腹腔镜在胰腺肿瘤诊断和分期中的价值

由于胰腺解剖位置深、早期症状不典型及缺乏特异性肿瘤标记物,胰腺肿瘤患者的准确诊断及分期一直是胰腺外科医师所面临的关键问题。腹腔镜技术在国外已开始用于胰腺肿瘤的诊断分期,而国内报道较少。笔者近年将腹腔镜探查（laparoscopic exploration,LE）用于胰腺肿瘤患者的术前诊断分期,取得满意效果,     

腹腔镜超声在胰腺壶腹部肿瘤分期诊断和治疗中的价值

目的 评价腹腔镜超声技术(LapUS)在胰腺和壶腹部癌肿分期诊断和治疗中的临床应用价值。方法 自1996年12月～1999年12月连续对46例怀疑胰腺和壶腹部肿瘤病人进行腹腔镜和腹腔镜超声分期诊断。并与术前影像学检查、手术中发现及术后标本病理学检查进行前瞻对比研究。着重检查肿瘤范围、周围血管侵犯、周围淋巴结转移、浆膜浸润和肝、邻近脏器转移;对可疑病变和肿大的淋巴结进行腹腔镜超声引导下穿刺活检。判断肿瘤切除性。结果 46例病人中。LapUS发现肿块性病灶44例,2例阻塞性黄疸确诊为壶腹部结石嵌顿排除肿瘤。44例肿块性病变中41例为恶性肿瘤,3例为炎性病变,肿瘤诊断正确率为93．2％。本组未发生腹腔镜和腹腔镜超声检查有关并发症。结论腹腔镜和腹腔镜超声检查应列为重要的分期诊断工具,剖腹探查前常规应用可明显提高诊断正确率、完善肿瘤分期诊断和可切除性判断。可避免不必要的剖腹探查术。在微创外科诊治中具有重要的临床应用价值。     

腹腔镜及腹腔镜超声在胰腺癌分期中的应用进展

术前胰腺癌分期对手术方式的选择及患者的预后判断至关重要,传统分期方法主要依靠CT检查进行,但容易漏诊肝脏内较小、较隐蔽的转移灶,对胰腺癌侵犯血管的判断能力及肿瘤生长部位容易受主观因素的影响;增强型CT在预测不可切除的胰腺癌方面准确率较高（90%～100%）,但在判断可根治性切除方面却有限。近年,腹腔镜及腹腔镜超声在胰腺癌分期中的临床价值逐渐受到重视。经腹腔镜及腹腔镜超声检测对胰腺癌分期阳性预测指数较高,容易发现隐性的、较隐蔽的胰腺癌转移灶,在区分确实不能根治切除方面具有重要意义。本文现就腹腔镜及腹腔镜超声在胰腺癌分期中的应用进展做一综述。     

腹腔镜在胰腺癌分期中的应用(文献综述)

临床资料显示对一些术前 CT认为可能切除的局限性进行期胰腺癌行腹腔镜 (laparoscopy,LP)检查能避免不必要的探查术 ,由于这部分比例小 ,尚不能作为术前常规检查 ,在计划探查术前有选择地做 LP可能更合适 ,更经济。     

经尿道腔内超声在膀胱肿瘤诊断和分期中的价值

目的　探讨经尿道腔内超声在膀胱肿瘤诊断和分期中的价值。　方法　总结 70例膀胱癌患者经尿道腔内超声诊断及分期的结果 ,并与膀胱镜、经腹壁超声、CT、MRI、术后病理结果对比。　结果　经尿道腔内超声肿瘤检出率 99.1% ,高于膀胱镜和经腹壁超声检出率 ;膀胱肿瘤分期与病理符合率 :T110 0 .0 %、T2 95 .8%、T3 82 .4 %、T45 5 .6 %。　结论　经尿道腔内超声能清晰显示早期膀胱肿瘤及其浸润深度 ,是早期膀胱肿瘤诊断及分期的重要方法之一     

腹腔镜在消化系恶性肿瘤分期中的应用

长期以来对消化系恶性肿瘤病人开腹探查明确分期 ,不仅切除率较低 (约 5 0 % ) ,手术并发症较多(15 %～ 2 0 % ) ,有一定的死亡率 (0～ 10 % ) ,而且病人痛苦大 ,花费高 ,使免疫力本已低下的肿瘤患者承受不必要的创伤打击 ,对不能切除者更是得不偿失。即使是术前各种先进的影像学检查认为可以切除的腹部恶性肿瘤 ,在开腹探查时也有 2 0 %～ 30 %因腹腔内隐匿的种植播散、肝及区域性淋巴结转移而失去治愈性切除的机会[1] 。腹腔镜探查 ,特别是联合应用腹腔镜超声诊断技术在检查腹腔内隐性转移灶方面具有独特的优势 ,不仅可以直接进行织织活检…     

腹腔镜在胰腺癌分期中的应用

临床资料显示对一些术前CT认为可能切除的局限性进行期胰腺癌行腹腔镜（laparoscopy,LP)检查能避免不必要的探查术，由于这部分比例小，尚不能作为术前常规检查，在计划探查术前有选择地做LP可能更合适，更经济。     

血清肿瘤标志物在胰腺癌诊断和分期中的意义

目的评估血清肿瘤标志物CA19-9和CA242在胰腺癌诊断和分期中的价值。方法通过病历回顾,收集整理CA19-9和CA242的检测结果及相应的临床资料。利用美国国家综合癌症网络的分期标准进行TNM分期,根据肿瘤能否切除进行分层分析。结果CA19-9和CA242在良、恶性胰腺疾病之间差异有统计学意义,Ⅱ、Ⅲ、Ⅳ期胰腺癌与Ⅰ期胰腺癌相比CA19-9显著升高,CA19-9和CA242在手术无法切除组明显高于可切除组,差异均有统计学意义。结论CA19-9与胰腺癌分期和进展关系密切,对胰腺癌的诊断分期和可切除性评估有重要的临床意义。     

腹腔镜技术在胰腺肿瘤诊治中的应用范围

正腹腔镜手术视野清,微创优势明显,已逐步取代传统开腹手术成为绝大多数腹部疾病的首选术式。但胰腺解剖复杂,手术难度高,术后并发症多,腹腔镜胰腺手术相对落后。近年来,一些富有创新精神的胰腺外科医生掌握了腹腔镜技术,将其用于胰腺肿瘤的诊断和治疗,取得令人满意的效果。现就本     

对比增强超声造影在胃癌术前T分期中的诊断价值

目的探讨对比增强超声造影对胃癌术前T分期的临床诊断价值。方法采用六氟化硫微气泡造影剂和连续实时成像的对比脉冲序列技术．对8例健康志愿者进行超声造影．并与正常胃螺旋CT增强造影结果相对照：对62例经胃镜活检证实的胃癌患者术前行超声造影．并与术后病理检查结果对照。结果8例正常胃壁在对比增强超声造影动脉期、平衡期呈3层结构，门脉期呈单层结构。3层结构中内层轻度增强相应于黏膜层：中间层低增强相应于黏膜下层：外层明显增强相应于肌肉-浆膜层。62例经腹超声检查胃癌术前T分期的准确率为72．9％．对比增强超声造影T分期准确率为88．1％，两者T分期的差异有统计学意义（X2=4．37，P=0．036）。结论正常胃壁在对比增强超声造影下可显示单层或3层结构．这为判断胃癌浸润深度提供了理论基础。对比增强超声造影对胃癌术前T分期具有较高的临床应用价值。     

Diagnostic laparoscopy and laparoscopic ultrasonography optimize the staging and resectability of intraabdominal neoplasms

BACKGROUND: Despite technical improvements, preoperative imaging studies often fail to predict intraoperative findings. We investigated the potential use of diagnostic laparoscopy (DL) and laparoscopic ultrasonography (LUS) for the assessment of disease in patients with abdominal neoplasms. METHODS: Fifty consecutive patients with abdominal neoplasms underwent spiral computed tomography with oral and intravenous contrast using 5-mm contiguous sections. In addition, eight patients underwent ultrasonography, six underwent magnetic resonance imaging, and eight underwent positron emission tomography. All patients then underwent DL and LUS using a 7.5-MHz ultrasound probe. RESULTS: There were 29 men and 21 women with a mean age of 63 years (range, 35-84). Most had a diagnosis of colorectal cancer (19 cases), melanoma (12 cases), or hepatoma (five cases). In nine cases (18%), DL revealed peritoneal metastatic implants not shown on preoperative images. In 18 cases (36%), LUS was more accurate than preoperative imaging. Combined DL and LUS findings radically changed the operative management in 16 patients (32%). CONCLUSION: As compared with preoperative imaging, the combination of DL and LUS provides more accurate information regarding staging and resectability. Moreover, it helps to determine the extent of operation and reduces the number of unnecessary laparotomies. DL and LUS should be used as an adjunct to preoperative imaging studies in patients with primary or metastatic intraabdominal neoplasms.     

TNM staging and assessment of resectability of pancreatic cancer by laparoscopic ultrasonography

Background: Laparoscopic ultrasonography (LUS) is an imaging modality that combines laparoscopy and ultrasonography. The purpose of this prospective blinded study was to evaluate the TNM stage and assessment of resectability by LUS in patients with pancreatic cancer. Methods: Of the 71 consecutive patients admitted to our department, 36 were excluded from the study, mainly due to evident signs of metastatic disease or another condition that would preclude surgery. Thus, a total of 35 patients were enrolled in the study. All patients underwent abdominal CT scan, ultrasonography, endoscopic ultrasonography (EUS), diagnostic laparoscopy, and LUS. Histopathologic examination was considered to be the final evaluation for LUS in all but three patients, where EUS was used as the reference. Results: The accuracy of LUS in T staging was 29/33 (80%); in N staging it was 22/34 (76%); in M staging, it was 23/34 (68%); and in overall TNM staging, it was 23/34 (68%). In assessment of nonresectability, distant metastases, and lymph node metastases, the sensitivity was 0.86, 0.43 and 0.67, respectively, for LUS alone. Combining the information gleaned from laparoscopy and LUS, the accuracy in finding nonresectable tumors was 89%. Conclusions: Diagnostic laparoscopy with LUS is highly accurate in TNM staging and assessment of resectability of pancreatic cancer and should be considered an important modality in the assessment algorithm. Received: 6 July 1998/Accepted: 13 October 1998     

The use of diagnostic laparoscopy supported by laparoscopic ultrasonography in the assessment of pancreatic cancer

Background: Pancreatic resection with curative intent is possible in a select minority of patients with carcinomas of the pancreatic head. Diagnostic laparoscopy supported by laparoscopic ultrasonography combines the proven benefits of staging laparoscopy with high-resolution intraoperative ultrasound, thus allowing the surgeon to perform a detailed assessment of the pancreatic cancer. Methods: In a prospective study of 26 patients with obstructive jaundice from a carcinoma of the head of the pancreas, the curative resectability of tumors was assessed by ultrasound (26 cases), computerized tomography (26 cases), endoscopic ultrasound (16 cases), and a combination of diagnostic laparoscopy and laparoscopic ultrasound (26 cases). Results: The findings of ultrasound and computerized tomography were comparable: 50% of patients were excluded from curative resection. Endoscopic ultrasound provided precise information on the primary tumors. The accuracy of the combined diagnostic laparoscopy and laparoscopic ultrasound, when compared with ultrasound, computerized tomography, and endoscopic ultrasound, was better with respect to minute peritoneal or hepatic metastasis: 80.7% (or a further 30.7%) of patients did not qualify for curative resection. Conclusions: Diagnostic laparoscopy supported by laparoscopic ultrasonography enables detection of previously unsuspected metastases; thus, needless laparotomy can be avoided. It should therefore be considered the first step in any potentially curative surgical procedure. Received: 12 April 1997/Accepted 30 April 1998     

The effects of staging laparoscopy on trocar site and peritoneal recurrence of pancreatic cancer

Background: Staging laparoscopy (SL) has been used to assess resectability of patients with pancreatic cancer. It has lead to increased resectability rates and decreased morbidity. However, experimental data suggests that laparoscopy and peritoneal insufflation can promote tumor growth and potential recurrence. Few clinical data exist to allow assessment of whether these theoretical concerns translate into clinical problems. The purpose of this study was to determine if SL increases the incidence of trocar-site and peritoneal recurrence of pancreatic cancer. Methods: A retrospective review of all patients evaluated for pancreatic cancer from 1996 to 2001, inclusive, was included in this study. Patients were divided into five groups: nonoperative management (NM), SL followed by resection (SL-R), SL without resection (SL-NR), exploratory laparotomy with resection (EL-R), and exploratory laparotomy without resection (EL-NR). Patient records were assessed for postoperative occurrence of carcinomatosis and/or malignant ascites, trocar- or incisional-site recurrence, use of postoperative chemotherapy or radiation therapy, and survival. Results: A total of 235 patients were included. Peritoneal progression of disease: NM 15.9%, SL 24.2%, EL 31.6% (p = 0.03). Trocar/incisional recurrence: SL 3.0%, EL 3.9% (p = NS). Use of chemotherapy/radiotherapy: NM 29.4%, SL-R 76.5%, SL-NR 62.5%, EL-R 69.6%, EL-NR 41.5%. Median survival (months): NM 3; SL-R 15, EL-R 10 (p = NS); SL-NR 6, EL-NR 5 (p = NS). Conclusion: SL does not increase the occurrence of trocar-site disease or peritoneal disease progression of pancreatic cancer. Patients who are found not to be resectable by SL are more likely to receive postoperative treatment. However, this does not appear to affect survival greatly. Nevertheless, avoidance of nontherapeutic laparotomy is worthwhile in these patients. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 12–15 March 2003     

Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by Computed Tomography

Background Computed tomography (CT) is insensitive to small metastatic deposits in patients with pancreatic cancer. This study aimed to evaluate additional staging information obtained by laparoscopy in the subset of patients with locally extending pancreatic cancer but no evidence of distant disease using computed tomography.Methods Between April 2000 and February 2004, 74 patients with locally unresectable pancreatic cancer and no evidence of metastasis detected by high-quality pancreas protocol computed tomography underwent outpatient staging laparoscopy and peritoneal lavage cytology.Results Occult tumor was found during staging laparoscopy in 25 of the 74 patients (34%). The results were positive for peritoneal lavage cytology in 27% (20/74), for liver lesions in 16% (12/74), and for peritoneal implants in 7% (5/74) of the patients. Body and tail tumors were twice as likely as pancreatic head tumors to have unsuspected metastasis (53% vs 28%).Conclusions Even the best computed tomography scan is not adequate for accurate staging of locally extended pancreatic cancer because occult distant disease will be found in half of the patients with left-sided disease and one-fourth of those with right-sided pancreatic cancer.Presented as a poster at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Denver, Colorado, 26–27 March 2004     

Evaluation of the role of laparoscopic ultrasonography in the staging of oesophagogastric cancers

Introduction  The role of laparoscopic ultrasound (LUS) during staging laparoscopy for pancreatic cancers is established but remains debatable in evaluating oesophagogastric cancers. Methods  A retrospective consecutive case series consisting of patients undergoing staging laparoscopy in two centres (centre A and B) was carried out over a 5-year period (2000–2005). Patients in centre B underwent LUS following laparoscopic assessment using a 7.5-MHz probe. Staging laparoscopy in both centres was performed using a standardised three-port protocol using a 30° laparoscope. All suspicious lesions were sent for histological assessment for confirmation of malignancy. Results  There were 201 patients in centre A (83 gastric, 138 lower oesophageal/junctional cancers) and 119 patients in centre B (51 and 68, respectively). There were no differences between the two centres for patient demographics and tumour site. There was no difference between the two centres for the detection of metastatic disease using laparoscopic assessment alone (A 13% versus B 20%, p = 0.12). However, there was a significant difference (13% versus 28%, p = 0.001) with the additional use of LUS in centre B. The findings in the additional 8% (n = 9) were para-aortic lymphadenopathy (n = 5), liver metastasis (n = 3) and local extension (n = 1). Five had gastric and four lower oesophageal/junctional cancers. The negative predictive value was 6.4% for centre A and 4.5% for centre B. Conclusion  The addition of LUS increased the detection rate of metastasis by 8% but there was little impact on the false-negative rate. LUS is useful in detecting metastatic lymphadenopathy beyond the limits of curative resection and liver metastasis.     

Role of staging laparoscopy in gastric malignancies - our institutional experience

AIM: To investigate the value of staging laparoscopy with laparoscopic ultrasound (LUS) and peritoneal lavage cytology in patients with newly-diagnosed gastric tumours in our department.METHODS: Retrospective review of prospectively-collected data was conducted in all patients with newly-diagnosed gastric tumours on oesophagogastroduode-noscopy between December 2003 and July 2008. All the patients had a pretreatment histological diagnosis and were discussed at the hospital multidisciplinary tumour board meeting for their definitive management. Computed tomography scan was performed in all patients as a part of standard preoperative staging work up. Staging laparoscopy was subsequently performed in selected patients and staging by both modalities was compared.RESULTS: Twenty seven patients were included. Majority of patients had cardio-oesophageal junction adenocarcinoma. Thirteen patients (48%) were up-staged following staging laparoscopy and one patient was downstaged (3.7%). None of the patients had procedure-related complications. None of the patients with metastasis detected at laparoscopy underwent laparotomy. Gastrectomy after staging laparoscopy was performed in 13 patients (9R0 resections, 3 R1 resections and 1 R2 resection). Only one patient did not have gastrectomy at laparotomy because of extensive local invasion. Three patients were subjected to neoadjuvant therapy following laparoscopy but only one patient subsequently underwent gastrectomy. CONCLUSION: In this small series reflecting our institutional experience, staging laparoscopy appears to be safe and more accurate in detecting peritoneal and omental metastases as compared to conventional imaging. Peritoneal cytology provided additional prognostic information although there appeared to be a high false negative rate.     

The role of laparoscopy in preoperative staging of esophageal cancer

Background: Diagnostic laparoscopy has been used to determine resectability and to prevent unnecessary laparotomy in patients with advanced esophageal cancer. The objective of this prospective study was to evaluate the role of laparoscopy in conjunction with computed tomography (CT) scan in staging patients with esophageal cancer. Methods: From March 1995 to October 1998, 59 patients with biopsy-proven esophageal cancer underwent diagnostic laparoscopy with concurrent vascular access device and feeding jejunostomy tube placement. Results: Laparoscopy changed the treatment plan in 10 of 59 patients (17%). Of the patients with normal-appearing regional or celiac nodes, 78% were confirmed by biopsy to be tumor free, whereas 76% of patients with abnormal-appearing nodes were confirmed by biopsy to have node-positive disease. Conclusions: Diagnostic laparoscopy is useful for detecting and confirming nodal involvement and distant metastatic disease that potentially would alter treatment and prognosis in patients with esophageal cancer. Received: 16 May 1999/Accepted: 10 November 1999/Online publication: 24 March 2000     

Early experience of laparoscopic ultrasonography in the management of pancreatic carcinoma

Summary A 7.5-MHz linear array ultrasound probe has been developed for the evaluation of solid organs at laparoscopy. Twelve patients with suspected carcinoma of the head of the pancreas, considered at initial investigation to have resectable disease, were submitted to laparoscopy. In 4 patients, diagnostic laparoscopy revealed hepatic metastases (4 patients), peritoneal dissemination of tumor (2), and malignant ascites (1). Laparoscopic ultrasonography demonstrated hepatic metastases in four patients and hepatic cysts in two further patients. Ultrasound evaluation of the pancreas revealed lymphadenopathy (4 patients), local infiltration (2), and portal vein displacement or invasion (4). An anomalous right hepatic artery arising from the superior mesenteric artery was identified in one patient. Overall, laparoscopy identified advanced disease in four patients. Laparoscopic ultrasonography, while detecting advanced disease in a further two patients, predicted resectable disease in six patients (50%). Only one of the six patients submitted to laparotomy was found to have irresectable disease due to lymph-node metastases. Laparoscopic ultrasound examination of the pancreas and liver has improved the early staging of pancreatic carcinoma and should be undertaken at an early stage in the management of such patients.     

Utility of staging laparoscopy in subsets of biliary cancers

Background The aim of this study was to evaluate the utility of staging laparoscopy in patients with biliary cancers in the era of modern diagnostic imaging. Methods From September 2002 through August 2004, 39 consecutive patients with potentially resectable cholangiocarcinoma underwent preoperative staging laparoscopy before laparotomy. Preoperative imaging included ultrasonography and triphasic computed tomography for all patients and magnetic resonance cholangiography in 35 patients (90%). Final pathological diagnosis included 20 hilar cholangiocarcinomas (HC), 11 intrahepatic cholangiocarcinomas (IHC), and eight gallbladder carcinomas (GBC). Results During laparoscopy, unresectable disease was found in 14/39 patients (36%). The main causes of unresectability were peritoneal carcinomatosis (11/14) and liver metastases (5/14). At laparotomy, nine patients (37%) were found to have advanced disease precluding resection. Vascular invasion and nodal metastases were the main causes of unresectability during laparotomy (eight out of nine). In detecting peritoneal metastases and liver metastases, laparoscopy had an accuracy of 92 and 71%, respectively. All patients with vascular or nodal involvement were missed by laparoscopy. For prediction of unresectability disease, the yield and accuracy of laparoscopy were highest for GBC (62% yield and 83% accuracy), followed by IHC (36% yield and 67% accuracy) and HC (25% yield and 45% accuracy) Conclusion Staging laparoscopy ensured that unnecessary laparotomy was not performed in 36% of patients with potentially resectable biliary carcinoma after extensive preoperative imaging. In patients with biliary carcinoma that appears resectable, staging laparoscopy allows detection of peritoneal and liver metastasis in one third of patients. Both vascular and lymph nodes invasions were not diagonsed by this procedure. Due to these limitations, laparoscopy is more useful in ruling out dissemination in GBC and IHC than in HC.