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Upper Gastrointestinal (lips to ileocecal valve, including esophagus and stomach)

E471: Streamlining care for gastric cancer patients utilizing intra-operative ultrasound

Introduction: Staging of gastric cancer often includes endoscopic ultrasound and, if the tumor is not early stage, a staging laparoscopy is also performed to assess for peritoneal disease. Patients requiring neoadjuvant chemotherapy also require port-a-cath placement. These procedures can be cumbersome for patients as they involve multiple providers with multiple instances of anesthesia.

Methods: In an effort to streamline care for gastric cancer patients, patients were offered diagnostic laparoscopy and concomitant intra-operative ultrasound to assess tumor depth of invasion into the gastric wall. If the tumor was identified as locally advanced on intra-operative ultrasound, a port-a-cath was placed at that time. From 2013-2022, ten patients underwent this streamlined model of care. Intra-operative ultrasound was performed through a 12 mm laparoscopic port with the use of the B-K Medical flex Focus 400 Ultrasound scanner. Peritoneal washings were sent in the usual fashion.

Results:

All ten patients had tumors that were able to be identified for depth of invasion into the gastric wall. All the tumors were identified to be locally advanced (T3 or greater). They all also had uncomplicated port-a-cath insertions. Intra-operative ultrasound added an average of five minutes to the overall operative time. No single-use instruments were utilized for the intraoperative ultrasound part of the procedure.

Conclusions:

Intra-operative ultrasound can be safely performed at the time of staging laparoscopy for patients with gastric cancer and provides excellent identification of tumor depth. The addition of a 12 mm port does not significantly add to the morbidity of the procedure, while the additional diagnostic yield allows for patients to undergo the same number of procedures with fewer providers, less frequent anesthesia, and less time. This patient- centered approach could be used to decrease the time from diagnosis to initiation of neoadjuvant chemotherapy.

Learning Objectives:

  • understand the utility of intra-operative ultrasound in staging of gastric cancer.
  • describe a more streamlined, patient-centered approach to gastric cancer staging.
  • define the intra-operative ultrasound settings needed to evaluate the stomach for tumor.