Velanovich V
Division of General Surgery, Henry Ford Hospital, Detroit, MI 48202-2689, USA.
Surgery. 1998 Oct;124(4):773-80; discussion 780-1. doi: 10.1067/msy.1998.91270.
Laparoscopy in the evaluation of intra-abdominal malignancies has become a debated issue. Proponents have claimed that it increases resectability rates, whereas opponents suggest that many patients require laparotomy regardless of the laparoscopic findings. The purpose of this study was to compare outcomes in patients undergoing staging laparoscopy versus those who were managed by initial exploratory laparotomy.
The medical records of all patients during an 18-month period who underwent surgical evaluation for upper gastrointestinal or hepatobiliary malignancies were reviewed. Forty-eight patients underwent staging laparoscopy (SL) initially; 80 patients underwent initial exploratory laparotomy (EL). Data obtained included type of cancer, laparoscopic findings, laparoscopic determination of resectability, laparoscopic procedures, open determination of resectability, open procedures, and length of stay (LOS). Statistical analysis was done by using Fisher exact test or the Mann-Whitney U test.
The malignancies of 75% of patients were deemed resectable by SL. Of these, 77.8% were resected. This compares to 56.3% resectability rate in the EL group (P = .025). SL findings in patients with unresectable malignancies were carcinomatosis (75%), liver metastasis (33.3%), and direct invasion (16.7%). In the 8 false-negative SLs, 75% were unresectable as a result of vascular invasion and 25% for other reasons. Findings in the EL group whose malignancies were unresectable were carcinomatosis (34.3%), direct invasion (22.6%), liver metastasis (42.9%), and vascular invasion only (17.1%). Therefore 82.9% of patients in the EL group could have been determined to have unresectable malignancy by SL. In the EL group 22.5% of the laparotomies were nontherapeutic, whereas 4.2% of patients in the SL group underwent nontherapeutic laparotomy. Average LOS for unresectable patients in the SL group was 0.5 days, with 75% discharged the same day of operation. This compares to 10.9 days in the EL group (P < .00001) and 7.6 days in the nontherapeutic EL group (P < .00001).
SL increases the resectability rate, decreases the nontherapeutic laparotomy rate, and decreases LOS in patients with unresectable disease. SL is poor at detecting unresectability as a result of vascular invasion only, but this accounts for less than one-fifth of patients. Laparoscopic sonography and palliation may further decrease the need for EL.
腹腔镜检查用于评估腹内恶性肿瘤已成为一个有争议的问题。支持者声称它能提高可切除率，而反对者则认为许多患者无论腹腔镜检查结果如何都需要开腹手术。本研究的目的是比较接受分期腹腔镜检查的患者与接受初始探查性开腹手术的患者的结局。
回顾了18个月期间所有接受上消化道或肝胆恶性肿瘤手术评估的患者的病历。48例患者最初接受了分期腹腔镜检查（SL）；80例患者接受了初始探查性开腹手术（EL）。获得的数据包括癌症类型、腹腔镜检查结果、腹腔镜确定的可切除性、腹腔镜手术、开腹确定的可切除性、开腹手术以及住院时间（LOS）。采用Fisher精确检验或Mann-Whitney U检验进行统计分析。
SL认为75%的患者的恶性肿瘤可切除。其中，77.8%的患者接受了切除手术。相比之下，EL组的可切除率为56.3%（P = 0.025）。不可切除恶性肿瘤患者的SL检查结果为癌性腹膜炎（75%）、肝转移（33.3%）和直接侵犯（16.7%）。在8例假阴性SL检查中，75%因血管侵犯而不可切除，25%因其他原因不可切除。EL组中恶性肿瘤不可切除的患者的检查结果为癌性腹膜炎（34.3%）、直接侵犯（22.6%）、肝转移（42.9%）和仅血管侵犯（17.1%）。因此，SL可确定EL组中82.9%的患者患有不可切除的恶性肿瘤。在EL组中，22.5%的开腹手术为非治疗性手术，而SL组中4.2%的患者接受了非治疗性开腹手术。SL组中不可切除患者的平均住院时间为0.5天，75%的患者在手术当天出院。相比之下，EL组为10.9天（P < 0.00001），非治疗性EL组为7.6天（P < 0.00001）。
SL提高了可切除率，降低了非治疗性开腹手术率，并缩短了不可切除疾病患者的住院时间。SL在检测仅因血管侵犯导致的不可切除性方面较差，但这占患者不到五分之一。腹腔镜超声检查和姑息治疗可能会进一步减少对EL的需求。
