Background:
Staging laparoscopy is a valuable tool and a recommended technique for the staging of gastric cancer[1][2]. However there is no uniform consensus on indications for staging laparoscopy[3]. NCCN recommends in category 2B for a subset with T3/ N+, whereas ESMO guidelines give a III,B recommendation for all resectable gastric cancers. Considering surgical practice in India, a standard protocol is yet to be agreed upon[4].
Aim:
To investigate feasibility of staging laparoscopy prior to neoadjuvant chemotherapy in locally advanced gastric and OG junction cancers
Objectives
Primary:
1.To know the role of staging Laparoscopy (SL) in locally advanced stomach and OG junction cancers
Secondary:
1.To study the morbidity and mortality associated with SL
2. To study the pattern of positive findings and analyze risk factors (patient and disease related) associated with positive findings in SL
3. To compare role of imaging with SL in detection of peritoneal metastasis
Materials and methods:
Study period:
May 2018- May 2020
Study setting: RCC, Trivandrum
Inclusion Criteria:
1.Newly diagnosed biopsy proven cases of locally advanced gastric adenocarcinoma defined as >cT2 and/or N+.
2.Age 20-70 years
3.Patients fit for perioperative chemotherapy and surgery-
ECOG:PS 0-2
4.Willing to give Informed consent
Exclusion criteria:
1.Patients who received some treatment outside.
2.Patients with synchronous malignancy
3.Patients unfit for laparoscopic procedure or general anesthesia
4.Patients presenting with obstruction, bleeding or perforation.
Methodology:
Newly diagnosed cases of gastric adenocarcinoma presenting to RCC during the study period will be considered for the study. After taking informed consent, a detailed history and physical examination will be done. Demographic data will be acquired. The results of hematology, serum biochemistry, endoscopy and pathology will be recorded. At presentation contrast enhanced CT of chest and abdomen will be studied. If the disease is cT3/4 N0/+ M0 in the CT imaging, patients will undergo staging laparoscopy. Those patients with a localized operable disease in the laparoscopy and negative peritoneal washings will receive further treatment. (NACT followed by surgery). Patients with positive disease in SL will be put on palliation. All the data will be subjected to statistical analysis to obtain any significant results.
Staging laparoscopy technique
A 10mm trocar is inserted under direct vision along the anticipated laparotomy incision. Under 15 mmHg pressure pneumoperitoneum created and the abdomen is evaluated with a 30° angle laparoscope. The whole abdomen is inspected including the parietal and visceral peritoneum in every quadrant, the pelvis, the anterior and posterior surface of the liver, porta hepatitis, gastrohepatic omentum, duodenum, transverse mesocolon and celiac region. Typically, two additional 5 mm ports are necessary for exposure. The non regional lymph node areas and entire viscera of peritoneal cavity will be inspected. Any lesions likely to be metastases are sampled and analyzed by histopathology. Frozen section may be used for ensuring adequacy of biopsy. At least 100 ml of the fluid used for peritoneal washing will be aspirated and sent for cytological examination.
Definition of ‘Positive SL’
1) Ascites and/or Peritoneal disease (after positive biopsy/cytology) 2) Non-regional lymph node metastasis(eg. para-aortic lymph nodes) 3) Other metastatic deposits in abdomen
Follow up:
All patients subjected to SL will be followed up for 1 month and any morbidity or mortality will be recorded.