Determining the Role of Preoperative Laparoscopic Staging in Prevention of Inappropriate Laparotomies inPatients with Gastric Adenocarcinoma.

Abstract

Background: Today the use of laparoscopy before laparotomy is an effective method for decision-making in patients with gastric adenocarcinoma. The reliance on CT scans for decision-making purposes is not only unhelpful, yet also misleading . Nonetheless, indications for laparoscopy and its application are changing daily. The low quality of diagnostic tools and epidemiological situation in our country requires that an independent study should be done in this case.

 Materials and Methods: All patients in the interval from the 12th month of 1388 until the 5th month of 1389 who were diagnosed as new cases of gastric adenocarcinoma and admitted to Shahid Sadoghy Hospital, Yazd, Iran were included in this experimental study. At _rst indication, laparoscopy was de_ned. All patients with complications who needed palliative surgery such as intolerable dysphagia, obstruction, bleeding or perforation in addition to those with distant metastases were excluded.TNM score and staging were noted for all patients. There were 26 patients who underwent laparoscopies to determine TNM scores and staging. These patients were divided into three groups: 1. Patients eligible for surgery with no neoadjuvant chemotherapy. 2. Patients needing neoadjuvant chemotherapy prior to laparatomy. 3. Non-operable patients, who only required chemotherapy. Subsequently, surgical pathological staging and TNM were determined for all 37 patients and used as the gold standard for comparison with other methods.

 Results: A total of 30 (88.9%) patients with the aid of CT scans were classied as stages  and , where laparoscopy estimated six patients as stages and , and surgical pathology diagnosed five (13.5%) cases out of the 37. The 37 patients were divided into the following groups: A-11 patients on clinical evaluation required laparotomy, but no laparoscopy was indicated. B-7 patients were identified as stages  and  who underwent surgery without neoadjuvant chemotherapy. C-8 patients were candidates for neoadjuvant chemotherapy after laparotomy. D-11 patients were estimated as inoperable and were only given chemotherapy. Of these, one patient was assumed to be operable with laparoscopy, yet was unoperable in laparatomy. Another patient did not receive neoadjuvant chemotherapy due to the lower estimation of laparoscopy.

Conclusion: If patient management solely depended on the results of CT scans, therefore a total of 87% of patients were mismanaged. With laparoscopy, however, 30 patients (81%) were correctly managed whereas seven patients (19%) were not. There were _ve patients with surgical pathological stages  and  who did not benefit from laparoscopy and two patients were mismanaged because of incorrect laparoscopic information. No similarities with pathological and CT scan results according to TNM and staging were noted, so there was signi_cant statistical diferrence. The results of TNM and staging scores of 30 patients who had laparoscopies were similar to the surgical TNM and staging scores, so there was no signi_cant statistical diferrence Therefore, conventional CT scans are less sensitive than usuall in our city. Since access to multi-detector CT scans and endosonography is very dif_cult in our city, therefore we could not use them for better patient management which is a pitfall for this study. Thus, use of laparoscopy before laparotomy not only decrease the un nessessary laparotomies rate,but also help us in selecting the patients who need neoadjuvant chemotherapy before surgery.