Pancreatic Head Mass: What Can Be Done?
Diagnosis: Laparoscopy

Tibor Belágyi, Attila Oláh

Petz Aladár Teaching County Hospital. Gyõr, Hungary

 

 

History. The first report of laparoscopy in America was published in 1911 by Bertram M. Bernheim of Jonhs Hopkins University. Using a rigid cystoscope the abdomen was explored for metastatic disease. The first series of laparoscopic investigations for pancreatic cancer was presented by Cushieri in 1978. Laparoscopy was used to diagnose and stage pancreatic cancer. In this way they could avoid a significant number of laparotomies in cases, when surgical palliation was not necessary.

 

Imaging procedures. The sensitivity and specificity of imaging modalities are elevated, but they are unable to provide precise information on the nature of pancreatic head mass. They are unsatisfactory and in some cases, not precise differentiating between a benign and a malignant lesion and in the evaluation of resectability.

 

Laparoscopy. I tried to summarize the benefits of laparoscopy and to evaluate its role in diagnosis, histologic confirmation, staging and in certain situations in the treatment of pancreatic head masses.

 

Diagnosis. Laparoscopy enables us to examine the serosal surfaces of abdominal organs. We can insufflate and enter the lesser sac and mobilize the head of the pancreas. Anatomic survey of the liver, biliary tree, pancreas and peripancreatic structures is mandatory. Particular attention is directed toward the pelvis, as it is often the site of the earliest metastatic disease. However, by itself it does not address the dilemma of differentiating between benign and malignant disease.

 

Histologic confirmation. With the use of intraoperative fine-needle aspiration cytology (FNA), tissue biopsy (TB) and peritoneal washings cytology (PWC) we can histologically evaluate the abnormalities. Ingemar Ihse, reported in the Word Journal of Surgery that the sensitivity of FNA and TB is about 90% and their specificity is about 100%. A positive biopsy from the peritoneal surfaces or from the liver proves unresectability.

 

Staging. Staging laparoscopy has been shown to be able to demonstrate previously unsuspected, small-volume intraabdominal metastases, typically in the liver and on the surfaces of the peritoneum. Other evidence for local unresectability is tumor extension into adjacent soft tissue planes, such as mesenteric root, hepatoduodenal ligament, retroperitoneum, or regional lymph node enlargement with histologic confirmation. The sensitivity of laparoscopy for peritoneal metastases is about 89%, the specificity for carcinomatosis is about 100% [Catheline JM, et al. Surgical Endoscopy 1999; 13:239-45].

 

Laparoscopic ultrasonography. Laparoscopic ultrasonography (LUS) has been described to detect metastatic lesions below the capsule of the liver, tumor invasion of the retroperitoneum and the portal vein, and nodal metastatic spread. These findings are the main criteria for determining local unresectability of a pancreatic cancer. The sensitivity of LUS in demonstrating pathologic changes is 96%.

 

Laparoscopy + LUS. Laparoscopy supported by LUS, combines the benefits of a staging laparoscopy with the benefits of an intraoperative ultrasound. LUS enables the detection of previously unsuspected metastases. LUS has all the advantages of EUS and in addition can identify nodal, hepatic and extrahepatic - peritoneal - metastatic spread. The use of intraoperative biopsy should assist in identifying nodal disease.

 

Staging. When predicting tumor resectability laparoscopy with LUS is more specific (88% vs. 50%) and accurate (89% vs. 65%) than laparoscopy alone.

 

Staging (T stage). In the role of staging, the combination of laparoscopy with LUS is more specific for assessing unresectibility (T stage) as compared to US (100% vs. 64%, P<0.05) and CT (100% vs. 47%, P<0.005).

 

Staging (N stage). No imaging investigation is able to assess stage accurately. Nodal enlargement is frequently the result of reactive hyperplasia and smaller nodes may harbour micrometastases. Nodal malignancy requires biopsy confirmation.

 

Staging (M stage). In the M stage, laparoscopy with LUS is significantly more sensitive than US (94% vs. 29%, P<0.001) and CT (94% vs. 33%. P<0.005).

 

Treatment. The role of laparoscopy in the resection of pancreatic head mass is controversial. The technical difficulties of laparoscopic resection will limit its widespread application. Laparoscopy is capable of finding and histologically confirming soft tissue and lymph node metastases, thus, in skillful hands retroperitoneal lymphadenectomy can be performed.

 

Treatment. The main options for palliation are endoscopic or percutaneous biliary stent insertion, or surgical biliary and/or duodenal bypass. Most periampullary lesions develop biliary obstruction and these patients need long-term biliary decompression. Those who are good operative candidates with good physiologic condition and who are expected to survive more than 6 months would benefit from laparoscopic palliation [Westcott CJ et al. World Journal of Surgery 1999; 23:378-83]. But its widespread application will be limited by the technical demands of laparoscopic choledochojejunostomy.

 

Summary I. Because laparoscopy with LUS is the most reliable method for verifying metastatic changes, they reliably predict tumor unresectability. All nonresectable patients could be found with the combination of EUS + LAP + LUS.

 

Summary II. This justifies its mandatory use before laparotomy in patients, with potentially resectable lesions. Laparoscopy with LUS should be considered the first step in any potentially curative surgical procedure.