Volumen 1 Numero 8 OCTUBRE 2011 BOLETIN ALACE · Volumen 1 Numero 8 Un fenómeno digno de destacar,...

EDITORIAL NOTES: que hemos aprendido?: Eduardo M Targarona Servicio de cirugía Hospital Santpau Universidad Autonoma Barcelona

GUIA DE LECTURA

OCTUBRE 2011 Volumen 1 Numero 8

BOLETIN ALACE

Hace pocos meses se publicó la revisión actualizada del White Paper sobre N.O.T.E.S(1).

Dicho White Paper, publicado por primera vez en 2006(2), es la ‘hoja de ruta’ planteada por

NOSCAR (Natural Orifice Surgery Consortium for Assesment and Research), el consorcio

establecido entre la Sociedad Americana de Cirugía Endoscópica (SAGES) y la Sociedad

Americana de Endoscopia Flexible (ASGE) para coordinar el desarrollo de NOTES. La idea

de NOTES, cuyos primeros casos de cirugía transvaginal (apendicetomía, colecistectomía)

pasaron desapercibidos en manos de ginecólogos (3), no fructificó hasta que el grupo Apollo,

un task force liderado por A. Kalloo y dedicado al desarrollo de la endoscopia flexible no se

lo planteó a finales de los años 90 (4). Sin duda, de forma similar a la primera colecistecto-

mía laparoscópica, presentada por Perissat en un congreso del American College of Surgeons,

que encendió la mecha explosiva de la cirugía laparoscópica en USA, el vídeo de G.V. Rao

and N. Reddy (5) presentando una apendicetomía transgástrica fue también el catalizador que

favoreció la difusión e interés en NOTES.

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NOTES: que hemos aprendido?: Eduardo M Targarona Servicio de cirugía Hospital Santpau Universidad Autonoma Barcelona

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Volumen 1 Numero 8

Hace pocos meses se publicó la revisión actualizada del White Paper sobre N.O.T.E.S(1). Dicho White Paper, publi-cado por primera vez en 2006(2), es la ‘hoja de ruta’ planteada por NOSCAR (Natural Orifice Surgery Consortium for Assesment and Research), el consorcio establecido entre la Sociedad Americana de Cirugía Endoscópica (SAGES) y la Sociedad Americana de Endoscopia Flexible (ASGE) para coordinar el desarrollo de NOTES. La idea de NOTES, cuyos primeros casos de cirugía transvaginal (apendicetomía, colecistectomía) pasaron desapercibidos en manos de ginecólogos (3), no fructificó hasta que el grupo Apollo, un task force liderado por A. Kalloo y dedicado al desarrollo de la endoscopia flexible no se lo planteó a finales de los años 90 (4). Sin duda, de forma similar a la primera colecis-tectomía laparoscópica, presentada por Perissat en un congreso del American College of Surgeons, que encendió la mecha explosiva de la cirugía laparoscópica en USA, el vídeo de G.V. Rao and N. Reddy (5) presentando una apendi-cetomía transgástrica fue también el catalizador que favoreció la difusión e interés en NOTES. En el momento actual muchos cirujanos pueden considerar NOTES como un concepto acabado. Es inevitable decir que las optimistas y tal vez exageradas expectativas iniciales en su aplicación clínica no se han cumplido, pero sin embargo, la forma en que se ha desarrollado en los últimos 6 años así como las posibles perspectivas futuras me-rece una reflexión en el momento actual. NOTES apareció 20 años después del desarrollo desordenado de la cirugía laparoscópica. Además, la percepción inmediata del grupo promotor fue que la aplicación clínica de este concepto podía ser peligrosa y con potenciales im-portantes complicaciones. Desde un punto de vista quirúrgico ‘clásico’, la perforación de la pared del tubo digestivo se entiende como una grave complicación, y lógicamente, la hipótesis de que una perforación controlada para efectuar una intervención a su través es potencialmente beneficiosa conlleva un radical cambio de paradigma lo que indujo en su inicio múltiples y razonables dudas y controversias (6-8). Es por ello que la iniciativa de ambas sociedades (SAGES y ASGE) en la creación de un grupo de interés que intentara ordenar y que además planificara el posible desarrollo de lo que inicialmente era simplemente una idea es digna de valoración y es un modelo de desarrollo pre-viamente no considerado en el mundo de la cirugía mínimamente invasiva en particular y en la comunidad quirúrgica en general. Las recomendaciones de NOSCAR incluían la necesidad de disponer modelos experimentales, trabajar en equipo entre cirujanos y gastroenterólogos y la vez recomendaba que toda actividad clínica o publicación relativa fuera realizada bajo la autorización del comité de investigación del hospital donde se realizaba la intervención. De forma mimética, se establecieron alianzas similares en los diferentes continentes (Euro-NOTES, NOSLA (Latinoamérica), Asia NOTES) e incluso se creó una sociedad específica (EATS, www.eats.org). El primer White Pa-per definía perfectamente los escollos o puntos sobre los que se debía investigar para poder efectuar cualquier pro-cedimiento tipo NOTES (tabla I), y probablemente una de las lecciones aprendidas más interesantes es que todos estos puntos han sido investigados y existe una respuesta objetiva a cada una de las cuestiones planteadas. Así, es posible acceder a través de estómago, vagina o recto a la cavidad peritoneal, es posible navegar por el interior del abdomen, disecar una vesícula o manipular un asa intestinal, y es posible cerrar la viscerotomia de forma segura, sin que este tipo de abordaje incremente o signifique un mayor riego infeccioso (9). A la vez, también durante estos cinco años ha sido posible, de una forma mayoritariamente ordenada y bajo la supervisión de los comités de investigación hospitalarios en la mayoría de los casos, trasladar estas técnicas al ser humano, aunque con un balance menos satis-factorio, habiéndose practicado unos 2000 casos mediante técnicas NOTES en la clínica humana, una cifra mínima si comparamos con el número de colecistectomías laparoscópicas efectuadas en los primeros meses tras su descrip-ción. Ello es consecuencia, y también es otra lección aprendida, de que NOTES es conceptualmente interesante y factible, pero es excepcionalmente complejo y técnicamente demasiado demandante con el instrumental actualmente disponible. Prueba de ello es que la intervención globalmente mejor aceptada y más frecuentemente realizada ha sido la colecistectomía transvaginal, la técnica que es más sencilla desde el punto de vista de acceso y cierre, y además, en la mayoría de las ocasiones se ha llevado a cabo de forma hibrida ante la imposibilidad de efectuarla de forma NO-TES pura por la falta de plataformas estables e instrumental adecuado que permitan a la vez exponer y disecar de forma eficiente (10-13). El registro voluntario de los casos incluidos en bases de datos auditadas por sociedades y grupos con interés también ha permitido conocer la incidencia de complicaciones, y es destacable la baja incidencia de las mismas, cuando se efectuado de forma controlada y estrictamente supervisado por los comités de investiga-ción de los hospitales.


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Un fenómeno digno de destacar, obvia consecuencia de la intuitiva percepción de un mayor riesgo, ha sido la necesi-dad de reevaluar la forma en que se implementa la ‘innovación quirúrgica’ en la práctica clínica. Son bien conocidas las dificultades para llevar a cabo estudios prospectivos y randomizados en cirugía, y por otra parte, la ‘innovación’, entendida como una modificación que potencialmente puede mejorar un procedimiento, es fácilmente llevado a la práctica sin necesidad de una exhausta evaluación previa. La EAES (European Association of Endoscopic Surgery) desarrolló una conferencia de consenso que constituye una lúcida reflexión ante el cambio cada vez más rápido y sin alternativas hacia una cirugía marcadamente tecnológico dependiente (14). Por otra parte, se ha desarrollado el con-cepto IDEAL (15, tabla II) como paradigma del método científico, de forma similar al desarrollo de fármacos, en la evaluación de nuevos procedimientos quirúrgicos. Finalmente, el estudio prospectivo randomizado es la confirmación definitiva de las posibles ventajas de un procedimiento, y en la actualidad existen varios estudios en marcha, que se pueden consultar fácilmente en www.trial.gov, que podrán orientar de forma definitiva en algunos puntos de NOTES.

Al valorar el estado actual de NOTES, en la que probablemente la opinión generalizada es de un enlenteci-miento y/o estancamiento en su avance, es necesario considerar dos puntos, que probablemente se viven de forma diferente, al menos uno de ellos, entre USA y el resto del mundo. Una dificultad universal es el momento de recesión económica y la conciencia de que los avances necesarios desde el punto de vista tecnológico son enormemente cos-tosos y probablemente poco rentables lo que frena a la industria en su inversión. La necesidad de una plataforma es-table, concepto totalmente diferente del endoscopio flexible conlleva un gran esfuerzo tecnológico, cuyo ejemplo ini-cial es Endosamurai (Olympus), Anubiscope (Storz) o Direct drive endoscopic system (DDES; Boston Scientific) y que probablemente no se parecerán en nada a opciones futuras tele manipuladas o bajo control robótico, extensión lógica de esta tecnología. Otro punto de conflicto es la dificultad incrementada en los Estados Unidos en la traslación de las técnicas endoscópicas desarrolladas en el laboratorio a la práctica clínica ante la imposibilidad de su remuneración adecuada al coste tecnológico o su aceptación como procedimiento remunerable por los proveedores sanitarios norte-americanos. Sin embargo, este panorama tan poco definido, ha significado un estímulo para el desarrollo de otros modelos de cirugía mínimamente invasiva que tienen como objetivo la reducción a un mínimo de la agresión quirúrgica. La filo-sofía y la dificultad técnica de NOTES ha estimulado sin duda el concepto del acceso de incisión única transumbilical, opción técnica que intuitivamente se considera más fácilmente adaptable y que en este momento está en plena fase de desarrollo (16). Es fácil prever que durante los próximos meses, el concepto de Reduced Port Surgery, limitando el tamaño y numero de trocares junto a una tecnología mejorada (cámaras intrabdominales con control magnético per-cutáneo o instrumental percutáneo) favorecerá una cirugía mínimamente invasiva todavía menos agresiva (17).

Una duda inicial fue predecir quien efectuaría esta cirugía, y aparecía en el horizonte el cirujano/gastroenterólogo hibrido. Otros opinaban que sería una buena manera de que el cirujano general recuperara o adqui-riera habilidades necesarias en endoscopia flexible, idea sugerente que debería ser implementada en los centros de formación quirúrgica. Parece que NOTES ha interesado básicamente a cirujanos, con escasos endoscopistas que se hayan sumado al proyecto. Otro punto de conflicto es la dificultad incrementada en los Estados Unidos en la trasla-ción de las técnicas endoscópicas desarrolladas en el laboratorio a la práctica clínica ante la imposibilidad de su re-muneración adecuada al coste tecnológico o su aceptación como procedimiento remunerable por los proveedores sanitarios norteamericanos. Sin embargo, este panorama tan poco definido, ha significado un estímulo para el desarrollo de otros modelos de cirugía mínimamente invasiva que tienen como objetivo la reducción a un mínimo de la agresión quirúrgica. La filo-sofía y la dificultad técnica de NOTES ha estimulado sin duda el concepto del acceso de incisión única transumbilical, opción técnica que intuitivamente se considera más fácilmente adaptable y que en este momento está en plena fase de desarrollo (16). Es fácil prever que durante los próximos meses, el concepto de Reduced Port Surgery, limitando el tamaño y numero de trocares junto a una tecnología mejorada (cámaras intrabdominales con control magnético per-cutáneo o instrumental percutáneo) favorecerá una cirugía mínimamente invasiva todavía menos agresiva (17).

Una duda inicial fue predecir quien efectuaría esta cirugía, y aparecía en el horizonte el cirujano/gastroenterólogo hibrido. Otros opinaban que sería una buena manera de que el cirujano general recuperara o adqui-riera habilidades necesarias en endoscopia flexible, idea sugerente que debería ser implementada en los centros de formación quirúrgica. Parece que NOTES ha interesado básicamente a cirujanos, con escasos endoscopistas que se hayan sumado al proyecto.


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Volumen 1 Numero 8

Otro punto de conflicto es la dificultad incrementada en los Estados Unidos en la traslación de las técnicas endoscópicas desarrolladas en el laboratorio a la práctica clínica ante la imposibilidad de su remuneración adecuada al coste tecnológico o su aceptación como procedimiento remunerable por los proveedores sanitarios norteamerica-nos. Sin embargo, este panorama tan poco definido, ha significado un estímulo para el desarrollo de otros modelos de cirugía mínimamente invasiva que tienen como objetivo la reducción a un mínimo de la agresión quirúrgica. La filo-sofía y la dificultad técnica de NOTES ha estimulado sin duda el concepto del acceso de incisión única transumbilical, opción técnica que intuitivamente se considera más fácilmente adaptable y que en este momento está en plena fase de desarrollo (16). Es fácil prever que durante los próximos meses, el concepto de Reduced Port Surgery, limitando el tamaño y numero de trocares junto a una tecnología mejorada (cámaras intrabdominales con control magnético per-cutáneo o instrumental percutáneo) favorecerá una cirugía mínimamente invasiva todavía menos agresiva (17).

Una duda inicial fue predecir quien efectuaría esta cirugía, y aparecía en el horizonte el cirujano/gastroenterólogo hibrido. Otros opinaban que sería una buena manera de que el cirujano general recuperara o adqui-riera habilidades necesarias en endoscopia flexible, idea sugerente que debería ser implementada en los centros de formación quirúrgica. Parece que NOTES ha interesado básicamente a cirujanos, con escasos endoscopistas que se hayan sumado al proyecto.

Correspondencia: Prof. EM Targarona Servicio de Cirugía Hospital d Santpau Universidad Autónoma de Barcelona Padre Claret, 167 08025 Barcelona [email protected]

Les invitamos a enviar su opinión , comentarios o las críticas al Email :[email protected]

mailto:[email protected]

SECCION CASOS CURIOSOS:

SINDROME DE COTARD

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Volumen 1 Numero 8

La característica más llamativa del síndrome de Cotard es que los pacientes que lo su-

fren tienen la creencia que están muertos , que no tienen nervios, ni sangre ni cerebro ni

otros órganos, creen que se están pudriendo, incluso dicen oler como se pudre su carne.

Se perciben como muertos vivientes o zombies. Otras veces creen ser inmortales aunque

solo sean piel y huesos. Creen ser muertos vivientes. Los aquejados con este síndrome tienen delirio nihilistico o de negación. Comienzan con la negación de la existencia del

exterior y llegan luego a negar su propia existencia. Se aíslan del mundo.

Principales síntomas:

Depresión, Pensamientos suicidas, Creencia que no existe su cuerpo. Es un delirio el

paciente cree estar viviendo algo de forma real cuando solo se da en su imaginación

Creencia que se están quedando sin sangre, Pensamientos negativos, Creencia que ya

están muertos- Con delirios olfativos ellos incluso huelen que se están pudriendo, Creencia que los gusanos están bajo su

piel, Creencia que son inmortales, Creencia que se están descomponiendo, Creencia que no tienen órganos internos. Anal-

gesia o ausencia de dolor, Automutilaciones

PRESENTACION DE CASO:

Paciente mujer Edad 48 años, Estado civil: Lleva viuda desde los 24 años, lugar de residencia: Estados Unidos y Co-

lombia.

Trastornos del estado de ánimo: durante su estancia en los Estados Unidos sufrió episodios depresivos recurrentes, fue

tratada con distintos antidepresivos. Al perder su trabajo presenta síntomas depresivos, insomnio recurrente, incapacidad

para sentir placer, ansiedad, sentimiento de culpa y minusvalía. Después aparecieron las ideas suicidas, hubo varios inten-

tos de suicidio (cortes superficiales en las muñecas). Al parecer al darse cuenta no era capaz de suicidarse aparecieron otros síntomas. Comenta: “El 20 de febrero vi que salía un humo por mi boca, al día siguiente me miré al espejo y mis ojos habían cam-

biado, no tenían vida. Me di cuenta que ese humo que salía por mi boca era mi alma saliendo de mi cuerpo”.

A partir de ese momento, creencia de ser una muerta viviente, se veía como una zombie. comenzó a desarrollar

alucinaciones olfativas, decía su cuerpo se estaba pudriendo y ella lo olía. Sensacion cosquilleo bajo la piel como si l

os gusanos la estuvieran devorando. Al ser consciente de que estaba muerta dejo

de comer, porque decía que “los muertos no comen”, esto provocó un drástico

descenso de peso. Se le realizaron estudios de neuroimagen para detectar si

había algún problema cerebral, pero todos dieron negativos. A ser un caso extraño y no haber muchos casos descritos en en mundo no se sabía

bien que tratamiento ponerle a la paciente. Algo había que hacer, el descenso de peso era preocupante. Se comienza a tratar con distintos medicamentos antipsicóticos

(como Prozac , flouxetina). Pasaron unos meses y aparentemente no había señales de mejora. Se recurrió a una herra-

mienta terapéutica, la terapia electro convulsiva a fin de incrementar el flujo sanguíneo en

su cerebro. Después de 6 sesiones, los delirios comenzaron a controlarse hasta llegar a

desaparecer.

http://espectadores.net/las-mejores-peliculas-de-zombies/

http://www.revolucionnaturalista.com/2008/09/el-cerebro-paranormal.html

http://depsicologia.com/category/depresion/

http://depsicologia.com/el-suicidio-se-puede-evitar/

http://es.wikipedia.org/wiki/Delirio

http://www.blogmedicina.com/category/insomnio/

http://es.wikipedia.org/wiki/Zombi

http://espaciociencia.com/descubren-gusanos-gigantes-que-hace-260-millones-de-aos-vivan-bajo-la-arena/

http://espaciociencia.com/descubren-gusanos-gigantes-que-hace-260-millones-de-aos-vivan-bajo-la-arena/

http://www.mind-surf.net/drogas/antipsicoticos.htm

http://es.wikipedia.org/wiki/Delirio

SECCION:

LO QUE NUNCA ME ENSEÑARON LA CIRUGIA ES COMO LA MUSICA

SECCION: CIRUGIA BASADA EN EVIDENCIAS: Efectividad de la Cirugía Laparoscópica para Colecistolitiasis y Coledocolitiasis: Revisión Global de la Evidencia. Dra. Mónica Uribe León

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Para participar envienos sus aportes personales que le impactaron al siguiente correo: boletí[email protected]

En los Archivos Adjuntos, podrá leer el articulo completo con el título: 01 CIRUGIA DE EVIDENCIA VIA BILIAR

Les invitamos a enviar su opinión , comentarios o las críticas al Email :[email protected]

Cuando era residente de cirugía uno de los aspectos que privilegiábamos en nuestro aná-

lisis era el factor rapidez. Clasificábamos a nuestros maestros y colegas por su velocidad

quirúrgica. Mientras más rápido terminaba una cirugía asumíamos que era mejor. Algu-

nos justificaban su lentitud en función de mejores resultados. Otros justificaban que la

rapidez era sinónimo de conocimiento y por consiguiente la lentitud era ignorancia. Pasó un buen tiempo para darme cuenta que habían algunos cirujanos que no eran velo-

ces pero que terminaban rápido sus cirugías. Habían otros factores que recién aprendí:

conocimiento de la anatomía, conocimiento de la patología, buena exposición, buena

ayudantía, buena iluminación y otros muchos más.

A todos estos factores los clasifiqué como RITMO.

El buen cirujano tiene que tener ritmo, como el tango.

Dr. José De Vinatea De Cárdenas

El objetivo del presente estudio fue evaluar la evidencia disponible respecto de la efectividad de la cirugía laparoscó-pica en el tratamiento de la colelitiasis y la litiasis de la vía biliar (LVBP). Se realizo una revisión global de la evidencia disponible. Se realizaron búsquedas en las bases de datos MEDLINE, EMBASE y the Cochrane Library (1998-2008). Se incluyeron guías de práctica clínica (GPC), revisiones sistemáticas (RS), ensayos clínicos con asignación aleato-ria (EC) y estudios observacionales. Los datos disponibles y la evidencia generada se clasificaron en base a la propuesta del Centro de Oxford de Medici-na Basada en la Evidencia. Se incluyeron 87 estudios (3 GPC, 12 RS, 23 EC, 13 estudios de cohortes, 3 estudios transversales, 2 estudios de casos y de controles y 31 series de casos). En comparación con la colecistectomía abierta, la colecistectomía laparoscópica (CL) se asocia con menor tiempo operatorio y estancia hospitalaria y mejor calidad de vida (evidencia de alta calidad). El uso de profilaxis antibiótica no parece reducir la tasa de infección en pacientes de bajo riesgo (evidencia de alta calidad). Aunque se han descrito numerosas técnicas para realizar una CL, su eficacia no es aun concluyente (evidencia de baja calidad). La cirugía en dos etapas es la estrategia más adecuada para los pacientes de alto riesgo con LVBP (evidencia de alta calidad). La mortalidad del tratamiento laparoscópico de la LVBP es similar a la de la cirugía abierta; y como su eficacia es similar a la del tratamiento endoscópico (evidencia de alta calidad). Se puede concluir señalando que la evidencia disponible respecto de la efectividad de la cirugía laparoscópica para el tratamiento de la colelitiasis y la LVBP es es-casa y de baja calidad metodológica; y que se requieren estudios de mejor calidad para valorar de forma más apro-piada estas técnicas. Material, C.; Pineda, V.; Tort, M.; Targagona, E.; Villegas, P. R. & Alonso, P. Effectiveness of laparoscopic surgery for gallstones and common bile duct lithiasis: a systematic overview. Int. J. Morphol., 28(3):729-742, 2010.

SECCION: ANALISIS CRITICO: EL ROL DEL ESTADIAJE LAPAROSCÓPICO EN CÁNCERES INTRA-ABDOMINALES

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Uno de los aspectos más importantes en oncología es la necesidad de una exacta determinación del estadío de la enfermedad al

momento del diagnóstico. Este paso permite diseñar la estrategia terapéutica y definir el pronóstico del paciente. Antes de los

grandes avances tecnológicos actuales en la mayoría de pacientes, la determinación del estadío de enfermedad se realizaba en el

quirófano durante una laparotomía exploratoria. Por supuesto, este es un método bastante agresivo para hacer un diagnóstico,

pero que sin embargo, aún se sigue empleando pero ahora en cada vez menor número de pacientes.

Los métodos de estadiaje oncológico preoperatorio han mejorado notablemente en sensibilidad, especificidad, valor predictivo

positivo y negativo, y sus niveles de exactitud diagnóstica son cada vez mayores. No cabe duda que la tomografía es el mejor

método actualmente para la determinación del nivel de avance de la enfermedad a nivel local y regional como del compromiso

metastásico a distancia. Sin embargo, es importante aclarar que las tomografías de hace 20 años no son las mismas que las que

vemos ahora. La tomografía espiral multicortes (TEM) (multidetector computed tomography MDCT ) ha permitido alcanzar una

precisión diagnóstica mayor del 90% en la mayoría de cánceres. Por ejemplo, en cáncer de páncreas el porcentaje de la TAC

(tomografía axial computarizada) para definir resecabilidad (estadiaje locorregional) era del 70% y gran parte de estos pacientes

debían ser explorados quirúrgicamente. Actualmente con el TEM la resecabilidad se determina hasta en un 90% de casos con

suma precisión.

En la época de la década del 90 no se contaba aún con esta tecnología por lo que muchos pacientes se perjudicaban al ser someti-

dos a una laparotomía innecesaria, en la que lo único que se hacía era el famoso “open/close”. Con esta cirugía se expone al pa-

ciente a riesgos como complicaciones de la herida operatoria, dolor, estancia hospitalaria de varios días y al riesgo bajo pero exis-

tente de la anestesia general sin mayor beneficio.

La cirugía mínimamente invasiva aparece como una excelente alternativa complementaria para realizar un estadiaje mucho más

preciso detectando principalmente depósitos metastásicos de poca magnitud no detectables por TAC, como pequeños implantes

peritoneales o metástasis hepáticas menores de 10 mm. Además útil en evitar los efectos negativos mencionados de la laparoto-mía innecesaria.

Así la laparoscopía encontró su rol en el estadiaje primordialmente en los cánceres del aparato digestivo los cuales por su ubica-

ción intra-abdominal tienen la proclividad a diseminarse principalmente al peritoneo y al hígado. Por lo tanto, el principal lugar

de metástasis de estas neoplasias es el abdomen. Sin embargo, los patrones de diseminación dependen del comportamiento bioló-

gico de cada cáncer y esto determina la mayor o menor utilidad de la laparoscopía de estadiaje. Por ejemplo, el cáncer gástrico

tiene una gran predilección en sus estadíos avanzados a producir carcinomatosis peritoneal antes que metástasis hepáticas. Lo

contrario ocurre con la mayoría de cánceres colorrectales en los que predomina su propensión a las metástasis hepáticas antes que

las peritoneales. Así mismo, el cáncer de cabeza de páncreas tiene mayor propensión a la invasión locorregional y a las metástasis

hepática, mientras que el cáncer de cola de páncreas tiene una gran tendencia a la carcinomatosis peritoneal desde el momento en

que se hace el diagnóstico. Por ende, la importancia de la laparoscopía variará de acuerdo al cáncer que estemos enfrentando. In-

cluso dependerá del estadío tomográfico que estemos presuponiendo y del tipo histológico obtenido en la biopsia. Por ejemplo, un

carcinoma de células en anillo de sello del estómago o un adenocarcinoma mucinoso pobremente diferenciado del colon con sos-

pecha de compromiso tumoral transmural seguramente será candidato para una laparoscopía preopratoria, a diferencia de un cán-

cer de estómago submucoso menor de 2cm tubular bien diferenciado en el que la chance de metástasis a distancia es mínimo.

En algún momento se planteó que todos los pacientes con cáncer abdominal fueran sometidos a una laparoscopía preoperatoria de

estadiaje, sobretodo para cáncer gástrico y páncreas. Actualmente, por lo dicho anteriormente, este método debe ser selectivo.

Debería aplicarse en forma individualizada sólo a pacientes con riesgo de metástasis peritoneal y/o hepática en los que no se han

detectado éstas en un estudio TEM con cortes de mínimo 5 mm. Puede aplicarse necesariamente también en pacientes que aún

teniendo bajo riesgo de metástasis tengan lesiones dudosas en el estudio TEM.

SECCION: ANALISIS CRITICO: EL ROL DEL ESTADIAJE LAPAROSCÓPICO EN CÁNCERES INTRA-ABDOMINALES

Página 8

Volumen 1 Numero 8

.

Es importante también mencionar que la ultrasonografía laparoscópica (USL) agrega mayor sensibilidad al estadiaje sobretodo

para las metástasis hepáticas. También se viene usando para definir el grado de infiltración local vascular principalmente en

cáncer de páncreas, sin embargo, la ultrasonografía endoscópica ha ganado terreno en esta área desplazando el rol de la USL

para este fin. Así mismo el PET-CT se viene probando como método preoperatorio para la detección de metástasis no detecta-das por el TEM, y estamos a la espera que se defina su exacto rol en el estadiaje de los cánceres abdominales.

En conclusión, el rol de la laparoscopía de estadiaje para los cánceres del aparato digestivo, evoluciona constantemente, y su

utilidad se va reduciendo a un selecto grupo de pacientes debido al avance de la tecnología en radiología, y que seguro en el

futuro tal vez eviten llevar a sala de operaciones incluso para una laparoscopía a pacientes con enfermedad metástasica inope-

rable.

El estudio de Chang y cols (Chang L, Stefanidis D, Richardson WS, Earle DB, Fanelli RD. The role of staging laparoscopy for

intraabdominal cancers: an evidence-based review. Surg Endosc (2009) 23:231-241) es una revisión basada en evidencias al

respecto de este tema. Será de mucha utilidad contrastar la opinión crítica vertida, con las evidencias plasmadas en este artícu-

lo, sin embargo deben tomar en cuenta que la revisión se hizo hasta el 2006 y en estos 5 años han seguido habiendo muchos

cambios.

DR. GUSTAVO REAÑO PAREDES

SERV. CIRUGÍA DE PÁNCREAS, BAZO Y RETROPERITONEO

HOSPITAL NAC. G. ALMENARA I. ESSALUD

Podrá ver el articulo completo en los Archivos Adjuntos con el titulo: 02 ANALISIS CRITICO: THE ROLE OF STAGING LAPAROSCOPY FOR INTRAABDOMINAL CANCERS

rocaudal laparoscópica

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729

Int. J. Morphol.,28(3):729-742, 2010.

Effectiveness of Laparoscopic Surgery for Gallstones andCommon Bile Duct Lithiasis: a Systematic Overview

Efectividad de la Cirugía Laparoscópica para Colecistolitiasis y Coledocolitiasis:Revisión Global de la Evidencia

*Carlos Manterola; **Viviana Pineda; ***Montserrat Tort;****Eduardo Targarona; *****Román Villegas Portero & ******Pablo Alonso

MANTEROLA, C.; PINEDA, V.; TORT, M.; TARGARONA, E.; VILLEGAS, P. R. & ALONSO, P. Effectiveness of laparoscopicsurgery for gallstones and and common bile duct lithiasis: a systematic overview. Int. J. Morphol., 28(3):729-742, 2010.

SUMMARY: The aim of the present study was to evaluate the available evidence on the effectiveness of laparoscopic surgeryfor treating gallstones and common bile duct lithiasis (CBDL). A systematic overview was performed. Medline, EMBASE and TheCochrane Library were searched (1998-2008). Systematic reviews (SR), clinical practice guidelines (CPG), randomised clinical trials(RCT) and observational studies were included. Internal validity and overall quality of the evidence were assessed. The available evidencewas classified according to the Oxford Centre for Evidence Based Medicine proposal. 87 studies were included in this review (12 SR, 23RCT, 3 CPG, 13 cohort studies, 3 cross-sectional studies, 2 case and control studies and 31 case series). Compared with opencholecystectomy, laparoscopic cholecystectomy (LC) is associated with shorter operating time, shorter hospital stay and better quality oflife (high quality evidence). The use of antibiotic prophylaxis does not appear to reduce the infection rate in low-risk patients (highquality evidence). Although many techniques have been advocated to perform LC their effectiveness is as yet inconclusive (low-qualityevidence). Two-stage surgery is the most appropriate strategy for high-risk patients with CBDL (high-quality evidence). Mortality issimilar to open surgery, as the effectiveness is similar to that of endoscopic treatment (high-quality evidence). As a conclusion we canstate that the evidence concerning the effectiveness of laparoscopic surgery for gallstones and CBDL is scarce and of low methodologicalquality and that better quality studies are warranted to assess these techniques more adequately.

KEY WORDS: Cholecystolithiasis; Choledocholithiasis; Cholelithiasis; Gallstones; Laparoscopy; Cholecystectomy;Laparoscopic; Technology Assessment; Biomedical.

INTRODUCTION

The use of laparoscopic procedures for treatinghepato-biliary diseases started in the late eighties whenMouret, Doubois and Perissat performed the first laparoscopiccholecystectomies (LC) in-patients with cholecystolithiasis(Perissat, 1989; Litynski, 1999; Vecchio, 2000; Reynolds,2001; Jaffray, 2005). LC quickly became the first-linetreatment for uncomplicated cholecystolithiasis (Weil, 1992),

promoting research on the application of laparoscopicprocedures in various surgical contexts. Many approacheswere quickly developed and the field has undergonerevolutionary changes (Matthews, 1999; Young-Fadok, 2000).Evidence in favour of LC, however, is scarce. Furthermore,the advantages of laparoscopic techniques do not appear tooutweigh those of open approaches yet (Troidl, 1999).

* Full Professor, Hepatobiliary Surgery Unit, Department of Surgery, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile.** Assistant Professor, Mastology Unit, Department of Surgery, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile.*** Iberoamerican Cochrane Centre, Spain. Epidemiology and Public Health Department, Universidad Autónoma de Barcelona, Hospital de Sant Pau,

Barcelona, Spain.**** Full Professor, Department of Surgery, Hospital de Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain.***** Andalusian Agency for Health Technology Assessment, Sevilla, Spain.****** Iberoamerican Cochrane Centre, Spain. Epidemiology and Public Health Department, Universidad Autónoma de Barcelona, Hospital de Sant Pau,

Barcelona, Spain. Sources of financial support: Andalusian Agency for Health Technology Assessment and DID-UFRO Project DI09-0060 of the Universidad de La

Frontera Research Direction.

730

The aim of this study was to systematically reviewthe available evidence on the effectiveness of laparoscopicsurgery for treating gallstones and common bile duct lithiasis(CBDL).

MATERIAL AND METHOD

The following databases were searched: CochraneLibrary, Medline and EMBASE. The TRIP Database engineand several international technology assessment agencieswere also searched. All studies evaluating the effectivenessof laparoscopic treatment in patients with cholecystolithiasisor CBDL, published between 1988 and 2007 in English,French or Spanish were considered. Firstly, systematicreviews (SR), clinical practice guidelines (CPG) andrandomised clinical trials (RCTs) were retrieved. The internalvalidity of studies was assessed and synthesised in evidencetables (SIGN, 2004). If this type of design was not availableobservational studies were included. The available evidencewas classified according to the system proposed by theOxford Centre for Evidence Based Medicine (OCEBM,2006) and the overall quality of the evidence for eachintervention was rated as high, moderate or low quality in amodified approach of the GRADE system (Guyatt, 2006).This approach considers not just the study design but otherissues like internal validity, consistency, precision of results,and whether evidence assessment was direct or indirect.

We did not formulate recommendations in this reportbecause these are specific to each setting. Besides the overallquality of the evidence and the balance between risks andbenefits, recommendations need to take into account localfactors, values and preferences, the baseline risk of thepopulation of interest, and costs (Guyatt, 2006).

RESULTS

1951 records were retrieved and 87 studies meetingthe selection criteria were finally included (Fig. I).

Effectiveness of laparoscopic cholecystectomy

Laparoscopic versus open cholecystectomy. Four SRs(ANDEM, 1994; Downs, 1996; Korolija, 2004; Keus, 2006a;Keus, 2006b), two RCTs (Mimica, 2000; Ros, 2001), threecohort studies (Devereaux, 2005; Elder, 1996; Finan, 2006),one CPG (Zacks, 2002), one cross-sectional study (Collet,1997) and one case series (Ibrahim, 2006) were included.One SR concluded that laparoscopic techniques take longer

than conventional techniques. LC implied a shorter hospitalstay and greater comfort for the patient compared with opensurgery. However, expertise played a key role in the resultsas both duration and complications were reduced when thetreatment was performed by more experienced surgeons(ANDEM, 1994), (Treatment studies 2a).

Two SR evaluated the effectiveness, safety andpostoperative recovery of LC compared with open andminilaparotomic cholecystectomy no difference wasobserved in postoperative symptomatic relief. The incidenceof postoperative pain, morbidity and mortality were lowerin patients who underwent LC than in those who underwentconventional open surgery. Postoperative ventilatoryfunction was better in LC patients. No differences wereobserved with minilaparotomic cholecystectomy. Thefrequency of biliary complications was higher in LC thanin both conventional and minilaparotomic procedures. Thesurgeons' training and expertise played a significant role interms of surgical morbidity. Length of hospital stay wassimilar for both LC and minilaparotomic cholecystectomybut recovery time was slightly shorter for LC (Downs, 1996;Keus, 2006a). Other SR concluded that there are notdifferences between open and laparoscopic groups in termsof morbilidity, mortality and frequency of biliarycomplications, but hospital stay was lower in laparoscopicgroup (Keus, 2006b), (Treatment studies 1a).

A multicenter RCT comparing LC withminilaparotomic cholecystectomy concluded that LC entailslonger operating time and a slightly shorter hospital stay(Elder, 1996). LC was associated only with shortertemporary disability (12.7 vs. 16.0 days, p<0,001). Of noteis the fact that the study may have been biased by differencesin surgical experience using the two techniques since therewere more experienced surgeons in the LC group (Elder,1996), (Treatment studies 1b). Another RCT examiningrespiratory function in patients that had undergonelaparoscopic or open cholecystectomy showed thatventilatory parameters were similar in both groups, beingon average 40% worse than at baseline (Keus, 2006a),(Treatment studies 2b).

A cohort study that aimed to compare the resultsbetween expert surgeons and surgical trainees found nosignificant differences in either the conversion rate or theoperating time (Elder, 1996). A similar study noted thatmortality risk was lower with LC than with the openprocedure (Zacks, 2002). A population-based studyperformed by the French Society of Endoscopic andOperative Radiology Surgery (SFERO) indicated aconversion rate of 6.9%, a morbidity rate of 4.9% and amortality rate of 0.2% (Collet, 1997), (Treatment studies 4).

MANTEROLA, C.; PINEDA, V.; TORT, M.; TARGARONA, E.; VILLEGAS, P. R. & ALONSO, P. Effectiveness of laparoscopic surgery for gallstones and and common bile duct lithiasis: asystematic overview. Int. J. Morphol., 28(3):729-742, 2010.

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Fig. 1. Flow diagram of studies.

Following a SR of the evidence one clinical practiceguideline (CPG) showed that LC improves quality of lifesooner than open cholecystectomy. Nevertheless, long-termLC results were similar to the open procedure (Korolija,2004), (Treatment studies 1a); and a prospective cohortsupports the utility of LC by showing not only a significantreduction of GI postoperative symptoms but also markedimprovement in patients' general QOL (Finan, 2006).(Treatment studies 2b).

Related with eventual risk factors for conversion toopen surgery in patients undergoing laparoscopiccholecystectomy, a large prospective case series concludedthat male gender, advanced age (over 60 years), higher bodyweight > 65 kg, acute cholecystitis, previous upper abdomi-nal surgery, junior surgeons, and diabetes associated withHba1c > 6. are variables to consider as potential associatedfactor (Ibrahim, 2006), (Treatment studies 4).


732

Special groups of patients. Two SR, 3 RCTs, 3 cohortstudies, 1 case-control study and 10 case series were found.The SR concluded that LC resulted in less postoperative pain,shorter hospital stay and fewer complications compared withthe open approach in patients aged 65 or older (Weber, 2003),(Treatment studies 3a). Furthermore, a cohort studyexamining mortality rate for LC versus opencholecystectomy noted that the mortality rate wassignificantly reduced for LC in the subgroup of patients aged70 to 79 (Feldman, 1994). In addition, a retrospective caseseries with patients aged 70 or over who underwent LC notedfound a shorter hospital stay, lower morbidity and mortalityrates, and better postoperative recovery compared with theopen technique (Perez Lara, 2006), (Treatment studies 4).

Assessment of two prospective case series includingpregnant women with symptomatic and complicatedcholecystolithiasis who underwent LC revealed noconversion or morbidity, faster recovery, and nocomplications among the infants. According to the authors,special care should be taken with the trocar position inwomen after their 32nd week of pregnancy, a maximumpneumoperitoneum level of 10 mmHg should be used andthe routine intraoperative cholangiography (RIOC) shouldbe avoided (Sungler, 2000; Daradkeh, 1999), (Treatmentstudies 4).

In patients with cirrhosis and portal hypertensionChild A and B, one RCT found lower blood loss (75.5 vs.112.5 mL, p<0,001), lower morbidity (13,2% vs. 30%, p <0,001) and shorter time to resume eating (18.3 vs. 44.2 hours,p<0,05) in the LC group compared with open surgery (Ji,2005), (Treatment studies 2b). A case control study showedthe conversion and morbidity rate was higher in the cirrhosisgroup than in the control group (Fernandes, 2000),(Treatment studies 3b); and two case series shows similarresults than the previous RCT reported in patients withcirrhosis and portal hypertension Child A and B (Palanivelu,2006; da Silveira, 2006).

A SR based on 5 RCT concluded that earlylaparoscopic cholecystectomy during acute cholecystitis issafe and provide shorter hospital stay (Gurusamy, 2006),(Treatment studies 1a). One RCT on acute cholecystitis (AC)compared safety and cost-effectiveness of urgent versuselective LC (use of percutaneous decompression prior to LC).Elective surgery did not show any advantages in terms ofoperating time, complication rate, blood loss, and conversionrate or hospital stay as compared with urgent LC (Sungler,2000). Another low quality RCT comparing safety and resultsof LC vs. open surgery in patients with gangrenous AC founda similar operating duration and hospital stay but time toreturn to work was longer in the open group (Kiviluoto,

1998), (Treatment studies 2b). A retrospective cohortexamining patients with AC who underwent open andlaparoscopic procedures noted that LC was superior, withlower analgesic use, shorter hospital stay and less temporaldisability (Glavic, 2001). A case series examining patientswith AC, gallbladder gangrene, hydrops and gallbladderempyema observed a conversion rate of 20.5% and amorbidity of 17% (Eldar, 1998). A retrospective case seriesof LC for AC found similar results to those described forcholecystolithiasis, except in operating time and conversionrate which were significantly higher (Lujan, 1995), andanother larger case series described statistical diferences ofconversion rate between patients with AC vs. Chroniccholecystitis (20.6% vs 4.2%) (Tan, 2006), (Treatmentstudies 4).

Several studies on the effectiveness of LC in chronicinflammation conditions, including Mirizzi syndrome, werealso found. One cohort study comparing simple cholelithiasisand complicated cholelithiasis (Mirizzi syndrome andfistulae) groups found similar results in conversion rate andmorbidity, and a longer operating time in the complicatedcholelithiasis group (Perez-Morales, 2005). Case seriesshowed widely variable results, with conversion rates rangingfrom 22.2% to 74% in patients with Mirizzi syndrome(Bagia, 2001; Schafer, 2003). One series reported a morbidityrate of 10.3%44 (Treatment studies 4).

Antibiotic prophylaxis. One SR, 2 RCTs and 1 CPG werefound. One SR that included a meta-analysis concluded thatthe use of antibiotic prophylaxis for LC in low-risk patientsdid not reduce surgical wound infection or remote infectionrates (Al-Ghnaniem, 2006), (Treatment studies 1a). One RCTshowed similar results (Koc, 2003). Another low quality RCTcomparing the use of antibiotic prophylaxis with mechanicalprophylaxis (gallbladder removal with a polyethylene bag)observed a similar postoperative infection rate in both groups(Harling, 2000), (Treatment studies 2b). One CPG, currentlyunder revision, evaluated the requirement of antibioticprophylaxis in different types of surgery; it concluded thatnot only was prophylaxis not proven effective for thispurpose but that its use may potentially increase hospitalantibiotic use with little clinical benefit (SIGN, 2004).

Routine intraoperative cholangiography. Sevenobservational studies were found (one cohort study and 5case series). One cohort study compared routineintraoperative cholangiography (RIOC) with selectivecholangiography (in cases of suspected CBDL or unclearanatomy). RIOC did not improve the identification of hiddencommon bile duct (CBD) or reduce the number of bile ductinjuries, and it lengthened operating time and increasedassociated costs (Ladocsi, 1997), (Diagnostic studies 3b).


733

Retrospective case series observed an average time for RIOCof 12±9 minutes, a conversion rate of 6.9%, morbidity rateof 1.2%, and retained CBD of 4% (Millat, 1997); but a largerecently published case series observed 27,2% of abnormalcholangiograms in elective LC and 94.1% of abnormalcholangiograms in patients admitted with biliaryemergencies, concluding that in their experience 10% ofabnormal cholangiograms occurred in patients withoutpreoperative risk factors for bile duct stones (Hamouda,2007), (Diagnostic studies 3b). Another retrospective caseseries evaluated LC without RIOC but including selectivepreoperative endoscopic cholangiography, and observed thatonly 0.5% of all patients had retained stones (Thornton,2002); another one suggest that selective intraoperativecholangiography would miss a proportion of patients withcholedocholithiasis (Tan, 2006). Finally another case seriesrecommended the use of routine laparoscopic ultrasound toreduce the need for intraoperative cholangiography duringcholecystectomy, due to a 95% sensitivity, 100% specificity,100% positive predictive value and 99.4% negativepredictive value (Machi, 2007), (Diagnostic studies 3b).

Laparoscopic cholecystectomy related bile duct injuries.Cystic and hepatic duct lesions are among the most frequentcomplications of laparoscopic cholecystectomy (LC) (Kwon,2001; Regoly-Merei, 1998; Targarona, 1998; Nuzzo, 2005),with values varying from 11.9% to 43% for morbidity and1.7% to 12% for mortality (Regoly-Merei, 1998; Targarona,1998; Sarmiento, 2004; Sicklick, 2005). Their incidence isapproximately 0.31 to 1.34 per 1,000 cases. A survey wasconducted among 1661 American surgeons to investigatethe frequency of major bile duct injuries during LC. With a45% response rate the prevalence of bile duct injuries wasestimated to be around a third of procedures (34.1%). Mostcomplications occurred during the first 50 procedures which,despite the limitations of the report, suggest that most lesionsare associated with inadequate expertise. Nevertheless, atleast a third of those lesions might be associated with otherfactors such as those derived from inappropriate surgicalmaneuvers (Archer, 2001). A similar study with a 58%response rate observed 75.7% of major lesions, with nodifferences between the type of technique used or the use ofRIOC (Nuzzo, 2005), (Treatment studies 4).

Regarding the repair of these lesions, two low qualityRCT suggest that biliary stenting alone is as effective asbiliary stenting with sphincterotomy in the treatment ofuncomplicated post-laparoscopic cholecystectomy bile leaks(Mavrogiannis, 2006; Carr-Locke 2006), (Treatment studies2b). A prospective case series described the results of anumber of major lesions requiring complex reconstructionsuch as hepaticojejunostomy. These lesions required a me-dian of 9 days’ hospital stay, and morbidity and mortality

rates of 42.9% and 1.7% respectively were reported(Sicklick, 2005). One small case series that assessedlaparoscopic repair of minor lesions reported that most ofthese only involved simple sutures associated with theendoscopic drainage (Kwon, 2001), (Treatment studies 4).One retrospective case series applied a quality-of-lifequestionnaire in 59 patients who had undergone surgicalreconstruction after a bile duct lesion during LC and nodifferences between the patient and control groups wereobserved in any of the assessed domains (Sarmiento, 2004).Finally, a case control study comparing costs in a group ofpatients undergoing LC, with bile duct injuries, vs. a groupof patients that had undergone cholecystectomy withoutlesions, did not find any significant differences in costsassociated with bile duct injuries (Woods, 1996), (Treatmentstudies 3b).

Technological variants. Twenty one studies were found.13 RCT, two cohort studies and 6 case series (four of themretrospective and two prospective). Routine intraoperativeaspiration of gallbladder during laparoscopiccholecystectomy seems to be associated to less postoperativemorbidity proportion respect to traditional LC (Calik, 2007).Undertaking LC without pneumoperitoneum is one of themultiple variants described for LC and is supported by twolow quality RCTs (Kitano, 1993; Barczynski, 2004) and alsoby a retrospective case series (Nande, 2002). The reductionin the number of access ports (Trichak, 2003) and the use of'mini-laparoscopy' and 'mini-instruments' is upheld bymedium-quality RCTs and by a prospective case series(Nuzzo, 2005; Novitsky, 2005; Lai, 2003). The use of roboticsystems is supported by a low quality RCT (Zhou, 2006).The use of neodynium YAG laser, which did not show anysignificant benefit over electrosurgery, is backed by two low-quality RCTs (Corbitt, 1991; Bordelon, 1993) and two caseseries (Lane, 1993; Mohiuddin, 2006). Ultrasound dissection,which might imply benefits over conventional electroscalpeldissection, is supported by two medium-quality RCTs(Janssen, 2003; Cengiz, 2005). Gallbladder dissection withbipolar cautery scissors, a variant that was not superior tomonopolar scissors, is supported by a low-quality RCT(Edelman, 1995). In two low-quality RCT assistance with awater irrigation system and a hydrodissection withadrenaline-lidocaine-saline solution, as an alternative todissection, showed clinically modest results (Shekarriz,2003) and no differences respect to traditional dissectionsystem (Caliskan, 2006). The use of various types of ligatureand suture as an alternative to conventional stapling issupported by a retrospective cohort81 and two retrospectivecase series (Yano, 2003; Yeh, 2004). Finally, the use of 0.5%bupivacaine-soaked Surgicel in the gallbladder proved in acohort study, appear to be effective for control visceral painafter laparoscopic cholecystectomy, but port-site infiltration


734

alone would be ineffective (Verma, 2006), (Treatment studies2b and 4).

Laparoscopic cholecystectomy as short-stay majorsurgery. In the 90s, LC was regarded as a way to reducehospital stay in patients undergoing cholecystectomy (Verma,2006). However, this potential benefit of LC with earlydischarge versus the standard protocol is supported only byobservational studies with non-conclusive results (Grace,1991; Martinez Vieira, 2004; Lau, 2002; Pattillo, 2004; Bue-no Lledo, 2006), (Treatment studies 4).

Effectiveness of laparoscopic treatment for common bileduct lithiasis.

The ideal treatment for CBDL remains controversial.Options vary from endoscopic papillotomy to laparotomicor laparoscopic choledochotomy, including bile ductexploration via the cystic duct (Paganini, 2007). CBDLtreatment has mainly been undertaken by endoscopy priorto LC. This strategy appears to resolve CBDL in most casesbut is likely to find no evidence of the presence of a stone in20-60% of patients and is associated with a considerablemorbidity risk (Paganini, 2007; Smith, 1997; Joyce, 1991;Prat, 1996; Costi, 2007; Trondsen, 1998).

There are also reports on primary choledochorraphyversus choledochorraphy with a Kehr tube or modifiedbiliary endoprosthesis. It is generally accepted that two-stagesurgery (endoscopic papillotomy followed by LC) is the mostappropriate strategy for high-risk patients, such as those withcholangitis and pancreatitis (Liu, 2001). However, for lowrisk patients, a one-step strategy has progressively beenadopted in clinical practice, this involves LC andlaparoscopic bile duct exploration (transcystic or viacholedochotomy). There is yet no specified algorithm forthe laparoscopic treatment of CBDL (Cuschieri, 1999; Wei,2003), and this uncertainty become evident in the findingsof the 5 available SRs (Martin, 2006; Pichon Riviere, 2005;Tranter, 2002; Vial, 2005; Clayton, 2006).

The Institute for Health and Clinical Effectivenessreport concludes that effectiveness of bile duct laparoscopicexploration is very high (90% in most studies) and similarto that of endoscopic treatment. Endoscopic morbidity isabout 8% and is related to the procedure (pancreatitis,perforation and bleeding). Morbidity of bile ductlaparoscopic exploration includes the risk of incompletestone (5%) or stricture removal (3%), and the need forconversion to open surgery (4%). Disadvantages of thelaparoscopic method include the need for highly trainedsurgeons and specific equipment (Pichon Riviere, 2005),(Treatment studies 1a).

Three SRs comparing endoscopic treatment withsurgical treatment of CBDL (open and laparoscopic) haverecently been published (Martin, 2006; Pichon Riviere, 2005;Tranter, 2002; Vial, 2005). These reviews conclude that bileduct laparotomic exploration is more effective thanendoscopic treatment for bile duct cleaning. Endoscopictreatment requires a higher number of procedures per patientand a longer hospital stay and is at least as safe and effective.Nevertheless, no clear advantages, in terms of lack ofresponse to treatment, morbidity or mortality have beenobserved (Martin, 2006; Pichon Riviere, 2005; Tranter, 2002;Vial, 2005), (Treatment studies 1a).

Another SR comparing endoscopic and surgery vs.surgery alone for CBDL treatment with the gallbladder insitu, verified that there was no significant difference insuccessful duct clearance, mortality, morbidity betweenthe endoscopic and surgical groups. There was also nosignificant difference between the endoscopic andlaparoscopic surgery groups. So authors concluded thatboth approaches have similar outcomes, and treatmentshould be determined by local resources and expertise(Clayton, 2006), (Treatment studies 1a).

On the other hand, a recently published low-qualityRCT compare success rate, length of hospital stay, clinicalresults, and costs of sequential treatment (ERCP followedby LC) vs. the laparoendoscopic rendezvous in patientswith CBDL and verified that laparoendoscopic rendezvoustechnique allows a higher rate of CBDL clearance, shorterhospital stay and cost reduction respect the ERCP followedby LC group (Morino, 2006), (Treatment studies 2b).

Another aspect to consider is bile duct drainagevia choledochotomy plus ulterior choledochorraphy witha Kehr tube. One recent published SR tried to assess thebenefits and harms of routine primary closure versus T-tube drainage following laparoscopic common bile ductstone exploration and concluded that there is insufficientevidence to recommend T-tube drainage or primaryclosure after laparoscopic common bile duct stoneexploration (Gurusamy, 2007), (Treatment studies 1a).Other studies available to date on this subject areobservational [three cohort studies (Griniatsos, 2005;KimK, 2004; Lien, 2005) and two case series (Decker,2003; Fanelli, 2001)] and their results support the use ofbiliary endoprosthesis after bile duct laparoscopicexploration as a safe, quick and effective alternative.Biliary endoprosthesis is a minimally invasive therapythat implies a shorter hospital stay and seems to reducemorbidity after the insertion of a Kehr tube (Griniatsos,2005; KimK, 2004; Lien, 2005; Decker, 2003; Fanelli,2001), (Treatment studies 4).


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DISCUSSION

Following the great technological advances that haveoccurred in recent years laparoscopic treatment is generallyconsidered a quick and safe procedure. A high level oftraining in the procedure is required, however, and thenumber of complications appears to decrease as experienceincreases. In this overview, LC for patients withcholecystolithiasis and acute cholecystitis is associated witha longer operating time, a shorter hospital stay and a better

postoperative quality of life in comparison with open surgery.Although it is a relatively safe procedure, there is a higherrisk of bile duct injuries and complex repair surgery is oftenrequired. (High quality evidence). LC seems a relatively safeprocedure for special groups of patients such as the elderly,pregnant women or patients with cirrhosis and portalhypertension Child A y B (Low quality evidence) (ANDEM,1994; Downs, 1996; Korolija, 2004; Mimica, 2000; Ros,

Clinical question Number of studies Quality of theevidence

Summary of findings

High LC is associated with longer operating time, a shorterhospital stay and a better postoperative course for patientswith cholecystolithiasis.

LC vs. open cholecystectomy. 4 SRs2 RCTs3 Cohort studies1 CPG1 C ross-sectionalstudy1 case series

Low LC can be a safe procedure for special groups of patientssuch as the elderly, pregnant women and patients withcirrhosis and portal hypertension Child A y B.

Moderate LC results in less postoperative pain, shorter hospital stayand fewer complications compared with open approach inpatients aged 65 and older.

Moderate LC is a safe procedure in patients with acutecholecystitis.

LC in special groups ofpatients.

2 SR3 RCTs3 Cohort studies1 C ase controlstudies10 case series Low It has shown to be a safe procedure for special groups of

patients such as the elderly, pregnant women and patientswith cirrhosis and portal hypertension Child A y B.

Use of antibiotic prophylaxisfor LC.

1 SR2 RCTs1 CPG

High Use of antibiotic prophylaxis in low-risk patientsundergoing a LC does not offer any additional benefits interms of reduction of postoperative infection rates.

Use of routine intra operativecholangiography during LC.

1 Cohort studies5 case series

Low There is scarce evidence about the need of RIOC duringLC and results do not support its use.

LC-related bile duct injuries. 1 C ase controlstudies2 C ross-sectionalstudies3 case series

Moderate Higher risk of bile duct injuries mainly associated withexperience, which often requires more complex repairsurgeries.

Technological variants forLC.

13 RCTs2 Cohort studies6 case series

Low Multiple variants for LC have been described; however,there is little evidence for their effectiveness.

LC as short-stay majorsurgery.

1 Cohort studies4 case series

Low No evidence of major complications of outpatient LC.

High Two-stage surgery is the most appropriate strategy forhigh-risk patients.

Effectiveness of laparoscopictreatment for common bileduct lithiasis.

5 SR1 RCT1 CPG3 Cohort studies3 case series

Low One-time laparoscopic treatment has been incorporatedfor low-risk patients. Use of biliary endoprosthesis afterbile duct laparoscopic exploration may be a s afe,effective alternative as compared with the implantation ofa Kehr drainage.

LC: laparoscopic cholecystectomy; SR: systematic reviews; RCT: randomised clinical trial; CPG: clinical practice guideline; RIOC: routine intraoperativecholangiography.High quality: it is very unlikely that future studies change our confidence in the estimate of effect and therefore our confidence is high. Moderate quality:it is likely that future studies change our confidence in the estimate of effect. Low quality: it very likely that future studies change our confidence in theestimate of effect, therefore our confidence is low.

Table I. Evidence Table.


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2001; Elder, 1996; Finan, 2006; Zacks, 2002; Collet, 1997;Ibrahim, 2006; Weber, 2003; Feldman, 1994; Perez Lara,2006; Sungler, 2000; Daradkeh, 1999; Ji, 2005; Fernandes,2000; Palanivelu, 2006; da Silveira, 2006; Gurusamy, 2006;Chandler, 2000; Kiviluoto, 1998; Glavic, 2001; Eldar, 1998;Lujan, 1995; Tan, 2006; Perez-Morales, 2005; Bagia, 2001;Schafer, 2003; Kwon, 2001; Woods, 1996).

Antibiotic prophylaxis in low-risk patientsundergoing LC does not offer any additional benefits interms of reduction of postoperative infection rates (Highquality evidence). There is little available evidence on theneed for routine intraoperative cholangiography during LCand results so far do not support its use (Low qualityevidence). Several variants of LC have been described, butevidence about their effectiveness is scarce (Low qualityevidence). On the other hand, there is no evidence of majorcomplications with outpatient LC (Low quality evidence)(Al-Ghnaniem, 2003; Koc, 2003; Harling, 2000; SIGN,2004; Ladocsi, 1997; Millat, 1997; Thornton, 2002; Kitano,1993; Barczynski, 2004; Nande, 2002; Trichak, 2003;Novitsky, 2005; Lai, 2003; Zhou, 2006; Corbitt, 1991;Bordelon, 1993; Lane GE, 1993; Janssen, 2003; Cengiz,2005; Edelman, 1995; Shekarriz, 2003; Bencini, 2003;Yano, 2003; Verma, 2006; Grace, 1991; Martinez Vieira,2004; Lau, 2002; Pattillo, 2004; Bueno Lledo, 2006).

Regarding laparoscopic treatment for CBDL theavailable evidence suggests that two-stage surgery is themost appropriate strategy for high-risk patients (Highquality evidence). For low-risk patients the one-steplaparoscopic treatment has progressively been incorporatedinto clinical practice. Furthermore, the use of biliaryendoprosthesis after bile duct laparoscopic exploration maybe a safe and effective alternative as compared with theimplantation of a Kehr tube (Low quality evidence) (Smith,1997; Joyce, 1991; Prat, 1996; Costi, 2007; Trondsen, 1998;Liu, 2001; Cuschieri, 1999; Wei, 2003; Gurusamy, 2007;Griniatsos, 2005; KimK, 2004; Lien, 2005; Decker, 2003;Fanelli, 2001).

From the present overview we can conclude thatstudies with a better methodological quality are warrantedto assess the issues reported here. In the LC context, theeffectiveness and safety of laparoscopic therapy versusconventional surgery should be assessed in low-riskpatients. Other issues yet to be clarified are the need or notfor antibiotic prophylaxis in high-risk patients and the cost-effectiveness of LC and its different technological variants.For CBDL, the effectiveness and safety of laparoscopictreatment versus conventional surgery in low-risk patientsshould be established. Finally, the effectiveness and safetyof one-time laparoscopic treatment versus two-stage surgery

in low-risk patients and also the effectiveness ofcholedochorraphy without endoprosthesis should bedetermined (Table I).

Despite the wide implementation of laparoscopicprocedures the available evidence for their effectivenessin the treatment of gallstones and CBDL is scarce and oflow methodological quality. Adequately powered head-to-head studies are warranted in order to clarify these issues.These trials should have a rigorous design with participantsbeing randomised to clinicians who will only undertakethe intervention they are expert in (Howes, 1997).

ACKNOWLEDGEMENTS

This overview was conducted under the direction ofthe Andalusian Agency for Health Technology Assessmentwithin the collaboration framework established in theNational Health System Quality Plan, thanks to theagreement between the Carlos III Institute (Ministry ofHealth) and the Foundation Progress and Health.

We would like to express our gratitude to CarolynNewey for her help reviewing and editing of this overview.

MANTEROLA, C.; PINEDA, V.; TORT, M.;TARGARONA, E.; VILLEGAS, P. R. & ALONSO, P.Efectividad de la cirugía laparoscópica para colecistolitiasisy coledocolitiasis: Revisión global de la evidencia. Int. J.Morphol., 28(3):729-742, 2010.

RESUMEN: El objetivo del presente estudio fue evaluarla evidencia disponible respecto de la efectividad de la cirugíalaparoscópica en el tratamiento de la colelitiasis y la litiasis de lavía biliar (LVBP). Para ello, se realizó una revisión global de laevidencia disponible. Se realizaron búsquedas en las bases de da-tos MEDLINE, EMBASE y The Cochrane Library (1998-2008).Se incluyeron guías de práctica clínica (GPC), revisiones sistemá-ticas (RS), ensayos clínicos con asignación aleatoria (EC) y estu-dios observacionales. Se valoró la validez interna y la calidad glo-bal de los estudios. Los datos disponibles y la evidencia generadase clasificaron en base a la propuesta del Centro de Oxford de Me-dicina Basada en la Evidencia. 87 estudios fueron incluidos en estarevisión (3 GPC, 12 RS, 23 EC, 13 estudios de cohortes, 3 estu-dios transversales, 2 estudios de casos y de controles y 31 series decasos). En comparación con la colecistectomía abierta, lacolecistectomía laparoscópica (CL) se asocia con menor tiempooperatorio y estancia hospitalaria y mejor calidad de vida (eviden-cia de alta calidad). El uso de profilaxis antibiótica no parece redu-cir la tasa de infección en pacientes de bajo riesgo (evidencia dealta calidad). Aunque se han descrito numerosas técnicas para rea-lizar una CL, su eficacia no es aún concluyente (evidencia de baja


737

calidad). La cirugía en dos etapas es la estrategia más adecuadapara los pacientes de alto riesgo con LVBP (evidencia de alta cali-dad). La mortalidad del tratamiento laparoscópico de la LVBP essimilar a la de la cirugía abierta; y como su eficacia es similar a ladel tratamiento endoscópico (evidencia de alta calidad). Se puedeconcluir señalando que la evidencia disponible respecto de la efec-tividad de la cirugía laparoscópica para el tratamiento de lacolelitiasis y la LVBP es escasa y de baja calidad metodológica; yque se requieren estudios de mejor calidad para valorar de formamás apropiada estas técnicas.

PALABRAS CLAVE: Colelitiasis; Colecistolitiasis;Coledocolitiasis; Cálculos biliares; Laparoscopia;Colecistectomía laparoscópica; Evaluación de tecnología sani-taria.

REFERENCES

Al-Ghnaniem, R.; Benjamin, I.S. & Patel A.G. Meta-analysissuggests antibiotic prophylaxis is not warranted in low-risk patients undergoing laparoscopic cholecystectomy.Br. J. Surg., 90:365-66, 2003.

A.N.D.E.M. Agence Nationale pour le Développement del’Évaluation Médicale. Evaluation des methodescoelioscopiques en chirurgie digestive, 1994.

Archer, S. B.; Brown, D. W.; Smith, C. D.; Branum, G. D.& Hunter, J. G. Bile duct injury during laparoscopiccholecystectomy: results of anational survey. Ann. Surg.,234:549-58, 2001.

Bagia, J. S.; North, L. & Hunt, D. R. Mirizzi syndrome: anextra hazard for laparoscopic surgery. ANZ J. Surg.,71:394-97, 2001.

Barczynski, M. & Herman, R. M. Low-pressurepneumoperitoneum combined with intraperitoneal salinewashout for reduction of pain after laparoscopiccholecystectomy: A prospective randomized study. Surg.Endosc., 18:1368-73, 2004.

Bencini, L.; Boffi, B.; Farsi, M.; Sanchez, L. J.; Scatizzi;M. & Moretti R. Laparoscopic cholecystectomy:retrospective comparative evaluation of titanium versusabsorbable clips. J. Laparoendosc. Adv. Surg. Tech. A,13:93-8, 2003.

Bordelon, B. M.; Hobday, K. A. & Hunter, J. G. Laser vselectrosurgery in laparoscopic cholecystectomy. Aprospective randomized trial. Arch. Surg., 128:233-6,1993.

Bueno Lledo, J.; Planells Roig, M.; Arnau Bertomeu, C.;Sanahuja Santafe, A.; Oviedo Bravo, M.; Garcia Espi-nosa, R.; Marti Obiol, R. & Espi Salinas, A. Outpatientlaparoscopic cholecystectomy: a new gold standard forcholecystectomy. Rev. Esp. Enferm. Dig., 98:14-24,2006.

Calik, A.; Topaloglu, S.; Topcu, S.; Turkyilmaz, S.;Kucuktulu, U. & Piskin B. Routine intraoperativeaspiration of gallbladder during laparoscopiccholecystectomy. Surg. Endosc., 21:1578-81, 2007.

Caliskan, K.; Nursal, T. Z. & Yildirim, S. Hydrodissectionwith adrenaline-lidocaine-saline solution in laparoscopiccholecystectomy. Langenbecks Arch. Surg., 391:359-63,2006.

Carr-Locke, A. D. 'Biliary stenting alone versus biliarystenting plus sphincterotomy for the treatment of post-laparoscopic cholecystectomy bile leaks'. Eur. J.Gastroenterol. Hepatol., 18:1053-5, 2006.

Cengiz, Y.; Janes, A.; Grehn, A. & Israelsson, L. A.Randomized trial of traditional dissection withelectrocautery versus ultrasonic fundus-first dissectionin patients undergoing laparoscopic cholecystectomy. Br.J. Surg., 92:810-3, 2005.

Chandler, C. F.; Lane, J. S.; Ferguson, P.; Thompson, J. E.& Ashley, S. W. Prospective evaluation of early versusdelayed laparoscopic cholecystectomy for treatment ofacute cholecystitis. Am. Surg., 66:896-900, 2000.

Clayton, E. S.; Connor, S.; Alexakis, N. & Leandros, E. Meta-analysis of endoscopy and surgery versus surgery alonefor common bile duct stones with the gallbladder in situ.Br. J. Surg., 93:1185-91, 2006.

Collet, D. Laparoscopic cholecystectomy in 1994. Resultsof a prospective survey conducted by SFCERO on 4,624cases. Societe Francaise de Chirurgie Endoscopique etRadiologie Operatoire. Surg. Endosc., 11:56-63, 1997.

Corbitt J. D. Jr. Laparoscopic cholecystectomy: laser versuselectrosurgery. Surg. Laparosc. Endosc., 1:85-8, 1991.

Costi, R.; DiMauro, D. & Mazzeo, A. Routine laparoscopiccholecystectomy after endoscopic sphincterotomy forcholedocholithiasis in octogenarians: is it worth the risk?Surg. Endosc., 21:41-7, 2007.

Cuschieri, A.; Lezoche, E.; Morino, M.; Croce, E.; Lacy, A.& Toouli, J. E.A.E.S. multicenter prospective


738

randomized trial comparing two-stage vs single-stagemanagement of patients with gallstone disease and ductalcalculi. Surg. Endosc., 13:952-7, 1999.

Daradkeh, S.; Sumrein, I.; Daoud, F.; Zaidin, K. & Abu-Khalaf, M. Management of gallbladder stones duringpregnancy: conservative treatment or laparoscopiccholecystectomy? Hepatogastroenterology, 46:3074-6, 1999.

da Silveira, E. B. Outcome of cirrhotic patients undergoingcholecystectomy: applying Bayesian analysis ingastroenterology. J. Gastroenterol. Hepatol., 21:958-62, 2006.

Decker, G.; Borie, F.; Millat, B.; Berthou, J. C.; Deleuze,A. & Drouard, F. One hundred laparoscopiccholedochotomies with primary closure of thecommon bile duct. Surg. Endosc., 17:12-8, 2003.

Devereaux, P. J.; Bhandari, M.; Clarke, M.; Montori, V.M.; Cook, D. J. & Yusuf, S. Need for expertise-basedrandomised controlled trials. BMJ, 330(7482):88,2005.

Downs, S. H. Systematic review of the effectiveness andsafety of laparoscopic cholecystectomy. Ann. R. Coll.Surg. Engl., 78(3 Part 2):241-323, 1996.

Edelman, D. S. & Unger, S. W. Bipolar versus monopolarcautery scissors for laparoscopic cholecystectomy: arandomized, prospective study. Surg. Laparosc.Endosc., 5:459-62, 1995.

Elder, S.; Kunin, J.; Chouri, H.; Sabo, E.; Matter, I.; Nash,E. & Schein, M. Safety of laparoscopiccholecystectomy on a teaching service: a prospectivetrial. Surg. Laparosc. Endosc., 6:218-20, 1996.

Elder, S.; Sabo, E.; Nash, E.; Abrahamson, J. & Matter, I.Laparoscopic cholecystectomy for the various typesof gallbladder inflammation: a prospective trial. Surg.Laparosc. Endosc., 8:200-7, 1998.

Fanelli, R. D. & Gersin, K. S. Laparoscopic endobiliarystenting: a simplified approach to the management ofoccult common bile duct stones. J. Gastrointest. Surg.,5:74-80, 2001.

Feldman, M. G.; Russell, J. C.; Lynch, J. T. & Mattie, A.Comparison of mortality rates for open and closedcholecystectomy in the elderly: Connecticut statewidesurvey. J. Laparoendosc. Surg., 4:165-72, 1994.

Fernandes, N. F.; Schwesinger, W. H. & Hilsenbeck, S. G.Laparoscopic cholecystectomy and cirrhosis: a case-con-trol study of outcomes. Liver Transpl., 6:340-4, 2000.

Finan, K. R.; Leeth, R. R.; Whitley, B. M.; Klapow, J. C. &Hawn, M. T. Improvement in gastrointestinal symptomsand quality of life after cholecystectomy. Am. J. Surg.,192:196-202, 2006.

Glavic, Z.; Begic, L.; Simlesa, D. & Rukavina, A. Treatmentof acute cholecystitis. A comparison of open vslaparoscopic cholecystectomy. Surg. Endosc., 15:398-401, 2001.

Grace, P. A.; Quereshi, A.; Coleman, J.; Keane, R.; McEntee,G. & Broe, P. Reduced postoperative hospitalization afterlaparoscopic cholecystectomy. Br. J. Surg., 78:160-2,1991.

Griniatsos, J.; Karvounis, E.; Arbuckle, J. & Isla, A. M. Cost-effective method for laparoscopic choledochotomy. ANZJ. Surg., 75:35-8, 2005.

Gurusamy, K. S. & Samraj, K. Early versus delayedlaparoscopic cholecystectomy for acute cholecystitis.Cochrane Database Syst. Rev., (4):CD005440, 2006.

Gurusamy, K. & Samraj, K. Primary closure versus T-tubedrainage after laparoscopic common bile duct stoneexploration. Cochrane Database Syst. Rev.,(1):CD005641, 2007.

Guyatt, G.; Gutterman, D.; Baumann, M. H.; Addrizzo-Harris, D.; Hylek, E. M. & Phillips, B. Grading strengthof recommendations and quality of evidence in clinicalguidelines: report from an american college of chestphysicians task force. Chest, 129:174-81, 2006.

Hamouda, A. H.; Goh, W.; Mahmud, S.; Khan, M. & Nassar,A. H. Intraoperative cholangiography facilitates simpletranscystic clearance of ductal stones in units withoutexpertise for laparoscopic bile duct surgery. Surg.Endosc., 21:955-99, 2007.

Harling, R.; Moorjani, N.; Perry, C.; MacGowan, A. P. &Thompson, M. H. A prospective, randomised trial ofprophylactic antibiotics versus bag extraction in theprophylaxis of wound infection in laparoscopiccholecystectomy. Ann. R. Coll. Surg. Engl., 82:408-10,2000.

Howes, N.; Chagla, L.; Thorpe, M. & McCulloch, P. Surgicalpractice is evidence based. Br. J. Surg., 84:1220-3, 1997.


739

Ibrahim, S.; Hean, T. K.; Ho, L. S.; Ravintharan, T.; Chye,T. N. & Chee, C. H. Risk factors for conversion to opensurgery in patients undergoing laparoscopiccholecystectomy. World J. Surg., 30:1698-704, 2006.

Janssen, I. M.; Swank, D. J.; Boonstra, O.; Knipscheer, B.C.; Klinkenbijl, J. H. & van Goor, H. Randomizedclinical trial of ultrasonic versus electrocautery dissectionof the gallbladder in laparoscopic cholecystectomy. Br.J. Surg., 90:799-803, 2003.

Jaffray, B. Minimally invasive surgery. Arch. Dis. Child,90:537-42, 2005.

Ji, W.; Li, L. T.; Wang, Z. M.; Quan, Z. F.; Chen, X. R. & Li,J. S. A randomized controlled trial of laparoscopic ver-sus open cholecystectomy in patients with cirrhotic por-tal hypertension. World J. Gastroenterol., 11:2513-17,2005.

Joyce, W. P.; Keane, R.; Burke, G. J.; Daly, M.; Drumm, J.;Egan, T. J. 6 Delaney, P. V. Identification of bile ductstones in patients undergoing laparoscopiccholecystectomy. Br. J. Surg., 78:1174-6, 1991.

Keus, F.; de Jong, J. A.; Gooszen, H. G. & van Laarhoven,C. J. Laparoscopic versus open cholecystectomy forpatients with symptomatic cholecystolithiasis. CochraneDatabase Syst. Rev., (4):CD006231, 2006.

Keus, F.; de Jong, J. A.; Gooszen, H. G. & van Laarhoven,C. J. Laparoscopic versus small-incisioncholecystectomy for patients with symptomaticcholecystolithiasis. Cochrane Database Syst. Rev.,(4):CD006229, 2006.

Korolija, D.; Sauerland, S.; Wood-Dauphinee, S.; Abbou,C. C.; Eypasch, E. & Caballero, M. G. Evaluation ofquality of life after laparoscopic surgery: evidence-basedguidelines of the European Association for EndoscopicSurgery. Surg. Endosc., 18:879-97, 2004.

Kim, E. K. & Lee, S. K. Laparoscopic treatment ofcholedocholithiasis using modified biliary stents. Surg.Endosc., 18:303-6, 2004.

Kitano, S.; Iso, Y.; Tomikawa, M.; Moriyama, M. &Sugimachi, K. A prospective randomized trial comparingpneumoperitoneum and U-shaped retractor elevation forlaparoscopic cholecystectomy. Surg. Endosc., 7:311-4,1993.

Kiviluoto, T.; Siren, J.; Luukkonen, P. & Kivilaakso, E.

Randomised trial of laparoscopic versus opencholecystectomy for acute and gangrenous cholecystitis.Lancet, 1(9099):321-5, 1998.

Koc, M.; Zulfikaroglu, B.; Kece, C. & Ozalp, N. Aprospective randomized study of prophylactic antibioticsin elective laparoscopic cholecystectomy. Surg. Endosc.,17:1716-8, 2003.

Kwon, A. H.; Inui, H. & Kamiyama, Y. Laparoscopicmanagement of bile duct and bowel injury duringlaparoscopic cholecystectomy. World J. Surg., 25:856-61, 2001.

Ladocsi, L. T.; Benitez, L. D.; Filippone, D. R. & Nance, F.C. Intraoperative cholangiography in laparoscopiccholecystectomy: a review of 734 consecutive cases. Am.Surg., 63:150-6, 1997.

Lai, E. C.; Fok, M. & Chan, A. S. Needlescopiccholecystectomy: prospective study of 150 patients.Hong Kong Med. J., 9:238-42, 2003.

Lane, G. E. & Lathrop, J. C. Comparison of results of KTP/532 laser versus monopolar electrosurgical dissectionin laparoscopic cholecystectomy. J. Laparoendosc. Surg.,3:209-14, 1993.

Lau, H. & Brooks, D. C. Transitions in laparoscopiccholecystectomy: the impact of ambulatory surgery.Surg. Endosc., 16:323-6, 2002.

Lien, H. H.; Huang, C. C.; Huang, C. S.; Shi, M. Y.; Chen,D. F.; Wang, N. Y. & Tai, F. C. Laparoscopic commonbile duct exploration with T-tube choledochotomy forthe management of choledocholithiasis. J.Laparoendosc. Adv. Surg. Tech. A, 15:298-302, 2005.

Litynski, G. S. Profiles in laparoscopy: Mouret, Dubois, andPerissat: the laparoscopic breakthrough in Europe (1987-1988). JSLS, 3:163-7, 1999.

Liu, T. H.; Consorti, E. T.; Kawashima, A.; Tamm, E. P.;Kwong, K. L. & Gill, B. S. Patient evaluation andmanagement with selective use of magnetic resonancecholangiography and endoscopic retrogradecholangiopancreatography before laparoscopiccholecystectomy. Ann. Surg., 234:33-40, 2001.

Lujan, J. A.; Parrilla, P.; Robles, R.; Torralba, J. A.; GarciaAyllon, J.; Liron, R. & Sanchez-Bueno, F. Laparoscopiccholecystectomy in the treatment of acute cholecystitis.J. Am. Coll. Surg., 181:75-7, 1995.


740

Machi, J.; Oishi, A. J.; Tajiri, T.; Murayama, K. M.;Furumoto, N. L. & Oishi, R. H. Routine laparoscopicultrasound can significantly reduce the need for selectiveintraoperative cholangiography during cholecystectomy.Surg. Endosc., 21:270-4, 2007.

Martin, D. J.; Vernon, D. R. & Toouli, J. Surgical versusendoscopic treatment of bile duct stones. CochraneDatabase Syst. Rev., (2):CD003327, 2006.

Martinez Vieira, A.; Docobo Durantez, F.; Mena Robles, J.;Duran Ferreras, I.; Vazquez Monchul, J.; Lopez Bernal,F. & Romero Vargas, E.Laparoscopic cholecystectomyin the treatment of biliary lithiasis: outpatient surgery orshort stay unit? Rev. Esp. Enferm. Dig., 96:452-5, 456-9, 2004.

Mavrogiannis, C.; Liatsos, C.; Papanikolaou, I. S.;Karagiannis, S.; Galanis, P. & Romanos, A. Biliarystenting alone versus biliary stenting plus sphincterotomyfor the treatment of post-laparoscopic cholecystectomybiliary leaks: a prospective randomized study. Eur. J.Gastroenterol. Hepatol., 18:405-9, 2006.

Matthews, J. B. Minimally invasive surgery: how goes therevolution? Gastroenterology, 116:513, 1999.

Millat, B.; Deleuze, A.; de Saxce, B.; de Seguin, C. &Fingerhut, A. Routine intraoperative cholangiographyis feasible and efficient during laparoscopiccholecystectomy. Hepatogastroenterology, 44:22-7,1997.

Mimica, Z.; Biocic, M.; Bacic, A.; Banovic, I.; Tocilj, J. &Radonic, V. Laparoscopic and laparotomiccholecystectomy: a randomized trial comparingpostoperative respiratory function. Respiration,67:153-8, 2000.

Mohiuddin, K.; Nizami, S.; Fitzgibbons, R. J. Jr; Watson,P.; Memon B. & Memon, M. A. Predicting iatrogenicgall bladder perforation during laparoscopiccholecystectomy: a multivariate logistic regressionanalysis of risk factors. ANZ J. Surg., 76:130-2, 2006.

Morino, M.; Baracchi, F.; Miglietta, C.; Furlan, N.; Ragona,R. & Garbarini, A. Preoperative endoscopicsphincterotomy versus laparoendoscopic rendezvousin patients with gallbladder and bile duct stones. Ann.Surg., 244:889-93, 2006.

Nande, A. G.; Shrikhande, S. V.; Rathod, V.; Adyanthaya,K. & Shrikhande, V. N. Modified technique of gasless

laparoscopic cholecystectomy in a developing country:a 5-year experience. Dig. Surg., 19:366-71, 2002.

Novitsky, Y. W.; Kercher, K. W. & Czerniach, D.Advantages of mini-laparoscopic vs conventionallaparoscopic cholecystectomy: results of a prospectiverandomized trial. Arch. Surg., 140:1178-83, 2005.

Nuzzo, G.; Giuliante, F. & Giovannini, I. Bile duct injuryduring laparoscopic cholecystectomy: results of anItalian national survey on 56 591 cholecystectomies.Arch. Surg., 140:986-992, 2005.

O.C.E.B.M. Centre for Evidence-Based Medicine.Available from: http://cebm.jr2.ox.ac.uk access on 6June 2006.

Paganini, A. M.; Guerrieri, M. & Sarnari, J. Thirteen years'experience with laparoscopic transcystic common bileduct exploration for stones. Effectiveness and long-term results. Surg. Endosc., 21:34-40, 2007.

Palanivelu, C.; Rajan, P. S. & Jani, K. Laparoscopiccholecystectomy in cirrhotic patients: the role ofsubtotal cholecystectomy and its variants. J. Am. Coll.Surg., 203:145-51, 2006.

Pattillo, J. C.; Kusanovic, R.; Salas, P.; Reyes, J.; Garcia-Huidobro, I. & Sanhueza, M. Outpatient laparoscopiccholecystectomy. Experience in 357 patients. Rev. Med.Chil., 132:429-36, 2004.

Perez Lara, F. J.; de Luna Diaz, R.; Moreno Ruiz, J.;Suescun Garcia, R.; del Rey Moreno, A.; HernandezCarmona, J. & Oliva Munoz, H. Laparoscopiccholecystectomy in patients over 70 years of age: reviewof 176 cases. Rev. Esp. Enferm. Dig., 98:42-8, 2006.

Perez-Morales, A.; Roesch-Dietlen, F.; Diaz-Blanco, F. &Martinez-Fernandez, S. Safety of laparoscopiccholecystectomy in complicated vesicular disease. Cir.Cir., 73:15-8, 2005.

Perissat, J.; Collet, D. R. & Belliard, R. Gallstones:laparoscopic treatment, intracorporeal lithotripsyfollowed by cholecystostomy or cholecystectomy--apersonal technique. Endoscopy, 21(1):373-4, 1989.

Pichon Riviere, A.; Augustovski, F.; Bardach, A.; GarciaMarti, S.; Lopez, A. & Glujovsky, D. Laparoscopyusefulness in the management of biliary tract stones.Buenos Aires, Institute for Clinical Effectiveness andHealth Policy (IECS), 2005.


741

Prat, F.; Amouyal, G.; Amouyal, P.; Pelletier, G.; Fritsch, J.& Choury, A. D. Prospective controlled study ofendoscopic ultrasonography and endoscopic retrogradecholangiography in patients with suspected common bileduct lithiasis. Lancet, 347:75-9, 1996.

Regoly-Merei, J.; Ihasz, M.; Szeberin, Z.; Sandor, J. & Mate,M. Biliary tract complications in laparoscopiccholecystectomy. A multicenter study of 148 biliary tractinjuries in 26, 440 operations. Surg. Endosc., 12:294-300,1998.

Reynolds, W. Jr. The first laparoscopic cholecystectomy. JSLS,5:89-94, 2001.

Ros, A.; Gustafsson, L.; Krook, H.; Nordgren, C.E.; Thorell,A.; Wallin, G. & Nilsson, E. Laparoscopiccholecystectomy versus mini-laparotomycholecystectomy: a prospective, randomized, single-blindstudy. Ann. Surg., 234:741-9, 2001.

Sarmiento, J. M.; Farnell, M. B.; Nagorney, D. M.; Hodge,D. O. & Harrington, J. R. Quality-of-life assessment ofsurgical reconstruction after laparoscopiccholecystectomy-induced bile duct injuries: what happensat 5 years and beyond? Arch. Surg., 139:483-8, 2004.

Schafer, M.; Schneiter, R. & Krahenbuhl, L. Incidence andmanagement of Mirizzi syndrome during laparoscopiccholecystectomy. Surg. Endosc., 17:1186-90, 2003.

Shekarriz, H.; Shekarriz, B. & Kujath, P. Hydro-Jet-assistedlaparoscopic cholecystectomy: a prospective randomizedclinical study. Surgery, 133:635-40, 2003.

Sicklick, J. K.; Camp, M. S.; Lillemoe, K. D.; Melton, G. B.;Yeo, C. J.; Campbell, K. A; Talamini, M. A.; Pitt H. A.;Coleman, J.; Sauter, P. A.& Cameron, J. L. Surgicalmanagement of bile duct injuries sustained duringlaparoscopic cholecystectomy: perioperative results in200 patients. Ann. Surg., 241:786-92, 2005.

S.I.G.N. Scottish Intercollegiate Guidelines Network. SIGN50: a guidelines developers’ handbook. Edinburgh, SIGN,2004.

Smith, M. 2nd; Wheeler, W. & Ulmer, M. B. Comparison ofoutpatient laparoscopic cholecystectomy in a privatenonteaching hospital versus a private teaching communityhospital. JSLS, 1:51-3, 1997.

Sungler, P.; Heinerman, P. M. & Steiner, H. Laparoscopiccholecystectomy and interventional endoscopy for

gallstone complications during pregnancy. Surg.Endosc., 14:267-71, 2000.

Tan, J. T.; Suyapto, D. R.; Neo, E. L. & Leong, P. S.Prospective audit of laparoscopic cholecystectomyexperience at a secondary referral centre in South Aus-tralia. ANZ J. Surg., 76:335-8, 2006.

Targarona, E. M.; Marco, C.; Balague, C.; Rodriguez, J.;Cugat; E.; Hoyuela, C.; Veloso, E. & Trias, M. How,when, and why bile duct injury occurs. A comparisonbetween open and laparoscopic cholecystectomy. Surg.Endosc., 12:322-6, 1998.

Thornton, D. J.; Robertson, A. & Alexander, D. J.Laparoscopic cholecystectomy without routine operativecholangiography does not result in significant problemsrelated to retained stones. Surg. Endosc., 16:592-5, 2002.

Tranter, S. E. & Thompson, M. H. Comparison of endoscopicsphincterotomy and laparoscopic exploration of thecommon bile duct. Br. J. Surg., 89:1495-504, 2002.

Trichak, S. Three-port vs standard four-port laparoscopiccholecystectomy. Surg. Endosc., 17:1434-6, 2003.

Troidl, H. Disasters of endoscopic surgery and how to avoidthem: error analysis. World J. Surg., 23:846-55, 1999.

Trondsen, E.; Edwin, B.; Reiertsen, O.; Faerden, A. E.;Fagertun, H. & Rosseland, A. R. Prediction of commonbile duct stones prior to cholecystectomy. Arch. Surg.,133:162-6, 1998.

Vecchio, R.; MacFayden, B. V. & Palazzo, F. History oflaparoscopic surgery. Panminerva Med., 42:87-90, 2000.

Verma, G. R.; Lyngdoh, T. S.; Kaman, L. & Bala, I.Placement of 0.5% bupivacaine-soaked Surgicel in thegallbladder bed is effective for pain after laparoscopiccholecystectomy. Surg. Endosc., 20:1560-4, 2006.

Vial, M.; Manterola, C.; Pineda, V. & Losada, H.Coledocolitiasis. Elección de una terapia basada en laevidencia. Revisión sistemática de la literatura. Rev. Chil.Cir., 57:404-11, 2005.

Weber, D. M. Laparoscopic surgery: an excellent approachin elderly patients. Arch. Surg., 138:1083-8, 2003.

Wei, Q.; Wang, J. G.; Li, L. B. & Li, J. D. Management ofcholedocholithiasis: comparison between laparoscopiccommon bile duct exploration and intraoperative


742

endoscopic sphincterotomy. World J. Gastroenterol.,9:2856-8, 2003.

Weil, B. Cholelithiasis: therapeutic strategy. Report froman European concensus conference. Gastroenterol. Clin.Biol., 16:251-4, 1992.

Woods, M. S. Estimated costs of biliary tract complicationsin laparoscopic cholecystectomy based upon Medicarecost/charge ratios. A case-control study. Surg. Endosc.,10:1004-7, 1996.

Yano, H.; Okada, K.; Kinuta, M.; Nakano, Y.; Tono, T.;Matsui, S.; Iwazawa, T.; Kanoh, T. & Monden, T.Efficacy of absorbable clips compared with metal clipsfor cystic duct ligation in laparoscopic cholecystectomy.Surg. Today, 33:18-23, 2003.

Yeh, C. N.; Jan, Y. Y.; Liu, N. J.; Yeh, T. S. & Chen, M. F.Endo-GIA for ligation of dilated cystic duct duringlaparoscopic cholecystectomy: an alternative, novel, andeasy method. J. Laparoendosc. Adv. Surg. Tech. A,14:153-7, 2004.

Young-Fadok, T. M.; Smith, C. D. & Sarr, M. G.Laparoscopic minimal-access surgery: where are wenow? Where are we going? Gastroenterology, 118:S148-65, 2000.

Zacks, S. L.; Sandler, S. R.; Rutledge, R. & Brown, S. R. Jr.A population-based cohort study comparing laparoscopiccholecystectomy and open cholecystectomy. Am. J.Gastroenterol., 97:334-40, 2002.

Zhou, H. X.; Guo, Y. H.; Yu, X. F.; Bao, S. Y.; Liu, J. L.;Zhang, Y. & Ren, Y. G. Zeus robot-assisted laparoscopiccholecystectomy in comparison with conventionallaparoscopic cholecystectomy. Hepatobiliary Pancreat.Dis. Int., 5:115-8, 2006.

Correspondence to:

Dr. Carlos Manterola

Department of Surgery

Universidad de La Frontera.

Casilla 54-D, Temuco

CHILE

Phone: 56-45-325760

Fax: 56-45-325761

Email: [email protected]

Received: 19-03-2010

Accepted: 25-05-2010


REVIEW

The role of staging laparoscopy for intraabdominal cancers:an evidence-based review

L. Chang Æ D. Stefanidis Æ W. S. Richardson ÆD. B. Earle Æ R. D. Fanelli

Received: 6 May 2008 / Accepted: 8 July 2008 / Published online: 24 September 2008

� Springer Science+Business Media, LLC 2008

Abstract Diagnostic laparoscopy is minimally invasive

surgery for the diagnosis of intraabdominal diseases. The

aim of this review is a critical examination of the available

literature on the role of laparoscopy for the staging of

intraabdominal cancers. A systematic literature search of

English-language articles on MEDLINE, the Cochrane

database of evidence-based reviews, and the Database of

Abstracts of Reviews of Effects was performed for the

period 1995–2006. The level of evidence in the identified

articles was graded. The search identified and reviewed

seven main categories that have received attention in the

literature: esophageal cancer, gastric cancer, pancreatic

cancer, hepatocellular carcinoma, biliary tract cancer,

colorectal cancer, and lymphoma. The indications, con-

traindications, risks, benefits, diagnostic accuracy of the

procedure, and its associated morbidity are discussed. The

limitations of the available literature are highlighted, and

evidence-based recommendations for the use of laparos-

copy to stage intraabdominal cancers are provided.

Keywords Diagnostic laparoscopy �Intraabdominal cancer � Staging laparoscopy

Diagnostic laparoscopy is minimally invasive surgery for

the diagnosis of intraabdominal diseases. The procedure

enables direct inspection of large surface areas of intraab-

dominal organs; facilitates obtaining biopsy specimens,

cultures and aspirates; allows the use of laparoscopic

ultrasound; and makes therapeutic intervention possible.

Diagnostic laparoscopy has been applied to many clin-

ical situations with variable success. Its application for the

staging of intraabdominal cancers is known as staging

laparoscopy (SL). This article aims to review and grade the

available evidence (Table 1) on the role of SL for a variety

of intraabdominal cancers.

To achieve our objective, a systematic literature search

of English-language articles on MEDLINE, the Cochrane

database of evidence-based reviews, and the Database of

Abstracts of Reviews of Effects (DARE) was performed

for the period 1995–2006. A detailed description of this

method has been published previously [1]. This review

addresses seven main categories identified and reviewed in

the literature: esophageal cancer, gastric cancer, pancreatic

cancer, hepatocellular carcinoma, biliary tract cancer,

colorectal cancer, and lymphoma.

Staging laparoscopy for esophageal cancer

Patients with esophageal cancer often present with an

advanced stage with lymph-node or even distant

L. Chang (&)

Department of General Surgery, Virginia Mason Medical Center,

1100 Ninth Avenue, Seattle, WA 98101, USA

e-mail: [email protected]; [email protected]

D. Stefanidis

Department of General Surgery, Carolinas Medical Center,

Charlotte, NC, USA

W. S. Richardson

Department of Surgery, Ochsner Clinic, New Orleans, LA, USA

D. B. Earle

Department of Surgery, Baystate Medical Center, Springfield,

MA, USA

R. D. Fanelli

Department of Surgery, Surgical Specialists of Western New

England, PC and Berkshire Medical Center, Pittsfield, MA,

USA

123

Surg Endosc (2009) 23:231–241

DOI 10.1007/s00464-008-0099-2

metastases. For this reason, the overall prognosis for

patients with esophageal cancer is poor.

Patients with advanced cancer commonly undergo pre-

operative chemotherapy and radiation in an attempt to

improve survival. Thus, the value of precise staging is

important to separate patients with an early-stage tumor

who are candidates for immediate curative resection from

those who need neoadjuvant therapy. The most common

radiologic tests used to confirm the stage of the tumor are

computed tomography (CT) scan, endoscopic ultrasound,

and positron emission tomography (PET) scan. Staging

laparoscopy may aid in more accurate staging of esopha-

geal cancers to guide the most appropriate treatment and

avoid nontherapeutic laparotomy.

Staging laparoscopy is most commonly performed with

the patient under general anesthesia in supine position.

After pneumoperitoneum has been safely established, an

angled laparoscope placed through an umbilical port site is

recommended for optimal visualization. Additional ports in

the left upper quadrant and epigastric area can be placed as

needed for tissue manipulation.

Full inspection of the peritoneal cavity is performed to

evaluate for peritoneal or liver metastases. If no distant

disease is discovered initially, then the left lateral lobe of

the liver is elevated to expose the gastroesophageal junc-

tion with the patient placed in steep reverse Trendelenburg

position. The tumor is inspected for extension into the

surrounding area. Biopsies can be performed for lymph

nodes in the gastrohepatic ligament or celiac axis suspected

to be malignant. An optional laparoscopic feeding jeju-

nostomy may be placed if neoadjuvant therapy is planned.

In addition, combined thoracoscopic/laparoscopic stag-

ing has been described to improve staging for esophageal

cancer by increasing the number of positive lymph nodes

identified compared with conventional staging [2]. Spe-

cifically for the thoracoscopic evaluation, the patient is in

full, left lateral decubitus position with single-lung venti-

lation. Two to three thoracic trocars are placed, and the

mediastinal pleura overlying the esophagus is incised to

identify lymph nodes and to perform biopsies for them as

needed.

Staging laparoscopy should be used for patients with

esophageal cancer who are potential candidates for curative

surgical resection based on preoperative staging showing

no evidence of lymph node or distant metastases. Fur-

thermore, the procedure can be used to place enteral

feeding access for patients who are candidates for neoad-

juvant therapy, particularly if percutaneous endoscopic

gastrostomy is not feasible. In contrast, SL is contraindi-

cated for patients with known metastatic disease. In

addition, dense intraabdominal adhesions from prior sur-

gery, particularly in the upper abdomen, may preclude

successful laparoscopy.

Because patients with distant or lymph node metastasis

are best treated with chemotherapy and radiation as neo-

adjuvant therapy or even palliation, SL can potentially

decrease the time to this adjuvant treatment. The average

length of hospital stay after SL typically is only 1–3 days,

which compares favorably with that for open exploration.

Subsequently, this faster postoperative recovery may lead

to a shortened interval to the appropriate therapy. However,

this assumed benefit of earlier adjuvant therapy for patients

with metastatic disease has not been measured specifically

in the literature.

Complications after SL for esophageal cancer are low,

and no mortality has been reported. Potential complications

include bleeding, infection, esophageal injury during

inspection, and the general risks associated with anesthesia.

One report documented perforation at the feeding jeju-

nostomy tube site as well as pulmonary edema due to

unexpected aortic valve stenosis [3]. False-negative diag-

nostic laparoscopy can potentially lead to unnecessary

laparotomy. No adverse oncologic effects of SL for

esophageal cancer have been reported.

When all preoperative imaging indicates no metastatic

disease, SL with or without laparoscopic ultrasound has a

sensitivity of 71% for finding peritoneal metastases, 78%

for finding nodal metastases, and 86% for finding liver

metastases (level 2 evidence) [4]. This compares with

respective ultrasound sensitivities of 14, 11, and 86% and

CT scan sensitivities of 14, 55, and 71% (level 2 evidence)

[4]. The accuracy is reported to be 75–80% (level 3 evi-

dence) [3]. However, several reports indicate that only

0.08–10% of patients actually had a change in their man-

agement based on the results of laparoscopy (levels 2 and 3

evidence) [4, 5].

In the hands of a skilled thoracic surgeon, combined

thoracoscopic and laparoscopic staging can be performed

more than 70% of the time [2]. Compared with final

pathologic staging, thoracoscopic and laparoscopic staging

has a sensitivity of 64%, a specificity of 60%, and an

accuracy of 60% (level 2 evidence) [6].

The available literature has limitations with regard to SL

for esophageal cancer, and no level 1 evidence exists. A

small number of reports have been published by highly

specialized centers, which may make the reproducibility of

their results difficult. In addition, studies differ in their

Table 1 Levels of evidence

Level 1 Evidence from properly conducted randomized,

controlled trials

Level 2 Evidence from controlled trials without randomization

Cohort or case-control studies

Multiple time series dramatic uncontrolled experiments

Level 3 Descriptive case series, opinions of expert panels

232 Surg Endosc (2009) 23:231–241

123

technique and intended hypotheses. The impact of the

surgeon’s expertise on the diagnostic accuracy of the pro-

cedure is unknown. Thus, the overall analysis of SL for

esophageal cancer is difficult given the inconsistency of the

reported data.

Summary of SL for esophageal cancer

Based upon our review of the literature, diagnostic lapa-

roscopy for staging can be performed safely for patients

with esophageal cancer. Patients considered to be candi-

dates for curative resection (with early-stage esophageal

cancer and no evidence for distant or lymph node metas-

tases on high-quality preoperative imaging) may benefit

from SL. Laparoscopy also provides the opportunity for

enteral feeding tube placement without the need for lapa-

rotomy. The procedure also may facilitate a shorter time to

adjuvant therapy initiation than laparotomy, but data are

limited, and additional research is needed to elucidate the

true value of diagnostic laparoscopy in this setting.

Staging laparoscopy for gastric cancer

Because many patients with gastric cancer present with

locally advanced or metastatic disease, accurate staging of

gastric cancer aids in the appropriate treatment selection

for both cure and palliation. Palliative resection may be

indicated for gastric cancer causing obstruction, hemor-

rhage, or perforation. However, surgical resection alone for

patients with advanced disease has not been shown to

improve survival.

Studies investigating neoadjuvant protocols for locally

advanced gastric cancers are ongoing, which makes accu-

rate staging imperative. Moreover, even after many

preoperative radiologic tests (CT scan, endoscopic and

transabdominal ultrasound, and PET scan) for staging of

gastric tumors, a proportion of patients are found at

exploration to have unsuspected, unresectable disease.

Thus, SL may aid in more accurate staging of gastric

cancers and guide appropriate treatment without the mor-

bidity associated with exploratory laparotomy.

The SL procedure is most commonly performed with the

patient under general anesthesia in the supine position.

After safe establishment of pneumoperitoneum, an angled

laparoscope typically is inserted through an umbilical port

site. If present, ascites can be aspirated and sent for

cytology. In the absence of ascites, 200 ml of normal saline

can be instilled into the peritoneal cavity and aspirated

from the pelvis and bilateral subdiaphragmatic spaces for

cytologic examination [7]. Full inspection of the peritoneal

cavity is performed to evaluate for peritoneal or liver

metastases. Laparoscopic ultrasound may aid in the

detection of deep hepatic lesions.

If no metastatic disease is discovered, then the left lat-

eral lobe of the liver is elevated to expose the entire

stomach. The perigastric nodes along the greater and lesser

curvature are inspected, and biopsies are performed if

necessary. In addition, the porta hepatis and gastrohepatic

ligaments are inspected carefully. Next, the gastric tumor

itself is inspected for extraserosal invasion and infiltration

into surrounding structures. If the tumor is posterior, then

the lesser sac must be accessed to gain appropriate

visualization.

Staging laparoscopy is indicated for patients who have

T3 or T4 gastric cancer without evidence of lymph node or

distant metastases on high-quality preoperative imaging.

Accurate preoperative staging determines the most appro-

priate therapy for gastric cancer. Staging laparoscopy can

identify patients with locally advanced disease and

metastasis that may be treated best with neoadjuvant or

palliative chemotherapy rather than surgical resection.

These patients may potentially be spared the risks and

complications of a nontherapeutic laparotomy and may

have a shorter convalescence period with an earlier start of

chemotherapy.

Staging laparoscopy should not be undertaken for

patients with gastric cancer complicated by obstruction,

hemorrhage, or perforation in need of palliative surgery. In

addition, patients with early-stage gastric cancer (T1 or T2)

should proceed directly to surgical resection without SL.

Complications of SL with gastric cancer tend to be rare

and include bleeding, infection, and visceral injury. No

mortality has been reported. Although no direct compari-

sons have been made between SL and exploratory

laparotomy for gastric cancer staging, the average length of

hospital stay after SL is reported to be 1 to 2 days, which

compares favorably with stays after exploratory laparot-

omy for other indications [8, 9]. No adverse oncologic

effects of SL for gastric cancer have been reported.

Staging laparoscopy can identify unsuspected metastatic

disease in 13% to 57% of patients despite negative pre-

operative imaging studies (levels 2 and 3 evidence) [7, 10–

14]. Accuracy is reported to range from 89% to 100% in

different series (levels 2 and 3 evidence) [7, 11–15]. In

addition, exploratory laparotomy has been avoided in 17–

40% of cases (levels 2 and 3 evidence) [7, 8, 13–15]. The

SL procedure is more sensitive (96%) for detecting hepatic

metastasis than either CT (52%) or ultrasound (37%) (level

3 evidence) [15]. Similarly, SL sensitivity also is better for

detecting peritoneal metastasis (laparoscopy, 69%; ultra-

sound, 23%; CT, 8%) (level 3 evidence) [15].

The additional value of laparoscopic ultrasound has not

yet been determined. Peritoneal washings positive for

cancer cells have been demonstrated to correlate with the

extent of disease (T1/T2, 0%; T3/T4, 10%; and M?, 59%)

(level 3 evidence) [16].

Surg Endosc (2009) 23:231–241 233

123

The quality of the available literature on SL for gastric

cancer is limited because no level 1 evidence exists. In

addition, studies differ in their technique and use of lapa-

roscopic ultrasound and peritoneal washings. Many reports

do not clearly state preoperative imaging or postoperative

pathology. The impact of the surgeon’s expertise on the

diagnostic accuracy of the procedure also is unknown. The

reported data are not consistent across studies, making their

analysis difficult.

Summary of SL for gastric cancer

Based on our review of the literature, SL can be performed

safely for patients with gastric cancer. The procedure

should be considered for patients with T3 or T4 tumors

who are thought to have localized or locally advanced

disease according to high-quality preoperative imaging. In

contrast, the procedure has a very low yield for patients

with early-stage disease (T1 or T2) and therefore is not

necessary for this patient population.

Staging laparoscopy for pancreatic cancer

Pancreatic cancer has a dismal overall 5-year survival rate

(\5%), and most patients have inoperable disease at

diagnosis. Even after aggressive preoperative imaging,

many patients are found to have unresectable disease dur-

ing laparotomy. Staging laparoscopy may benefit patients

with pancreatic adenocarcinoma by sparing those with

imaging-occult incurable disease the morbidity, inconve-

nience, and expense of a nontherapeutic operation. In

addition, it may lead to better selection of palliative

treatments for patients with locally advanced disease.

The procedure is performed with the patient under

general anesthesia using initial access near the umbilicus.

Additional ports are placed as necessary to complete a

thorough evaluation of peritoneal surfaces including the

suprahepatic and infrahepatic spaces, surface of the bowel,

lesser sac, root of the transverse mesocolon and small

bowel mesentery, ligament of Treitz, paracolic gutters, and

pelvis. Often, frequent bed position changes are necessary

for full visualization of the aforementioned areas.

In addition to visual inspection, peritoneal washings can

be performed, ascitic fluid can be sent for cytology, and

biopsies of suspicious lesions can be obtained. When no

metastatic disease is identified with inspection, a detailed

laparoscopic ultrasound examination may be used to

evaluate the deep hepatic parenchyma, portal vein, mes-

enteric vessels, celiac trunk, hepatic artery, entire pancreas,

and even periportal and paraaortic lymph nodes. The

addition of color flow Doppler can further assist in the

assessment of vascular patency.

The extent of inspection during SL for pancreatic ade-

nocarcinoma has been controversial. Advocates of a short-

duration procedure based only on inspection of abdominal

organ surfaces argue that the procedure can be performed

quickly (usually within 10–20 min), requires only one port,

does not require significant expertise, minimizes the risk of

potential complications from dissection near vascular

structures, and has good diagnostic accuracy [17, 18].

Conversely, advocates of a more extensive procedure

that includes opening of the lesser sac and assessment of

the vessels argue that the diagnostic accuracy of the pro-

cedure can be enhanced by detection of metastatic lesions

in the lesser sac, vascular invasion by the tumor, or deep

hepatic metastasis, which often are missed by visual

inspection alone. They further insist that it can be per-

formed safely without a significant increase in morbidity

and within a reasonable time [19–21]. It is very important,

therefore, to consider these differences in technique during

evaluation of reports on the diagnostic yield of SL for

patients with pancreatic adenocarcinoma.

The primary indication for SL is imaging-occult meta-

static pancreatic adenocarcinoma or unsuspected locally

advanced disease detected in patients with resectable dis-

ease based on preoperative imaging. Other indications

include assessment of disease extent before administration

of neoadjuvant chemoradiation as well as selection of

palliative treatments for patients with locally advanced

disease. However, SL should not be performed for patients

with known metastatic disease. Dense adhesions that

impair visual inspection may compromise the diagnostic

yield of the procedure.

Procedure-related morbidity is reported to range from

0% to 4% [17–46]. Most complications are minor and

include wound infections, port-site bleeding, or subcuta-

neous emphysema. Nevertheless, major complications such

as myocardial infarction, pulmonary embolism, and intes-

tinal or vascular injury have been described. The majority

of the literature reports mortality rates of 0% [17–46].

However, at least one death has been reported due to a

missed colonic injury during the procedure.

Conversions to open surgery are uncommon and in one

large series were reported to occur for less than 2% of the

patients [21]. The hospital length of stay after SL is

reported to range from 1 to 4 days [39]. Evidence suggests

that the hospital stay is shorter after laparoscopic staging

than after open staging for pancreatic cancer patients [26].

For patients with locally advanced disease, SL is reportedly

superior to exploratory laparotomy because it decreases

length of hospital stay, increases the number of patients

who receive chemotherapy, and shortens the time to initi-

ation of such treatment [34, 47].

With regard to oncologic safety, initial concerns for

port-site recurrence after laparoscopic procedures for

234 Surg Endosc (2009) 23:231–241

123

cancer patients have not been substantiated. Multiple

studies report a 0–2% incidence of port-site recurrences

after SL, which is similar to that after open explorations for

cancer patients [24, 39, 47]. In one study of 235 patients

comparing exploratory laparotomy with SL, laparoscopy

was not associated with increased port-site recurrences or

peritoneal disease progression [47]. Furthermore, evidence

from the Surveillance Epidemiology and End Results

(SEER) database suggests no survival differences between

pancreatic cancer patients who underwent a laparoscopic

procedure and those who had open surgery [48].

For detecting imaging-occult unresectable pancreatic

adenocarcinoma, the literature reports that SL has a median

sensitivity of 94% (range, 93–100%), a median specificity

of 88% (range, 80–100%), and a median accuracy of 89%

(range, 87–98%) (levels 2 and 3 evidence) [18–39].

However, the procedure misses 6% (range, 5–25%) of

patients whose disease is identified as unresectable during

an ensuing laparotomy (levels 2 and 3 evidence) [18–39].

Overall, 4% to 36% of patients can potentially avoid a

nontherapeutic laparotomy (levels 2 and 3 evidence) [18–

39]. A number of studies also have evaluated the added

benefit of laparoscopic ultrasound at the time of laparo-

scopic staging. These studies indicate that the diagnostic

accuracy of the procedure can be improved by 12–14%

(levels 2 and 3 evidence) [19–24, 35–38].

Peritoneal washings are reported to augment the yield of

the procedure. Reports on the sensitivity of peritoneal

washings have ranged widely from 25% to 100%) [18, 33,

40–42]. The highest sensitivity for peritoneal cytology is

reported for patients with a disrupted ventral pancreatic

margin, in which case, peripancreatic fatty tissue cannot be

differentiated from the tumor by helical CT scan (level 3

evidence) [42].

In addition, locally advanced pancreatic cancers have a

higher incidence of positive cytology (level 3 evidence)

[28, 33, 43]. Furthermore, studies have shown a 7–14%

incidence of positive peritoneal washings if no other met-

astatic disease is found during preoperative imaging and

SL (level 3 evidence) [18, 33]. This incidence seems to be

lower in studies that include a variety of periampullary

tumors (level 2 evidence) [30].

The diagnostic yield of the procedure also depends on

the histology, stage of disease, tumor size, and location.

There is convincing evidence that the yield of SL is sig-

nificantly higher for patients with pancreatic cancer than

for those with types of periampullary tumors (level 3 evi-

dence) [27, 28, 32, 39]. Furthermore, SL also appears to

have a higher yield for patients with locally advanced

cancer than for patients with localized disease. Identifica-

tion of metastatic disease by SL for patients with locally

advanced disease detected by high-quality imaging studies

is reported in 34–37% of cases, which compares favorably

with the identification rates for metastatic disease among

patients with localized disease (level 3 evidence) [17, 43,

44].

Tumors of the pancreas body and tail are associated with

a higher likelihood for unsuspected metastasis found at

laparoscopy (level 3 evidence) [18, 33]. Larger tumors

appear to be associated with a higher incidence of imaging-

occult metastatic disease (level 3 evidence) [28, 39, 45,

46]. Although the tumor size at which the risk of occult M1

disease justifies the added time and cost of laparoscopy is

currently unknown, some studies suggest that tumors larger

than 3 cm are more likely to be associated with metastatic

disease at exploration (level 3 evidence) [45, 46]. More-

over, a CA 19–9 level lower than 150 has been associated

with a lower likelihood for metastatic disease and conse-

quently a lower yield for SL (level 3 evidence) [49].

Although high-quality evidence on the cost effective-

ness of SL is lacking, the literature suggests that SL is more

cost effective than open exploration when it is the only

procedure required (i.e., for patients with unsuspected

metastatic disease identified during SL) (level 2 evidence)

[50]. This is a consequence of decreased patient length of

hospital stay. On the other hand, the cost effectiveness of

SL when applied in the diagnostic algorithm of all pan-

creatic cancer patients appears linked directly to the yield

of the procedure in identifying patients with imaging-

occult disease. In a cost utility analysis of the most effec-

tive management strategy for pancreatic cancer patients, at

least a 30% yield was needed for SL to be more cost

effective than open exploration (level 3 evidence) [51].

The quality of the available studies on SL for patients

with pancreas cancer is limited. No level 1 evidence exists.

Furthermore, population-based data are very limited

because the majority of studies are single-institution

reports from highly specialized centers, making general-

izations difficult and allowing institutional and personal

biases to be introduced into the results. In addition,

reported data are not uniform across studies, making their

analysis difficult. A number of studies assess the role of

laparoscopy indirectly without performance of a single

laparoscopic staging procedure (referred to as ‘‘phantom’’

studies by some authors). These studies assume that only

visible metastatic disease would have been detected at the

time of laparoscopy, ignoring the value of laparoscopic

ultrasound and cytology.

Other studies do not clearly report the quality of pre-

operative imaging, the criteria used to define resectability,

or the number of R0 resections. Furthermore, studies often

evaluate nonhomogeneous patient samples, including

patients with localized and locally advanced pancreatic

cancers as well as patients with periampullary and other

nonpancreatic cancers or even benign disease and do not

report results separately.

Surg Endosc (2009) 23:231–241 235

123

Summary of SL for pancreatic cancer

Based on our review of the literature, SL can be performed

safely and effectively for patients with pancreatic adeno-

carcinoma. The procedure should be considered after high-

quality imaging studies have excluded metastatic disease

for appropriately selected patients with either localized or

locally advanced pancreatic adenocarcinoma. The use of

laparoscopic ultrasound and peritoneal washings is

encouraged because they may improve the diagnostic

accuracy of the procedure. Based on the available evi-

dence, selective rather than routine use of the procedure

may be better justified and more cost effective for those

with larger tumors; tumors involving the pancreatic neck,

body, or tail; and patients with clinical, laboratory, or

imaging findings suggestive of more advanced disease.

Nevertheless, the effectiveness of such selection criteria

needs to be verified by additional prospective studies.

Staging laparoscopy for hepatocellular carcinoma

The prognosis of patients with hepatocellular carcinoma

may be improved with the appropriate selection of treat-

ment based on extent of disease. Subsequently, accurate

identification of all hepatic lesions including size, number,

and location is critical to therapy. Because peritoneal dis-

ease is uncommon with hepatocellular carcinoma,

inspection of peritoneal surfaces with diagnostic laparos-

copy alone tends to be less valuable than SL with

laparoscopic ultrasound. The appropriate identification of

patients who have unresectable disease using SL with

laparoscopic ultrasound not only will spare these patients a

nontherapeutic laparotomy with its associated morbidity,

but also may alter treatment plans. Additional benefits

include decreased patient morbidity, hospital stay, and

costs, as well as earlier adjuvant treatment. A 60% drop in

hospital charges for patients undergoing SL compared with

open laparotomy patients has been described for this pop-

ulation [52].

Staging laparoscopy generally is performed with the

patient under general anesthesia in the supine position.

After establishment of pneumoperitoneum, an angled

laparoscope through an umbilical port is recommended

for optimal visualization of the entire liver. Additional

ports can be placed in the right anterior axillary line and

epigastric area as needed. A standard laparoscopic ultra-

sound probe is used for systematic examination of the

entire liver to identify all lesions suspected to be malig-

nant. Ultrasound-guided core biopsy should be used for

suspicious lesions that are unresectable or preclude

curative resection. Biopsy of resectable lesions need not

be performed.

Patients with primary hepatic tumors whose proposed

curative resection is based on preoperative identification of

disease size and location with adequate hepatic reserve are

the best candidates for SL. Conversely, known unresectable

hepatic disease such as major vessel or organ invasion

would be a contraindication for SL. In addition, patients

with dense intraabdominal adhesions, particularly sur-

rounding the liver, from prior surgery may not be ideal

candidates for SL and laparoscopic ultrasound.

Procedure-related complications are uncommon, and no

mortality has been reported. Bleeding, infection, bowel

injury, bile leak, and anesthesia-related complications may

occur. Compared with open exploration, patients under-

going SL with laparoscopic ultrasound are reported to have

a shorter hospital stay (9 vs. 2.2–5 days, respectively) and

earlier adjuvant therapy (within 23 vs. 6 days, respectively)

(levels 2 and 3 evidence) [52, 53]. No adverse oncologic

effects of the procedure have been described.

For identifying hepatic tumors using, triphasic CT scan

is less sensitive than laparoscopic ultrasound in correlation

studies and highly dependent on tumor size, with detection

rates of 71% for tumors size 0–1 cm, 84% for tumors size

1–2 cm, 96% for tumors size 2–3 cm, and 100% for tumors

larger than 3 cm (100%) (level 2 evidence) [54]. Laparo-

scopic ultrasound can detect 9.5% more tumors (most

smaller in size than 1 cm) than CT alone (level 2 evidence)

[54]. Staging laparoscopy correctly identifies 63% to 67%

of patients with unresectable disease (levels 2 and 3 evi-

dence) [52, 53]. Unresectable disease was most commonly

missed by SL because of vascular invasion, lymph node

metastases, and adjacent organ invasion. With the combi-

nation of SL and laparoscopic ultrasound, 16% to 25% of

patients may avoid open laparotomy (levels 2 and 3 evi-

dence) [52, 53].

The quality and amount of the available literature on SL

for primary hepatic tumors are limited, and no level 1

evidence exists. The designs of these studies differ. Some

compare combined SL and laparoscopic ultrasound with

preoperative imaging, whereas others compare it with

exploratory laparotomy. There also is inconsistency in the

type of preoperative imaging and the specific CT scan

techniques used. In addition, the impact of each surgeon’s

expertise with laparoscopic ultrasound on the diagnostic

accuracy of the procedure remains unknown. These limi-

tations make firm recommendations difficult.

Summary of SL for hepatocellular carcinoma

Based on our review of the literature, SL with laparoscopic

ultrasound can be performed safely for patients with pri-

mary hepatic tumors or hepatocellular carcinoma. Patients

with primary hepatic cancers that appear resectable on

preoperative imaging may benefit from SL with

236 Surg Endosc (2009) 23:231–241

123

laparoscopic ultrasound used to evaluate extent, location,

and size of disease. Results of SL have the potential to alter

treatment appropriate to the extent of disease. Selection

criteria that may increase the yield and cost effectiveness

of the procedure still need to be determined, and further

studies are needed.

Staging laparoscopy for biliary tract tumors

Biliary tract tumors can be divided into two main categories:

gallbladder cancers and cholangiocarcinomas. The two

groups differ in their patterns of spread and their prognoses.

Gallbladder cancer tends grow more rapidly, with earlier

dissemination, which makes SL a more useful tool in this

setting. In contrast, cholangiocarcinomas tend to be more

locally invasive, decreasing the yield of SL. Preoperative

imaging to determine resectability of all biliary tract cancers

often includes ultrasound, CT scan, direct cholangiography

(percutaneous transhepatic cholangiography or endoscopic

retrograde cholangiopancreatography), and/or magnetic

resonance cholangiopancreatography. These radiologic

preoperative studies are used to evaluate the extent of tumor

within the biliary tree, vascular invasion, hepatic lobar

atrophy, and metastatic disease. The goal of SL would be to

spare patients from a laparotomy for incurable disease and to

offer the associated benefits of decreased morbidity and

pain, faster recovery, and earlier adjuvant treatment. Nota-

bly, however, many gallbladder cancers are incidental

findings during or after laparoscopic cholecystectomy. Thus,

for patients with gallbladder cancers found after cholecys-

tectomy, liver resection is indicated as a secondary

procedure, thereby obviating the need for SL.

Typically, SL is performed with the patient under gen-

eral anesthesia in the supine position. After establishment

of pneumoperitoneum, an angled laparoscope through an

umbilical port is recommended for optimal visualization of

the entire abdominal cavity. Additional ports can be placed

in the right anterior axillary line and epigastric area as

needed. Careful and thorough inspection of the peritoneum,

pelvis, liver surfaces, porta hepatis, gastrohepatic ligament,

and omentum should be performed. A standard laparo-

scopic ultrasound probe may improve the yield of lesions

found in the liver as well as lymph node metastasis found

in the porta hepatis and celiac nodal areas. Biopsy speci-

mens of peritoneal metastases, nodes suspected to be

malignant, and hepatic lesions should be obtained to

determine the extent of disease.

The indications for the use of SL to detect biliary tract

tumors differ slightly depending on the origin of the cancer.

For gallbladder cancer, SL generally is indicated for

patients with known or suspected gallbladder cancer but no

evidence of unresectable or metastatic disease unless noted

as an incidental finding after cholecystectomy. With cho-

langiocarcinomas, SL is indicated for stage T2 or T3 hilar

cholangiocarcinoma without evidence of unresectable or

metastatic disease determined by preoperative imaging.

Alternatively, SL is contraindicated for known metastatic or

unresectable disease and known stage T1 disease found

incidentally for gallbladder cancer. Dense intraabdominal

adhesions from prior surgery, particularly surrounding the

porta hepatis, may be considered a relative contraindication.

The reported incidence of complications is low, with no

mortality. Potential risks include bleeding, infection, and

bile leak, particularly if liver biopsy is performed. Addi-

tional risks include those associated with surgical

laparoscopy in general and those associated with anesthe-

sia. The assumed benefit of earlier adjuvant therapy for

patients with metastatic disease has not been addressed in

the literature. However, the average length of hospital stay

after SL is 2 to 3 days, which compares favorably with

laparotomy (level 2 evidence) [55, 56]. There have been no

reported adverse oncologic effects of SL for biliary cancer.

Staging laparoscopy can add further information to

standard preoperative imaging by identifying peritoneal or

superficial liver metastases (23%), which often are not

detected with radiology (level 3 evidence) [57]. For gall-

bladder cancer, the overall yield for unresectable disease

found with SL is reported to be 48%, with a diagnostic

accuracy of 58% (level 2 evidence) [55]. For cholangio-

carcinoma, as many as 9–42% [56–58] of patients may

avoid laparotomy with an accuracy of 42–53% (levels 2

and 3 evidence) [58]. For detecting unresectable disease,

SL has a reported sensitivity of 60% and a negative pre-

dictive value of 52% (level 2 evidence) [56].

The yield of SL for gallbladder cancer is slightly higher

than for cancers of the biliary tree due to the higher inci-

dence of peritoneal and liver metastases associated with

gallbladder cancer. One study suggests that the yield for

cholangiocarcinoma may be improved if SL is limited to

patients with higher-stage primary tumors on preoperative

imaging (T2 and T3) because few patients with stage T1

disease are deemed unresectable by laparoscopy (9%) [55].

The added benefit that laparoscopic ultrasound improves

the diagnostic yield of the procedure has been inconsistent

in the literature (0–41%) (levels 2 and 3 evidence) [57, 58].

The reported literature on SL used for biliary tract

cancer patients is limited, and no level 1 evidence exists. A

small number of reports describe highly specialized centers

with variations in technique. In addition, some studies span

a period of 7–10 years, which likely affects the quality of

preoperative imaging and laparoscopic technique at the

beginning and end of the study. The impact of the sur-

geon’s expertise on the diagnostic accuracy of the

procedure is unknown. These shortcomings of the literature

limit our ability to provide strong recommendations.

Surg Endosc (2009) 23:231–241 237

123

Summary of SL for biliary tract cancers

Based upon our review of the literature, SL can be per-

formed safely for patients with cancers of the biliary tract

and gallbladder. Staging laparoscopy may be used for

suspected gallbladder cancers believed to be resectable by

preoperative, high-quality imaging studies. However, SL

generally is not used for patients in whom an incidental

gallbladder cancer was identified after cholecystectomy.

Patients with biliary tract cancers or cholangiocarcinomas

also may benefit from SL through the identification of

imaging-occult disease in the peritoneum, the lymph nodes,

or the liver itself. The benefit of the procedure may be

maximized for patients with locally advanced cholangio-

carcinoma (stage T2 and T3) because the yield of the

procedure with this patient population is higher. Laparo-

scopic ultrasound may improve the yield of the procedure.

However, additional data are needed.

Staging laparoscopy for colorectal cancer

In the primary treatment of colorectal cancer, SL seldom

is used because surgical resection and palliation typically

are indicated to prevent bleeding, obstruction, and perfo-

ration even in patients with advanced disease. However,

patients who have liver metastases from a primary colo-

rectal cancer may be candidates for curative resection

when no other extrahepatic disease exists and when all the

disease in the liver is resectable. Thus, for these patients,

SL can provide more accurate identification of all hepatic

lesions than noninvasive imaging including size, number,

and location.

Similar to SL for primary hepatic tumors, SL and lap-

aroscopic ultrasound can identify patients with unsuspected

extrahepatic metastatic disease. The identification of these

patients may spare them the morbidity of a nontherapeutic

open laparotomy and may alter treatment plans. As with

other intraabdominal cancers, SL may lead to lower hos-

pital costs, shorter length of stay, and earlier adjuvant

therapy than open exploration without resection.

The technique is similar to SL in other settings. The

patient is placed in the supine position, and pneumoperi-

toneum is established. An angled laparoscope through an

umbilical port is recommended for optimal visualization of

the entire abdominal cavity. Additional ports can be placed

as needed. A standard laparoscopic ultrasound probe often

is used for systematic examination of the entire liver to

identify all lesions suspected to be malignant. The ultra-

sound examination also should include the porta hepatis

and celiac lymph nodes. Ultrasound-guided biopsy of

peritoneal, lymph node, and unsuspected liver lesions

should be obtained.

The primary indication of SL in this population is

resectable liver metastases from colorectal cancer without

concomitant evidence of extrahepatic metastatic disease on

noninvasive imaging. Conversely, patients with known

extrahepatic metastatic disease or unresectable hepatic

disease should not undergo SL. Dense intraabdominal

adhesions from prior surgery, particularly surrounding the

liver, may preclude adequate examination and thorough

SL.

In general, the morbidity and mortality for SL in these

patients are low, and the complications include bleeding,

infection, bowel injury, bile leak, and other complications

associated with laparoscopy. However, complications are

reported to be as high as 28%, including pneumonia and

myocardial infarction [59]. The hospital length of stay is

demonstrated to be significantly shorter for SL (1.2 days)

than for open laparotomy (5.8 days) [60]. A 55% reduction

in total hospital charges, with the greatest savings in room

and board charges, has been reported with SL compared

with open exploration (level 2 evidence) [60]. No adverse

oncologic effects have been described.

Studies comparing open intraoperative ultrasound with

laparoscopic ultrasound and preoperative CT scanning for

colorectal metastases have shown that the yield is best with

open intraoperative ultrasound, followed by laparoscopic

ultrasound (98% yield; one detected lesion less than with

open intraoperative ultrasound) and CT scan (78% yield)

[61]. Furthermore, SL and laparoscopic ultrasound have

better sensitivity than noninvasive imaging studies for the

detection of nodal metastases (94% for laparoscopic

ultrasound vs 18% for preoperative imaging) [62]. The

combination of SL and laparoscopic ultrasound is reported

to detect unresectable disease in 25–42% of patients for

whom preoperative radiologic testing showed potentially

curable disease [59, 60]. The use of laparoscopic ultra-

sound can further identify unresectable disease, which may

not be seen with laparoscopic inspection alone [60]. In

addition, the findings of the procedure have altered the

management for 33% to 48% of patients [59, 62, 63].

The Clinical Risk Score (CRS) system was developed to

predict which patients will most likely benefit from SL.

This system uses five preoperative criteria, which are

independent factors of prognosis: (1) lymph node-positive

colon cancer, (2) disease-free interval shorter than

12 months (time from discovery of primary colon cancer to

discovery of liver metastases), (3) more than one hepatic

tumor, (4) carcinoembryonic antigen greater than 200 ng/

ml within 1 month after surgery, and (5) size of largest

hepatic tumor greater than 5 cm. Each factor is assigned

one point. If the CRS is greater than 2, then the yield of SL

is higher [60].

The quality and amount of the available literature on SL

for colorectal cancer liver metastasis is limited because no

238 Surg Endosc (2009) 23:231–241

123

level 1 evidence exists. Although most studies use lapa-

roscopic ultrasound to establish resectability, institutions

differ in their technique and expertise. The impact of the

surgeon’s expertise on the diagnostic accuracy of the pro-

cedure is unknown. The limited available evidence impairs

our ability to provide firm recommendations.

Summary of SL for colorectal cancers

Based upon our review of the literature, SL can be per-

formed safely for patients with hepatic metastasis of

colorectal cancer. Patients with isolated colorectal hepatic

metastases who are candidates for liver resection may

benefit from SL with laparoscopic ultrasound. The patients

most likely to benefit from this procedure are those who

have more than two poor outcome factors as described by

the CRS.

Staging laparoscopy for lymphoma

Hodgkin’s lymphoma originates in one nodal group and

spreads in a stepwise manner to contiguous nodal groups.

Staging laparoscopy may be useful in determining the stage

and location of the disease, and this may affect decisions

regarding treatment, particularly the administration of che-

motherapy. In contrast, for non-Hodgkin’s lymphoma, the

exact extent of the disease has less impact on the treatment

course, so SL is less frequently performed in cases of non-

Hodgkin’s lymphoma. Staging laparoscopy may spare

patients the morbidity of a laparotomy and provide tissue to

confirm the diagnosis of non-Hodgkin’s lymphoma or allow

the surgical staging of Hodgkin’s lymphoma. Staging lap-

aroscopy also can be used for patients who need

laparoscopic splenectomy as treatment and may lead to less

pain, faster recovery, and earlier definitive treatment.

The technique of SL for lymphoma tends to be more

involved than SL for simple inspection of the peritoneal

surfaces with other cancers. Patients are commonly placed at

a 45� angle in the left decubitus position. A laparoscopic

hand-assisted technique may be used, especially when

splenectomy is planned. The steps of SL are similar to those

used in the traditional open procedure including inspection

for gross abnormalities; core liver biopsy of each hepatic

lobe and wedge biopsy of left lateral liver segment; laparo-

scopic ultrasound to search for hepatic lesions; splenectomy

with removal of the organ intact; lymph node sampling of the

iliac, celiac, portal, mesenteric, and periaortic areas; lymph

node excision of abnormal nodes identified at preoperative

testing with application of clips in those excision areas; and

oophoropexy posterior to the uterus.

The primary indication for SL in non-Hodgkin’s lym-

phoma is a tissue diagnosis through biopsy of

intraabdominal lymph nodes in the absence of peripheral

lymphadenopathy, particularly when percutaneous core

needle biopsy has been nondiagnostic. In addition, SL can

be used for accurate staging of Hodgkin’s lymphoma when

staging affects decisions for appropriate treatment or

prognosis. Staging laparoscopy also may be indicated for

restaging after treatment or when recurrence is suspected.

Published morbidity rates range widely (1–20%) and

include complications such as small bowel perforation,

abscess, pancreatitis, bleeding, and pneumonia [64–66].

Conversion to laparotomy is reported to occur in 5–17% of

the cases. No mortality has been reported [64–66]. The

presumed benefit of earlier adjuvant therapy has not been

addressed in the literature, but length of hospital stay after

diagnostic laparoscopy is reported to vary from 1 to 4 days

[64, 65]. No adverse oncologic effects from the procedure

have been reported.

Data on the accuracy of the procedure come mainly

from feasibility studies and are sparse. Compared with

percutaneous biopsy, laparoscopic biopsy is demonstrated

to have superior sensitivity (87% vs. 100%), specificity

(93% vs. 100%), and accuracy (33% vs. 83%) (level 3

evidence) [64].

The quality of the available literature on SL for lym-

phoma is primarily limited to retrospective reviews. In

addition, the number of available studies is quite small.

Furthermore, some studies compare the accuracy of the

procedure with that of historical controls for open surgery,

which increases the bias of the results. Surgical technique

differs according to institution and surgeon experience,

making generalizations difficult and strong recommenda-

tions impossible.

Summary of SL for lymphomas

Based on our review of the literature, SL for lymphopro-

liferative disorders is safe and effective. The best

indication for SL in lymphoproliferative disorders may be a

tissue diagnosis of non-Hodgkin’s lymphoma when core

needle biopsy is nondiagnostic. In addition, SL is indicated

for primary staging or even restaging of Hodgkin’s lym-

phoma when accurate staging affects decisions for

appropriate treatment and prognosis. Furthermore, lapa-

roscopy may be performed when splenectomy is required

in this patient population.

References

1. Guidelines for diagnostic laparoscopy. Retrieved March 25, 2008

at http://www.sages.org/sagespublication.php?doc=12

2. Krasna MJ, Reed CE, Nedzwiecki D, Hollis DR, Luketich JD,

DeCamp MM, Mayer RJ, Sugarbaker DJ CALGB, Surgeons

Surg Endosc (2009) 23:231–241 239

123

http://www.sages.org/sagespublication.php?doc=12

Thoracic (2001) CALGB 9380: a prospective trial of the feasi-

bility of thoracoscopy/laparoscopy in staging esophageal cancer.

Ann Thorac Surg 71:1073–1079

3. Heath EI, Kaufman HS, Talamini MA, Wu TT, Wheeler J,

Heitmiller RF, Kleinberg L, Yang SC, Olukayode K, Forastiere

AA (2000) The role of laparoscopy in preoperative staging of

esophageal cancer. Surg Endosc 14:495–499

4. Bonavina L, Incarvone R, Lattuada E, Segalin A, Cesana B,

Peracchia A (1997) Preoperative laparoscopy in management of

patients with carcinoma of the esophagus and of the esophag-

ogastric junction. J Surg Oncol 65:171–174

5. Romijn MG, van Overhagen H, Spillenaar Bilgen EJ, Ijzermans

JN, Tilanus HW, Lameris JS (1998) Laparoscopy and laparo-

scopic ultrasonography in the staging of oesophageal and cardial

carcinoma. Br J Surg 85:1010–1012

6. Krasna MJ, Jiao X, Mao YS, Sonett J, Gamliel Z, Kwong K,

Burrows W, Flowers JL, Greenwald B, White C (2002) Thora-

cosopy/laparoscopy in the staging of esophageal cancer. Surg

Laparosc Endosc Percutan Tech 12:213–218

7. D’Ugo DM, Pende V, Persiani R, Rausei S, Picciocchi A (2003)

Laparoscopic staging of gastric cancer: an overview. J Am Coll

Surg 196:965–974

8. Asencio F, Aguilo J, Salvador JL, Villar A, De la Morena E,

Ahamad M, Escrig J, Puche J, Viciano V, Sanmiguel G, Ruiz J

(1997) Video-laparoscopic staging of gastric cancer. Surg Endosc

11:1153–1158

9. Hulscher JBF, Nieveen van Dijkum EJ, de Wit LT, van Delden

OM, van Lanschot JJ, Obertop H, Gouma DJ (2000) Laparoscopy

and laparoscopic ultrasonography in staging carcinoma of the

gastric cardia. Eur J Surg 166:862–865

10. Gross E, Bancewicz J, Ingram G (1984) Assessment of gastric

cancer by laparoscopy. Br Med J 288:1577

11. Possik RA, Franco EL, Pires DR, Wohnrath DR, Ferreira EB

(1986) Sensitivity, specificity, and predictive value of laparos-

copy for the staging of gastric cancer and for the detection of liver

metastases. Cancer 58:1–6

12. Kriplani AK, Kapur BML (1991) Laparoscopy for the preoper-

ative staging and assessment of operability in gastric carcinoma.

Gastrointest Endosc 37:441–443

13. Lowy AM, Mansfield PF, Leach SD, Ajani J (1996) Laparoscopic

staging for gastric cancer. Surgery 119:611–614

14. Burke EC, Karpeh MS, Conlon KC, Brennan MF (1997) Lapa-

roscopy in the management of gastric adenocarcinoma. Ann Surg

225:262–267

15. Stell DA, Carter CR, Stewart I, Anderson JR (1996) Prospective

comparison of laparoscopy, ultrasonography, and computed

tomography in the staging of gastric cancer. Br J Surg 86:1260–

1262

16. Conlon KC (2001) Staging laparoscopy for gastric cancer. Ann

Ital Chir 72:33–37

17. Luque-de Leon E, Tsiotos GG, Balsiger B, Barnwell J, Burgart

LJ, Sarr MG (1999) Staging laparoscopy for pancreatic cancer

should be used to select the best means of palliation and not

only to maximize the resectability rate. J Gastrointest Surg

3:111–117

18. Jimenez RE, Warshaw AL, Rattner DW, Willett CG, McGrath D,

Fernandez-Del Castillo C (2000) Impact of laparoscopic staging

in the treatment of pancreatic cancer. Arch Surg 135:409–414

19. Schachter PP, Avni Y, Shimonov M, Gvirtz G, Rosen A, Czer-

niak A (2000) The impact of laparoscopy and laparoscopic

ultrasonography on the management of pancreatic cancer. Arch

Surg 135:1303–1307

20. Minnard EA, Conlon KC, Hoos A, Dougherty EC, Hann LE,

Brennan MF (1998) Laparoscopic ultrasound enhances standard

laparoscopy in the staging of pancreatic cancer. Ann Surg

228:182–187

21. Hunerbein M, Rau B, Hohenberger P, Schlag PM (1998) The role

of staging laparoscopy for multimodal therapy of gastrointestinal

cancer. Surg Endosc 12:921–925

22. Durup Scheel-Hincke J, Mortensen MB, Qvist N, Hovendal CP

(1999) TNM staging and assessment of resectability of pancreatic

cancer by laparoscopic ultrasonography. Surg Endosc 13:967–

971

23. Doran HE, Bosonnet L, Connor S, Jones L, Garvey C, Hughes M,

Campbell F, Hartley M, Ghaneh P, Neoptolemos JP, Sutton R

(2004) Laparoscopy and laparoscopic ultrasound in the evalua-

tion of pancreatic and periampullary tumours. Dig Surg 21:305–

313

24. Pietrabissa A, Caramella D, Di Candio G, Carobbi A, Boggi U,

Rossi G, Mosca F (1999) Laparoscopy and laparoscopic ultra-

sonography for staging pancreatic cancer: critical appraisal.

World J Surg 23:998–1002

25. Awad SS, Colletti L, Mulholland M, Knol J, Rothman ED,

Scheiman J, Eckhauser FE (1997) Multimodality staging opti-

mizes resectability in patients with pancreatic and ampullary

cancer. Am Surg 63:634–638

26. Conlon KC, Dougherty E, Klimstra DS, Coit DG, Turnbull AD,

Brennan MF (1996) The value of minimal access surgery in the

staging of patients with potentially resectable peripancreatic

malignancy. Ann Surg 223:134–140

27. Vollmer CM, Drebin JA, Middleton WD, Teefey SA, Linehan

DC, Soper NJ, Eagon CJ, Strasberg SM (2002) Utility of staging

laparoscopy in subsets of peripancreatic and biliary malignancies.

Ann Surg 235:1–7

28. Pisters PW, Lee JE, Vauthey JN, Charnsangavej C, Evans DB

(2001) Laparoscopy in the staging of pancreatic cancer (review,

45 references). Br J Surg 88:325–337

29. Kwon AH, Inui H, Kamiyama Y (2002) Preoperative laparo-

scopic examination using surgical manipulation and

ultrasonography for pancreatic lesions. Endoscopy 34:464–468

30. Nieveen van Dijkum EJ, Romijn MG, Terwee CB, de Wit LT,

van der Meulen JH, Lameris HS, Rauws EA, Obertop H, van

Eyck CH, Bossuyt PM, Gouma DJ (2003) Laparoscopic staging

and subsequent palliation in patients with peripancreatic carci-

noma. Ann Surg 237:66–73

31. Friess H, Kleeff J, Silva JC, Sadowski C, Baer HU, Buchler MW

(1998) The role of diagnostic laparoscopy in pancreatic and pe-

riampullary malignancies. J Am Coll Surg 186:675–682

32. Barreiro CJ, Lillemoe KD, Koniaris LG, Sohn TA, Yeo CJ,

Coleman J, Fishman EK, Cameron JL (2002) Diagnostic lapa-

roscopy for periampullary and pancreatic cancer: what is the true

benefit? J Gastrointest Surg 6:75–81

33. Liu RC, Traverso LW (2005) Diagnostic laparoscopy improves

staging of pancreatic cancer deemed locally unresectable by

computed tomography. Surg Endosc 19:638–642

34. Holzman MD, Reintgen KL, Tyler DS, Pappas TN (1997) The

role of laparoscopy in the management of suspected pancreatic

and periampullary malignancies. J Gastrointest Surg 1:236–243

35. Tilleman EH, de Castro SM, Busch OR, Bemelman WA, van

Gulik TM, Obertop H, Gouma DJ (2002) Diagnostic laparoscopy

and laparoscopic ultrasound for staging of patients with malignant

proximal bile duct obstruction. J Gastrointest Surg 6:426–430

36. John TG, Wright A, Allan PL, Redhead DN, Paterson-Brown S,

Carter DC, Garden OJ (1999) Laparoscopy with laparoscopic

ultrasonography in the TNM staging of pancreatic carcinoma.

World J Surg 23:870–881

37. Callery MP, Strasberg SM, Doherty GM, Soper NJ, Norton JA

(1997) Staging laparoscopy with laparoscopic ultrasonography:

optimizing resectability in hepatobiliary and pancreatic malig-

nancy. J Am Coll Surg 185:33–39

38. Bemelman WA, de Wit LT, van Delden OM, Smits NJ, Obertop

H, Rauws EJ, Gouma DJ (1995) Diagnostic laparoscopy

240 Surg Endosc (2009) 23:231–241

123

combined with laparoscopic ultrasonography in staging of cancer

of the pancreatic head region (see comment). Br J Surg 82:820–

824

39. Stefanidis D, Grove KD, Schwesinger WH, Thomas CR Jr (2006)

The current role of staging laparoscopy for adenocarcinoma of

the pancreas: a review. Ann Oncol 17:189–199

40. Fernandez-del Castillo CL, Warshaw AL (1998) Pancreatic

cancer. laparoscopic staging and peritoneal cytology. Surg Oncol

Clin North Am 7:135–142

41. Fernandez-Del Castillo C, Rattner DW, Warshaw AL (1995)

Further experience with laparoscopy and peritoneal cytology in

the staging of pancreatic cancer. Br J Surg 82:1127–1129

42. Schmidt J, Fraunhofer S, Fleisch M, Zirngibl H (2004) Is peri-

toneal cytology a predictor of unresectability in pancreatic

carcinoma? Hepatogastroenterology 51:1827–1831

43. Liu RC, Traverso LW (2004) Laparoscopic staging should be

used routinely for locally extensive cancer of the pancreatic head.

J Gastrointest Surg 8:923–924

44. Shoup M, Winston C, Brennan MF, Bassman D, Conlon KC

(2004) Is there a role for staging laparoscopy in patients with

locally advanced, unresectable pancreatic adenocarcinoma? J

Gastrointest Surg 8:1068–1071

45. Yoshida T, Matsumoto T, Morii Y, Ishio T, Kitano S, Yamada Y,

Mori H (2002) Staging with helical computed tomography and

laparoscopy in pancreatic head cancer. Hepatogastroenterology

49:1428–1431

46. Morganti AG, Brizi MG, Macchia G, Sallustio G, Costamagna G,

Alfieri S, Mattiucci GC, Valentini V, Natale L, Deodato F, Mu-

tignani M, Doglietto GB, Cellini N (2005) The prognostic effect

of clinical staging in pancreatic adenocarcinoma. Ann Surg Oncol

12:145–151

47. Velanovich V (2004) The effects of staging laparoscopy on trocar

site and peritoneal recurrence of pancreatic cancer. Surg Endosc

18:310–313

48. Urbach DR, Swanstrom LL, Hansen PD (2002) The effect of

laparoscopy on survival in pancreatic cancer. Arch Surg

137:191–199

49. Connor S, Bosonnet L, Alexakis N, Raraty M, Ghaneh P, Sutton

R, Neoptolemos JP (2005) Serum CA19-9 measurement increases

the effectiveness of staging laparoscopy in patients with sus-

pected pancreatic malignancy. Dig Surg 22:80–85

50. Andren-Sandberg A, Lindberg CG, Lundstedt C, Ihse I (1998)

Computed tomography and laparoscopy in the assessment of the

patient with pancreatic cancer. J Am Coll Surg 186:35–40

51. Obertop H, Gouma DJ (1999) Essentials in biliopancreatic stag-

ing: a decision analysis. Ann Oncol 10(Suppl 4):150–152

52. Jarnagin WR, Bodniewicz J, Dougherty E, Conlon K, Blumgart

LH, Fong Y (2000) A prospective analysis of staging laparoscopy

in patients with primary and secondary hepatobiliary malignan-

cies. J Gastrointest Surg 4:34–43

53. Lo CM, Lai EC, Liu CL, Fan ST, Wong J (1998) Laparoscopy

and laparoscopic ultrasonography avoid exploratory laparotomy

in patients with hepatocellular carcinoma. Ann Surg 227:527–532

54. Foroutani A, Garland AM, Berber E, String A, Engle K, Ryan

TL, Pearl JM, Siperstein AE (2000) Laparoscopic ultrasound vs.

triphasic computed tomography for detecting liver tumors. Arch

Surg 135:933–938

55. Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR

(2002) Staging laparoscopy in patients with extrahepatic biliary

carcinoma. Ann Surg 235:392–399

56. Tilleman EH, de Castro SM, Busch OR, Bemelman WA, van

Gulik TM, Obertop H, Gouma DJ (2002) Diagnostic laparoscopy

and laparoscopic ultrasound for staging of patients with malig-

nant proximal bile duct obstruction. J Gastroint Surg 6:426–430

57. van Delden OM, de Wit LT, Nieveen van Dijkum EJM, Smits NJ,

Gouma DJ, Reeders JW (1997) Value of laparoscopic ultraso-

nography in staging of proximal bile duct tumors. J Ultrasound

Med 16:7–12

58. Connor S, Barron E, Wigmore SJ, Madhavan KK, Parks RW,

Garden OJ (2005) The utility of laparoscopic assessment in the

preoperative staging of suspected hilar cholangiocarcinoma. J

Gastrointest Surg 9:476–480

59. Thaler K, Kanneganti S, Khajanchee Y, Wilson C, Swanstrom L,

Hansen PD (2005) The evolving role of staging laparoscopy in

the treatment of colorectal hepatic metastasis. Arch Surg

140:727–734

60. Jarnagin WR, Conlon K, Bodniewicz J, Dougherty E, Dematteo

RP, Blumgart LH, Fong Y (2001) A clinical scoring system

predicts the yield of diagnostic laparoscopy in patients with

potentially resectable hepatic colorectal metastases. Cancer

91:1121–1128

61. Milsom JW, Jerby BL, Kessler H, Hale JC, Herts BR, O’Malley

CM (2000) Prospective, blinded comparison of laparoscopic

ultrasonography vs contrast-enhanced computerized tomography

for liver assessment in patients undergoing colorectal carcinoma

surgery. Dis Colon Rectum 43:44–49

62. Goletti O, Celon G, Galatioto C, Viaggi B, Lippolis PV, Pieri L,

Cavina E (1998) Is laparoscopic sonography a reliable and sen-

sitive procedure for staging colorectal cancer? Surg Endosc

12:1236–1241

63. Rahusen FD, Cuesta MA, Borgstein PJ, Bleichrodt RP, Barkhof

F, Doesburg T, Meijer S (1999) Selection of patients for resection

of colorectal metastases to the liver using diagnostic laparoscopy

and laparoscopic ultrasonography. Ann Surg 230:31–37

64. Asoglu O, Porter L, Donohue JH, Cha SS (2005) Laparoscopy for

the definitive diagnosis of intraabdominal lymphoma. Mayo Clin

Proc 80:625–631

65. Baccarani U, Carroll BJ, Hiatt JR, Donini A, Terrosu G, Decker

R, Chandra M, Bresadola F, Phillips EH (1998) Comparison of

laparoscopic and open staging in Hodgkin’s disease. Arch Surg

133:517–522

66. Silecchia G, Raparelli L, Perrotta N, Fantini A, Fabiano P,

Monarca B, Basso N (2003) Accuracy of laparoscopy in the

diagnosis and staging of lymphoproliferative diseases. World J

Surg 27:653–658

Surg Endosc (2009) 23:231–241 241

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