Role of staging laparoscopy in gastric cancer management: Evaluation of occult disease and its influence on clinical decision making.

BACKGROUND

Accurate staging is critical in gastric cancer, as the presence of peritoneal metastasis directly influences treatment strategy and prognosis. Despite advances in cross-sectional imaging, occult peritoneal disease may remain undetected. Staging laparoscopy has been increasingly utilized to improve diagnostic accuracy; however, its true impact on clinical decision-making and the predictive factors for occult metastasis remain areas of ongoing investigation.

METHODS

This retrospective study included patients with biopsy-proven gastric adenocarcinoma who underwent staging laparoscopy between March 2019 and April 2025 at a high-volume tertiary center. Patients with radiologically metastatic disease or incomplete clinical data were excluded. All patients had clinically M0 disease on preoperative imaging. The primary outcome was the detection rate of occult stage IV disease and its impact on treatment strategy. Secondary outcomes included concordance between frozen and final cytology, postoperative outcomes, and identification of predictors for peritoneal metastasis. Multivariable logistic regression analysis was performed to determine independent risk factors.

RESULTS

A total of 301 patients were included in the final analysis. Staging laparoscopy identified occult metastatic disease in 65 patients, corresponding to an upstaging rate of 21.6% (95% CI: 16.9-26.3%). Malignant cytology and peritoneal implants were detected in 13.9% and 17.3% of patients, respectively. Frozen cytology demonstrated high specificity (95%) but limited sensitivity (67%) compared to final cytology. Treatment strategy was altered in all patients with newly detected metastatic disease, avoiding non-beneficial surgical intervention. Multivariable analysis revealed that only clinical nodal stage was independently associated with positive peritoneal cytology and/or peritoneal involvement (OR 2.42, 95% CI: 1.4-4.2, p = 0.001). The procedure was associated with low morbidity (0.66%) and minimal mortality (0.33%).

CONCLUSION

Staging laparoscopy provides substantial diagnostic value in detecting radiologically occult metastatic disease in gastric cancer and significantly influences treatment planning. Its routine use in appropriately selected patients improves staging accuracy and helps prevent unnecessary surgical interventions. Clinical nodal status appears to be the strongest independent predictor of occult peritoneal disease.