[Surgery under peritoneoscopy--impact on gastroenterology].
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Digestive System Surgical Procedures↗
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[Ultrasound, computed tomography and laparoscopy. Efficacy in the detection of primary and metastatic hepatic tumors. Comparative study].
OBJECT: To compare ultrasound, computed tomography and peritoneoscopy in the diagnosis of primary and metastatic hepatic tumors. DESIGN: Prospective trial of a cohort patients during a year. PLACE: Digestive Disease Department in a National referral Cancer Center. PATIENTS: Forty five patients with intraabdominal tumors for pretreatment evaluation. Intervention; Ultrasonography, computed tomography and peritoneoscopy performed in a period of ten days. MEASUREMENTS: sensibility, specificity and efficiency comparison of results by Chi square test, with Yates correction (X2 Yates), measure of pre test and post test probabilities using Bayes theorem. RESULTS: In hepatic humors, peritoneoscopy was the most sensitive, specificity was similar for the three procedures (p greater than 0.1), in the detection of hepatic metastases peritoneoscopy was the most sensitive 91.6% vs 50% (p less than 0.05) similar specificity and high positive predictive value for the three procedures, comparable with the post test probabilities. CONCLUSIONS: In the detection of focal hepatic lesions, peritoneoscopy was the best method; in case of doubt, failure of non invasive procedures or the need of biopsy samples must be considered the procedure of choice.
Adolescent↗
[Laparoscopy in the detection of hepatic metastasis of early bronchial cancer (100 laparoscopies)].
Staging 125 cases of primary lung cancer, peritoneoscopy for detection of liver metastasis was done each time it was possible. 100 peritoneoscopies were done, 92 were available. Tolerance was excellent. First investigation showed 16,3% liver metastasis. Higher frequency (35,3%) is found in oat cells carcinomas and lower in epidermoids (13,1%) and adenocarcinomas and/or undifferentiated (7,1%). Above all, in 7,6% of cases, peritoneoscopy alone was able to give diagnosis of liver metastasis not detected by other means. Peritoneoscopy shows no false positive, is safe and more effective than scans of biologic tests, can be repeated, and must become part of staging of lung cancers.
Carcinoma, Bronchogenic↗
Disease stage of chronic hepatitis C assessed by both peritoneoscopic and histologic findings and its relationship with response to interferon therapy.
BACKGROUND: Disease stage in patients with chronic hepatitis C was assessed by both peritoneoscopy and histology and correlated with responses to interferon therapy. METHODS: The subjects were 105 patients with chronic hepatitis C treated with interferon who were classified into 28 sustained responders, 34 transient responders, and 43 nonresponders according to alanine aminotransferase normalization. The influence of various patient's characteristics on responses to interferon therapy was investigated by multivariate analysis. RESULTS: Patients were categorized into 21 patients who exhibited a "smooth liver" on peritoneoscopy and did not demonstrate histologic bridging fibrosis (group I) and 84 patients who exhibited a "granular" or "nodular liver" on peritoneoscopy and/or had histologic bridging fibrosis (group II). Multivariate analysis showed that genotype 2a/2b (p = .0002), low viremia (p = .0048), and early disease stage (group I) (p = .0290) were significant independent factors contributing to sustained response, and that early disease stage (group I) (p = .0010) and genotype 2a/2b (p = .0085) were those contributing to sustained or transient response. Neither peritoneoscopic nor histologic findings alone were a significant factor influencing responses to interferon therapy. CONCLUSION: Disease stage assessed by both peritoneoscopic and histologic findings may serve as a reliable marker for predicting responses to interferon therapy in chronic hepatitis C.
Adult↗
[The contribution of laparoscopy to diagnosis of malignant lymphomas (author's transl)].
Peritoneoscopy revealed in 15 patients with malignant lymphomas splenomegaly (13 patients), hepatomegaly (10 patients, 8 of them with impressive or suspicious alterations of the liver surface) and enlargement of retroperitoneal lymph nodes or localised infiltration of a jejunal loop (3 patients). Aimed biopsy of liver, spleen or lymph nodes frequently established the diagnosis definitively. The various features of malignant lymphomas observable at peritoneoscopy are described. Based on these experiences peritoneoscopy is recommended in suspected malignant lymphomas as a real diagnostic aid.
Humans↗
Peritoneoscopic study on rat liver cell necrosis induced by carbon tetrachloride and allyl formate.
The surface changes of acute centrolobular and perilobular necrosis were studied in rat liver using peritoneoscopy. Centrolobular necrosis as induced by carbon tetrachloride and perilobular necrosis by allyl formate. Vessels observed on the control rat liver surface were identified as terminal hepatic veins by irrigation of the hepatic vein with a barium solution. Polygonal whitish markings were observed on the liver surface 48 hours after carbon tetrachloride administration. Terminal hepatic veins were regularly distributed throughout the central portions of the whitish areas. Reddish spots about 0.1 mm in diameter were scattered about the terminal hepatic veins. The reddish spots and whitish areas corresponded to the histological findings of central liver cell necrosis and infiltration by Kupffer and white blood cells. Six hours after allyl formate administration, round reddish spots about 0.3 mm in diameter were regularly distributed on the liver surface among the terminal hepatic veins. These spots corresponded to the histological findings of liver cell necrosis around the portal area. In summary, acute centrolobular and perilobular liver cell necrosis were newly observed as reddish spots by peritoneoscopy.
Animals↗
Intraperitoneal chromic phosphate in peritoneoscopically confirmed stage I ovarian adenocarcinoma.
From December 15, 1975 to June 16, 1980, 20 evaluable patients with International Federation of Gynaecology and Obstetrics Stage I invasive adenocarcinoma of the ovary were entered into a prospective study, including pretherapy restaging peritoneoscopy followed by treatment with intraperitoneal chromic phosphate if there was no evidence of residual macroscopic tumor. During a follow-up of 1 1/2 to 6 years (median, 3 years and 1 month), the survival rate without evidence of recurrent ovarian carcinoma was 95%. Moreover, there was a total absence of complications with the use of the sequential steps of pretherapy peritoneoscopy, a normal preinjection peritoneogram, injection of chromic phosphate in large volumes of solution, frequent change of position of the patient after injection, and abdominal scans after injection. This method appears to be safe and is associated with a significantly high survival rate.
Adenocarcinoma↗
Focal hepatic candidiasis with perihepatic adhesions: laparoscopic and immunohistologic diagnosis.
Two patients developed fever, cholestasis, and neutropenia following chemotherapy for acute leukemia. Computed tomographic scans of the liver were nondiagnostic, but peritoneoscopy in each case showed diffuse studding of the liver surface with white plaques. Microbiological cultures of the biopsy specimens were negative, but direct immunofluorescence stains of deparaffinized sections of the biopsies confirmed candidiasis. Follow-up laparoscopy in 1 patient after 2 mo of treatment with amphotericin B showed development of diffuse perihepatic adhesions. Peritoneoscopy is valuable in the diagnosis and management of focal hepatic candidiasis, and an etiologic diagnosis can be provided by immunohistology when microbiological culture of the biopsy specimen is negative or unavailable.
Adult↗
Peritoneoscopic versus surgical placement of peritoneal dialysis catheters: a prospective randomized study on outcome.
The most commonly used technique for insertion of peritoneal dialysis (PD) catheters is open surgical approach by minilaparotomy. Percutaneous implantation via the peritoneoscopic technique is expanding. Studies have suggested that PD catheters placed peritoneoscopically have longer survival rate than surgically placed ones. However, these studies were not randomized, where the surgical group had more patients who were obese or had prior abdominal surgery, and therefore, the selection of patients may have biased the results. We conducted a prospective randomized study in which patients underwent PD catheter placement by either the surgical or the peritoneoscopic technique. In the period from October 1992 through October 1995, 148 double-cuff, curled-end, swan-neck PD catheters were placed in 148 patients. The outcome of the 76 patients in whom the PD catheters were placed peritoneoscopically was compared with that of the 72 patients in whom the catheters were placed surgically. Early peritonitis episodes (within 2 weeks of catheter placement) occurred in 9 of 72 patients (12.5%) in the surgical group, versus 2 of 76 patients (2.6%) in the peritoneoscopy group (P = 0.02). This higher rate of infection was most likely related to a higher exit site leak in the surgical group (11.1%) as compared with the peritoneoscopy group (1.3%). Moreover, peritoneoscopically placed catheters were found to have better survival (77.5% at 12 months, 63% at 24 months, and 51.3% at 36 months) than those placed surgically (62.5% at 12 months, 41.5% at 24 months, and 36% at 36 months) with P = 0.02, 0.01, and 0.04, respectively. We conclude that peritoneoscopically placed PD catheters have a longer survival rate than surgically placed ones. Furthermore, the rate of exit site leak and early infection is lower in the peritoneoscopic method.
Adolescent↗
Tuberculous peritonitis in 11 children: clinical features and diagnostic approach.
BACKGROUND: Tuberculous peritonitis (TBP) is a rare manifestation of childhood tuberculosis characterized by long-lasting abdominal symptoms and exudate and lymphocytes in the ascitic fluid. The diagnosis of TBP is rarely established unless a high index of suspicion is maintained. METHODS: The diagnostic features of 11 cases who were hospitalized with TBP in the Pediatric Infectious Diseases Ward of Dicle University Hospital, Turkey, were evaluated retrospectively. RESULTS: Seven cases were male and the ages of all cases ranged between 1 and 11 years. The onset of symptoms was 1-12 months (mean +/- SD 3.1 +/- 2.7 months) prior to the admission time. Nine patients gave a history of familial tuberculosis. Three cases had Bacillus Calmette-Guérin (BCG) scars and the results of five tuberculin unit (TU) tests in cases without and with BCG were over 10 and 15 mm, respectively. The most common presenting clinical symptoms and signs at admission were abdominal distention and ascites (100%), fever (27%) and loss of weight (18%). One case had accompanying tuberculous meningitis and two cases had concomitant pulmonary tuberculosis. Only one of 11 samples of ascitic fluid yielded Mycobacterium tuberculosis by the polymerase chain reaction method and no other microbiologic evidence was obtained in culture specimens. Ultrasonographic and computed tomographic imagings revealed high-density ascites that contributed well to the diagnosis. The diagnosis in two patients was proven histopathologically via peritoneoscopy and laparoscopy. All cases were treated with isoniazide, rifampisin for 9 months and pyrazinamide for the first 2 months. CONCLUSIONS: Radiologic diagnostic techniques, positive skin tests and a history of exposure to tuberculosis may contribute to the diagnosis of TBP, helped by clinical symptoms and findings, particularly when invasive diagnostic methods via peritoneoscopy and laparoscopy are not available in developing countries.
Ascites↗
Peritoneoscopic placement of peritoneal dialysis catheter and bowel perforation: experience of an interventional nephrology program.
BACKGROUND: Bowel perforation is an uncommon but serious complication of peritoneoscopic peritoneal dialysis (PD) catheter insertion. The approach to diagnosis of bowel perforation utilizing this technique has not been previously published. The authors report their experience with the diagnosis and management of bowel perforation in the context of peritoneoscopic placement of PD catheters. METHODS: The authors retrospectively reviewed the records of 750 PD catheters inserted over a 12-year period (January 1991 to May 2003) utilizing peritoneoscopic technique. RESULTS: Six (0.8%) patients experienced bowel perforation during the procedure. The diagnosis was made immediately during the procedure in 5 (83%) of the 6 patients. Of these 5, peritoneoscopy confirmed intrabowel position of the cannula by visualizing bowel mucosa (n = 3) and hard stool (n = 1). The fifth patient showed extrusion of fecal matter upon trocar withdrawal before peritoneoscopy. All 5 had emanation of foul-smelling gas through the cannula. Bowel rest and broad-spectrum intravenous antibiotics were initiated. Of the 5, 1 required surgery, whereas the others were discharged home after 3 days. The sixth patient had fever, severe peritoneal irritation, and polymicrobial peritonitis the morning after the procedure. In this patient, no evidence of bowel injury was noted during the procedure except for brief emanation of foul-smelling gas. He required surgical intervention. CONCLUSION: Bowel perforation can be diagnosed immediately in most patients undergoing peritoneoscopic PD catheter insertion. A majority of these patients can be treated medically. The surgical team should be consulted if the patient shows clinical deterioration or has signs of peritoneal irritation.
Abdomen, Acute↗
Dose-intense taxol: high response rate in patients with platinum-resistant recurrent ovarian cancer.
BACKGROUND: Paclitaxel (Taxol), a diterpene plant product that promotes tubulin polymerization, has documented activity against a number of solid tumors, including ovarian cancer and breast cancer. PURPOSE: Our purpose was to conduct a phase II clinical trial investigating the response of patients with advanced recurrent ovarian carcinoma to high-dose paclitaxel combined with granulocyte colony-stimulating factor (G-CSF). METHODS: A prospective phase II clinical trial of patients with advanced-stage, recurrent ovarian cancer was undertaken. Patients received 250 mg/m2 paclitaxel every 21 days; cycles were given on a rigid schedule; delays were permitted only for extreme circumstances. G-CSF at a dose of 10 micrograms/kg per day was given to ameliorate myelo-suppression. If a patient showed fever and neutropenia, G-CSF dosage was increased to 20 micrograms/kg per day so that paclitaxel dose intensity could be maintained. Patients were assessed for response every two cycles, and those with complete radiographic resolution of disease underwent peritoneoscopy. RESULTS: Forty-four patients were assessable for response. Twenty-one had a reduction in tumor volume greater than 50%, yielding an objective response rate of 48% (21 of 44 patients; 95% confidence interval, 32%-63%). Six (14%) of the 44 patients had complete radiographic resolution of disease; two of the six also had negative biopsy specimens and washings at peritoneoscopy. Age, number of prior regimens, and clinical platinum resistance did not influence response rate or ability to maintain dose intensity. Dose intensity was maintained at the targeted level for up to 14 consecutive cycles of therapy. CONCLUSIONS: We observed a 48% response rate with dose-intense paclitaxel for patients with advanced-stage, platinum-resistant, recurrent ovarian cancer. The response rate is higher than previously reported for paclitaxel at a lower dose in similar cohorts of patients treated without G-CSF. Comparison of phase II studies of paclitaxel suggests a dose-response relationship. Therapy with dose-intense paclitaxel and G-CSF should be considered for patients with advanced, platinum-refractory ovarian cancer.
Adult↗
Newer diagnostic approaches to the evaluation of gynecologic malignancies.
The use of peritoneoscopy, lymphangiography, ultrasonography, computerized tomography, and thin-needle aspiration in the evaluation of gynecologic malignancies is discussed. Peritoneoscopy has made a large impact on the staging and follow-up of patients with ovarian cancer. Lymphangiography, combined more recently with ultrasonography or computerized tomography, appears to be especially useful in evaluating patients with cervical cancer for lymph node metastases outside the usual radiation treatment fields. Ultrasonography and computerized tomography are useful for evaluating masses for resectability and treatment response, planning radiation therapy, detecting metastases and ascites, and directing thin-needle aspiration of masses. Thin-needle aspiration techniques are now available which provide a means for sampling areas which were previously inaccessible except to open operative biopsy or where biopsy might result in serious complications.
Biopsy, Needle↗
Interventional nephrology in Brazil: current and future status.
The care of chronic kidney disease patients frequently involves many diagnostic and interventional procedures. Most of these procedures are currently performed by radiologists, vascular surgeons, and general surgeons. This has caused fragmented medical care, which has led many nephrologists to introduce a new paradigm, often referred as interventional nephrology (IN). The aim of this study was to establish the extent of involvement of the Brazilian nephrology community with regard to specific IN procedures. From October 2004 to February 2005, questionnaires were sent by e-mail to all 2500 nephrologists throughout Brazil. The enrollment questionnaire was composed of five sections, with questions about renal biopsy, specific training in ultrasonography, peritoneal dialysis access (insertion of peritoneal catheters guided or not by peritoneoscopy), hemodialysis vascular access (ability to place tunneled catheters, construction of arteriovenous fistulas, and other vascular access procedures), and the nephrologist's interest in being trained in IN. A total of 239 nephrologists answered the questionnaire. Only 18% of Brazilian nephrologists perform kidney biopsy guided by ultrasonography assisted by a radiologist. On the other hand, 42% of them reported that this procedure was done without any image support. Most of the respondents (85%) indicated that they were not formally trained to perform renal ultrasonography. When asked about peritoneal dialysis catheter placement, 66% of the respondents reported that they referred their patients to a surgeon for this procedure. The insertion of peritoneal dialysis catheters guided by peritoneoscopy was reported by 3% of the respondents. Similar to the results for peritoneal dialysis catheter placement, the majority of the respondents (77%) indicated no training in the insertion of tunneled catheters for temporary hemodialysis. Regarding the interest of nephrologists to participate in an IN program, the great majority (87%) responded that they would like to be trained in these procedures. Most nephrologists are not trained in IN procedures. Therefore, in Brazil, it will be necessary to develop training centers for IN that will allow nephrologists to optimize nephrology care.
Arteriovenous Shunt, Surgical↗
Peritoneoscopic features of intraabdominal vessels in cirrhosis of the liver.
Peritoneoscopy was carried out in 57 cirrhotic patients in order to evaluate the morphological features of intraabdominal veins. These were described either as normal or characterized by minimal, moderate, or marked alterations: accordingly, the patients were classified into four groups. Intrahepatic and intrasplenic pressures were measured in most patients; abnormally elevated values were found in every case, and the higher figures belonged to the subjects with minor involvement of the intraabdominal veins. Superficial collateralization and oesophageal varices appeared unrelated to changes in these veins, whereas splenomegaly was mostly found in patients with normal or slightly altered intraabdominal veins. Percutaneous splenoportography was performed in 16 patients, and venographic appearances did not correlate with peritoneoscopic features of the intraabdominal veins. Ascites, on the other hand, was exclusively present in patients with alterations in these veins. It is suggested that some pathogenetic relationship might exist between changes in intraabdominal veins seen by peritoneoscopy and ascites.
Abdomen↗
Diagnosis and significance of liver metastases in small cell carcinoma of the lung.
One hundred fifty-seven consecutive patients with small cell lung cancer seen at the National Cancer Institute over a four-year period underwent a series of pretherapy liver staging procedures to determine optimal means of detection and prognostic implications of hepatic metastases. Liver evaluation included physical examination, liver function tests, and liver scan (radionuclide or computerized tomography [CT]), as well as percutaneous and/or peritoneoscopy-directed liver biopsy when possible (74%). Liver metastases were detected in 26% of patients. Peritoneoscopy was the most sensitive method of liver evaluation and increased the detection of liver metastases when done in a sequential fashion after percutaneous liver biopsy from 18 to a total of 27 patients. Of the noninvasive procedures, radionuclide and CT liver scan were the most accurate concurring with liver biopsy in 87% of patients but permitting correct discrimination of stage in excess of 96% of patients. The accuracy of this noninvasive procedure was enhanced by an algorithm combining the results of radionuclide liver scan with liver function tests to detect patients with high or low likelihood of liver involvement. The survival and response of patients with liver metastases was significantly worse than those without such metastases with no three-year disease-free survivors among patients with liver metastases.
Actuarial Analysis↗
Decreased plasma fibronectin in liver diseases correlated to the severity of fibrotic, inflammatory and necrotic changes of liver tissue.
We applied a modified enzyme-linked immunosorbent assay (ELISA) for the measurement of human plasma fibronectin and determined the level of plasma fibronectin in 90 patients with various liver diseases and 10 normal subjects. Diagnoses were made by liver biopsy under peritoneoscopy. Plasma fibronectin was significantly decreased in liver cirrhosis patients, but not in acute hepatitis or chronic hepatitis patients. Decreased plasma fibronectin was correlated poorly with 18 laboratory tests, including liver function tests, and inflammatory marker determinations performed prior to peritoneoscopy. A correlation was found between the decreased plasma fibronectin and the severity of fibrotic, inflammatory and necrotic changes of the liver. These results suggested that the level of plasma fibronectin may reflect the severity of tissue injury resulting from chronic liver diseases.
Acute Disease↗
[The diagnostic use of laparoscopy in liver pathology in light of the evolution of imaging diagnosis].
We considered 87 patients suffering from chronic hepatic pathology. 62 patients have resulted suffering from cirrhosis or chronic active hepatitis, 25 from neoplasias. In the patient's group with chronic liver disease the humoral tests were not able to differentiate between cirrhosis or chronic active hepatitis. In the present retrospective experience echography showed sensibility 0.53 and specificity 0.91. In cirrhosis group, sensibility 0.5 and specificity 0.60 in chronic active hepatitis, sensibility 0.8 and specificity 0.95 in the neoplasia group. Peritoneoscopy showed sensibility 0.97 and specificity 0.93 in the cirrhosis group and sensibility 0.90 and specificity 1.00 in the neoplasia group. We had one case of major complication: hemoperitoneum from tear of adhesion secondary to previous laparotomy. We can conclude that peritoneoscopy is an useful procedure in the study of liver chronic disease and it still finds indication in selected cases of focal illness.
Biopsy↗