Evaluation of Abdominal Malignancies by Minimal Access Surgery: Our Experience in a Rural Setup in Central India

INTRODUCTION

A proper diagnosis, pretherapeutic staging for assessment of resectability in abdominal malignancy, is important to select the patient for appropriate treatment strategies. Identifying tumors that are not surgically resectable is the most important issue at hand. Performing laparotomies in patients with nonresectable abdominal tumors may increase mortality and morbidity, and cost as well as affect quality of life in the remaining lifetime.¹

The magnified view offered by the laparoscope enables the surgeon to detect small liver, peritoneal, and omental metastases that are not visible with current noninvasive imaging modalities.

If the distance between the tip of the telescope and object is 5 cm, we get a six times magnification. If it is 15 cm, the magnification is 2.2 times, and if it is 33 cm, we can see the same size object.²

If laparoscopic findings result in an unresectable disease, then further management can be planned, such as neoadjuvant chemotherapy, radiotherapy, etc. Laparoscopy can give a tissue diagnosis and include a biopsy where the definitive treatment or surgery is not possible. Obtaining biopsies of organs, lymph nodes, and suspicious lesions during laparoscopy is an important part of the diagnosis and staging of malignancies.

Thus, it is recommended that diagnostic laparoscopy for staging of abdominal malignancy be performed in cases where resectability is doubtful in spite of preoperative imaging, or at the time of planned laparotomy.³

Many authors have stressed the importance of laparoscopic ultrasonography during diagnostic laparoscopy for abdominal malignancy. Ultrasonography during laparoscopy gives the surgeon information that otherwise would not be obtained from laparoscopic visual exploration. Lesions deep in the parenchyma of an organ, especially solid organs such as the liver and pancreas, can be identified by ultrasonography. Invasion of a tumor into other structures, such as major vessels, can also be evaluated, thus determining that the tumor is not resectable in a patient who otherwise might undergo laparotomy.³

Since the introduction of laparoscopic staging, lavage of the peritoneal cavity has been added to the procedure. Free cancer cells found in the peritoneal lavage fluid are thought to induce or indicate early peritoneal seedling with subsequent peritoneal metastases.

Diagnostic laparoscopy can be beneficial to the patient in avoiding unnecessary surgery, unnecessary delay in diagnosis and treatment, and in shortening the operative and hospitalized periods. The usefulness and efficacy of laparoscopy as a preoperative tool in the management of intra-abdominal malignancy for diagnosis, evaluation, staging, and therapeutic assessment are the areas which need appraisal and analysis to standardize the procedure and bring into a more frequent use.

This study explores the applications of laparoscopy with imaging studies in staging and diagnosis of abdominal malignancy and its advantages over only imaging studies and conventional laparotomy, and it seeks to suggest implementation of a defined protocol in mandating diagnostic laparoscopy as a necessary diagnostic tool before an explorative laparotomy.

AIM AND OBJECTIVES

To assess the role of diagnostic staging laparoscopy in abdominal malignancies. To evaluate the role of laparoscopy as a diagnostic tool in abdominal malignancies. To compare the findings of laparoscopy with noninvasive imaging modalities and assess the efficacy of laparoscopy as a definitive tool in the evaluation of staging and operability before definitive intervention.

MATERIALS AND METHODS

This study was a prospective observational study. The study was conducted in the Department of Surgery, AVBRH, Sawangi (Meghe), Wardha. The sample size taken was 250. It was calculated according to the formula stated below:

n = sample size, Z = standard normal distribution = 1.96, P = expected beneficial population = 20%, d = absolute precision = 5% points (15%–25%), and N = (1.96 × 1.96) × 0.2 × (0.8)/(0.05 × 0.05) = 245.86 = 246

The ethical committee clearance was taken. The duration of the study was 3.5 years (July 2013–October 2016).

OBSERVATIONS AND RESULTS

This prospective study was carried out from July 2013 till October 2016. A total of 250 patients with abdominal malignancies were enrolled in the study. The observations have been shown in the form of charts and tables for ease of understanding as follows. Most of the cases were of colorectal malignancies followed by gastric malignancy. The mean age of presentation was 52 years, with a range between 16 years and 80 years. In our study, out of 250 patients, 175 (70%) were males and 75 (30%) were females. Among 250 patients, all patients presented with loss of appetite and weight, 204 (81.6%) presented with pain in abdomen, 124 (49.6%) with lump in abdomen, 110 (44%) with vomiting, 52 (20.8%) with jaundice, 91 (36.4%) with Malena, 79 (31.6%) with hematochezia, and 98 (39.2%) with altered bowel habits (Fig. 1).

The distribution of abdominal malignancies based on the type of cancer was as follows. Out of 250 patients, 105 (42%) patients were of colorectal malignancy, 67 (26.8%) patients were of carcinoma stomach, 23 (9.2%) patients were of biliary tract tumors, 9 (3.6%) patients were of hepatocellular carcinoma (HCC), 7 (2.8%) patients were of periampullary carcinoma, 19 (7.6%) patients were of carcinoma head of pancreas, and 9 (3.6%) patients were of ovarian malignancy. Six (2.4%) patients had presentation of metastatic disease with unknown primary. In these six cases, with the help of radiology, through endoscopic evaluation and tumor markers, tissue diagnosis could not be obtained, and the source of primary could not be detected. Out of five (2%) patients in other groups, one had duodenal malignancy, one had jejunal malignancy, one had ileal malignancy, and two cases were of undescended testis (abdominal) harboring malignancy. Out of 105 cases of colorectal malignancies, 54 (22%) cases were of carcinoma colon, including carcinoma appendix and caecum and 51 (20.4%) cases were of rectal malignancy. Out of 23 cases of biliary tract tumors, 15 (6%) cases were of gall bladder carcinoma, and 8 (3.2%) cases were of cholangiocarcinoma (Fig. 2).

The distribution of abdominal malignancies based on the radiological stage of the cancer was as follows. Out of 250 patients, 30 (12%) patients were in stage I, 122 (48.8%) patients were in stage II, 92 (36.8.8%) patients were in stage III, and 6 (2.4%) patients were in stage IV (Fig. 3).

The distribution of abdominal malignancies according to the stage of the cancer based on laparoscopy was as follows. Out of 250 patients, 12 (4.8%) patients were in stage I, 69 (27.6%) patients were in stage II, 77 (30.8%) patients were in stage III, and the remaining most of the patients were in stage IV, i.e., 92 (36.8%) (Table 1).

After comparing radiological and laparoscopic staging, after diagnostic laparoscopy, a considerable number of cases getting diagnosed at stage IV as the p value is quite significant. The sensitivity of diagnostic laparoscopy in the overall abdominal malignancy is 93.88%, specificity 54.44%, and diagnostic accuracy 68.91%. After comparing radiological and laparoscopic staging, 34.4% of cases were diagnosed as metastatic disease (stage IV) by diagnostic laparoscopy, which was understated by radiological imaging (Table 2).

Operability is with regard to the patient. If a malignant disease can be cured with a radical surgery, such a patient is said to be operable. If one cannot cure a malignant disease by a surgical procedure, it is called inoperable. Resectability is with regard to the tumor. A lesion or tumor is said to be unresectable if there is local fixity or neural/vascular encasement. In our study, the reason for unresectability was local tumor fixity to adjacent structures and neural/vascular encasement. Out of 105 patients of colorectal malignancies, 31 (29.52%) patients were unresectable. 10 patients underwent palliative colostomy/diversion procedures, followed by chemotherapy. Rest of the patients were subjected to chemotherapy directly. Out of 67 patients of carcinoma stomach, 40 (59.70%) patients were unresectable, and a palliative bypass was done in four patients. Rest of the patients were subjected to chemotherapy. Out of 23 cases of biliary tract tumors, 15 patients were of gall bladder malignancies, and all patients were unresectable. In gall bladder cancers, no further palliative procedure was done. All were subjected to chemotherapy. Out of eight cases of cholangiocarcinoma, two cases were subjected to biliary stenting, and six cases were subjected to percutaneous transhepatic biliary drainage (PTBD). Out of 19 patients of pancreatic malignancies, 16 (84.21%) patients were unresectable. One patient underwent palliative triple bypass procedure, and rest were subjected to chemotherapy. Out of nine patients ofHCC, 9 (100%) patients were unresectable. Out of seven patients of periampullary malignancies, six (85.7%) patients were unresectable. Two cases were subjected to biliary stenting, and four were subjected toPTBD. Out of nine cases of ovarian malignancies, 7 (77.77%) cases were unresectable and were subjected to chemotherapy. Out of five cases, in the miscellaneous group, palliative bypass procedure (gastrojejunostomy) was done for duodenal malignancy. As the total number of patients in stage III and IV were 169, of which, 77 were of stage III of which 24 were of colorectal and 22 were of gastric malignancy. Of the two malignancies in stage III, 19 patients of colorectal malignancy were resectable, and 11 of gastric malignancies were resectable being Stage IIIA—T3N1M0 disease (Tables 3 and 4).

In our study, a total of 139 patients were unresectable. The reason for unresectability was more than one of the above-mentioned causes in the same patient, i.e., a single patient can have liver metastasis with local fixity with peritoneal metastasis (Table 5).

Due to the use of diagnostic laparoscopy, out of 250 cases of abdominal malignancies, in 120 (48%) patients, nontherapeutic laparotomy could be prevented. In the rest of the unresectable patients, 19 patients were subjected to laparotomy for bypass procedures.

DISCUSSION

CONCLUSION

This study highlights the emphatic utility of diagnostic laparoscopy procedures in staging and management of abdominal malignancy. Laparoscopic evaluation of a patient with intra-abdominal malignancies is a desirable tool against imaging modalities in improving the detection of metastatic disease and accurate staging of the disease process.

LIMITATIONS OF STUDY

Long-term follow-up of patients could not be done.

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