P-OGC36 Staging Laparoscopy in Oesophago-gastric cancers; A highly selective approach and its impact on patient outcome during COVID 19

Background Staging laparoscopy is performed in all Oesophago-gastric cancer patients suitable for radical treatment with tumour staged ≥T2 prior to neoadjuvant chemotherapy. In response to COVID 19 pandemic, on 25th March 2020, the joint statement issued by the Royal College of Surgeons and AUGIS advised all laparoscopic procedures should be avoided due to the risk of virus transmission associated with aerosol-generating procedures. In accordance with the guidance, a more selective approach on who underwent a staging laparoscopy was followed. This audit explores its impact on patient outcome comparing data from pre COVID period with the COVID period. Methods Retrospective and prospective data was collected for 24months on all OG cancer patients from 25th March2019 to 24th March2021. ‘Pre COVID’ period was defined as 25th March 2019 to 24th March 2020 and ‘COVID’ period was defined as 25th March 2020 to 24th March 2021. All patients with Oesophago-gastric cancer with MDT cancer staged ≥T2, suitable for neoadjuvant chemotherapy were included. Patients with tumour staged <T2 and or diagnosed with squamous cell carcinoma involving upper or middle third of oesophagus were excluded. Fishers Exact model using SPSS V24 was used to identify any statistically significant differences between the 2 groups. Results Pre-COVID Period: 80patients underwent staging laparoscopy. Of these, 9patients(11.6%) with tumour staged as ≥T3 were declined curative surgery due to advanced disease(n = 2), metastatic disease(n = 3) or both(n = 4). In total, 40patients underwent curative surgery and there were 0 open/close laparotomies. COVID Period: Of the 79patients suitable for staging laparoscopy, only 7patients(8.7%) underwent laparoscopy. Of these, 3patients(3.8%) with tumour staged as ≥T3 were declined curative surgery due to advanced disease(n = 2) and metastatic disease(n = 1). In total, 33patients underwent curative surgery and only 1patient had an open/close laparotomy due to a liver metastases. No statistically significant difference was found p = 0.0913 Conclusions Staging laparoscopy is a useful tool for accurate staging of Oesophago-gastric cancers. It helps avoid unnecessary open and close laparotomy due to advanced disease and also allows us to assess patient fitness to major surgery. During the pandemic, the number of staging laparoscopies performed declined significantly but with no statistically significant difference to patient outcome. Thus we conclude, the COVID 19 pandemic has enabled us to have a selective approach to performing staging laparoscopy in Oesophago-gastric patients with advanced disease staged ≥T3 only.

Patient with ataxia telangiectasia undergoing elective staging laparoscopy: a case report and literature review

Ataxia telangiectasia is a rare autosomal recessive condition which develops due to a mutation in the ataxia telangiectasia mutated gene (ATM gene). As a result of this mutation, the ability of the DNA to undergo repair is undermined. The resulting cellular demise is responsible for the diverse presentation of the clinical condition. Neurological symptoms such as cerebellar ataxia, abnormal eye movements and malignancies occur commonly. Immunodeficiency predisposes these patients to recurrent infections. Perioperative management of patients with this rare condition can be associated with increased morbidity. Therefore, it is recommended that patients with ataxia telangiectasia should be managed in a multidisciplinary center, under the supervision of senior clinicians who have the insight into the clinical needs of such patients. We report herein, the perioperative management of a patient with Ataxia telangiectasia undergoing laparoscopic procedure. Continuous....

Comparison of Staging Laparoscopy for Peritoneal Metastases with or without Pressurized Intra-Peritoneal Aerosol Chemotherapy (PIPAC)

Background Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has been introduced for palliative treatment of peritoneal cancer (PC) and is currently tested also in the neoadjuvant and prophylactic setting. The aim was therefore to compare safety and tolerance of staging laparoscopy with or without PIPAC. Methods This retrospective analysis compared consecutive patients undergoing staging laparoscopy alone for oesogastric cancer with patients having PIPAC for suspected PC of various origins from January 2015 until January 2020. Safety was assessed by use of the Clavien classification for complications and CTCAE for capturing of adverse events. Pain and nausea were documented by use of a visual analogue scale (VAS: 0-10: maximal intensity). Results Overall, 25 PIPAC procedures were compared to 24 in the laparoscopy group. PIPAC procedures took a median of 35 min (IQR: 25-67) longer. Four patients experienced at least one complication in either (p=0.741). No differences were noted for postoperative nausea (p=0.961) and pain levels (p=0.156). Median hospital stay was 2 (IQR: 1-3) for PIPAC and 1 (IQR: 1-2) for the laparoscopy group (p=0.104). Conclusions The addition of PIPAC did not jeopardize safety and postoperative outcomes of staging laparoscopy alone. Further studies need to clarify its oncological benefits.

EP.TH.528The Accuracy of the Multi-slice detector CT Scan (MDCT) in staging borderline resectable periampullary carcinoma

Objectives Assess MDCT accuracy in staging cancers periampullary cancers. Introduction Periampullary malignancies are highly aggressive with poor outcomes. Surgery is the only curative option. It is crucial to define the patients who can advantage from a Whipple’s resection and who can avoid. Methodology and Results RCT investigated randomly 28 patients over 15 months. The patients were sub-divided into 2 groups. Group A, we relied mainly on the MDCT for preoperative staging, while in Group B staging laparoscopy was added before the abdominal exploration. Sensitivity of the MDCT and its accuracy were 100% in defining the signs of irresectability. For borderline staging, the accuracy of the scan was 62.5% and 71%, in groups A and B. The Overall accuracy of MDCT was 75%. It decreased to 68.1% for borderline lesions. The addition of staging laparoscopy to the diagnostic work up, increased the accuracy to 92.5%. The camera test was able to see occult findings which were missed in the images. liver Mets and malignant peritoneal fluid were localized in 18% and 9% respectively. 3 cases in group A and one in group B underwent unnecessary laparotomy. Thus, the false negative incidences were 21% and 7% in group A and B, with overall incidence 14.2%. Conclusion MDCT is highly sensitive and specific with high stage periampullary cancers. These parameters drop in border tumors with reduced accuracy in detecting the degree of vascular abutment and distant-occult findings. Addition of other adjuncts to decrease the rate of un-indicated laparotomy is advised.

TP6.2.15 Staging Laparoscopy and Peritoneal Cytology for Gastric and Gastro-oesophageal Junction Malignancy: an Audit from a Single Oesophagogastric Resection Centre

Aims AUGIS recommends staging laparoscopy in all gastric cancers and selected gastro-oesophageal junction (GOJ) cancers. We previously audited our practice of staging laparoscopy and peritoneal cytology and found that in a cohort of 158 consecutive patients, no tumours less than T3 with negative nodes had positive cytology, resulting in change in practice to selectively use peritoneal cytology in patients with a T-stage of 3 and above or N+ disease. Our aim was to assess the impact of this audit on current practice. Methods We retrospectively reviewed the notes of patients undergoing staging laparoscopy and oesophagogastroduodenoscopy (OGD) identified by MDT from January 2019 to December 2019. Patients who underwent resection on the same day were excluded. Results 63 patients underwent staging laparoscopy and OGD, 54 for GOJ and 9 for gastric disease. The majority were staged as T3 or T4a (81%). As a result of staging laparoscopy and OGD, 4 (6%) patients were changed from curative to palliative pathway, 2 (3%) of whom had positive cytology. No patients had positive peritoneal cytology for a T stage of 2 and below with no positive nodes, further demonstrating the safety of the recommendation. Conclusions Peritoneal cytology has a low yield in changing the clinical course of patients but can upstage up to 6% of patients. The re-audit backs up the previous guidance in the safety of using our current threshold for recommending peritoneal cytology and potentially prevents delaying treatment while waiting for cytology results.

Usefulness of Diagnostic Staging Laparoscopy for Advanced Gastric Cancer

Background For advanced gastric cancer (AGC), peritoneal metastasis is the most common determinant of unresectability, but accurate preoperative diagnosis for peritoneal metastasis is challenging. Staging laparoscopy (SL) can detect unsuspected peritoneal metastasis. This study retrospectively evaluated the utility of SL and its indication in patients with AGC. Methods In this study, we enrolled 114 patients with pathologically diagnosed gastric adenocarcinoma who underwent SL. Results Of the 114 patients, 43 (37.7%) had peritoneal metastasis (P1 or CY1). Higher age, larger tumor size, type 4 GC, deeper tumor depth, elevated CA125, and ascites findings in preoperative CT were found to be significant predictors of peritoneal metastasis. In multivariate analysis, peritoneal metastasis was associated with type 4 GC (odds ratio [OR]: 6.11; 95% confidence interval [CI]: 1.87-19.8; P < .01) and ascites in CT (OR: 4.25; 95% CI: 1.48-12.1; P < .01). Conclusions Staging laparoscopy is an effective tool to detect peritoneal metastasis from AGC. It can increase the curative resection rate and decrease unnecessary laparotomies.

Utility of molecular analysis of peritoneal fluid in staging laparoscopy of advanced oesophagogastric junction and gastric cancer prior to neoadjuvant treatment

The significance of molecular analysis of peritoneal fluid in staging laparoscopy of oesophagogastric junction (EGJ) and gastric cancer is still controversial. METHODS: A retrospective analysis of prospective data collection of all patients diagnosed with locally advanced gastric neoplasia or Siewert II-III EGJ cancer from July 2009 to October 2019 who underwent staging peritoneal lavage prior to neoadjuvant treatment was performed. Cytology studies and molecular analysis of peritoneal lavage were performed by real-time reverse transcriptase polymerase chain reaction (RT_PCR) of carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) as tumor makers. RESULTS: 168 patients were operated. Citology and molecular analysis were performed in 138 patients. Macroscopic carcinomatosis (P+) was evidenced in 12.3% (17 patients). Of the remaining 87.7% (121 patients), 9.9% (12 patients) had positive cytology. In 21% (29 patients) disseminated macroscopic or microscopic disease (P + or Cyt+) was identified. 11.6% (16 patients) were P0Cyt- but RT-PCR+. Of these, 9 responded to chemotherapy before salvage surgery. The sensitivity of cytology and molecular analysis was 0.70 and 0.76, respectively (p = 0.67). The survival of Cyt-RT_PCR + vs. Cyt + RT_PCR + patients was similar (p = 0.1). However, there were no differences in the survival curves between Cyt-RT_PCR- patients vs Cyt-RT_PCR + patients who underwent salvage surgery (p = 0.69). CONCLUSION: Molecular analysis showed a sensitivity of 76%. In our study, the survival of P0 Cyt-RT_PCR + patients responding to chemotherapy and undergoing surgery was similar to that of P0 Cyt-RT_PCR- patients but less disease free survival.