Laparoscopy in the evaluation of patients with upper gastrointestinal malignancies

Laparoscopy represents a valuable staging modality in many intra-abdominal malignancies. The primary advantage of laparoscopic staging is prevention of nontherapeutic laparotomy as most patients with intra-abdominal metastases do not benefit from resection, and the identification of metastases by laparoscopy can spare these patients the morbidity of laparotomy. However, the place of laparoscopy in the staging algorithm for patients with upper gastrointestinal malignancies is still evolving. This chapter proposes that staging laparoscopy is best applied to patients with upper gastrointestinal malignancies after conventional staging (imaging) has failed to identify distant metastasis and prior to the attempted resection of the primary tumor. This approach is supported by the fact that most esophageal, gastric, hepatobiliary, and pancreatic malignancies present at an advanced stage and the incidence of "occult" intra-abdominal metastases is high. Additionally, postoperative pain is minimized after diagnostic laparoscopy and time to additional therapy for these patients with advanced malignancy is less than after laparotomy. Lastly, therapeutic maneuvers including placement of vascular or enteral access devices can be performed at the time of staging examination. This chapter will outline the technique and application of laparoscopy in the staging of esophageal, gastric, pancreatic, and hepatobiliary malignancies as practiced at our institution and reported by others.