Diagnosis and therapy of malignant peritoneal mesothelioma

Malignant peritoneal mesothelioma is an uncommon tumor with great diagnostic and therapeutic problems. Symptoms, clinical features and course of the disease are described in three patients which were seen at our hospital within the last years. At the beginning there are often severe weight loss, malaise and sometimes fever of unknown origin. Abdominal pain, increased abdominal girth or nausea indicate advanced tumor stages in most cases. Ultrasonography and computed tomography of the abdomen can give important information during the diagnostic approach. Nevertheless, the definite diagnosis can only be established by laparoscopy or open surgery with biopsy for a histological examination. Despite intern and extern radiotherapy as well as systemic and/or local chemotherapy the prognosis of malignant peritoneal mesothelioma remains unfavourable. Mean survival time ranges from six to 18 months.     

Diagnosis of abdominal tuberculosis by transabdominal ultrasound-guided needle biopsy.

Laparotomy and laparoscopy have been used for biopsy of pelvic masses in the differential diagnosis between abdominal tuberculosis and ovarian cancer. We suggest the use of transabdominal needle biopsy under ultrasound guidance in such cases. Two women developed abdominal distention, one of whom had been receiving medical treatment for known tuberculosis. In both cases, ultrasonography showed a pelvic mass and ascites associated with high levels of CA 125. A transabdominal ultrasonographically-guided biopsy of the masses with a trucut needle established their tuberculous origin. The transabdominal sonographic needle biopsy is a reliable diagnostic procedure in the differential diagnosis between abdominal tuberculosis and ovarian malignancy. This minimally invasive procedure saves the patient with tuberculosis from unnecessary laparotomy.     

Laparoscopic diagnosis of tuberculous ascites

We report 14 patients with tuberculous peritonitis presenting as persistent and exudative ascites. We found a primary site of tuberculous infection in only 10% of the patients. PPD test was positive in 9 patients. Ascitic fluid showed a protein content in excess of 3.5 g/dl. and more than 300 cells/mm3, mainly lymphocytes, in all patients, Ziehl stain and the culture for Tb. bacilli were negative in all cases. The confirmatory diagnosis was made by laparoscopy and peritoneal biopsy. Good views were obtained on all occasions, and there was no morbidity. Appearances were similar in all cases. Multiple white tubercles were scattered over the parietal and visceral peritoneum. filmy adhesions were present. Four patients had cirrhotic liver disease confirmed by laparoscopy. The biopsy specimen showed caseating granulomata, and the auramine stain was positive in four cases. We conclude that laparoscopy and biopsy is a safe and effective method of obtaining an early diagnosis in patients with tuberculous ascites, especially if they also have cirrhosis.     

Kala-azar acquired in Croatia]

Six weeks after his return from a two-week vacation in Croatia a 52 year-old janitor from Graz complained of loss of appetite, fever, headache, and a 9-kg weight loss. The spleen was enlarged to 16cm as measured by sonography. Laboratory tests revealed pancytopenia, a prolonged prothrombin time and elevation of serum LDH concentration. While repeated bone marrow biopsy showed no signs of leishmaniasis, high antibody titers against leishmania antigen led to the diagnosis of kala-azar. The indirect immunofluorescent antibody test (1:128) and a haemagglutination-inhibition test (1:512) showed diagnostic elevations of titers. Therapy with pentostam led to prompt defervescence and resulted in a full recovery of the patient. After six weeks a marked decrease of antibody titers in the haemagglutination-inhibition test (1:16) could be observed. Leishmaniasis has to be considered in patients with fever of unknown origin who return from Mediterranean countries. Despite a negative bone marrow biopsy a diagnosis is possible on the basis of serological tests. This is important because effective therapy is available as illustrated by this patient and because of the fact that the disease runs a lethal course if the diagnosis is missed.     

Macrobiopsy of the spleen: proposal for a laparoscopic approach

The spleen plays an important role in the immune response; however, its function is not yet fully understood. Splenectomy is still proposed for diagnosis in some patients with splenic focal lesions or splenomegaly. Often in these patients, an adequate splenic biopsy would be sufficient to obtain the correct diagnosis and address the appropriate non-surgical management. While percutaneous fine needle biopsy preserves the spleen and its functions, in some instances the tissue sample obtained is inadequate for a definitive diagnosis. We report a technique of laparoscopic macrobiopsy of the spleen, performed in two patients with splenic focal lesions. It requires, as a first step, the clipping of the splenic artery before the origin of the left gastroepiploic artery, to reduce the risk of bleeding. Macrobiopsy of the spleen, including the focal lesion, was performed using monopolar cautering scissors. This technique provided an adequate amount of tissue for diagnosis, and it was possible to preserve the spleen.     

Sonographically guided renal mass biopsy: indications and efficacy.

PURPOSE: To review the clinical indications, pathologic results, and success rate of all our sonographically guided solid renal mass biopsies over a 5-year period. METHODS: Between 1993 and 1998, 44 consecutive patients underwent sonographically guided percutaneous biopsy of a solid renal mass. Indications included prior history of nonrenal malignancy, metastatic disease of unknown primary origin, previous contralateral nephrectomy for a renal cell neoplasm, a renal transplant mass, suspected renal lymphoma, history of tuberous sclerosis, and poor surgical candidacy. Aspiration biopsies were initially performed with 22- to 18-gauge spinal needles. If the initial cytologic evaluation findings were nondiagnostic, core biopsies were then performed with 20- to 18-gauge core biopsy guns. Dictated sonographic reports of the biopsies were reviewed to determine the following: indication for biopsy, location and size of the renal mass, needle gauge and type, number of needle passes, and complications. Final cytologic and surgical pathologic records were reviewed. RESULTS: Thirty-six (82%) of the 44 biopsy specimens were diagnostic. Aspirated smears were diagnostic in 24 (67%) of these cases, with the diagnosis made on the basis of cell block alone in an additional 2 (6%). A definitive diagnosis came from core biopsy alone in 10 cases (28%). The 18-gauge core needle yielded diagnostic results more reliably than the 20-gauge core needle, and a significant correlation was seen between core biopsy needle size and the rate of diagnostic core samples (P = .017). Pathologic diagnoses included renal cell carcinoma (n = 18), lymphoma (n = 4), oncocytic neoplasm (n = 4), transitional cell carcinoma (n = 2), angiomyolipoma (n = 1), papillary cortical neoplasm (n = 1), and metastatic carcinoma (n = 6). Complications were seen in 4 (9%) of 44 cases; all were treated conservatively. CONCLUSIONS: For specific clinical indications, sonographically guided fine-needle aspiration and core biopsy of a solid renal mass can be performed safely. In many cases, a definitive diagnosis can be made on the basis of fine-needle aspiration alone. However, diagnosis may ultimately require core biopsy, for which 18-gauge core needles would be more reliably diagnostic than 20-gauge needles.     

腹腔镜技术诊治慢性腹痛的临床应用(附36例报告)

目的探讨腹腔镜在诊断和治疗不明原因慢性腹痛中的作用。方法回顾分析不明原因慢性腹痛36例的临床资料。结果34例明确病因，有效率为94口。诊断为肠粘连15例，妇科疾病8例，慢性阑尾炎5例，结核性腹膜炎2例，小肠恶性淋巴瘤1例，腹膜转移癌、回盲部憩室，肠套叠各1例。其中26例在腹腔镜下行治疗，占72．2％。探查或治疗术后均无严重并发症。结论腹腔镜诊断慢性腹痛准确率较高，且有大部分病例可做相应的治疗，值得临床推广应用。     

Laparoscopy and histology in the diagnosis of chronic liver disease

We compared laparoscopy with histology in identifying fattychange, fibrosis, the degree of inflammatory activity, cirrhosisand the cause of liver disease. Laparoscopic liver biopsy wasperformed in 145 consecutive patients. The laparoscopist andthe histologist were provided with similar clinical and biochemicalinformation. Both scored the appearances on respective examinationsfor the degree of fatty change, fibrosis and activity, presenceor absence of cirrhosis; and provided a provisional diagnosis.The final diagnosis was determined by clinicopathological conferenceand clinical follow-up. Laparoscopy was successfully performedin 142 patients (97.9%). Compared with histology, the sensitivityand specificity of laparoscopy for identifying fatty changewere 96.4% and 100%, 100% and 95% for fibrosis and 94% and 95%for inflammatory activity, respectively. For cirrhosis, laparoscopywas 100% sensitive and 97.1% specific. Histology missed 10 casesof cirrhosis (6.1%). Histology did, however, provide additionalinformation in 9 patients (6.3%) which contributed to the finaldiagnosis. Overall, histology is required in addition to laparoscopyin cases where the aetiology is unclear. The sensitivityandspecificity in identifying fatty change, fibrosis, activityand cirrhosis are similar for laparoscopy and histology. Thecombination of information gained on laparoscopy with histologyprovidesthe diagnosis in most patients. Laparoscopy may replace theneed for liver biopsy in patients in whom the aetiological diagnosisis not in question and the biopsy is being performed to stagethe disease. We use it as an integral part of the workup ofa patient with liver disease.     

Tuberculous peritonitis: fatality associated with delayed diagnosis

We describe a fatal case of tuberculous peritonitis and review the literature on the diagnostic modalities available to diagnose this entity. We suspect a delayed diagnosis resulted in the death of our patient. Today, the prompt diagnosis of an unknown ascitic process involves laparoscopy. A patient with unknown large volume ascites is the easiest and safest to laparoscope. Using a mini laparoscope, a bedside procedure with instantaneous return can be done. The newer noninvasive tests like determination of ascites fluid adenosine deaminase activity and polymerase chain reaction may be helpful in the prompt diagnosis of peritoneal tuberculosis. We recommend that patients with clinical presentation suggestive of peritoneal tuberculosis have either an aggressive diagnostic workup using high-yield tests or a trial of antituberculous therapy.     

腹腔镜检查不孕症398例分析

目的 应用腹腔镜诊断技术探讨不孕症的病因，评价腹腔镜对不孕症的诊断价值。方法 应用腹腔镜对398例不孕症妇女的盆腔疾病和不孕的影响因素进行分析。结果 腹腔镜检查发现盆腔器质性病变359例，检查阳性率为90．20％。慢性盆腔炎、子宫内膜异住症和多囊卵巢是引起不孕的主要盆腔疾病，分别占54．52％、18、34％和10，30％；慢性盆腔炎患者中91．70％有1侧或双侧输卵管梗阻；子宫内膜异住症患者中20．55％有输卵管梗阻。本资料398例中，有156例病人术前进行了输卵管碘油检查，96例与腹腔镜检查结果一致，两者符合率为61．53％；术前227例患者进行阴道超声检查，经腹腔镜证实159例，符合率70．04％(159／227)。结论 应用腹腔镜技术对不孕症的病因诊断有重要价值，盆腔炎输卵管梗阻率在继发不孕患者中的发病率高于原发不孕患者；在原发不孕惠者中，以子宫内膜异位症、多囊卵巢多见；对怀疑有盆腔疾病或原因不明的不孕患者应尽早腹腔镜诊治。     

Coeliac disease in patients with cerebellar ataxia of unknown origin

BACKGROUND: Neurological symptoms of unknown origin are common in coeliac disease (CD). Evidence suggests that CD may also contribute to the development of idiopathic late-onset ataxia. AIM: To evaluate the frequency of CD in patients with cerebellar ataxia of unknown origin. METHODS: The medical files of adult patients with the diagnosis of cerebellar ataxia of unknown origin (n=44) were evaluated. Serum gliadin, endomysial, and serum tissue transglutaminase antibodies were used as screening tests for CD. Subjects with positive results were referred to small-bowel biopsy. RESULTS: The frequency of CD was as high as 9.1% in all patients. A thorough interview and review of the patient files indicated alcohol abuse as a cause for cerebellar disease in almost half (45.5%) of our patients. When the cases with alcohol abuse were omitted, the calculated frequency of CD was 16.7% in patients with ataxia of unknown origin. CONCLUSION: CD is a common association with cerebellar disease and the disease should be considered in all patients with ataxia of unknown origin.     

Bedside diagnostic laparoscopy to diagnose intraabdominal pathology in the intensive care unit

Introduction

Delayed diagnosis of intraabdominal pathology in the intensive care unit (ICU) increases rates of morbidity and mortality. Intraabdominal pathologies are usually identified through presenting symptoms, clinical signs, and laboratory and radiological results; however, these could also delay diagnosis because of inconclusive laboratory tests or imaging results, or the inability to safely transfer a patient to the radiology room. In the current study we evaluated the safety and accuracy of bedside diagnostic laparoscopy to confirm the presence of intraabdominal pathology in an ICU setting.

Methods

This retrospective study, carried out between January 2006 and June 2008, evaluated the diagnostic accuracy of bedside diagnostic laparoscopy performed on patients with a suspicion of ongoing intraabdominal pathology. Clinical indications for bedside diagnostic laparoscopy were: ultrasonography (US) images of gallbladder distension or wall thickening of more than 3 to 4 mm, with or without pericholecystic fluid; elevation of laboratory tests (bilirubin, transaminases, myoglobin, lactate dehydrogenase, creatine phosphokinase, gamma-glutamyltransferase); high level of lactate/metabolic acidosis; CT images inconclusive for intraabdominal pathology; or inability to perform a CT scan. Patients did not undergo bedside diagnostic laparoscopy if they presented clear indications for open surgery, coagulopathy, abdominal wall infection or high intraabdominal pressure.

Results

Thirty-two patients underwent bedside diagnostic laparoscopy (Visiport Plus, Autosuture, US), 14 of whom had been admitted to the ICU for major trauma, 12 for sepsis of unknown origin and 6 for complications after cardiac surgery. The procedure was performed on an average of eight days after ICU admission (95% confidence interval = 5 to 15 days) and mean procedure duration was 40 minutes. None of the procedures resulted in complications. Bedside diagnostic laparoscopy was diagnostic for intraabdominal pathology in 15 patients, who subsequently underwent surgery, except in two cases of diffuse gut hypoperfusion. Diagnosis of cholecystitis was obtained in seven cases: two were treated with laparotomic cholecystectomy and five with percutaneous gallbladder drainage positioning.

Conclusions

Bedside diagnostic laparoscopy represents a safe and accurate technique for diagnosing intraabdominal pathology in an ICU setting and should be taken into consideration when patient transfer to radiology or the operating room is considered unsafe, or when routine radiological examinations are not conclusive enough to reach a definite diagnosis.     

播散型组织胞浆菌病1例报告并文献复习

提高对播散型组织胞浆菌病（PDH）的认识。方法：结合1例PDH患者的临床资料及文献复习,对本病病原学、流行病学、临床表现、诊断、鉴别诊断和治疗等方面进行分析。结果：患者以不规则发热、消瘦、全身淋巴结肿大为主要临床表现,组织病理学检查镜下找到组织胞浆菌孢子。氟康唑治疗有效。结论：PDH是由组织胞浆菌引起的累及全身单核巨噬细胞系统的深部真菌病,临床表现多样,确诊有赖于病原菌的检查。     

脾淋巴瘤的超声诊断价值及其分型

目的 探讨脾淋巴瘤的超声诊断价值及其分型.方法 对31例脾淋巴瘤的临床资料、超声表现与病理进行对比分析,并行超声分型.结果 31例脾淋巴瘤中,超声提示脾淋巴瘤3例,淋巴瘤脾累及5例,诊断正确率为25.8%.31例脾淋巴瘤超声表现可分为四型:①弥漫肿大型,占12.9%(4/31),肿大的脾内未见团块或结节;②粟粒结节型,占16.2%(5/31),脾内见大小不一的低回声结节(直径≤3 cm);③巨块型,占29.0%(9/31),肿块单发,直径大于3 cm,伴或不伴中心坏死;④混合型,占41.9%(13/31),脾肿大,内可见大小不一的低回声结节与团块.结论 超声对脾淋巴瘤的诊断有较高的临床价值,必要时可行超声引导下穿刺活检.     

Diagnosis of pulmonary infections in immunocompromised patients

In an immunocompromised patient with fever and pulmonary infiltrates, it frequently is difficult to decide which invasive procedure, if any, to use to obtain a definitive diagnosis. Because most lung infiltrates in immunosuppressed patients are caused by bacteria and sputum usually is readily available for examination, empiric therapy with potent, safe, broad spectrum, antibacterial drugs often is successful. Invasive procedures that prove a diagnosis may result in substantive changes in therapy in perhaps as few as 10 to 20 per cent of patients, and the procedure itself may harm the patient. In a unique study in which patients with acute pneumonitis without neutropenia were randomized to either empiric antibiotic treatment or treatment based on results of open lung biopsy, patients with open lung biopsy had a worse outcome, possibly related to morbidity of open lung biopsy. Furthermore, no diagnoses were provided by open lung biopsy that were not treated by the empiric regimen. A missed treatable disease may be tragic, however. A thoughtful clinician must evaluate each patient with careful consideration of the history in light of the underlying disease and its treatment, rapidity of clinical course, physical examination, and laboratory data, particularly the chest radiograph, sputum examination, and bleeding parameters. Fiberoptic bronchoscopy with washings and brushings is very safe; the addition of transbronchial biopsy adds diagnostic power at the price of some complications. Bronchoalveolar lavage is a very promising technique that probably will find widespread use. However, none of the foregoing techniques is completely sensitive. When no diagnosis is established and bronchoscopy studies are negative, open lung biopsy must be considered, especially when the chest radiograph or computed tomography scan suggests focal disease or lymphadenopathy. Needle aspiration can be used, particularly if local experience is favorable and lung disease is peripheral. When evaluating a procedure, local experience must be considered rather than reliance on published diagnostic yields and complication rates. New diagnostic and therapeutic developments may change decision analysis in the near future. At present, cultures for viruses and fungi and serologic techniques have little application at most medical centers, and decisions on data from invasive procedures pivot on interpretation of histology and smears. Development of assays for antigen (for example, Aspergillus) and rapid culture techniques (for example, cytomegalovirus and the shell vial method), coupled with new, effective antimicrobials, may demand maximum effort for a definitive diagnosis in every patient.     

Stereotactic core breast biopsy versus needle localization breast biopsy - the effect of initial diagnostic modality on surgical therapy in patients with breast cancer

Summary. The aim was to assess the effect of the initial diagnostic modality on surgical planning in patients with mammographically detected malignancies. A retrospective chart review of 40 patients with mammographically detected breast cancer was undertaken. The diagnosis was established in 20 patients by needle localization breast biopsy and in 20 patients by stereotactic core breast biopsy. In patients whose diagnosis was established by stereotactic core breast biopsy, all were treated with only one operation per patient. In those patients whose diagnosis was established by needle localization breast biopsy, an average of 2.1 surgeries per patient were required to diagnose and treat this group. Patients with abnormal mammograms should have the diagnosis established by stereotactic biopsy. If the lesion was malignant, a planned one-stage definitive operation was successful in all of our patients. We feel that stereotactic core biopsy is the preferred method for establishing a diagnosis in patients with suspicious mammographic findings.     

Usefulness and limitations of laparoscopy in the diagnosis of tuberculous peritonitis.

The value of laparoscopy in the diagnosis of tuberculous peritonitis was determined in 32 patients diagnosed histologically as having the condition. In 27 (85%) patients the diagnosis was obtained by laparoscopy combined with peritoneal biopsy. In five patients in whom laparoscopy was unsuccessful, the diagnosis was established by laparotomy. The visually established diagnosis was unreliable and needed histological confirmation. In the ascitic form of tuberculous peritonitis laparoscopy was a safe method which enabled a definitive diagnosis. In the fibroadhesive form of tuberculous peritonitis laparoscopy was risky and gave insufficient information, the diagnosis easily being established by laparotomy.     

Laparoscopic findings in primary sclerosing cholangitis

BACKGROUND AND STUDY AIMS: Primary sclerosing cholangitis (PSC) is a cholestatic disease characterized by segmental narrowing and dilatation of bile ducts. Few studies have been performed on the laparoscopic findings associated with this disease, and the present study was intended to assess the usefulness of laparoscopy for the diagnosis and staging of PSC. PATIENTS AND METHODS: Six patients were examined by laparoscopy with liver biopsy. Repeated laparoscopy was performed in three patients. RESULTS: Laparoscopy revealed coarse surface irregularity and discoloration. Surface irregularity was classified into four grades: smooth, shallowly depressed, undulated, and nodular. The affected area showed whitish yellow discoloration. The discolored area was demonstrated as a poorly stained area by intravenous injection of indocyanine green (ICG). Lobular markings became apparent because of the yellow color change in the portal tract, resulting in a leopardskin-like appearance. Lymph-vessel dilatation was seen in advanced stages. Repeated laparoscopy of a patient without treatment demonstrated a progression from a smooth surface to a shallow depression with leopardskin-like markings. On the other hand, the two patients treated with immunosuppressive agents showed improvement of liver swelling and disappearance of the leopardskin-like markings and lymph-vessel dilatation. CONCLUSIONS: Laparoscopy may provide useful information for the diagnosis and staging of PSC.     

US-guided percutaneous needle biopsy of the spleen using 18-gauge versus 21-gauge needles

PURPOSE: To compare the techniques of sonographically (US)-guided percutaneous needle biopsy of the spleen using 18-gauge and 21-gauge needles. METHODS: Forty-two patients undergoing 43 spleen biopsy procedures for focal lesions (n = 27 [16 single, 11 multiple]) or diffuse splenomegaly (n = 15) were analyzed. Two groups were divided randomly according to needle type: group 1 comprised 25 patients biopsied with an 18-gauge cutting needle for histologic examination; group 2 comprised 17 patients biopsied with a 21-gauge needle for histologic and cytologic examinations. Diagnostic accuracy, complication rate, and number of needle passes were compared between the 2 groups. RESULTS: Correct histopathologic diagnosis was obtained in 36 cases, whereas incorrect diagnosis occurred in 6 cases. The accuracy of US-guided spleen biopsy in this series was 85.7%, with 1 patient (2.4%) having postprocedural hemorrhage. Compared with the 21-gauge needle, the 18-gauge needle had higher diagnostic accuracy (P < 0.05), required fewer needle passes (P < 0.05), and there was no significant difference in overall complication rate. CONCLUSION: Because biopsy with an 18-gauge needle yields larger and unfragmented samples with higher diagnostic rate compared with a 21-gauge needle, and no increased rate of major complication requiring surgical intervention, it may be advantageous to use an 18-gauge cutting needle in the US-guided needle biopsy of splenic lesions.     

比较超声引导下粗针与细针在经皮脾穿刺活检中的应用价值

目的比较超声引导下18G粗针与21G细针脾穿刺活检的安全性和有效性。方法53例行超声引导下脾穿刺活检的患者,局灶性病变35例,弥漫性病变18例。18G粗针组35例应用组织切割针配以自动活检枪;21G细针组18例应用手动活检针。结果46例明确了诊断,7例假阴性,准确率86.8%,2组比较进针次数和诊断准确率均有显著差异（P=0.017,P=0.037）;1例并发出血,2组比较并发症的发生率没有统计学差异。结论18G针和21G针行超声引导下经皮脾穿刺活检均安全。18G粗针活检能够获得较多而完整的组织条,诊断的准确率较高,是获得病理诊断的有效方法。