174 J can chir, Vol. 53, No3, juin 2010
RECHERCHE
distant metastasis and tumour resectability.2,3,7 Endoscopic
ultrasound has the highest accuracy in assessing lymph
node involvement.2For determining resectability, previous
meta-analyses have shown that CT and MRI each have a
sensitivity of 82%.3All of the patients in our study had a
preoperative CT, with a sensitivity of 79%. Resectability
was more accurately predicted in patients who had EUS in
addition to a CT scan (83% sensitivity). Others have found
the best algorithm involving these techniques to be CT or
EUS as an initial test followed by the alternate technique
for patients with potentially resectable disease.2Whereas
the highest sensitivity in our study was with a combination
of CT, EUS and MRI (86%), there was a wide confidence
interval. In addition, the lowest sensitivity was in the CT
and MRI group.
Staging laparoscopy has been suggested as a modality to
identify unresectable disease for patients in whom ad-
vanced disease is suspected despite imaging findings to the
contrary. Laparoscopy has been suggested to prevent
10%–44% of patients from having an unnecessary laparo-
tomy by identifying those with unresectable disease not
identified by imaging.4,8,9 Laparoscopy has the advantage of
identifying small peritoneal and hepatic lesions not identi-
fied by noninvasive imaging.9In our study, the 9 patients
with metastatic disease at the time of surgery could have
been spared laparotomy if staging laparoscopy had been
performed. The 14 patients with locally advanced disease
could also have potentially been identified by staging
laparoscopy. Laparoscopy has been suggested to be most
beneficial in patients with presumed adenocarcinoma,
compared with pancreatic neoplasms of other histologies.9
Liver metastasis and peritoneal seeding were 2 of the most
common reasons for unresectability in the present study.
Only 1 staging laparoscopy was performed, and the patient
was spared an unnecessary laparotomy. The low rate of
staging laparoscopy likely has multiple causes. Many sur-
geons are reluctant to use operative time for staging
laparoscopy. There is also likely a perception of inflated
accuracy with cross-sectional imaging. Because the techni-
cal skills for this method of staging exist in our institution
and this study suggests its utility, perhaps staging lapa-
roscopy will be a way to decrease the rate of unresectable
disease found during surgery.
Techniques such as metal stenting of the bile duct and
duodenal stenting are available as effective palliation for
unresectable or metastatic cancer of the pancreatic head.1,10
By better identifying the patients most likely to benefit
from surgery, patients with metastatic or unresectable dis-
ease can be spared the risk associated with surgery and be
directed to safe, durable, less invasive palliation. This will
not only improve patient care but will also allow better use
of precious operating room time.
This study has shown that there is a high rate of unre-
sectable disease found at the time of laparotomy in patients
with cancer of the pancreatic head in our institution. With
the increasing availability of novel minimally invasive palli-
ation, laparotomy should be reserved for patients for
whom curative resection is planned. There may be a role
for prospectively evaluating newer technologies or devel-
oping staging protocols to allow better use of operating
room resources and help identify patients who have the
greatest likelihood of potentially curative resection.
Competing interests: None declared.
Contributors: All authors designed the study, analyzed the data,
reviewed the article and approved its publication. Dr. Croome acquired
the data and wrote the article.
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