Laparoscopic ultrasound: a surgical "must" for second line intra-operative evaluation of pancreatic cancer resectability

Abstract

Background: Advanced laparoscopy for pancreatic cancer surgery should include laparoscopic ultrasound (LUS), in order to accurately evaluate resectability and rule out the presence of undetected metastases and/or vascular infiltration. LUS should be done as a preliminary step whenever pre-operative imaging casts doubts on resectability.

Patients and methods: We hereby report our experience of 18 consecutive patients, aged 43-76, coming to our attention during a six months period (Jan-Jun 2013), with a diagnosis of pancreas head or body cancer.

Results: LUS allowed to rule out undetected metastases or mesenteric vessels infiltration in 11 patients (61.1%), who were submitted, as previously scheduled, to radical duodeno-pancreatectomy (9 cases) and spleno-caudal pancreatectomy (2 cases). Among the remaining patients, three had been correctly evaluated as non resectable radically at pre-operative work out, and confirmed at LUS, while LUS detected non resectable disease in further 4 patients (22.2%), who underwent palliative procedures. In 2 patients of this group liver micro-metastases were found, while 2 were excluded because of mesenteric vessels infiltration.

Conclusions: LUS provided a higher level of diagnostic accuracy, allowing in our experience to exclude 4 patients from radical surgery (22.2%). The evaluation of surgical resectability is an issue of crucial importance to decide surgical strategy in pancreas tumor surgery. In our opinion LUS should be considered a mandatory step in laparoscopic approach to pancreatic tumors, to better define disease staging and evaluate resectability.

Figures

Fig. 1

LUS: undetected hepatic micro-metastases.

Fig. 2

LUS: hypoechoic hepatic nodules suspect for metastases. Intra-operative ultrasonic-guided biopsy was performed.

Fig. 3

LUS with duplex Doppler showing impingement of pancreatic tumor into the mesenteric vein.

Fig. 4

LUS with duplex Doppler showing stenosis of the superior mesenteric vein due to tumor compression.