Selection of the appropriate treatment for gastric cancer requires accurate tumour staging. The clinical staging of patients with gastric cancer can be improved by laparoscopy, since it may identify intra-abdominal tumour deposits in lymph nodes, the liver or on peritoneal surfaces, which are not detectable by non-invasive imaging . Staging laparoscopy has therefore been recommended for all patients with gastric cancer considered for potentially curative gastrectomy . More precise clinical staging does not, however, benefit individual patients unless it results in either more effective or less invasive treatment. The routine use of staging laparoscopy in patients with gastric cancer has therefore been questioned.
Diagnostic laparoscopy has been advocated to select patients for neoadjuvant therapy as in European Organisation for Research on Treatment of Cancer protocol 40954. However, neither neoadjuvant radiotherapy nor chemotherapy is currently accepted as standard treatment for gastric cancer. Alternatively, diagnostic laparoscopy can be used to identify patients with intra-abdominal tumour deposits not detected by preoperative imaging and which preclude curative treatment. Patients with incurable disease found at laparoscopy may be spared an exploratory laparotomy. Such patients are currently the only ones to benefit from diagnostic laparoscopy.
The majority of patients with gastric cancer, however, will undergo laparotomy for gastrectomy with either curative intent or for palliation. This group also does not benefit from diagnostic laparoscopy. Moreover, some caution has been voiced because even minimally invasive procedures, especially those performed separately and under general anaesthesia, inflict surgical trauma with associated morbidity and mortality. In addition, the long-term effects of procedure-related immunosuppression in a patient who will later undergo potentially curable gastrectomy are not known
( 1 ).
The effect of laparoscopy on the human immune system has been compared with that of open surgery in several randomized trials. All trials documented profound effects of laparoscopy on both the cellular and the humoral immune response compared with the preoperative immune status, and in some studies the effects of laparoscopy were no different from those of laparotomy . Since the immunosuppression resulting from laparoscopic procedures could favour metastatic growth, the advantages of staging laparoscopy should be balanced carefully against the potential risks
(1, 2, 3,
Lehnert et al. conclude that laparoscopy should be reserved for patients with an increased risk of local irresectability or intra-abdominal metastases. This is the first study to evaluate prospectively the use of selective staging laparoscopy
in a consecutive series of all patients seen with gastric cancer
( 1 ).
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