Definitions of the grades of the recommendations (A, B, C) and the levels of evidence (I, II, III) are provided at the end of the "Major Recommendations" field.
General Recommendations for Diagnostic Laparoscopy
Diagnostic laparoscopy is a safe and well tolerated procedure that can be performed in an inpatient or outpatient setting under general or occasionally local anesthesia with intravenous sedation in carefully selected patients. Diagnostic laparoscopy should be performed by physicians trained in laparoscopic techniques who can recognize and treat common complications and can perform additional therapeutic procedures when indicated. During the procedure, the patient should be continuously monitored, and resuscitation capability must be immediately available. Laparoscopy must be performed using sterile technique along with meticulous disinfection of the laparoscopic equipment. Overnight observation may be appropriate in some outpatients.
Staging Laparoscopy (SL) for Esophageal Cancer
Technique
The patient is placed in the supine position, and pneumoperitoneum is established. A 30-degree laparoscope is recommended for optimal visualization. Additional ports in the left upper quadrant and epigastric area can be placed as needed. Full inspection of the peritoneal cavity helps evaluate for peritoneal or liver metastases. If no distant disease is discovered, then the left lateral lobe of the liver is elevated to expose the gastroesophageal junction, and the patient is placed in steep reverse Trendelenburg position. The tumor is inspected for extension into the surrounding area. Lymph nodes in the gastrohepatic ligament or celiac axis suspected to be malignant are biopsied. An optional laparoscopic feeding jejunostomy can be placed when neoadjuvant therapy is planned. In addition, combined thoracoscopic/laparoscopic staging has been described to improve staging for esophageal cancer by increasing the number of positive lymph nodes identified compared with conventional staging (Level II). Specifically for the thoracoscopic evaluation, the patient is in full, left lateral decubitus position with single-lung ventilation. Two to three thoracic trocars are placed, and the mediastinal pleura overlying the esophagus is incised to identify and biopsy lymph nodes as needed.
Indications
SL should be used for patients with esophageal cancer who are potential candidates for curative surgical resection based on a negative preoperative staging for lymph node or distant metastases. Furthermore, the procedure can be used for the placement of enteral feeding access in patients when a percutaneous endoscopic gastrostomy cannot be undertaken, and the patients are candidates for neoadjuvant chemotherapy.
Recommendations
SL can be performed safely in patients with esophageal cancer (Grade B). Patients who are considered to be candidates for curative resection (early stage esophageal cancer with no evidence for distant or lymph node metastases on high quality preoperative imaging) may benefit from SL (Grade B). SL also provides the opportunity for enteral feeding tube placement without the need for laparotomy. The procedure may also facilitate a shorter time to adjuvant therapy initiation compared with laparotomy, but data are too limited to provide a firm recommendation. Positive emission tomography scan and endoscopic ultrasound-fine needle aspiration may be more cost-effective compared with laparoscopy, but more evidence is needed to determine this. (Grade C)
For details of the rationale for the procedure and its diagnostic accuracy, see the original guideline document.
Definitions:
Levels of Evidence
| Level I |
Evidence from properly conducted randomized, controlled trials |
| Level II |
Evidence from controlled trials without randomization
Or
Cohort of case-control studies
Or
Multiple time series, dramatic uncontrolled experiments
|
| Level III |
Descriptive case series, opinions of expert panels |
Scale Used for Recommendation Grading
| Grade A |
Based on high-level (level I or II), well-performed studies with uniform interpretation and conclusions by the expert panel |
| Grade B |
Based on high-level, well-performed studies with varying interpretation and conclusions by the expert panel |
| Grade C |
Based on lower-level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel |
