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Staging laparoscopy in gastric cancer: updating.

Romeo Giuli MD, resident.
School of General and Emergency Surgery.
University of Siena.   Italy.

June 2002.     Review Article.    To the previous article

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, 4, 5, 6 ).

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 ).


1) T. Lehnert, B. Rudek, P. Kienle, K. Buhl and C. Herfarth. Impact of diagnostic laparoscopy on the management of gastric cancer: prospective study of 120 consecutive patients with primary gastric adenocarcinoma. British Journal of Surgery 2002, 89, 471-475.

2) Volz J, Volz-Köster S, Kanis S, Klee D, Ahlert C, Melchert F. Modulation of tumor-induced lethality after pneumoperitoneum in a mouse model. Cancer 2000; 89: 262-6.

3) Leung KL, Lai PBS, Ho RLK, Meng WCS, Yiu RYC, Lee JFY et al. Systemic cytokine response after laparoscopic assisted resection of rectosigmoid carcinoma. A prospective randomized trial. Ann Surg 2000; 231: 506-11.

4) Perttilä J, Salo M, Ovaska J, Grönroos J, Lavonius M, Katila A et al. Immune response after laparoscopic and conventional Nissen fundoplication. Eur J Surg 1999; 165: 21-8.

5) Hewitt PM, Ip SM, Kwok SPY, Somers SS, Li K, Leung KL et al. Laparoscopic-assisted vs. open surgery for colorectal cancer: comparative study of immune effects. Dis Colon Rectum 1998; 41: 901-9.

6) Ishida H, Murata N, Yamada H, Nomura T, Shimomura K, Fujioka M et al. Effect of CO2 pneumoperitoneum on growth of liver micrometastases in a rabbit model. World J Surg 2000; 24: 1004-8.

7) Gitzelmann CA, Mendoza-Sagaon M, Talamini MA, Ahmad SA, Pegoli W, Paidas CN. Cell-mediated immune response is better preserved by laparoscopy than laparotomy. Surgery 2000; 127: 65-71.

8) Bouvy ND, Marquet RL, Jeekel H, Bonjer HJ. Laparoscopic surgery is associated with less tumour growth stimulation than conventional surgery: an experimental study. Br J Surg 1997; 84: 358-61.

9) Bryan RT, Cruikshank NR, Needham SJ, Moffitt DD, Young JA, Hallissey MT et al. Laparoscopic peritoneal lavage in staging gastric and oesophageal cancer. Eur J Surg Oncol 2001; 27: 291-7.

10) Romijn MG, van Overhagen H, Spillenaar Bilgen EJ, Ijzermans JNM, Tilanus HW, Laméris JS. Laparoscopy and laparoscopic ultrasonography in staging of oesophageal and cardial carcinoma. Br J Surg 1998; 85: 1010-12.

11) Hulscher JBF, Nieveen van Dijkum EJM, deWit LT, van Delden OM, van Lanschot JJB, Obertop H et al. Laparoscopy and laparoscopic ultrasound in staging carcinoma of the gastric cardia. Eur J Surg 2000; 166: 862-5.

12) Zurab Tsereteli MD, Maria L. Terry MD, Steven P. Bowers MD, Hadar Spivak MD, Steven B. Archer MD, Kathy D. Galloway RN and John G. Hunter . Prospective randomized clinical trial comparing nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic surgery. J Am Coll Surg 2002; 195: 2, 173-179.

13) Sharon M. Weber, Ronald P. DeMatteo, Yuman Fong, Leslie H. Blumgart, William R. Jarnagin. Staging Laparoscopy in Patients With Extrahepatic Biliary Carcinoma Analysis of 100 Patients. ANNALS OF SURGERY 2002;235:392-399.

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