Pretherapeutic laparoscopic staging in advanced gastric carcinoma

Background and Study Aims: Direct visualization of the abdominal cavity by laparoscopy prior to multimodal treatment may be capable of improving the diagnostic precision of gastric cancer staging. The aim of this study was to evaluate whether diagnostic laparoscopy can influence treatment strategies in gastric cancer staged T3 and T4 by preoperative diagnostic tests. Patients and Methods: Extended diagnostic laparoscopy (EDL) was carried out in 111 patients with advanced gastric cancer staged T3 or T4 by computed tomography (CT) and endoluminal ultrasound (EUS). On Lauren's classification of gastric cancer, 46 % of the lesions were of the intestinal type and 54 % of the nonintestinal type. EDL was carried out with the patients under general anesthesia, and included visual inspection of the abdomen, with surgical exploration of initially inaccessible regions, laparoscopic ultrasound examination, peritoneal lavage, and biopsies. The information provided by laparoscopy was classified as 1) no additional information, 2) important additional findings independent of the tumor stage, 3) downgrading of the tumor to a more favorable stage, and 4) upgrading of the tumor to a less favorable stage. The results of EDL were then compared with those obtained by sonography, CT and EUS in combination. Results: EDL was performed successfully in 107 patients. In 56 of the 111 patients (50.5 %), no additional findings were obtained. In 5.4 % of cases, additional unforeseen information was found, not connected with the tumor but altering the management. EDL altered the preoperative diagnosis in 51 of the 111 patients (46.0 %), leading to changes in management in 45 of them (40.5 %). EUS provided additional information in eight cases (7.2 % of the whole group, or 15.7 % of those in whom the diagnosis had to be changed). Four metastases were detected using EDL. It was possible to rule out peritoneal spread in four patients, but it was newly detected in 26. Conclusions: Additional information by EDL about the tumor stage in gastric cancer led to a modification of the therapeutic strategy in 40 % of patients, in spite of earlier comprehensive diagnostic work-up using modern imaging procedures. EDL should therefore be mandatory if neoadjuvant treatment is planned, in order to avoid either undertreatment or overtreatment of this type of tumor.