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Staging Laparoscopy in Carcinoma of Stomach: A Comparison with CECT Staging

Staging Laparoscopy in Carcinoma of Stomach: A Comparison with CECT Staging Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2013, Article ID 674965, 5 pages http://dx.doi.org/10.1155/2013/674965 Clinical Study Staging Laparoscopy in Carcinoma of Stomach: A Comparison with CECT Staging 1 1,2 1 1 Showkat Majeed Kakroo, Arshad Rashid, Ajaz Ahmad Wani, Zahida Akhtar, 1 1 Manzoor Ahamad Chalkoo, and Asim Rafiq Laharwal Department of General Surgery, Government Medical College, Srinagar 190010, India Minimal Access Surgery, Lok Nayak Hospital, Maulana Azad Medical College, New Delhi 110002, India Correspondence should be addressed to Arshad Rashid; arsh002@gmail.com Received 2 March 2013; Revised 12 April 2013; Accepted 12 April 2013 Academic Editor: S. Curley Copyright © 2013 Showkat Majeed Kakroo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. aim of this study was to compare the role of diagnostic laparoscopy and contrast enhanced computed tomography (CECT) of abdomeninthe stagingofstomach carcinoma. Methods. This was a prospective study conducted in a tertiary care hospital over a period of two years and included 50 patients of endoscopy and biopsy proven stomach carcinoma that were found to be operable on CECT. Diagnostic laparoscopy was performed in all patients before proceeding to a formal laparotomy. Results. Metastasis was detected at diagnostic laparoscopy in 14 (28%) patients. CECT correctly identified the T stage in 22 (61%) patients. Overall accuracy of CECT for T staging was 74% with a a sensitivity of 65% and a specificity of 79%. Laparoscopy correctly identified the T stage in 26 (72%) patients. Overall accuracy of laparoscopy for T staging was 81% with a sensitivity of 76% and specificity of 86%. the most common N stage on CECT was N0 (50%). CECT correctly identified the N stage in 26 (72%) patients. Overall accuracy of CECT for N staging was 86% with a sensitivity of 50% and a specificity of 90%. the most common N stage on laparoscopy was N0 and N2 (42% each). Laparoscopy correctly identified the N stage in 27 (75%) patients. Overall accuracy of Laparoscopy for N staging was 88% with a sensitivity of 53% and specificity of 91%. Conclusion. Laparoscopy is a valuable technique in staging of stomach carcinoma and has an important role in the detection of intra-abdominal metastasis missed by CECT. 1. Introduction has underwent a boom [3–5]. CECT is used preoperatively primarily to determine the stage and extragastric spread of Gastric cancer remains one of the most common causes the carcinoma but has the propensity to underestimate the of death from cancer worldwide, especially in our part extent of disease, with small-volume metastatic disease being of the world. In Kashmir, the incidence rates for gastric appreciated only at open surgical exploration. Laparoscopy cancer have been estimated at 36.7/100000 per year in men has been suggested as a means for identifying such small- and 9.9/100000 per annum in women, respectively [1]. As volume disease. The aim of laparoscopic staging is to mimic the multidisciplinary management of gastrointestinal cancer staging at open exploration while minimizing morbidity, has evolved over the last decade, an accurate extent of enhancing recovery, and thus allowing for quicker adminis- disease workup has become essential for treatment planning. tration of adjuvant therapies if indicated [6–8]. Even aer ft a thorough radiological workup, many patients with stomach carcinoma are diagnosed as unresectable or metastatic on exploratory laparotomy. For the subgroup of 2. Methods and Materials patients who do not require palliation, exploration confers little benetfi andmay,onthe contrary,beassociatedwithsig- This was a prospective study conducted on 50 patients nicfi ant morbidity and mortality [ 2]. Since the introduction of endoscopic and biopsy proven stomach carcinoma that of contrast enhanced computed tomography (CECT) scan were foundtobeoperableonCECTofabdomen/pelvis. some 30 years back, the staging workup of gastric carcinoma The study was conducted over a period of two years in 2 International Journal of Surgical Oncology a tertiary care hospital of Kashmir. All the patients were Table 1: Metastases detected by laparoscopy. staged preoperatively by CECT of abdomen/pelvis done on Metastases <0.5 cm 0.5–1 cm >1cm a 32-slice helical CT scanner (Fxi, GE Medical Systems). Liver 6 2 1 Patients were kept fasting for six hours prior to their scan. Peritoneal 3 0 0 The patients were asked to take 500 mL, 250 mL, and 25 mL of water orally 120, 60, and 5 minutes, respectively, prior to Both of these 0 1 1 their scan. Five mm contiguous cuts were taken from the Overall 9 3 2 dome of diaphragm to the pubic rami. Scans were taken aer ft intravenous administration of 100 mL 60% iodinated contrast agent. Any area of gastric wall with thickness measuring (9 patients). Peritoneal metastases were seen in 5 patients more than 5 mm was considered abnormal. Irregularities in either isolated (3 patients) or in association with liver metas- the external surface of wall were considered serosal involve- tases (2 patients) (Table 1). As these peritoneal deposits were ment. Tumors conn fi ed to the gastric wall or intramural or not picked up by the CECT, comparison with diagnostic transmural involvement with a smooth outer wall and clear laparoscopy and histopathology was not possible, so these fat plane around tumor were considered T1/T2. Transmural patients were excluded from the study and received palliative tumors with irregularorblurred outerborder with or without treatment. Staging with preoperative CECT was compared perigastric fat stranding were considered as T3. Obliteration with the laparoscopic staging in the other 36 patients taking of fat plane between gastric tumor and adjacent organ or histopathological staging as the standard. eTh most common direct invasion of adjacent organ was taken as T4. Any T stage on CECT was T3 and T4 (44.44% each). Overall enlarged lymph node seen in the 16 anatomic sites as per the accuracy of CECT for T staging was 74% with a sensitivity of Japanese Research Society on Gastric Cancer classification 65% and a specificity of 79%. The most common T stage on was noted as nodal disease [9]. Regional lymph nodes were laparoscopy was T3 (50%). Overall accuracy of Laparoscopy considered to represent local metastases if they were solitary for T staging was 81% with a sensitivity of 76% and a or separate nodes 8 mm or greater in long-axis diameter with specificity of 86% ( Table 2). The most common N stage on enhancement, which was defined as attenuation greater than CECT was N0 (50%). Overall accuracy of CECT for N staging 85 Hounsfield units in the postcontrast portal venous phase. was 86% with a sensitivity of 50% and a specificity of 90%. The The CECT films were fully reviewed and discussed with a most common N stage on laparoscopy was N0 and N2 (42% qualified radiologist. each).OverallaccuracyofLaparoscopyforNstagingwas88% Diagnostic laparoscopy was done in all these patients with a sensitivity of 53% and a specificity of 91% ( Table 3). before proceeding with a formal exploratory laparotomy. This procedure was explained to the patients/attendants in detail and an informed consent was taken for the same. 4. Discussion Closed technique was used to gain access into abdomen. A formal diagnostic laparoscopy was undertaken through a In our study 50 patients underwent a diagnostic laparoscopy subumbilical port. After a thorough inspection of all four aer ft a preoperative CECT excluded any form of metastasis. quadrants of the peritoneal cavity was carried out, biopsies At diagnostic laparoscopy, out of these 50 patients, 14 patients were taken from any suspicious tissue. The lesser sac was revealed metastasis (9 hepatic, 5 peritoneal), conrfi med by inspected routinely and accessory ports were employed if frozen section. Of note was one patient in whom multiple needed. Peritoneal lavage was not included in the diagnostic large metastases were detected on laparoscopy (Figure 1). laparoscopy protocol. Definitive surgery was performed on uTh sanunnecessary laparotomy wasaverted in 14 (28%) the patients who were found resectable on laparoscopy. patients. Similar observations were made by Lowy et al. A formal staging of the patient was done as per the 7th (23%), Conlon (33.7%), Sotiropoulos et al. (31.1%), and edition of the UICC/TNM Classification [ 10], and a com- Burke et al. (37%) [11–14]. eTh magnicfi ation afforded by parison between the staging obtained from CECT and that laparoscopy makes it possible to even pick up small peritoneal from laparoscopy was made. Statistical Analysis was done nodules which are otherwise missed on imaging modalities by Graphpad Instat Version 3.10 for Windows (Graphpad (Figure 2). softwares Inc., San Diego, CA, USA). An ethical clearance was Owing to their hypervascularity, most gastric cancers obtained from the local ethics committee. areseenasenhancing lesions[15]. As regards the tumour (T) status, CECT correctly staged 22 (61%) patients. CECT over-staged 7 (19.4%) patients, and also under-staged the 3. Results same number of patients. CECT had a sensitivity of 65% and Fifty consecutive patients of stomach carcinoma, found to a specificity of 79% for T staging. Diagnostic laparoscopy be resectable on CECT, were enrolled. The mean age of correctly staged the T status in 26 (72%) patients and it presentation was 58.57 ± 5.7 years in males and 56.67 ± overstaged 4 (11.11%) patients, and understaged 6 patients 6.3 years in females. eTh maximum incidence of stomach (16.7%). Overall accuracy for T stage with laparoscopy was carcinoma in our study was found in the age group of 56 to 81% as against 74% of CECT with a sensitivity of 76% and a 65 years. Males outnumbered females by a factor of 2.85 : 1. specificity of 86% (𝑃 = 0.0324) . Our results are similar to Metastasis was detected at diagnostic laparoscopy in 14 those of the study conducted by Blackshaw et al. and D’Ugo (28%) patients. Hepatic metastasis was the most common et al. [16, 17]. International Journal of Surgical Oncology 3 Table 2: CECT/laparoscopic vis-a-vis histopathologic T and N staging. (a) Histopathologic T stage Histopathologic T stage CECT T stage Total Laparoscopic T stage Total T1/T2 T3 T4 T1/T2 T3 T4 T1/T2 3 1 0 4 T1/T2 4 1 0 5 T3 2 8 6 16 T3 3 10 5 18 T4 2 3 11 16 T4 0 1 12 13 Total 7 12 17 36 Total 7 12 17 36 (b) Histopathologic N stage Histopathologic N stage CECT N stage Total Laparoscopic N stage Total N0 N1 N2 N3 N0 N1 N2 N3 N0 14 2 2 0 18 N0 12 2 1 0 15 N1 0 2 2 0 4 N1 2 3 1 0 6 N2 2 2 10 0 14 N2 2 1 12 0 15 N3 0000 0 N3 0 000 0 Total 16614 0 36 Total 16 6140 36 Table 3: Statistical analysis of CECT and laparoscopic vis-a-vis histopathologic T and N staging. Sensitivity Specifity PPV NPV Accuracy CT LAP CT LAP CT LAP CT LAP CT LAP Tstatus T1/T2 75 80 88 90 43 57 97 97 86 89 T3 50 56 80 89 67 83 67 67 67 72 T4 69 92 70 78 65 71 74 95 69 83 Overall 65 76 7986 5870 7986 74 81 Nstatus N0 78 80 89 81 88 75 80 85 83 81 N1 50 50 88 90 33 50 94 90 83 83 N2 71 80 82 90 71 86 82 86 78 86 N3 0 0 100 100 0 0 100 100 100 100 Overall 50 53 90 91 48 53 89 90 86 88 As regards the nodal (N) status, CECT correctly staged 26 Laparoscopic gastrojejunostomy has been established as (72%) patients. It overstaged 4 (11.11%) patients, and under- a safe alternative to open approach for the palliation of staged 6(16.7%) patients.CECThad asensitivity of 50%and symptoms due to gastric outlet obstruction in unresectable a specificity of 90% for N staging. eTh relative insensitivity cancer stomach. Additional benefits of the laparoscopic of CECT for detecting nodal disease is due to its inability approach include decreased immune suppression, decreased to detect micrometastasis in the nodes [18]. Laparoscopy postoperative pain, early ambulation, and other advantages correctly staged N status in 27 (75%) patients, over-stage of minimally invasive surgery [21]. However, laparoscopic 5 (13.9%) patients, and under-stage 4 (11.11%) patients. The gastrojejunostomy was not offered to any of our patients, overall accuracy of laparoscopy for N staging was 88% as as we were not adequately experienced with this proce- against 86% of CECT scanning with a sensitivity of 53% and dure. a specificity of 91% (𝑃 = 0.4324) . Possik et al. reported an We acknowledge the fact that though the accuracy for overall accuracy of laparoscopy for N staging as 58.4% with a nodal status was marginally better for laparoscopy and did sensitivity of 60% and a specicfi ity of 90% [ 19]. Similar results not reach statistical significance, it does not preclude the use were observed by a study conducted by Muntean et al. in of diagnostic laparoscopy. The specific value of diagnostic which the overall laparoscopic N staging accuracy was 64.3% laparoscopy is in detecting minimal metastatic disease that with a sensitivity of 54.5% and a specificity of 100% [ 20]. is otherwise undetectable by routine imaging modalities. 4 International Journal of Surgical Oncology [2] N. Misra, R. Hardwick, and P. McCulloch, “eTh role of surgery in cancer stomach,” in Gastrointestinal Oncology: Evidence and Analysis,P.McCulloch, M. S. Karpah,D.J.Kerr, andJ.Ajani, Eds.,pp. 73–85, InformaHealthcareUSA,New York,NY, USA, 1st edition, 2007. [3] J. Davies, A. G. Chalmers, H. M. Sue-Ling et al., “Spiral com- puted tomography and operative staging of gastric carcinoma: a comparison with histopathological staging,” Gut,vol.41, no. 3, pp.314–319,1997. [4] T. Fukuya, H. Honda, K. Kaneko et al., “Efficacy of helical CT in T-staging of gastric cancer,” Journal of Computer Assisted Tomography,vol.21, no.1,pp. 73–81, 1997. Figure 1: Diagnostic laparoscopy showing liver metastasis. [5] J.Triller,R.Roder,A.Staoff rd,and R. Schroder,“CT in advanced gastric carcinoma: is exploratory laparotomy avoid- able?” European Journal of Radiology,vol.6,no. 3, pp.181–186, [6] K.C.P.Conlonand A. T. Rega,“Laparoscopic stagingand bypass,” in Maingots Abdominal Operations,M.J.Zinner and S. W. Ashley, Eds., p. 1245, Mcgraw Hill Companies, New York, NY, USA, 11th edition, 2007. [7] P. McCulloch, M. Johnson, R. Jairam, and W. Fischer, “Laparo- scopic staging of gastric cancer is safe and aeff cts treatment strategy,” Annals of theRoyal CollegeofSurgeonsofEngland,vol. 80,no. 6, pp.400–402,1998. Figure 2: Diagnostic laparoscopy showing peritoneal metastasis on [8] H. Feussner, K. Omote, U. Fink, S. J. Walker, and J. R. Siewert, diaphragm. “Pretherapeutic laparoscopic staging in advanced gastric carci- noma,” Endoscopy,vol.31, no.5,pp. 342–347, 1999. [9] Japanese Research Committee on Histological Classification of Gastric Cancer, “The general rules for the gastric cancer study 5. Conclusion in surgery and pathology. II. Histological classification of gastric cancer,” eTh Japanese Journal of Surgery ,vol.11,pp.140–145,1981. Laparoscopy is a valuable technique in staging stomach car- cinoma and has an important role in the detection of occult [10] S. B. Edge, D. R. Byrd, C. C. Compton et al., Eds., AJCC Cancer Staging Manual, Springer, New York, NY, USA, 7 edition, 2009. extensive intra-abdominal or metastatic disease not detected by conventional radiological staging. The value of diagnostic [11] A. M. Lowy, P. F. Mansfield, S. D. Leach, and J. Ajani, “Laparo- scopic staging for gastric cancer,” Surgery,vol.119,no. 6, pp.611– laparoscopy is in the prevention of unnecessary surgical 614, 1996. exploration and the resultant morbidity and mortality in patients with locally advanced or metastatic disease. [12] K. C. P. Conlon, “Staging laparoscopy for gastric cancer,” Annali Italiani di Chirurgia,vol.72, pp.33–37,2001. [13] G. C. Sotiropoulos, G. M. Kaiser, H. Lang et al., “Staging Conflict of Interests laparoscopy in gastric cancer,” European Journal of Medical Research,vol.10, no.2,pp. 88–91,2005. All the authors declare that there is no potential conflict [14] E. C. Burke, M. S. Karpeh,K.C.Conlon, andM.F.Brennan, of interests or any n fi ancial relation with the commercial “Laparoscopy in the management of gastric adenocarcinoma,” identities mentioned in the paper. Annals of Surgery,vol.225,no. 3, pp.262–267,1997. [15] F. Efsen and K. Fischerman, “Angiography in gastric tumours,” Authors’ Contribution Acta Radiologica,vol.15, no.2,pp. 193–197, 1974. [16] G. R. J. C. Blackshaw, J. D. Barry, P. Edwards, M. C. Allison, Showkat Majeed Kakroo and Arshad Rashid conceived the G. V. Thomas, and W. G. Lewis, “Laparoscopy significantly study, operated the patients, and draeft d the paper. Manzoor improves the perceived preoperative stage of gastric cancer,” Ahamad Chalkoo, Zahida Akhtar, Ajaz Ahmad Wani and Gastric Cancer,vol.6,no. 4, pp.225–229,2003. Asim Rafiq Laharwal were involved in the workup and post- [17] D. M. D’Ugo, R. Coppola, R. Persiani, P. Ronconi, F. Caracciolo, operative management of the patients and did the literature and A. Picciocchi, “Immediately preoperative laparoscopic survey and critical revisions of the paper. All the authors have staging for gastric cancer,” Surgical Endoscopy,vol.10, no.10, read and approved the paper. pp. 996–999, 1996. [18] J. S. Cho, J. K. Kim, S. M. Rho, H. Y. Lee, H. Y. Jeong, and C. S. Lee, “Preoperative assessment of gastric carcinoma: value References of two-phase dynamic CT with mechanical IV injection of contrast material,” American Journal of Roentgenology,vol.163, [1] M. S. Khuroo, S. A. Zargar, R. Mahajan, and M. A. Banday, no. 1, pp. 69–75, 1994. “High incidence of oesophageal and gastric cancer in Kashmir in a population with special personal and dietary habits,” Gut, [19] R. A. Possik, E. L. Franco, D. R. Pires, D. R. Wohnrath, and vol. 33,no. 1, pp.11–15,1992. E. B. Ferreira, “Sensitivity, specificity, and predictive value of International Journal of Surgical Oncology 5 laparoscopy for the staging of gastric cancer and for detection of liver metastases,” Cancer,vol.58, no.1,pp. 1–6, 1986. [20] V. Muntean, A. Mihailov, C. Iancu et al., “Staging laparoscopy in gastric cancer. Accuracy and impact on therapy,” Journal of Gastrointestinal and Liver Diseases,vol.18, no.2,pp. 189–195, [21] Y. B. Choi, “Laparoscopic gastrojejunostomy for palliation of gastric outlet obstruction in unresectable gastric cancer,” Surgical Endoscopy and Other Interventional Techniques,vol.16, no.11, pp.1620–1626,2002. 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Copyright © 2013 Showkat Majeed Kakroo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2013, Article ID 674965, 5 pages http://dx.doi.org/10.1155/2013/674965 Clinical Study Staging Laparoscopy in Carcinoma of Stomach: A Comparison with CECT Staging 1 1,2 1 1 Showkat Majeed Kakroo, Arshad Rashid, Ajaz Ahmad Wani, Zahida Akhtar, 1 1 Manzoor Ahamad Chalkoo, and Asim Rafiq Laharwal Department of General Surgery, Government Medical College, Srinagar 190010, India Minimal Access Surgery, Lok Nayak Hospital, Maulana Azad Medical College, New Delhi 110002, India Correspondence should be addressed to Arshad Rashid; arsh002@gmail.com Received 2 March 2013; Revised 12 April 2013; Accepted 12 April 2013 Academic Editor: S. Curley Copyright © 2013 Showkat Majeed Kakroo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. aim of this study was to compare the role of diagnostic laparoscopy and contrast enhanced computed tomography (CECT) of abdomeninthe stagingofstomach carcinoma. Methods. This was a prospective study conducted in a tertiary care hospital over a period of two years and included 50 patients of endoscopy and biopsy proven stomach carcinoma that were found to be operable on CECT. Diagnostic laparoscopy was performed in all patients before proceeding to a formal laparotomy. Results. Metastasis was detected at diagnostic laparoscopy in 14 (28%) patients. CECT correctly identified the T stage in 22 (61%) patients. Overall accuracy of CECT for T staging was 74% with a a sensitivity of 65% and a specificity of 79%. Laparoscopy correctly identified the T stage in 26 (72%) patients. Overall accuracy of laparoscopy for T staging was 81% with a sensitivity of 76% and specificity of 86%. the most common N stage on CECT was N0 (50%). CECT correctly identified the N stage in 26 (72%) patients. Overall accuracy of CECT for N staging was 86% with a sensitivity of 50% and a specificity of 90%. the most common N stage on laparoscopy was N0 and N2 (42% each). Laparoscopy correctly identified the N stage in 27 (75%) patients. Overall accuracy of Laparoscopy for N staging was 88% with a sensitivity of 53% and specificity of 91%. Conclusion. Laparoscopy is a valuable technique in staging of stomach carcinoma and has an important role in the detection of intra-abdominal metastasis missed by CECT. 1. Introduction has underwent a boom [3–5]. CECT is used preoperatively primarily to determine the stage and extragastric spread of Gastric cancer remains one of the most common causes the carcinoma but has the propensity to underestimate the of death from cancer worldwide, especially in our part extent of disease, with small-volume metastatic disease being of the world. In Kashmir, the incidence rates for gastric appreciated only at open surgical exploration. Laparoscopy cancer have been estimated at 36.7/100000 per year in men has been suggested as a means for identifying such small- and 9.9/100000 per annum in women, respectively [1]. As volume disease. The aim of laparoscopic staging is to mimic the multidisciplinary management of gastrointestinal cancer staging at open exploration while minimizing morbidity, has evolved over the last decade, an accurate extent of enhancing recovery, and thus allowing for quicker adminis- disease workup has become essential for treatment planning. tration of adjuvant therapies if indicated [6–8]. Even aer ft a thorough radiological workup, many patients with stomach carcinoma are diagnosed as unresectable or metastatic on exploratory laparotomy. For the subgroup of 2. Methods and Materials patients who do not require palliation, exploration confers little benetfi andmay,onthe contrary,beassociatedwithsig- This was a prospective study conducted on 50 patients nicfi ant morbidity and mortality [ 2]. Since the introduction of endoscopic and biopsy proven stomach carcinoma that of contrast enhanced computed tomography (CECT) scan were foundtobeoperableonCECTofabdomen/pelvis. some 30 years back, the staging workup of gastric carcinoma The study was conducted over a period of two years in 2 International Journal of Surgical Oncology a tertiary care hospital of Kashmir. All the patients were Table 1: Metastases detected by laparoscopy. staged preoperatively by CECT of abdomen/pelvis done on Metastases <0.5 cm 0.5–1 cm >1cm a 32-slice helical CT scanner (Fxi, GE Medical Systems). Liver 6 2 1 Patients were kept fasting for six hours prior to their scan. Peritoneal 3 0 0 The patients were asked to take 500 mL, 250 mL, and 25 mL of water orally 120, 60, and 5 minutes, respectively, prior to Both of these 0 1 1 their scan. Five mm contiguous cuts were taken from the Overall 9 3 2 dome of diaphragm to the pubic rami. Scans were taken aer ft intravenous administration of 100 mL 60% iodinated contrast agent. Any area of gastric wall with thickness measuring (9 patients). Peritoneal metastases were seen in 5 patients more than 5 mm was considered abnormal. Irregularities in either isolated (3 patients) or in association with liver metas- the external surface of wall were considered serosal involve- tases (2 patients) (Table 1). As these peritoneal deposits were ment. Tumors conn fi ed to the gastric wall or intramural or not picked up by the CECT, comparison with diagnostic transmural involvement with a smooth outer wall and clear laparoscopy and histopathology was not possible, so these fat plane around tumor were considered T1/T2. Transmural patients were excluded from the study and received palliative tumors with irregularorblurred outerborder with or without treatment. Staging with preoperative CECT was compared perigastric fat stranding were considered as T3. Obliteration with the laparoscopic staging in the other 36 patients taking of fat plane between gastric tumor and adjacent organ or histopathological staging as the standard. eTh most common direct invasion of adjacent organ was taken as T4. Any T stage on CECT was T3 and T4 (44.44% each). Overall enlarged lymph node seen in the 16 anatomic sites as per the accuracy of CECT for T staging was 74% with a sensitivity of Japanese Research Society on Gastric Cancer classification 65% and a specificity of 79%. The most common T stage on was noted as nodal disease [9]. Regional lymph nodes were laparoscopy was T3 (50%). Overall accuracy of Laparoscopy considered to represent local metastases if they were solitary for T staging was 81% with a sensitivity of 76% and a or separate nodes 8 mm or greater in long-axis diameter with specificity of 86% ( Table 2). The most common N stage on enhancement, which was defined as attenuation greater than CECT was N0 (50%). Overall accuracy of CECT for N staging 85 Hounsfield units in the postcontrast portal venous phase. was 86% with a sensitivity of 50% and a specificity of 90%. The The CECT films were fully reviewed and discussed with a most common N stage on laparoscopy was N0 and N2 (42% qualified radiologist. each).OverallaccuracyofLaparoscopyforNstagingwas88% Diagnostic laparoscopy was done in all these patients with a sensitivity of 53% and a specificity of 91% ( Table 3). before proceeding with a formal exploratory laparotomy. This procedure was explained to the patients/attendants in detail and an informed consent was taken for the same. 4. Discussion Closed technique was used to gain access into abdomen. A formal diagnostic laparoscopy was undertaken through a In our study 50 patients underwent a diagnostic laparoscopy subumbilical port. After a thorough inspection of all four aer ft a preoperative CECT excluded any form of metastasis. quadrants of the peritoneal cavity was carried out, biopsies At diagnostic laparoscopy, out of these 50 patients, 14 patients were taken from any suspicious tissue. The lesser sac was revealed metastasis (9 hepatic, 5 peritoneal), conrfi med by inspected routinely and accessory ports were employed if frozen section. Of note was one patient in whom multiple needed. Peritoneal lavage was not included in the diagnostic large metastases were detected on laparoscopy (Figure 1). laparoscopy protocol. Definitive surgery was performed on uTh sanunnecessary laparotomy wasaverted in 14 (28%) the patients who were found resectable on laparoscopy. patients. Similar observations were made by Lowy et al. A formal staging of the patient was done as per the 7th (23%), Conlon (33.7%), Sotiropoulos et al. (31.1%), and edition of the UICC/TNM Classification [ 10], and a com- Burke et al. (37%) [11–14]. eTh magnicfi ation afforded by parison between the staging obtained from CECT and that laparoscopy makes it possible to even pick up small peritoneal from laparoscopy was made. Statistical Analysis was done nodules which are otherwise missed on imaging modalities by Graphpad Instat Version 3.10 for Windows (Graphpad (Figure 2). softwares Inc., San Diego, CA, USA). An ethical clearance was Owing to their hypervascularity, most gastric cancers obtained from the local ethics committee. areseenasenhancing lesions[15]. As regards the tumour (T) status, CECT correctly staged 22 (61%) patients. CECT over-staged 7 (19.4%) patients, and also under-staged the 3. Results same number of patients. CECT had a sensitivity of 65% and Fifty consecutive patients of stomach carcinoma, found to a specificity of 79% for T staging. Diagnostic laparoscopy be resectable on CECT, were enrolled. The mean age of correctly staged the T status in 26 (72%) patients and it presentation was 58.57 ± 5.7 years in males and 56.67 ± overstaged 4 (11.11%) patients, and understaged 6 patients 6.3 years in females. eTh maximum incidence of stomach (16.7%). Overall accuracy for T stage with laparoscopy was carcinoma in our study was found in the age group of 56 to 81% as against 74% of CECT with a sensitivity of 76% and a 65 years. Males outnumbered females by a factor of 2.85 : 1. specificity of 86% (𝑃 = 0.0324) . Our results are similar to Metastasis was detected at diagnostic laparoscopy in 14 those of the study conducted by Blackshaw et al. and D’Ugo (28%) patients. Hepatic metastasis was the most common et al. [16, 17]. International Journal of Surgical Oncology 3 Table 2: CECT/laparoscopic vis-a-vis histopathologic T and N staging. (a) Histopathologic T stage Histopathologic T stage CECT T stage Total Laparoscopic T stage Total T1/T2 T3 T4 T1/T2 T3 T4 T1/T2 3 1 0 4 T1/T2 4 1 0 5 T3 2 8 6 16 T3 3 10 5 18 T4 2 3 11 16 T4 0 1 12 13 Total 7 12 17 36 Total 7 12 17 36 (b) Histopathologic N stage Histopathologic N stage CECT N stage Total Laparoscopic N stage Total N0 N1 N2 N3 N0 N1 N2 N3 N0 14 2 2 0 18 N0 12 2 1 0 15 N1 0 2 2 0 4 N1 2 3 1 0 6 N2 2 2 10 0 14 N2 2 1 12 0 15 N3 0000 0 N3 0 000 0 Total 16614 0 36 Total 16 6140 36 Table 3: Statistical analysis of CECT and laparoscopic vis-a-vis histopathologic T and N staging. Sensitivity Specifity PPV NPV Accuracy CT LAP CT LAP CT LAP CT LAP CT LAP Tstatus T1/T2 75 80 88 90 43 57 97 97 86 89 T3 50 56 80 89 67 83 67 67 67 72 T4 69 92 70 78 65 71 74 95 69 83 Overall 65 76 7986 5870 7986 74 81 Nstatus N0 78 80 89 81 88 75 80 85 83 81 N1 50 50 88 90 33 50 94 90 83 83 N2 71 80 82 90 71 86 82 86 78 86 N3 0 0 100 100 0 0 100 100 100 100 Overall 50 53 90 91 48 53 89 90 86 88 As regards the nodal (N) status, CECT correctly staged 26 Laparoscopic gastrojejunostomy has been established as (72%) patients. It overstaged 4 (11.11%) patients, and under- a safe alternative to open approach for the palliation of staged 6(16.7%) patients.CECThad asensitivity of 50%and symptoms due to gastric outlet obstruction in unresectable a specificity of 90% for N staging. eTh relative insensitivity cancer stomach. Additional benefits of the laparoscopic of CECT for detecting nodal disease is due to its inability approach include decreased immune suppression, decreased to detect micrometastasis in the nodes [18]. Laparoscopy postoperative pain, early ambulation, and other advantages correctly staged N status in 27 (75%) patients, over-stage of minimally invasive surgery [21]. However, laparoscopic 5 (13.9%) patients, and under-stage 4 (11.11%) patients. The gastrojejunostomy was not offered to any of our patients, overall accuracy of laparoscopy for N staging was 88% as as we were not adequately experienced with this proce- against 86% of CECT scanning with a sensitivity of 53% and dure. a specificity of 91% (𝑃 = 0.4324) . Possik et al. reported an We acknowledge the fact that though the accuracy for overall accuracy of laparoscopy for N staging as 58.4% with a nodal status was marginally better for laparoscopy and did sensitivity of 60% and a specicfi ity of 90% [ 19]. 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