- Among patients who had unsuspected metastatic pancreatic cancer discovered on initial exploration, those who underwent a staging laparoscopy had a shorter hospital stay and started chemotherapy sooner than those who went straight to laparotomy
- The laparoscopy group survived significantly longer than the laparotomy group, possibly due to the faster initiation of palliative chemotherapy
- Prophylactic biliary or gastric bypass may not be beneficial if patients are asymptomatic
- More complications occurred in patients who underwent a laparotomy and at least one biliary or gastric bypass than those who had only laparoscopy
When imaging suggests that a patient with pancreatic cancer has resectable disease, it is standard to then undergo an exploratory laparotomy in hopes that removal of the cancer will be possible. Traditionally, should metastatic disease be detected upon entering the abdomen, a prophylactic biliary or duodenal bypass is performed because it is presumed that tumor growth will eventually obstruct the biliary or gastrointestinal system.
Some surgeons now begin their operation with a staging laparoscopy so that patients who prove to have metastatic disease can be spared the more invasive laparotomy. Recent studies have demonstrated that patients found to have metastatic disease on laparoscopy demonstrate no higher incidence of biliary or gastric outlet obstruction in their remaining lifetime than patients explored with laparotomy.
Massachusetts General Hospital researchers Naomi M. Sell, MD, general surgery resident, Cristina R. Ferrone, MD, surgical director of the Liver Program in the Division of General Surgery, and colleagues have determined that patients who undergo staging laparoscopy have a significantly shorter time to chemotherapy and significantly improved survival. In Annals of Surgical Oncology, they advocate for the use of staging laparoscopy and suggest that prophylactic biliary or gastric bypass is not necessary for patients with metastatic pancreatic cancer.
Dr. Ferrone's team reviewed the records of 151 patients who presented to Mass General between August 2001 and February 2015 with presumed resectable pancreatic cancer that demonstrated metastatic disease at the time of operation. 62 had proceeded straight to laparotomy and 89 had undergone staging laparoscopy.
Most key demographic and preoperative clinical characteristics were comparable in the two groups of patients. The exception was that the proportion of patients with head lesions was significantly greater in the laparotomy group. Therefore, subanalyses of patients with head lesions were performed.
At the conclusion of the study, researchers found:
- Prophylactic bypass did not lead to a significant difference between the two groups with regard to the primary outcome—the incidence of cholangitis, gastric outlet obstruction or biliary stent placement—at 30 days. This was true for the entire cohort as well as for the subset of patients with head lesions
- Patients who underwent staging laparoscopy had a significantly shorter length of operation, had significantly less blood loss and were less likely to undergo at least one prophylactic bypass procedure, compared with the laparotomy group. They also had a significantly shorter hospital stay (0.8 days vs. 6.9 days, P < .001)
- Without the physiologic hit of a laparotomy, patients in the laparoscopy group were significantly more likely to receive palliative chemotherapy and were able to start chemotherapy significantly sooner. This was true overall as well as for patients with head lesions
The faster initiation of chemotherapy and decreased complication rate in the laparoscopy group may have contributed to the median overall survival being significantly longer compared to the laparotomy group (11.4 vs. 8.3 months, P < .001). Again, this was true for the entire cohort as well as patients with head lesions.
In multivariate analysis, laparoscopy and female sex were the factors significantly associated with improved overall survival. Even three months of additional survival, along with fewer days in the hospital, can mean a lot to patients with a devastating diagnosis.
Wound infections that occurred within 90 days of the operation were found in significantly more patients who underwent a laparotomy than those undergoing laparoscopy. Eight patients in the laparotomy group developed an intra-abdominal abscess, pancreatic fistula, delayed gastric emptying or an anastomotic leak. In terms of the latter complications, the study was not powered to detect significant differences between groups, but not a single patient from the laparoscopic group experienced any of them.
Patients thought to have resectable pancreatic cancer should undergo staging laparoscopy to ensure no evidence of metastases before moving forward with laparotomy. Prophylactic bypass is unnecessary and not beneficial in asymptomatic patients. In fact, such an intensive procedure in the setting of advanced disease may cause more morbidity than previously thought.
Learn about the Digestive Healthcare Center
Learn more about the Pancreas and Biliary Center