Staging of pancreatic head adenocarcinoma with spiral CT and endoscopic ultrasonography: an indirect evaluation of the usefulness of laparoscopy.

BACKGROUND: The interest of laparoscopy in the preoperative staging of pancreatic head adenocarcinoma before curative pancreaticoduodenectomy is a matter of controversy and depends on the accuracy of preoperative imaging techniques. AIM: To assess the potential value of laparoscopy when a standardised and optimal preoperative staging is performed, including spiral computed tomography (CT) and endoscopic ultrasonography (EUS). METHODS: All consecutive patients operated on with a view to curative pancreaticoduodenectomy for pancreatic head or ampullary adenocarcinoma in our centre from January 1998 to August 2000 were retrospectively studied. All of them had preoperative spiral CT and EUS. Tumour resectability was considered as highly probable (HP) or uncertain (U) according to well-defined criteria. Operative records of patients were reviewed to indirectly assess the effective resectability rate and the criteria responsible for unresectability and which of them would have been identified by laparoscopy if initially performed. RESULTS: 69 consecutive patients were studied. Resectability was HP (n = 56) or U (n = 13) after preoperative staging. Curative pancreatoduodenectomy was performed in 53 patients (77%) (48 HP, 5 U). Positive predictive value of preoperative imaging for highly probable resectability was 86% (48/56). Among the 16 unresectable tumours (8 HP, 8 U), the cause of non-resection would have been found at laparoscopy in 9 patients (56%) (6 HP, 3 U). Finally, if initially performed, laparoscopy would have avoided laparotomy in 9/69 patients (13%) (6/56 HP (11%); 3/13 U (23%)). CONCLUSIONS: With accurate preoperative staging using spiral CT and EUS, laparoscopy would detect tumours which were unresectable in 13% of patients with pancreatic head cancer. Laparoscopy remains useful in selected patients, such as those with preoperative uncertain resectability, in whom it can prevent unnecessary laparotomy in one fourth of patients. Copyright 2004 S. Karger AG, Basel and IAP     

Laparoscopy in primary carcinoma of the gallbladder.

Fifty-three patients with suspected gallbladder carcinoma underwent ultrasonography and laparoscopy. Laparoscopy correctly excluded malignancy in five patients when ultrasonography had suggested gallbladder neoplasia. Of 48 patients with gallbladder carcinoma, laparoscopy identified 46 (95.8%) as compared with 30 (62.5%) by ultrasonography (p less than 0.001). Distant metastases in the liver, parietal peritoneum, or omentum were present in 41 patients (85.4%) and were detected by laparoscopy in 39 (sensitivity 95%) and by ultrasonography in 21 (sensitivity 51.2%) (p less than 0.001). Combination of ultrasonography and laparoscopy improved the overall diagnostic accuracy to 100%. Laparoscopy provided histological diagnosis of the disease in 36 patients (75%) and circumvented unnecessary laparotomy in 40 (83.3%) patients by revealing advanced or associated disease. When laparoscopy suggested that the disease was localized, the diagnosis was correct in 83.3% (5 of 6) patients. Laparoscopy under local anesthesia is useful in the diagnosis and staging of gallbladder carcinoma, and therefore helpful in planning management.     

Multiport staging laparoscopy in esophageal and cardiac carcinoma

Between February 1993 and September 2000, 320 patients with esophageal cancer were referred to our oesophagogastric unit. One hundred and thirty-three consecutive patients with histologically proven carcinoma of the esophagus were assessed with a view to resection using multiport staging laparoscopy. Multiport staging laparoscopy was performed as a short stay/day case procedure in 133 patients with esophageal and oesophagogastric junctional carcinoma. Multiple ports were used to inspect the liver, omentum, peritoneal surfaces, coeliac/left gastric lymph nodes and obtain biopsies and cytology. Satisfactory assessment was possible in 127 cases (95%). Laparoscopy detected incurable disease in 31 patients (24%), some of whom had more than one contraindication to surgery, including hepatic metastases (n = 10), peritoneal metastases (n = 12) and malignant small volume ascites (n = 5). Lymph node metastases were confirmed histologically by biopsy at laparoscopy in 26 patients (fixed nodes, n = 14; mobile nodes, n = 12). Sensitivity for the detection of liver and peritoneal metastases was 100%, and lymph node metastases were 83%. Specificity for detection of hepatic metastases was 99%, 100% for peritoneal metastases and 82% for lymph node metastases. Ninety-nine patients proceeded to definitive surgery and only two were unresectable. Multiport laparoscopic assessment of metastases in patients with esophageal carcinoma avoids unnecessary surgery and allows for more efficient use of theatre and intensive care time.     

Determining resectability for hepatocellular carcinoma: the role of laparoscopy and laparoscopic ultrasonography

We reviewed our experience with preoperative determination of resectability in patients with hepatocel‐lular carcinoma (HCC) over the last 10 years, and evaluated the role of laparoscopy with laparoscopic ultrasonography (USG) since we instituted this technique in June 1994. From January 1989 to December 1998, 500 of 1741 patients with HCC (28.7%) were considered suitable for hepatic resection after preoperative assessment. Significantly more contrast‐enhanced computed tomography (CT) scans and fewer percutaneous USGs or hepatic arteriograms were performed in the 299 patients managed since June 1994 (group 2) than in the 201 patients managed before then (group 1). One hundred and ninety‐eight patients in group 2 (66%) underwent laparoscopy with laparoscopic USG. Unresectable disease was found in 41 patients in group 1 (20.4%) (all at laparotomy), and in 68 patients in group 2 (22.7%) (16 at laparotomy without laparoscopic examination, 31 at laparoscopic examination alone, and 21 at laparotomy after an inconclusive laparoscopic examination) (P = 0.5). The most common features of unresectable disease were the presence of bilobar intrahepatic metastases and an inadequate liver remnant with cirrhosis. The adoption of the laparoscopic examination after June 1994 improved the overall resection rate at laparotomy in group 2 from 77.3% to 86.2%, which was better than that in group 1 (79.6%,P = 0.057). For patients with unresectable disease, the operation time and hospital stay were significantly shorter in group 2. The postoperative morbidity and mortality rates were 9.8% and 4.9%, respectively, in group 1, and 5.9% and 2.9% in group 2. There was no operative morbidity in the 31 patients who had unresectable disease detected by the laparoscopic examination alone. Laparoscopy with laparoscopic USG avoids unnecessary laparotomy, and has a definite role in determining resectability in patients with HCC.     

A Prospective Comparison of Laparoscopy and Imaging in the Staging of Esophagogastric Cancer Before Surgery

Objective: To carry out a prospective comparison of laparoscopy and combined imaging (CT and ultrasound) in the preoperative staging of distal esophageal and gastric cancer in patients who were selected for surgery.
Methods: Patients with clinically overt metastases or a contraindication to major surgery were excluded. One hundred and forty-five patients underwent chest radiography, CT of mediastinum and abdomen, and ultra-sonography of abdomen and laparoscopy. The primary diagnoses were adenocarcinoma of the esophagogastric region in 110 cases, squamous cell carcinoma of the distal esophagus in 30 patients, and five miscellaneous.
Results: Thirty nine (27%) patients had metastatic disease outside the potential field of resection. Metastases were detected preoperatively by laparoscopy in 30 patients (sensitivity 77%) and by combined imaging in 15 (sensitivity 38%) ( p < 0.01). Twenty four patients with adenocarcinoma had metastases to the peritoneal cavity, which were detected preoperatively by laparoscopy in 23 (sensitivity 96%) and by combined imaging in five (sensitivity 21%) ( p < 0.01). Peritoneal metastases were not seen in patients with squamous cell carcinoma. Fifteen patients had hepatic metastases, which were detected preoperatively by laparoscopy in nine (sensitivity 60%) and by combined imaging in seven (sensitivity 47%). Laparoscopy was more sensitive than combined imaging in detecting metastases in patients with adenocarcinoma [laparoscopy 28, combined imaging 10 ( p < 0.01)].
Conclusion: Addition of laparoscopy to the staging protocol prevented unbeneficial thoraco-abdominal exploration in 20 patients with adenocarcinoma. Thus, laparoscopy should be used in the assessment of patients with adenocarcinoma of the esophagogastric region before performing excisional surgery.     

胆管疾病的腹腔镜内镜联合治疗

目的：探讨腹腔镜、内镜联合治疗胆管疾病的方法及疗效。方法：总结分析两家医院应用腹腔镜、十二指肠镜、胆道镜联合治疗1990例胆管疾病的资料。结果：腹腔镜、十二指肠镜联合治疗胆囊结石合并胆总管结石1350例，1次治愈率为93．6％；腹腔镜、胆道镜联合治疗胆管结石332例，治愈率为100％；三镜联合治疗胆管结石258例(29例合并胰腺炎)，Mirizzi综合征24例，治愈率为100％；腹腔镜胆肠吻合术，术前放置鼻胆引流管26例，治愈率为100％。均无严重手术并发症发生。共有1051例患者随访3个月～12年(平均7．8年)，结石复发10例，无胆管狭窄等远期并发症发生。结论：腹腔镜、内镜联合治疗胆管疾病较传统开腹手术创伤轻、痛苦小、手术并发症少。     

Experimental pain in gastroenterology: a reappraisal of human studies

Background: Even though endoscopic ultrasonography (EUS) has improved the pretherapeutic staging and assessment of resectability in patients with upper gastrointestinal (GI) tract malignancies, a considerable number of patients still have to undergo unnecessary explorative laparotomy to obtain the final assessment of resectability. The aim of the present study was to evaluate laparoscopic ultrasonography (LUS) and the combination of EUS and LUS in the pretherapeutic study of these patients with special reference to resectability. Methods: Each of 44 patients with esophageal, gastric, or pancreatic cancer was assigned to a treatment-related resectability group based on five different imaging modalities: computer tomography (CT) + ultrasonography (US), EUS, laparoscopy, LUS, and EUS + LUS. The findings with these imaging modalities were compared with intraoperative findings. Results: Overall group assignment accuracy showed significantly better results for EUS, LUS, and EUS + LUS than for CT + US and laparoscopy. EUS + LUS identified all non-resectable patients, whereas the sensitivity of CT + US, laparoscopy, and EUS were 14%, 36%, and 79%, respectively. Median time consumption for each EUS, laparoscopy, or LUS procedure was less than 25 min, and no complications were seen during or after the EUS, laparoscopy, or LUS procedures. Conclusion: Preliminary experience with the combination of EUS and LUS for pretherapeutic assessment of upper GI tract malignancies showed that this combination was superior to CT + US, laparoscopy, and EUS. EUS + LUS correctly identified all non-resectable patients, but two overstaged patients also indicated the need for larger prospective studies to identify the indications and the limitations of this new approach.     

Efficacy of multi-detector computerized tomography scan, endoscopic ultrasound, and laparoscopy for predicting tumor resectability in pancreatic adenocarcinoma

Background

Definitive treatment for pancreatic adenocarcinoma is surgical resection. Endoscopic ultrasound (EUS), multi-detector computerized tomography scan (MDCT), and laparoscopy are current preoperative methods for assessing the resectability in this malignancy. This study compared the efficacy of these methods in predicting the resectability of pancreatic adenocarcinoma.

Methodology

One hundred and fifty-seven patients considered for resection of pancreatic adenocarcinoma in two centers in Iran were evaluated. All of the patients were evaluated by MDCT and/or EUS; ones that had resectable tumor in imaging were assessed by laparoscopy/laparotomy. Patients undergoing pancreaticoduodenectomy were followed for 2 years.

Results

The majority (67 %) were male. The mean age was 66 years. The lesion was situated in the head of pancreas in 127 cases (81 %). Tumor resectability rate according to the MDCT scan/EUS, laparoscopy, and laparotomy was 6 %, 5 %, and 3 %, respectively. Only 3 % of the pancreatic adenocarcinoma cases were resectable at the time of diagnosis. Fifty percent of patients predicted to have resectable tumor according to MDCT/EUS and 37.5 % of cases that had resectable disease in laparoscopy were found to have unresectable lesions at laparotomy and or postsurgical follow up.

Conclusions

Prognosis continues to be dismal for pancreatic adenocarcinoma, and better methods to assess tumor resectability are needed.     

Minilaparoscopy versus conventional laparoscopy in the diagnosis of hepatic diseases

BACKGROUND: Minilaparoscopy (ML) is being used increasingly in the diagnosis of liver disease. This is a prospective study of the accuracy and safety of ML compared with conventional laparoscopy (CL) in the diagnostic workup of liver disease. METHODS: One hundred four patients with suspected liver disease were randomized either to undergo CL (n = 50) or ML (n = 54). CL was performed with a standard Storz laparoscope (? 11 mm, Storz GmbH, Tuttlingen, Germany) according to accepted guidelines. For ML a 1.9-mm small-diameter optical telescope was used (Richard Wolf GmbH, Knittlingen, Germany). In all cases, an attempt was made to obtain a liver biopsy specimen. RESULTS: Laparoscopy could successfully be performed in 100 of 104 (96%) patients with simultaneous procurement of biopsy specimens of the liver. In 4 cases, postoperative adhesions prevented sufficient inspection of the liver and in another patient the technique was switched from CL to ML for the same reason. Minor self-limiting bleeding at the biopsy site was observed in 20% of CL and 15% of ML examinations. One patient in each group required surgery for uncontrollable bleeding from the biopsy site. The patients' subjective perception of the examination was comparable in both groups. Compared with CL, ML could be performed in a significantly shorter time (27 vs. 22 min, p < 0.05). Liver cirrhosis diagnosed during laparoscopy was histologically confirmed in 77%, independent of the method of examination. Cirrhosis was diagnosed by histology in 1 of 14 (7%) and 1 of 21 (5%) patients without macroscopic signs of cirrhosis. CONCLUSIONS: Laparoscopy with a small diameter telescope in the workup of liver disease is comparable in terms of results to CL. Possible advantages of ML are a shorter examination time and a subjective impression of lower degree of invasiveness.     

Improved tumor staging by diagnostic laparoscopy.

This study was performed to assess the role of additional diagnostic laparoscopy in the preoperative staging of patients with adenocarcinoma of the esophagus, gastric cancer and pancreatic cancer prior to intended curative surgery. 89 patients with primary solid abdominal tumors were eligible for evaluation; of those 49 patients had a gastric cancer, 33 a pancreatic cancer and seven an adenocarcinoma of the esophagus. Patients without histologically proven metastases proceeded to laparotomy. Metastases were detectable laparoscopically in nine of 49 patients (18.4%) with gastric cancer (peritoneum n = 5, omentum n = 2, liver n = 2). Intraoperatively metastases were evident in further five cases (liver n = 3, peritoneum n = 2). In eleven of 33 patients (33%) with pancreatic cancer metastases were detected by laparoscopy (liver n = 6, peritoneum n = 2, liver and peritoneum n = 3) and in further four patients intraoperatively (liver n = 2, peritoneum n = 2). One of seven patients with an adenocarcinoma of the esophagus had liver metastases detected by laparoscopy. Intraoperatively no metastases were evident in those patients. Laparotomies were avoidable in 21 of the 89 patients (23.6%) who had a diagnostic laparoscopy prior to intended curative resection. Preoperative staging by additional diagnostic laparoscopy proved effective in patients with gastric and pancreatic cancer.     

青年人胃癌40例的临床,内镜及病理分析

４０例青年人胃癌，占同期我院胃镜检出胃癌６９９例的５．７％。男性２６例，女性１４例。３１～３５岁为１５例（３７．５％），最小年龄为１５岁。早期胃癌３例（７．５％），进展期癌３７例。手术切除率为４２．５％。５年生存率为１５％（６／４０）。本组发现５例胃癌与十二指肠溃疡共存。本文分析了青年人胃癌的特点与预后差的主要原因，并讨论了青年人胃癌与胃溃疡关系以及与十二指肠溃疡共存问题。     

Use of a lead shield for laparoscopic detection of the sentinel lymph nodes in gastric cancer

Background: Accurate staging of lymph node metastasis by sentinel node biopsy is easily achieved in conventional open gastric surgery. Staging is not easily achieved in laparoscopic surgery, however, because of the technical dif?culty in identifying sentinel nodes. We developed a laparoscopic method that involves lead shielding for detection of sentinel nodes in gastric cancer and examined the ef?cacy of this method. Methods: Laparoscopic sentinel node biopsy was performed in 18 patients with early gastric cancer. A combined dye‐ and radio‐guided method was used in the ?rst 10 patients; our radio‐guided lead shield method was used in the subsequent eight cases. Laparoscopy‐assisted distal gastrectomy was performed in all patients, and dissected nodes were examined by routine hematoxylin and eosin staining. The detection rate was compared between the two groups. Results: The detection rate for sentinel nodes was higher with the radio‐guided lead shield method (88%) than with the combined dye‐ and radio‐guided method (40%). Regional lymph node metastasis was recognized in one of 18 patients, and the sentinel node was positive in this case. Conclusions: Use of a lead shield is bene?cial for accurate laparoscopic detection of sentinel lymph nodes.     

The use of laparoscopy in retroperitoneal pathology

Laparoscopy is usually not performed for retroperitoneal disease. However, if the retroperitoneal process is palpable or displaces viscera, laparoscopy may allow visualization and directed biopsy. In a personal series of 316 laparoscopies reviewed retrospectively, 19 (6%) were performed primarily for retroperitoneal pathology. All patients had CT scans documenting a retroperitoneal process. A confirmed histologic diagnosis was obtained on directed laparoscopic biopsy in 16 patients, including 9 non-Hodgkin's lymphomas. There was no mortality or morbidity in this series. Laparoscopy is a useful modality in selected patients with retroperitoneal diseases, and its use should be considered when a histologic diagnosis is necessary.     

Diagnostic laparoscopy in the evaluation of the viral hepatitis patient with potentially resectable hepatocellular carcinoma

Background. Despite significant recent improvements in liver imaging, preoperative evaluation of the potentially resectable patient with viral Hepatitis and Hepatocellular Carcinoma (HCC) is often inaccurate. Diagnostic laparoscopy may change management for patients with under-appreciated nodular cirrhosis or intrahepatic metastases, preventing unnecessary open exploration. The purpose of this study is to determine the effectiveness of routine laparoscopy as a separate procedure prior to resection in the evaluation of patients with potentially resectable HCC. Methods. Patients with potentially resectable HCC were evaluated preoperatively with routine blood tests and axial imaging. All study patients also underwent diagnostic laparoscopy with laparoscopic ultrasonography. Laparoscopy was performed in an inpatient hospital setting, with 23 hour stays in most cases. Results. Among 65 patients evaluated with Hepatocellular Carcinoma between July 2001 and November 2003, 20 patients with potentially resectable disease were evaluated by diagnostic laparoscopy. All patients had viral Hepatitis: 16 with Hepatitis B and 4 with Hepatitis C. All study patients had cirrhosis; 18 classified as Child''s-Pugh A and 2 as Child''s-Pugh B. Diagnostic laparoscopy changed the management in 9/20 (45%) cases. Management was changed because of severe nodular cirrhosis in 4 cases, inaccurate assessment of intrahepatic metastases in 2 cases, inability to identify an HCC in 1 case, peritoneal carcinomatosis in 1 case, and inability to tolerate induction to general anesthesia in 1 case. Discussion. Diagnostic laparoscopy is useful in the evaluation of the potentially resectable patient with HCC. Information obtained from laparoscopy may change the clinical management in up to 45% of cases.     

诊断性腹腔镜的临床应用研究

目的：评价诊断性腹腔镜的检查方法、效果及安全性，提高腹部疑难疾病的早期诊断率。方法：回顾分析58例腹部疑难疾病患者的腹腔镜检查情况，其中腹水原因待查35例，腹水＋腹部包块23例。结果：58例患者中诊断为结核性腹膜炎31例，恶性腹膜间皮瘤23例，腹膜转移癌2例，盆腔结核及慢性盆腔炎各1例。不同疾病在腹腔镜下有不同表现。操作时间25－70min，平均38min。并发症为活检处出血4例，其中3例为自限性因，1例经局部喷洒凝血酶后停止，术后伤口漏水5例。对腹腔镜下有肯定判断的12例患者同时进行治疗。结论；腹腔镜检查具有安全、简便、微创、痛苦小、确诊率高等优点。诊断性腹腔镜值得进一步推广应用。     

Gastric adenocarcinoma in the gastric stump after partial gastrectomy.

Carcinomas of the gastric stump are divided into two types. In the main group of patients (n = 18), carcinoma developed after resection for benign ulcer disease, and in the second group (n = 4) after resection for early gastric carcinoma. In the first group, the mean age of the patients was 63, and the male-to-female ratio of 17:1. The mean interval between the primary operation and the diagnosis of cancer was 27 years. Biopsies were positive in 16 out of 18 patients. The resectability rate was 72%, resection being performed with curative intent in 50%. Total gastrectomy was performed in 50% of the cases. There were no postoperative deaths. The 5-year survival rate was 33% for all patients and 50% after tumoral resection. Early detection was achieved by means of an endoscopic survey of the gastric stump. A comparison between gastric stump carcinomas and other gastric carcinomas in our series fails to reveal any major differences. Gastric stump carcinoma is not specific. In the second group, the mean age of the patients was 72.5 and the sex ratio 1:1. The mean interval between the two operations was 5 years. The resectability rate was 100%, and all the patients survived with follow-up ranging from 2 to 10 years. The second lesion could be considered a metachronous cancer, but it may have been present and overlooked at the time of the initial gastrectomy. Differentiating between synchronous and metachronous lesions is quite difficult.     

Laparoscopic appendectomies: results of a monocentric prospective and non-randomized study

BACKGROUND/AIMS: Appendicitis is one of the most frequent causes of abdominal pain in western countries. It occurs in 6 to 7% of the United States population. Despite laboratory and imagery tests, 15 to 40% appendices removed by laparotomy appear to be normal at histological examination. Thus, others pathologies beside appendicitis may be found in patients with right lower quadrant pain. This had led some to advocate laparoscopy for patients suspected to have acute appendicitis. The aim of this study is to determine the contribution of laparoscopy in patients with right lower quadrant pain and the implications of removing a macroscopic normal appendix. Rates of all pathologies and normal appendices were found at laparoscopy. Morbidity, mortality rates and length of hospital stay linked to laparoscopic appendectomy. DESIGN: Prospective non-randomized study. METHODOLOGY: Between January 1995 and September 2004, 615 patients have been approached by laparoscopy for acute, subacute or chronic abdominal right-lower-quadrant pain in our Department of Digestive and Laparoscopic Surgery. Thirteen patients have not been hold and the study involves 602 patients including 311 men and 291 women with a mean age of 33 years. All removed tools have been analyzed histologically. During the same period, only 5 patients have been approached by laparotomy. RESULTS: Five hundred and thirty patients (88%) had appendicitis, 39 patients (6.5%) had another pathology and no disease was found in 33 patients (5.5%). According to the sex, appendicitis was found in 242 women (83.2%) versus 288 men (92.6%). Thirty-four women (11.7%) versus 5 men (2%) had another pathology. The local morbidity was 4.3%, the general morbidity 1% and the mortality was 0%. The average length of postoperative hospital stay was 4 days (range: 1-27). Oral intake was assumed on average 1.5 days postoperatively (range: 0-13). There were 10 reoperations (1.6%). CONCLUSIONS: Laparoscopy is a reliable technique, safe and reproducible. It is an effective and relatively atraumatic tool to investigate abdominal cavity. This allows an accurate decision-making, which is especially advantageous in young women who have a high rate of non-appendicular pathologies. Laparoscopy also reduces the rate of unnecessary abdominal exploration while realizing a correct diagnosis of others possible pathologies. We therefore advocate laparoscopy in patients with abdominal right-lower-quadrant pain, especially women.     

Is laparoscopy an advantage in the diagnosis of cirrhosis in chronic hepatitis C virus infection？

AIM: To evaluate the potential of laparoscopy in the diagnosis of cirrhosis and outcome of interferon treatment in HCV-infected patients. METHODS: In this retrospective study, diagnostic laparoscopy with laparoscopic liver biopsy was performed in 72 consecutive patients with chronic HCV infection. The presence or absence of cirrhosis was analyzed macroscopically by laparoscopy and microscopically by liver biopsy specimens. Clinical and laboratory data and outcome of interferon-alfa treatment were compared between cirrhotic and noncirrhotic patients. RESULTS: Laparoscopically, cirrhosis was seen in 29.2 % (21/72) and non-cirrhosis in 70.8 % (51/72) of patients. Cirrhotic patients were significantly older with a significant longer duration of HCV infection than noncirrhotic patients. Laboratory parameters (AST, y-GT, y-globulin fraction) were measured significantly higher as well as significantly lower (prothrombin index, platelet count) in cirrhotic patients than in non-cirrhotic patients. Histologically, cirrhosis was confirmed in 11.1 % (8/72) and non cirrhosis in 88.9 % (64/72). Patients with macroscopically confirmed cirrhosis (n=21) showed histologically cirrhosis in 38.1 % (8/21) and histologically non-cirrhosis in 61.9 % (13/21). In contrast, patients with macroscopically non-cirrhosis (n=51) showed histologically non cirrhosis in all cases (51/51). Thirty-nine of 72 patients were treated with interferon-alfa, resulting in 35.9 % (14/39) patients with sustained response and 64.1 % (25/39) with non response. Non-responders showed significantly more macroscopically cirrhosis than sustained responders. In contrast, there were no significant histological differences between non-responders and sustained responders. CONCLUSION: Diagnostic laparoscopy is more accurate than liver biopsy in recognizing cirrhosis in patients with chronic HCV infection.Liver biopsy is the best way to assess inflammatory grade and fibrotic stage. The invasive marker for staging, prognosis and management, and treatment outcome of chronic HCV-infected patients need further research and clinical trials. Laparoscopy should be performed for recognition of cirrhosis if this parameter is found to be of prognostic and therapeutic relevance in patients with chronic HCV infection.     

Laparoscopic pancreatic surgery: indications, techniques and preliminary results.

BACKGROUND/AIMS: The purpose of this study was to evaluate feasibility, effectiveness and reproducibility of laparoscopy in the diagnosis and management of pancreatic diseases. METHODOLOGY: At the Second Department of Surgery of the "Regina Elena" Institute for Cancer Research, between June 1995 and June 1997, possibilities of the laparoscopy in diagnosis and staging of pancreatic malignancies were studied. Twenty-four consecutive cases of pancreatic adenocarcinoma were observed: 10 patients were pre-operatively considered unresectable and 14 cases were submitted to a laparoscopic study. Moreover, in the period from January 1996 to June 1997, a study on the therapeutical potentialities of laparoscopy was performed, attempting 5 pure or assisted laparoscopic pancreatic resections. RESULTS: Three cases (21.4%) out of the 14 evaluated were found to be metastatic (liver and peritoneum); 11 patients were successfully resected with an open standard procedure. Laparoscopy allowed a correct staging in all cases, even in the 21.4% of ultrasonography (US), TC and angiographic false negatives. The 5 operative procedures consisted of one resection of a cystadenoma, one resection of a head cyst, one Wirsung lithotomy with pancreaticojejunostomy for lithiasic chronic pancreatitis, and two body-tail splenopancreatectomies (1 cystadenoma and 1 adenocarcinoma). Satisfactory early results were obtained in all these cases. CONCLUSIONS: Laparoscopic diagnosis and staging of pancreatic cancer is a valuable method which allows a very high accuracy. Pancreatic resections, even if feasible, are still to be considered an experimental procedure.     

Plasma arginine vasopressin concentration during laparoscopy

Plasma arginine vasopressin concentration (pAVP) was determined in 47 patients during the insufflation stage of laparoscopy. Laparoscopy was performed under local anesthesia in 39 patients, and under general anesthesia in 8. Pneumoperitoneum was induced with 3-4 1 nitrous oxide to a maximum intra-abdominal pressure of 10 mm Hg. Induction of pneumoperitoneum resulted in a prompt and significant increase in pAVP in every case. In 34% of cases, pAVP increased two- to fivefold as compared with preinduction levels; in 44.7% of cases, elevations of more than fivefold were seen. Increased arginine vasopressin secretion was not related to underlying liver disease, degree of anxiety, changes in blood pressure, heart rate, pCO2, pO2, serum bicarbonate or plasma osmolality. Elevated pAVP was associated with a significant increase in right atrial pressure. In conclusion, abdominal distension during laparoscopy was accompanied by an increase in pAVP. It seems likely that arginine vasopressin response could be due to a decrease in the left atrial transmural pressure gradient.