Laparoscopic staging of upper gastrointestinal malignancy.

BACKGROUND: Laparoscopic staging (LS) of upper gastrointestinal malignancy has decreased the number of non-curative laparotomies. However, as radiological techniques have improved the value of this invasive staging technique has decreased, with some units either being more selective or abandoning it altogether for certain tumour types. The aim of the present study is to prospectively evaluate the additional utility of LS of upper gastrointestinal malignancy after radiological staging with modern techniques. METHODS: One hundred and six consecutive patients assessed as having potentially curable upper gastrointestinal malignancy after radiological staging underwent LS between April 1999 and June 2001. Laparoscopic findings, outcome at laparotomy and complications were prospectively recorded. RESULTS: Laparoscopic staging detected incurable disease in 28 of the 106 patients (26%). The negative likelihood ratio was 0.36 (95% CI 0.24-0.53). Twenty-seven patients were considered incurable because of findings at laparoscopy and one on the findings of laparoscopic ultrasound. Ten patients underwent open palliative procedures and seven had non-therapeutic laparotomies giving a non-curative laparotomy rate of 16%. LS was most useful for primary liver and biliary tract tumours and was least useful for colorectal liver metastases. The most frequent findings denoting incurability were the presence of liver disease (12 cases) and peritoneal metastases (nine cases). Complications occurred in three patients with one death being attributable in part to the laparoscopy. CONCLUSIONS: Laparoscopy was useful in decreasing the number of non-therapeutic laparotomies, but laparoscopic ultrasound gave little additional benefit. The utility of LS was dependent on tumour type and in particular was of marginal benefit for colorectal liver metastases. LS remains a useful staging tool but should be applied selectively.

Risk of dissemination with biopsy of colorectal liver metastases.

PURPOSE: Liver surgeons usually recommend against biopsy of colorectal liver metastases because of the risk of local dissemination. To date, only case reports describing this problem have been published. This study is an attempt to quantify the risk of biopsy-related dissemination. METHODS: A multicenter, retrospective review was undertaken of cases of colorectal liver metastases presenting for surgery that had undergone a preoperative biopsy. RESULTS: Two hundred thirty-one cases of colorectal liver metastases presenting for surgery were identified. Forty-three cases had undergone a preoperative biopsy (18.6 percent). Seven patients had evidence of dissemination related to the biopsy, giving a risk of dissemination of 16 percent (95 percent confidence interval, 7-30 percent). The risk of dissemination was not related to the type of biopsy. Within the follow-up period (median, 21 months), 3 of the 7 cases with evidence of dissemination and 11 of the 35 without dissemination were alive without disease. Twenty-five percent of the 36 cases without dissemination were resected, whereas 6 of the 7 cases with dissemination were resected. CONCLUSIONS: There is a significant risk of local dissemination with biopsy of colorectal liver metastases. In this series this was independent of the type of biopsy. There was no demonstrated effect on resectability or survival, but numbers were small, and the median follow-up was short.

Inflammatory pseudotumor of the liver: demographics, diagnosis, and the case for nonoperative management.

BACKGROUND: Inflammatory pseudotumor of the liver (IPL) is an unusual tumor-like condition that is becoming recognized as an important differential diagnosis in the patient presenting with liver masses. This report describes six cases of IPL. STUDY DESIGN: Clinical, diagnostic, pathologic, and followup data were collected prospectively on six patients presenting to a specialist hepatobiliary unit. RESULTS: Six patients with IPL presented over a 2-year period. Median age was 35 years (range 2 to 79 years) and five patients were men. Three patients were Polynesian (Tongan and Samoan) and one was New Zealand Maori. Five patients presented with nonspecific symptoms (fever, arthralgia, myalgia) and IPL was an incidental finding in one patient. At presentation, four patients had elevated white cell counts, and five patients had abnormal liver function tests with elevations in alkaline phosphotase and gamma-glutamyl transferase the most commonly seen. Carcinogenic embryonic antigen and alpha fetoprotein were normal in all patients, although one was a known hepatitis B carrier. In all cases of IPL, diagnosis was made on core biopsy of the liver lesions and all patients were managed nonoperatively with complete resolution of the tumors. Two patients had marked reduction in systemic symptoms (fever and pain) from a short course of oral steroids. CONCLUSIONS: IPL appears to be a relatively common problem in Maori and Polynesians. Recognition and differentiation of this condition from malignant liver lesions are important to avoid unnecessary surgery.