Diagnostic Staging Laparoscopy in Gastric Adenocarcinoma: a review of best practices and quality assessment at a rural regional referral hospital
John A. Steinharter*1, Conor O'Neill2
1University of Vermont Robert Larner, MD School of Medicine, Burlington, VT; 2University of Vermont Cancer Center, University of Vermont Medical Center, Burlington, VT
The diagnostic staging laparoscopy (DSL) is a highly specific tool performed to stage peritoneal involvement of gastric cancer (GC). DSL provides more accurate staging of GC as compared to imaging alone without the morbidity associated with exploratory laparotomy. Our objective with this study was to establish a best practice protocol for DSL of GC at a rural regional referral center and provide tools for improved implementation of DSL for GC at equivalently resourced medical centers. The design of our study consisted of a literature review of current expert opinions on surgical procedure, recommended guidelines for patient selection, statistical efficacy, and the associated risks of DSL. Subsequently, patients with gastric cancer were identified through our Gastric Tumor Registry in the setting of the University of Vermont Cancer Center. All patients with subset histologies of GC were included. Results: A total of 247 patients (pts) from the Gastric Tumor registry from 2012 "“ 2021 were abstracted: 122 cases had a diagnosis of GC, of which 44 patients received DSL and 37 received a gastrectomy: 5% were cM1 pre-DSL (N=2/44); 21% cM0 pre-DSL found to be pM1 on DSL (N=9/44); 7%(N=3/44) were cM0 pre-baseline DSL, found to be pM1 on baseline DSL, went on to receive chemotherapy and had a reduction in disease burden, had a follow-up post-chemotherapy DSL to assess for surgical candidacy. Additionally, of the 44 cases who had a DSL, 84% (N=37/44) had a gastrectomy. Of the 37 cases with a gastrectomy, 46% (N=17/37) were performed at the same time as the DSL (one-stage) and 54% (N=20/37) were performed as a separate procedure (two-stage). Two-stage is the preferred method so that a patient is allowed time to undergo neo-adjuvant or systemic chemotherapy based on pathologic results. Documented reasons why a one-stage was performed included palliative reasons or surgeon clinical algorithm. Furthermore, there was a dearth of specimens collected during DSL: 25% had cytology samples (n=11/44) and 20.4% were from washings (n=9/44). Our interventions include presenting our findings at institutional multidisciplinary meetings and generating electronic medical record templated notes with specimen collection and evidence-based citations. In conclusion, DSL is a central staging mechanism for patients with resectable GC and, when performed appropriately, it is a powerful diagnostic tool. We found that DSL at our institution resulted in treatment change when used for cM0 pre-DSL found to be pM1 during DSL at rates consistent with available literature. However, barriers to DSL persisted in the last decade with insufficient specimen collection and procedures being performed as one-stage with undocumented reasoning. These barriers may be due to need for updated training on surgical and multidisciplinary approach to patients with GC within our regional catchment.
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