Laparoscopy Selection of patients with gastric adenocarcinoma for laparoscopic staging Abeezar I. Sarela, M.D. a , Robert Lefkowitz, M.D. b , Murray F. Brennan, M.D. a, *, Martin S. Karpeh, M.D. a a Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10021, USA b Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA Manuscript received October 29, 2004; revised manuscript June 28, 2005 Abstract Background: To refine selection criteria for laparoscopic staging of gastric adenocarcinoma, preoperatively available clinical and radiologic factors that may predict the risk of M1 disease were investigated. Methods: During 1993–2002, laparoscopy was performed if patients had minimal symptoms and there was no definite M1 disease at computed tomography (CT) scanning. High-quality, spiral, CT scans were reviewed in detail for 65 recent patients. Results: Laparoscopy was conducted for 657 patients and M1 was detected in 31%. M1 was significantly more prevalent with tumor location at the gastroesophageal junction (GEJ; M1 in 42%) or whole stomach (66%), poor differentiation (36%) or age 70 years (34%). On spiral CT scan, lymphadenopathy 1 cm (49%) or T3/T4 tumors (63%) were associated with significantly higher prevalence of M1. On multivariate analyses, only tumor location (GEJ or whole stomach) and lymphadenopathy were independently significant and M1 was not detected in any patient with neither risk factor. Conclusions: With spiral CT staging, laparoscopy may be avoided if the primary tumor is not at the GEJ or whole stomach and there is no lymphadenopathy. © 2006 Excerpta Medica Inc. All rights reserved. Keywords: Stomach neoplasm; Cancer; Minimal access surgery Laparoscopic staging can detect M1 disease that is not apparent on computed tomography (CT) scanning and avoid unnecessary laparotomy for up to one third of patients with newly diagnosed gastric adenocarcinoma [1]. On this basis, laparoscopy has been recommended for all patients who have locally advanced primary tumors (T2) by endoscopic or radiologic evaluation, have radiologic stage M0 disease, are medically fit for gastrectomy, and do not need an oper- ation for relief of gastric outlet obstruction or control of bleeding, irrespective of disease-stage [1]. Recently, there has been much interest in restricting laparoscopy to patients who are at high risk for M1 disease [2]. Such a selective strategy aims to avoid unnecessary laparoscopy for patients with truly M0 disease, with benefits of optimum resource utilization and prevention of potential complications such as trocar injury, port-site metastasis, or immunologic compro- mise. The issue of patient selection for laparoscopic staging has not been systematically addressed. Some investigators have suggested that laparoscopy should be limited to pa- tients who have radiologic suspicion of peritoneal metasta- sis by spiral CT scanning [3]. With such an approach, the main difficulty is that the suspicion of peritoneal disease is often based on entirely subjective findings of peritoneal or mesenteric thickening or infiltration and the reliability as well as reproducibility of such information is unclear. Oth- ers have selected patients with radiologic T3 or T4 tumors, but the accuracy of this strategy has not been reported [4–6]. Our group has previously reported fewer complications, less operating room time, and shorter hospital stay for pa- tients who underwent laparoscopic staging of gastric ade- nocarcinoma as compared to those who had a laparotomy [1]. In this previous study, subsequent laparotomy was not needed in any patient with laparoscopic M1 disease [1]. The * Corresponding author. Tel.: +1-212-639-8691; fax: +1-212-794- 5845 E-mail address: brennanm@mskcc.org The American Journal of Surgery 191 (2006) 134 –138 0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2005.10.015