Indian Journal of Surgical Oncology

, Volume 9, Issue 4, pp 488–494 | Cite as

Clinical Utility of Staging Laparoscopy for Advanced Obstructing Rectal Adenocarcinoma: Emerging Tool

  • Avanish SaklaniEmail author
  • P. Sugoor
  • A. Chaturvedi
  • R. Bhamre
  • S. Jatal
  • V. Ostwal
  • R. Engineer
Original Article


The multimodal treatment for advanced rectal adenocarcinoma mandates accurate preoperative staging with contrast-enhanced computed tomography (CECT) of the thorax, abdomen, and pelvis, and magnetic resonance imaging (MRI) of the pelvis. Unlike gastric cancer, the role of staging laparoscopy (SL) in advanced colorectal cancer has not been evaluated. This study aims to evaluate the clinical value of SL in treatment decision-making for advanced rectal cancer (RC) with near or complete obstructing tumors. Observational review of colorectal database at Tata Memorial Hospital from January 2013 to December 2016 identified 562 patients diagnosed and treated for advanced RC. Of the 562 cases, 48.7% (274) were clinically and radiologically diagnosed of near or complete obstructing advanced RC. Medical records of 34% (94/274) who underwent SL with diversion stoma (DS) were analyzed. In the absence of ascites, extensive peritoneal deposits, and unresectable liver metastases on SL, a curative treatment was offered, which entailed neoadjuvant chemoradiation (NACTRT), whereas the cohort of patients with extensive peritoneal disease received palliative therapy. Of the 94 patients with advanced RC, conventional imaging studies staged 73.5% (69/94) cohort as non-metastatic locally advanced and 26.5% (25/94) had potentially resectable metastatic RC. Pre-therapeutic SL upstaged the disease by 26% (18/69) and 8% (2/25) in locally advanced and potentially resectable metastatic RC cohorts, respectively. Treatment decision changed in 21.2% (20/94) of the patients, and midline laparotomy was thus avoided. In our observational study, SL was found to be a safe and effective staging modality in RC; it detected occult peritoneal disease and prevented midline laparotomy in 21.2% of the cohort, which was of value to determine treatment strategy in patients with advanced RC before initiating NACTRT. SL and laparoscopic-assisted de-functioning stoma were associated with minimal morbidity and led to early initiation of NACTRT.


Rectal cancer Staging laparoscopy Peritoneal deposits Neoadjuvant chemoradiation Diversion stoma 


Compliance with Ethical Standards

Data of this study were collected in the course of common clinical practice and, accordingly, the signed informed consent was obtained from each patient for any surgical and clinical procedure. The study protocol conforms to the ethical guidelines of the “World Medical Association Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects” adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, as revised in Tokyo 2004. No approval of the institutional review committee was needed.

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. 1.
    Siegel R, Naishadham D, Jemal A (2013) Cancer statistics. CA Cancer J Clin 63:11–30CrossRefGoogle Scholar
  2. 2.
    Edge SB (2010) American Joint Committee on Cancer. Colon and rectum, AJCC Cancer Staging Manual, 7th edn. Springer, New York, pp 143–164Google Scholar
  3. 3.
    Gunderson LL, Jessup JM, Sargent DJ, Greene FL, Stewart A (2010) Revised tumor and node categorization for rectal cancer based on surveillance, epidemiology, and end results and rectal pooled analysis outcomes. J Clin Oncol 28:256–263CrossRefGoogle Scholar
  4. 4.
    Benson AB, Bekaii-Saab T, Chan E et al (2012) Rectal cancer. J Natl Compr Cancer Netw 10:1528–1564CrossRefGoogle Scholar
  5. 5.
    Cervantes A, Chirivella I, Rodriguez-Braun E, Campos S, Navarro S, GarcíaGranero E (2006) A multimodality approach to localized rectal cancer. Ann Oncol 17:x129–x134CrossRefGoogle Scholar
  6. 6.
    Allaix ME, Fichera A (2013) Modern rectal cancer multidisciplinary treatment: the role of radiation and surgery. Ann Surg Oncol 20:2921–2928CrossRefGoogle Scholar
  7. 7.
    Gutman M, Kaplan O, Skornick Y, Greif F, Kahn P, Rozin RR (1989) Proximal colostomy: still an effective emergency measure in obstructing carcinoma of the large bowel. J Surg Oncol 41:210–212CrossRefGoogle Scholar
  8. 8.
    Milsom JW, Kim SH (1997) Laparoscopic versus open surgery for colorectal carcinoma. World J Surg 21:702–705CrossRefGoogle Scholar
  9. 9.
    Lehnert T, Rudek B, Kienle P, Buhl K, Herfarth C (2002) Impact of diagnostic laparoscopy on the management of gastric cancer: prospective study of 120 consecutive patients with primary gastric adenocarcinoma. Br J Surg 89:471–475CrossRefGoogle Scholar
  10. 10.
    Jerby BL, Milsom JW (1998) Role of laparoscopy in the staging of gastrointestinal cancer. Oncology (Williston Park) 12:1353–1360Google Scholar
  11. 11.
    BurkeEC KMS, Conlon KC, Brennan MF (1997) Laparoscopy in the management of gastric adenocarcinoma. Ann Surg 225:262–267CrossRefGoogle Scholar
  12. 12.
    Conlon KC (2001) Staging laparoscopy for gastric cancer. Ann Ital Chir 72:33–37PubMedGoogle Scholar
  13. 13.
    Northover JM (1997) Staging and management of colorectal cancer. World J Surg 21:702–705CrossRefGoogle Scholar
  14. 14.
    Iyer RB, Silverman PM, DuBrow RA, Charnsangavej C (2002) Imaging in the diagnosis, staging, and follow-up of colorectal cancer. AJR Am J Roentgenol 179:3–13CrossRefGoogle Scholar
  15. 15.
    De Geus-Oei LF, Vriens D, van Laarhoven HWM, der v, WTA G, WJG O (2009) Monitoring and predicting response to therapy with 18F-FDG PET in colorectal cancer: a systematic review. J Nucl Med 50:43S–54SCrossRefGoogle Scholar
  16. 16.
    Glimelius B, Tiret E, Cervantes A, Arnold D, ESMO Guidelines Working Group (2013) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 24:vi81–vi88CrossRefGoogle Scholar
  17. 17.
    Nelson DB, McQuaid KR, Bond JH, Lieberman DA, Weiss DG, Johnston TK (2002) Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc 55:307–314CrossRefGoogle Scholar
  18. 18.
    Cirocco WC, Rusin LC (1995) Factors that predict incomplete colonoscopy. Dis Colon Rectum 38:964–968CrossRefGoogle Scholar
  19. 19.
    Rex DK, Mark D, Clarke B, Lappas JC, Lehman GA (1996) Colonoscopy evaluations: justification by cost? Am J Gastroenterol 91:614–615PubMedGoogle Scholar
  20. 20.
    Marshall JB, Barthel JS (1993) The frequency of total colonoscopy and terminal ileal intubation in the 1990s. Gastrointest Endosc 39:518–520CrossRefGoogle Scholar
  21. 21.
    Huisman J, Leicher L, de Boer E et al (2017) Consequences of CT colonography in stenosing colorectal cancer. Int J Color Dis 32:367–373CrossRefGoogle Scholar
  22. 22.
    Grann A, Minsky BD, Cohen AM et al (1997) Preliminary results of preoperative 5-fluorouracil, low dose leucovorin and concurrent radiation therapy for clinically resectable T3 rectal cancer. Dis Colon Rectum 40:515–522CrossRefGoogle Scholar
  23. 23.
    Yeung JM, Maxwell-Armstrong C, Acheson AG (2009) Colonic tattooing in laparoscopic surgery—making the mark? Color Dis 11:527–530CrossRefGoogle Scholar
  24. 24.
    Greene FL (2001) Indications and general oncologic principles. In: Greene FL, Heniford BT (eds) Minimally invasive cancer management. Springer, New YorkCrossRefGoogle Scholar
  25. 25.
    Easter DW, Michaelson B (2001) Biopsy and staging-technical issues. In: Greene FL, Heniford BT (eds) Minimally invasive cancer management. Springer, New YorkGoogle Scholar
  26. 26.
    Hori Y (2008) Diagnostic laparoscopy guidelines: this guideline was prepared by the SAGES Guidelines Committee and reviewed and approved by the Board of Governors SAGES November 2007. Surg Endosc 22:1353–1383CrossRefGoogle Scholar
  27. 27.
    Weickert U, Jakobs R, Riemann JF (2005) Diagnostic laparoscopy. Endoscopy 37:33–37CrossRefGoogle Scholar
  28. 28.
    Sarela AI, Miner TJ, Karpeh MS, Coit DG, Jaques DP, Brennan MF (2006) Clinical outcomes with laparoscopic stage M1, unresected gastric adenocarcinoma. Ann Surg 243:189–195CrossRefGoogle Scholar
  29. 29.
    Mahadevan D, Sudirman A, Kandasami P, Ramesh G (2010) Laparoscopic staging in gastric cancer: an essential step in its management. J Minim Access Surg 6:111–113CrossRefGoogle Scholar
  30. 30.
    Hur H, Lee HH, Jung H, Song KY, Jeon HM, Park CH (2010) Predicting factors of unexpected peritoneal seeding in locally advanced gastric cancer: indications for staging laparoscopy. J Surg Oncol 102:753–757CrossRefGoogle Scholar
  31. 31.
    Sarela AI, Lefkowitz R, Brennan MF, Karpeh MS (2006) Selection of patients with gastric adenocarcinoma for laparoscopic staging. Am J Surg 191:134–138CrossRefGoogle Scholar
  32. 32.
    Nath J, Wigley C, Keighley MR, Perakath B (2009) Rectal cancer in young adults: a series of 102 patients at a tertiary care centre in India. Color Dis 11:475–479CrossRefGoogle Scholar
  33. 33.
    Pal M (2006) Proportionate increase in incidence of colorectal cancer at an age below 40 years: an observation. J Cancer Res Ther 2:97–99CrossRefGoogle Scholar
  34. 34.
    Gupta S, Bhattacharya D, Acharya AN, Majumdar S, Ranjan P, Das S (2010) Colorectal carcinoma in young adults: a retrospective study on Indian patients: 2000-2008. Color Dis 12:e182–e189CrossRefGoogle Scholar
  35. 35.
    Tamhankar AS, Ingle P, Engineer R, Bal M, Ostwal V, Saklani A (2016) Signet ring colorectal carcinoma: do we need to improve the treatment algorithm? World J Gastrointest Oncol 8:819–825CrossRefGoogle Scholar
  36. 36.
    Koea JB, Guillem JG, Conlon KC, Minsky B, Saltz L, Cohen A (2000) Role of laparoscopy in the initial multimodality management of patients with near-obstructing rectal cancer. J Gastrointest Surg 4:105–108CrossRefGoogle Scholar
  37. 37.
    Hill J, Kay C, Morton D, Magill L, Handley K, Gray RG (2016) CREST: randomised phase III study of stenting as a bridge to surgery in obstructing colorectal cancer. J Clin Oncol 34:abstr 3507CrossRefGoogle Scholar
  38. 38.
    Yoon HI, Koom WS, al KTH (2016) Upfront systemic chemotherapy and short-course radiotherapy with delayed surgery for locally advanced rectal cancer with distant metastases: outcomes, compliance, and favorable prognostic factors. PLoS One 11:e0161475CrossRefGoogle Scholar

Copyright information

© Indian Association of Surgical Oncology 2018

Authors and Affiliations

  • Avanish Saklani
    • 1
    Email author
  • P. Sugoor
    • 1
  • A. Chaturvedi
    • 1
  • R. Bhamre
    • 1
  • S. Jatal
    • 1
  • V. Ostwal
    • 1
    • 2
  • R. Engineer
    • 1
  1. 1.Department of Gastrointestinal Surgery and Colorectal Surgical OncologyTata Memorial HospitalMumbaiIndia
  2. 2.Department of Medical OncologyTata Memorial CentreMumbaiIndia

Personalised recommendations