British Journal zyxwvutsrqpon of Surgery zyxwvutsrqp 1995,82,352-354 Laparoscopy in the management of patients with cancer of the gastric cardia and oesophagus zyxw R. G. MOLLOY, J. S. McCOURTNEY and J. R. ANDERSON UniversityDepartment of Surgery, The Royal infirmay, Glasgow, UK Correspondence to: Mr J. R . Anderson, Department of General Surgery, Southern General Hospital, Glasgow G51 4T4 UK The role of laparoscopy in determining suitability for resection was prospectively evaluated in 244 patients with cancer of the gastric cardia and oesophagus. Laparoscopy enabled detection of inoperable disease in 92 patients (38 per cent), several of whom had more than one contraindication to surgery. Hepatic metastases (n zyxwvut = 75, 31 per cent), extensive peritoneal (n = 25, 10 per cent) or lymph node involvement (n zyxwvuts =5, 2 per cent) and direct invasion of the liver or colon (n = 5, 2 per cent) were considered contraindications to surgery. Laparoscopy was poorly tolerated in a further 11 (5 per cent) patients, who were not considered suitable for resection. Extra- abdominal metastatic disease was detected in 17 patients who appeared normal at laparoscopy, and a further six patients refused surgery. The remaining 118 patients underwent laparotomy with a view to resection which was successful in 85 (72 per cent). Laparoscopy thus prevented ill-advised laparotomy in 103 patients (42 per cent), either because of extensive intra-abdominal disease or poor tolerance to anaesthesia. Laparoscopy may be a valuable investigation when used to assess the feasibility of resection. Surgical resection offers effective palliation and potential cure in patients with carcinoma of the cardia and oesophagus. These tumours commonly present with distressing dysphagia which requires effective treatment even in the presence of advanced disease. ExploratoIy laparotomy and ill-advised attempts at resection, however, carry a high operative risk, especially in the presence of locally advanced or metastatic di~easel-~. The presence of liver metastases is associated with a median survival of 15 weeks and in this group of patients laser recanalization provides effective dysphagia palliation5. Accurate information on the location, size and spread of these tumours is essential to avoid ill-advised attempts at resection. The accuracy of laparoscopy, ultrasonography and computed tomography (CT) in detecting intra-abdominal metastases in patients with carcinoma of the oesophagus or gastric cardia has previously been reported from this unit6. Laparoscopy was more sensitive and more accurate than either ultrasonography or CT for detection of hepatic and peritoneal metastases, and was more accurate than ultrasonography with regard to nodal metastases. The present study confirmed the experience of otherP9. Whereas the presence of hepatic, omental or peritoneal metastases represents a contraindication to resection, the detection of locally advanced disease or nodal involvement does not prevent palliative resection. The role of laparoscopy in assessing the likelihood of successful resection is not clear. It might prevent unnecessary surgical exploration in patients with locally advanced or metastatic disease. This study prospectively examined the value of laparoscopy in determining intra- abdominal status and patient suitability for resection. Patients and methods Between August 1984 and July 1992, 244 consecutive patients with previously untreated and biopsy-proven carcinoma of the oesophagus or gastric cardia were assessed with a view to Paper accepted 14 July 1994 352 resection. All patients who were considered fit for surgery and had no evidence of metastatic disease at the time of referral or presentation were prospectively evaluated using ultrasonography, contrast-enhanced CT and laparoscopy. Rigid bronchoscopy was carried out in all patients with upper- and middle-third lesions. The impact of the laparoscopic findings on decision-making with respect to feasibility of resection was prospectively recorded by a single investigator. Laparoscopy was performed as a separate procedure under general anaesthesia with intermittent positive pressure ventilation using an Olympus 30" oblique-viewing laparoscope (Keymed, Southend-on-Sea, UK) with an Eder Insumat Insufflator (Dunn Surgical Limited, Mitcham, UK). Percu- taneous liver biopsy under direct vision was performed as clinically indicated. Results The patients comprised 165 men and 79 women of mean age 66 (range 30-49) years. Adenocarcinoma accounted for 165 tumours, the majority of which involved the lower third of the oesophagus and cardia. Squamous cell carcinoma accounted for a further 76 tumours. Three tumours were classified as either adenosquamous (n = 2) or carcinoid (n = 1). No intra-abdominal contraindication to resection was detected in 152 of the 244 patients (62 per cent) who underwent laparoscopy. There was no significant morbidity or mortality, however, laparoscopy and associated anaesthesia were poorly tolerated in 11 patients who displayed either cardiovascular instability during anaesthesia or a very slow functional recovery following laparoscopy. These patients were not therefore considered fit for major resectional surgery. Laparoscopy detected advanced local or metastatic disease in a total of 92 patients (38 per cent) (Table I). Several patients had more than one contraindication to surgery. Apart from two patients with renal metastases, abdominal ultrasmography and zyx CT did not contribute any additional information about intra-abdominal status. Thoracic CT and a variety of other investigations including rigid bronchoscopy, skin biopsy of suspicious lesions and isotope bone scan detected the presence of