Role of a spiral computed tomographic grading system in increasing the efficacy of laparoscopic staging for potentially resectable pancreatic and periampullary tumours

Background: In a recent review of patients with potentially resectable pancreatic malignancy in the authors' unit, it was shown that inappropriate laparotomy was avoided in 35 per cent of patients as a direct result of laparoscopy combined with laparoscopic ultrasonographic staging, following previous spiral computed tomography (CT). However, subsequent analysis has suggested that laparoscopy may have added to information already available on the CT scan in as few as 22 per cent of patients. The aim of this study was to seek to define spiral CT scan criteria that might provide a more selective approach to laparoscopic staging. Methods: Theatre records and the Lothian Surgical Audit Database were used to identify 124 patients between June 1995 and May 2000 whose investigations for suspected pancreatic tumours had included spiral CT followed by laparoscopic assessment (suspected tumour: pancreatic head, 88; periampullary, 25; lower bile duct, nine; duodenum, two). Each CT scan (with endoscopic retrograde cholangiopancreatography films if appropriate) was examined by a specialist pancreaticobiliary radiologist (D.N.R.) and graded ‘blindly’ according to a modified existing system for determining local resectability (0, no mass; A, fat plane between tumour and vessels; B, normal pancreas between tumour and vessels; C, mass convex to vessel; D, mass concave to vessel; E, vessel encircled; F, vessel occlusion) before the results were compared with findings at laparoscopy and laparotomy. Results: In groups 0, E and F, only four (7 per cent) of 59 patients benefited from laparoscopic assessment, whereas 27 (42 per cent) of 65 patients avoided an inappropriate laparotomy in groups A–D as a result of improved staging.0 A B C D E Fn 27 24 4 8 29 28 4 Resection 20 9 3 1 9 – – Irresectable  Laparoscopy 2 3 – – 3 2 –  Laparoscopy + laparoscopic US 1 – – 1 4 2 2  Laparoscopic US – 5 – 1 8 11 2 No laparotomy (other) 1 1 – 2 1 1 – Inappropriate laparotomy 3 6 1 3 4 12 –US, ultrasonographyConclusion: Based on these results, only patients graded A–D should undergo laparoscopic staging. By adopting this more selective policy in the future, the number of laparoscopic evaluations may be reduced by 48 per cent, while maintaining the efficacy of preventing inappropriate laparotomies at 42 per cent. © 2001 British Journal of Surgery Society Ltd