Staging of pancreatic head adenocarcinoma with spiral CT and endoscopic ultrasonography: an indirect evaluation of the usefulness of laparoscopy.
BACKGROUND
The interest of laparoscopy in the preoperative staging of pancreatic head adenocarcinoma before curative pancreaticoduodenectomy is a matter of controversy and depends on the accuracy of preoperative imaging techniques.


OBJECTIVE
To assess the potential value of laparoscopy when a standardised and optimal preoperative staging is performed, including spiral computed tomography (CT) and endoscopic ultrasonography (EUS).


METHODS
All consecutive patients operated on with a view to curative pancreaticoduodenectomy for pancreatic head or ampullary adenocarcinoma in our centre from January 1998 to August 2000 were retrospectively studied. All of them had preoperative spiral CT and EUS. Tumour resectability was considered as highly probable (HP) or uncertain (U) according to well-defined criteria. Operative records of patients were reviewed to indirectly assess the effective resectability rate and the criteria responsible for unresectability and which of them would have been identified by laparoscopy if initially performed.


RESULTS
69 consecutive patients were studied. Resectability was HP (n = 56) or U (n = 13) after preoperative staging. Curative pancreatoduodenectomy was performed in 53 patients (77%) (48 HP, 5 U). Positive predictive value of preoperative imaging for highly probable resectability was 86% (48/56). Among the 16 unresectable tumours (8 HP, 8 U), the cause of non-resection would have been found at laparoscopy in 9 patients (56%) (6 HP, 3 U). Finally, if initially performed, laparoscopy would have avoided laparotomy in 9/69 patients (13%) (6/56 HP (11%); 3/13 U (23%)).


CONCLUSIONS
With accurate preoperative staging using spiral CT and EUS, laparoscopy would detect tumours which were unresectable in 13% of patients with pancreatic head cancer. Laparoscopy remains useful in selected patients, such as those with preoperative uncertain resectability, in whom it can prevent unnecessary laparotomy in one fourth of patients.
Maire
Frédérique
F
Fédération Médico-Chirurgicale d'Hépato-Gastroentérologie, Hôpital Beaujon, Clichy, France. frederique.maire@bjn.ap-hop-paris.fr
Sauvanet
Alain
A
Trivin
Florence
F
Hammel
Pascal
P
O'Toole
Dermot
D
Palazzo
Laurent
L
Vilgrain
Valérie
V
Belghiti
Jacques
J
Ruszniewski
Philippe
P
Levy
Philippe
P
D000230:Adenocarcinoma / Q000175:diagnosis* / Q000601:surgery; D000328:Adult; D000368:Aged; D019160:Endosonography; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000592:standards*; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000175:diagnosis* / Q000601:surgery; D011300:Preoperative Care; D036542:Tomography, Spiral Computed