to chemotherapy or radiation therapy.

The accuracy of DSL is defined as the number of unresectable patients detected by DSL divided by the total number of unresectable cases [17]. Yield is defined as the number of unresectable patients detected by DSL divided by the total number of patients undergoing DSL [17]. The yield and/or accuracy of DSL for primary digestive cancers are illustrated by the following disease-specific examples.

Esophagogastric junction and gastric cancer — For patients with esophagogastric junction (EGJ) cancer of any stage or gastric cancer that is beyond T1 stage, we suggest routine DSL with peritoneal washing before open resection or neoadjuvant chemotherapy. Our suggestion is consistent with guidelines from the National Comprehensive Cancer Network (NCCN) [18] and the European Organisation for Research and Treatment of Cancer [19]. Despite such endorsements, DSL is underutilized for EGJ and gastric cancers [20,21].

Patients with adenocarcinoma arising from the intra-abdominal segment (ie, Siewert type II or III) (figure 1) and those with locally advanced gastric cancer are particularly prone to developing intraperitoneal metastasis. Intraperitoneal metastases are notoriously difficult to diagnose noninvasively by either CT or positron emission tomography (PET) [22,23]. In a prospective study, DSL outperformed PET scans in detecting occult peritoneal metastasis which changed treatment intent (19 versus 3 percent) [24].

Laparoscopy, while more invasive than CT or endoscopic ultrasound (EUS), has the advantage of directly visualizing the liver surface, peritoneum, and local lymph nodes. A substantial proportion of patients who have disease that is beyond T1 stage on EUS will be found to have peritoneal metastases despite having a negative CT or MRI scan. Peritoneal disease is detected in 43 to 52 percent of patients from the Japanese series and 7.8 to 40 percent of patients in studies from other countries [25,26]. In multiple cohort studies, DSL for EGJ and gastric cancers demonstrated a high accuracy of 93 to 95 percent [8,27].

Another advantage to laparoscopy is the opportunity to perform peritoneal washing in patients who have no visible evidence of peritoneal spread. In most series, a positive peritoneal cytology is a poor prognostic sign, even in the absence of overt peritoneal dissemination, and predicts for early peritoneal relapse and dismal prognosis [28,29]. Adding peritoneal washing to DSL further enhances its yield in detecting occult metastatic diseases [4,30]. After completion of neoadjuvant therapy for cytologic but not macroscopic metastatic disease, we repeat DSL before attempting any open resection [25,31].

We routinely obtain peritoneal washings during DSL in patients who lack visible peritoneal disease and refer patients with positive cytology in the absence of other evidence of metastatic disease for neoadjuvant approaches. To obtain washings, we generally infuse 200 cc of saline and collect the aspirate using a Lukens trap at each site. We send washing samples separately from the right upper quadrant, left upper quadrant, and pelvis. Immunohistochemistry stains can be applied to cytologic specimens for better sensitivity to detect malignant cells. (See "Surgical management of invasive gastric cancer", section on 'Neoadjuvant chemotherapy and chemoradiotherapy'.)

Risk factors associated with detecting peritoneal metastasis on DSL include T4 stage, N+ stage, poor differentiation, Borrmann type IV, high CA125, and large tumor diameter [32]. When large tumors (T3 or T4) only are considered, the diagnostic accuracy increases. In those with advanced (T4) primary tumors or a linitis plastica appearance, performance of a diagnostic laparoscopy may alter management (typically by avoiding an unnecessary laparotomy) in up to one-half of patients [33,34].

Some experts suggest that all patients with EUS stage T3/T4 disease undergo staging laparoscopy, but not those with earlier-stage disease [35]. However, we believe it can sometimes be difficult to differentiate T2 and T3 lesions on EUS, and up to 10 percent of patients with T2 disease may have peritoneal metastasis [36]. Thus, our practice is to use preoperative staging laparoscopy for any medically fit patient who appears to have more than a T1 lesion on EUS, no histologic confirmation of stage IV disease, and who would not otherwise require a palliative gastrectomy because of symptoms. Diagnostic laparoscopy is especially important for patients who are being considered for neoadjuvant therapy trials [3,37].

DSL is not routinely indicated for patients with proximal or middle esophageal cancer. A review of 195 patients with esophageal cancer, including proximal, middle, middle and distal, and distal esophageal cancer locations, found that the DSL altered treatment plans in 29 patients (15 percent) [38]. No patient with a proximal or middle esophageal cancer had unresectable or treatment-altering disease identified. However, 17 percent of patients with a distal esophageal cancer had regional or metastatic disease identified, which altered the initial treatment plan.

Many patients with gastric cancer present with bleeding or obstruction and require, at the minimum, a palliative procedure. For those with obstructive symptoms only, endoscopic stenting in conjunction with DSL can be used to provide appropriate palliation and diagnosis and spare patients an unnecessary laparotomy, unless image-guided percutaneous biopsy can be performed in lieu of DSL to establish a cancer diagnosis. Alternatively, a DSL can be performed with a laparoscopic gastrojejunostomy as a surgical palliation [39]. (See "Enteral stents for the palliation of malignant gastroduodenal obstruction".)

The diagnosis, staging, and accuracy of radiographic imaging are discussed elsewhere. Refer to individual topic reviews for treatment of gastric cancer based on the stage of disease. (See "Clinical features, diagnosis, and staging of gastric cancer" and "Clinical manifestations, diagnosis, and staging of esophageal cancer" and "Radiation therapy, chemoradiotherapy, neoadjuvant approaches, and postoperative adjuvant therapy for localized cancers of the esophagus".)

Pancreatic cancer — For pancreatic cancer, we perform DSL selectively in those who have a large tumor (>3 cm) or high tumor marker (eg, CA19-9 >150 U/mL). However, the criteria of DSL for pancreatic and periampullary cancer are controversial. Other experts may reasonably choose to perform or omit DSL based on the location of the tumor.

Pancreatic cancers are described by their location in the organ (ie, head, body, tail). Periampullary (peripancreatic) cancers include the ducts of the head and uncinate process of the pancreas, ampulla of Vater, distal common bile duct, and the duodenum. Many studies evaluating the yield of DSL have not differentiated pancreatic from nonpancreatic periampullary cancers [2,40,41].

Assessment of the regional extent of retroperitoneal disease by conventional radiographic imaging is limited. Meta-analyses found that 20 percent (range 14 to 38 percent) of patients with resectable diseases and 36 percent of those with locally advanced diseases could have avoided an open laparotomy if they had undergone a DSL following CT imaging [42,43]. A 2023 study of over 1000 patients showed a positive DSL rate of 18 percent [44]. Risk factors included age <60, indeterminate extrapancreatic lesions on preoperative imaging, body/tail tumor location, larger tumor size, and elevated serum CA 19-9.

However, DSL may not be beneficial for every patient with a suspected pancreatic or periampullary malignancy staged with increasingly higher-quality radiographic imaging [45].

●Consensus among experts advocates for performing DSL selectively prior to pancreatic resection, such as in patients with tumor ≥3 cm or with CA19-9 >150 U/mL [46,47].

●Evidence suggests that patients with cancers of the body or tail of the pancreas are more likely to benefit from DSL than those with a pancreatic head cancer. DSL identified occult disease 2.6 to 5 times as frequently with cancers in the pancreatic body or tail compared with cancers in the pancreatic head [48,49]. Current thinking is that tumors of the body and tail of the pancreas are asymptomatic for a longer period of time than cancers of the pancreatic head so that they are diagnosed at a later stage when peritoneal spread is more likely [50].

●There appears to be little advantage of performing DSL for periampullary cancers [51-57]. Unnecessary laparotomy was avoided in only 2.3 percent of patients with nonpancreatic periampullary cancer, compared with 35 percent for patients with cancer in the body and tail of the pancreas [57]. The reasons for this finding are unclear.

The diagnosis and staging of pancreatic cancer are discussed elsewhere. Refer to individual topic reviews for treatment of pancreatic cancer based on stage of disease. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer".)

The diagnosis and treatment of periampullary cancer are discussed elsewhere. (See "Ampullary carcinoma: Epidemiology, clinical manifestations, diagnosis and staging" and "Ampullary carcinoma: Treatment and prognosis".)

Biliary tract cancer — Biliary tract cancers include cholangiocarcinoma and gallbladder cancer. We suggest routine DSL for patients with gallbladder cancer, selective DSL for patients with cholangiocarcinoma of the proximal bile duct (intrahepatic and hilar), but no DSL for those with distal biliary cancers.

Gallbladder cancer — DSL prevents nontherapeutic laparotomy in 38 to 62 percent of gallbladder cancer patients [58]. Simple DSL can detect unresectable disease in up to 23 percent of patients, and the yield is further increased by adding laparoscopic ultrasound and laparoscopic lymph node biopsy [59]. Given the propensity for gallbladder cancer to spread to lymph nodes and peritoneal surfaces, experts recommend routine DSL for all patients suspected or proven to have gallbladder cancer prior to attempting open radical resection [40,60-62].

The diagnosis, staging, and treatment of biliary tract cancers, including cholangiocarcinoma and gallbladder cancer, are discussed elsewhere. (See "Gallbladder cancer: Epidemiology, risk factors, clinical features, and diagnosis" and "Surgical management of gallbladder cancer".)

Cholangiocarcinoma — Cholangiocarcinoma can arise anywhere along the biliary tree, including intrahepatic, hilar, and distal cholangiocarcinoma.

●For patients with intrahepatic cholangiocarcinoma, DSL detects unresectable disease in 20 to 36 percent of those with radiographically resectable disease [58,63,64]. Thus, expert consensus opinion recommends selective DSL in high-risk patients with elevated CA 19-9 levels or preoperative imaging demonstrating multicentric hepatic lesions, questionable vascular invasion, or extrahepatic metastasis [65].

●For patients with hilar cholangiocarcinoma, DSL detects unresectable disease in 24 percent (range 6 to 45 percent) of patients who are radiographically resectable [63,66,67]. Local invasion of hilar structures is a main determinant of resectability in hilar cholangiocarcinoma, which is not usually identified during DSL. Thus, an expert consensus opinion recommends selective DSL in high-risk patients [68]. Tumor size >4.5 cm, bilateral portal vein or main portal vein tumor involvement, and suspected lymph node or extrahepatic metastases were identified as risk factors that predicted positive findings on DSL [69].

●Distal cholangiocarcinoma is treated like periampullary cancer for which DSL is not performed. (See 'Pancreatic cancer' above.)

The diagnosis, staging, and treatment of cholangiocarcinoma are discussed elsewhere. (See "Clinical manifestations and diagnosis of cholangiocarcinoma" and "Systemic therapy for advanced cholangiocarcinoma" and "Adjuvant and neoadjuvant therapy for localized cholangiocarcinoma".)

Liver cancer — We suggest selective DSL with laparoscopic ultrasound in patients undergoing open resection for colorectal liver metastasis (CRLM), but no DSL for hepatocellular carcinoma (HCC).

Colorectal liver metastasis — Although the overall yield of DSL for CRLM resection is low [63], selected patients may benefit from it [70]. DSL is more likely to detect unresectable disease in patients with a disease-free interval <1 year, >1 CRLM, CRLM >5 cm, lymph node positive primary tumor, and carcinoembryonic antigen >200 ng/mL [71]. In patients who meet two or more of these criteria, more than a third were found to have unresectable disease on DSL [72-74]. Thus, DSL should be used selectively before open CRLM resection in those at high risk for occult metastasis.

The diagnosis, staging, and surgical management of CRLM are reviewed elsewhere. (See "Potentially resectable colorectal cancer liver metastases: Integration of surgery and chemotherapy" and "Hepatic resection for colorectal cancer liver metastasis".)

Hepatocellular carcinoma — Despite a reasonable early yield of 16 to 36 percent [63,75], increasingly sophisticated imaging has rendered DSL unnecessary for HCC. In a contemporary study of 56 patients, the yield of DSL was only 7 percent [76].

The diagnosis, staging, and surgical management of HCC are reviewed elsewhere. (See "Clinical features and diagnosis of hepatocellular carcinoma" and "Staging and prognostic factors in hepatocellular carcinoma" and "Surgical resection of hepatocellular carcinoma".)

Colon or rectal cancer — DSL is used infrequently in patients with colon or rectal cancer, as resection is increasingly carried out laparoscopically or robotically, and removal of the primary lesion is necessary in most patients to control or avoid bleeding, obstruction, and/or perforation of the colon [1]. DSL may be used selectively before open resection of CRLM. (See 'Colorectal liver metastasis' above.)

The diagnosis, staging, and surgical management of colon cancer and rectal cancers are reviewed elsewhere. (See "Clinical presentation, diagnosis, and staging of colorectal cancer" and "Overview of the management of primary colon cancer" and "Surgical treatment of rectal cancer".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Diagnostic laparoscopy" and "Society guideline links: Laparoscopic and robotic surgery" and "Society guideline links: Pancreatic cancer".)

SUMMARY AND RECOMMENDATIONS

●Role of DSL – The role of diagnostic staging laparoscopy (DSL) prior to a planned definitive resection of a digestive cancer is to determine the feasibility of the proposed cancer operation. DSL is performed to identify any local, regional, and/or metastatic disease that would preclude an attempt at an intended curative surgical procedure. (See 'Indications' above and 'Contraindications' above.)

●DSL procedure – The DSL procedure should be performed in an orderly fashion, carefully assessing for occult local, regional, and distant sites of disease. We perform a biopsy for suspicious lesions and cytology in the presence of ascites; peritoneal washing is added for esophagogastric junction (EGJ) and gastric cancer; laparoscopic ultrasound is added for primary to secondary liver tumors. (See 'Staging procedure' above.)

●DSL for esophageal or gastric cancer – (See 'Esophagogastric junction and gastric cancer' above.)

•For EGJ cancer of any stage or gastric cancer that is beyond T1 stage, we routinely perform DSL with peritoneal washing before open resection or neoadjuvant chemotherapy.

•We do not perform DSL for proximal or midesophageal tumors or early gastric cancer.

●DSL for pancreatic cancer – We perform DSL selectively in those who have a large pancreatic cancer (≥3 cm) or high tumor marker (eg, CA19-9 >150 U/mL). However, the criteria of DSL for pancreatic and periampullary cancer are controversial. Other experts may reasonably choose to perform or omit DSL based on the location of the tumor. (See 'Pancreatic cancer' above.)

●DSL for biliary tract cancer – (See 'Biliary tract cancer' above.)

•We routinely perform DSL for gallbladder cancer.

•For intrahepatic or hilar cholangiocarcinoma, we perform DSL selectively for tumor >4.5 cm, bilateral portal vein or main portal vein tumor involvement, and suspected lymph node or extrahepatic metastases.

•We do not perform DSL for distal biliary cancers.

●DSL for liver cancer – (See 'Liver cancer' above.)

•For patients undergoing open resection for colorectal liver metastasis (CRLM), we perform DSL with laparoscopic ultrasound selectively in patients who have a disease-free interval <1 year, >1 CRLM, CRLM >5 cm, lymph node positive primary tumor, or carcinoembryonic antigen >200 ng/mL.

•We do not perform DSL for hepatocellular carcinoma (HCC).