腹膜活检对结核性腹膜炎的诊断价值

目的评价经皮腹腔穿刺腹膜活检对结核性腹膜炎的诊断价值。方法使用自动弹簧活检针对34例临床上考虑为结核性腹膜炎患者进行腹膜活检,并进行病理诊断。结果34例患者均经一次穿刺取出腹膜壁层组织,经病理证实结核性腹膜炎26例、转移性腺癌3例、恶性淋巴瘤1例和大致正常腹膜组织4例,一次穿刺活检成功率为100％,经活检明确腹水病因的诊断率为88．2％。结论腹膜活检对结核性腹膜炎诊断及鉴别诊断,有重要的临床诊断价值。     

56例结核性腹膜炎患者CT影像分析

目的 探讨结核性腹膜炎（TBP）特征性CT影像表现及治疗中影像动态变化的特点。方法 回顾性分析56例临床及病理确诊的TBP患者,观察分析CT影像特征,包括腹腔积液、腹膜（壁腹膜、肝包膜、大网膜及肠系膜）及腹腔淋巴结。56例均行CT平扫+增强扫描。治疗过程中收集动态复查CT影像。结果 腹腔积液45例,大量1例,中少量44例,限制性38例,CT值>20 HU者34例。壁腹膜增厚46例,肝脏边缘部腹膜均有受累,均匀增厚17例,扁丘状凸起或腹膜结核瘤29例,增强扫描结核瘤边缘强化,肝包膜或肝脏受累15例;网膜增厚35例,结节及斑片34例,网膜饼1例,增强扫描网膜饼呈轻度不均匀强化;肠系膜增厚41例,表现为斑片、结节及线状、星芒状条索状高密度影,与肠袢粘连,增强扫描肠系膜血管包埋其内,走形扭曲。腹腔及腹膜后淋巴结增大19例,伴钙化5例,簇集状排列,增强扫描环状或蜂窝状强化。17例完整的动态CT图像,腹腔积液吸收最快,网膜及肠系膜病变吸收稍慢,腹膜结核瘤缩小速度最慢。结论 TBP的CT诊断为多种征象的综合,中少量腹腔积液伴壁腹膜、网膜及肠系膜的增厚粘连是最为常见的影像表现;CT影像动态变化对临床评价疗效具有重要意义。     

The effect of diaphragmatic peritoneal lymphatics on peritoneal adhesions: an experimental study

In this study, we examined the effect of diaphragmatic peritoneal lymphatic function on the formation of peritoneal adhesions. A two phased design was used in fifty-two Wistar albino female rats. In the first phase (n = 12), the effects of diaphragmatic peritoneum damage model on the cecum and the terminal ileum were evaluated. In the second phase, the rats (n = 40) were divided into two equal groups. The adhesion model was created only in the cecum and the terminal ileum in the first group, whereas the diaphragmatic peritoneal damage model was created in the second group together with the same adhesion model. The rats were sacrificed on day 10 postoperatively and the adhesions formed were graded. In the first group, adhesions were formed at grade 1 in 5 rats (25%), grade 2 in 11 rats (55%) and grade 3 in 4 rats (20%), whereas adhesions were formed at grade 1 in 2 rats (10%), grade 2 in 8 rats (40%) and grade 3 in 10 rats (50%) in the second group (X2: 21.65, p < 0.0001). Diaphragmatic peritoneal lymphatic function reduced the number of adhesions and severity of the adhesions which occurred among intraabdominal organs after laparotomy. These findings suggest that special care should be undertaken to avoid damaging the diaphragmatic peritoneum during abdominal surgery so as to reduce the incidence of peritoneal adhesions.     

Effect of laparoscopic and conventional colorectal resection on peritoneal fibrinolytic capacity: a prospective randomized clinical trial

BACKGROUND AND AIMS: Reduced fibrinolytic activity of the peritoneum seems to be the main cause of postoperative adhesions. This prospective randomized trial compared the peritoneal fibrinolytic activity between laparoscopic and conventional colorectal resection. METHODS: Parietal peritoneal biopsy specimens were taken in standardized elective laparoscopic ( n=14) and conventional ( n=16) colorectal resections at the beginning and at the end of surgery. Activities and concentrations of tissue-plasminogen activator (tPA), plasminogen activator (PAI) type 1, and tPA/PAI complex were determined by ELISA kits. RESULTS: There was no difference in age, sex, or body mass index between the two groups. Perioperative tPA activity decreased in both groups without differences between the groups. Concentrations and activities of tPA, PAI-1, and tPA/PAI complex did not differ between the groups at any time. CONCLUSION: Peritoneal concentrations and activities of tPA, PAI-1, and tPA/PAI complex are similar during laparoscopic and conventional colorectal resections. A capnoperitoneum of 12 mmHg over 3 h did not affect the peritoneal fibrinolytic activity     

Role of laparoscopic surgery in the etiologic diagnosis of exsudative ascites: a prospective study of 90 cases

PURPOSE: Peritoneal tuberculosis and carcinomatosis are the most frequent etiologies of exsudative ascitis and require rapid diagnosis and treatment. The purpose of this study has been to evaluate the predictive value of clinical and complementary data for the etiologic diagnosis of exsudative ascites and to assess the results of laparoscopic surgery. MATERIAL AND METHODS: We report a prospective long-term study conducted over 10 years, having included all cases of exsudative ascites of unidentified etiology. We excluded patients with a history of anterior laparotomy and patients having a contraindication for laparoscopic surgery. Clinical signs, results of the cytochemical and bacteriological exam of the ascetic liquid and findings from radiological exams and endoscopic investigations were noted. Open laparoscopic exploration noted the macroscopic aspect and many peritoneal biopsies were obtained as well as a liver biopsy when possible. Statistical analysis was performed with SPSS10.0 software. The degree of statistical significance was set for P<0.05. RESULTS: We included 90 cases of isolated exsudative ascites. There were 59 cases of tuberculosis and 31 of carcinomatosis. Mean patient age was 47 years with a sex ratio of 0.5. Bowel transit disorders were significantly in favor of a carcinomatosis (P=0.04) while fever and nocturnal sweats were suggestive of tuberculosis (P=0.04) but in both instances, the positive predictive value (PPV) of these two signs was weak, respectively 29% and 43%. Relative to chemical and cytologic study of ascitic fluid, hemorrhagic fluid, low white cell count, low lymphocyte differential and presence of atypical cells were significantly linked with the carcinomatosis (P=0.01) but with a PPV<85%. Radiological exams were not very contributive for the etiologic diagnosis. The laparoscopic peritoneal aspect was typical of tuberculosis in 90% of proved cases and in 29% of carcinomatosis cases, underlying the importance of peritoneal biopsies for histological study. Hepatic tuberculosis was associated with peritoneal localisation in 48% of cases. We had no surgical mortality and the morbidity was about 1%. CONCLUSION: Etiological diagnosis of exsudative ascitis remains difficult to establish. Peritoneal biopsies under videolaparoscopy are currently the "gold standard" for diagnosis.     

Endoscopic diagnosis of segmental colonic tuberculosis.

We report colonoscopic findings in 29 proven cases of segmental colonic tuberculosis. The colonoscopic appearances of tuberculosis included: mucosal nodules and ulcers, stricture with nodules and ulcerations, and mucosal nodules with or without pseudopolypoid folds. In 12 (41%) of 29 patients colonoscopy biopsies enabled a histologic diagnosis to be made on the basis of typical granulomas. Culture of biopsy tissue on Lowenstein Jensen media isolated Mycobacterium tuberculosis in six (40%) of 15 patients. Combined histologic and bacteriologic evaluation established the diagnosis in 60% of patients. We conclude that even though target biopsy is an effective method of diagnosis, anti-tuberculous chemotherapy may be started on the basis of the endoscopic appearance if there is a high clinical suspicion of tuberculosis.     

Laparoscopy in the diagnosis and differential diagnosis of ascites]

Out of 2,500 patients who underwent laparoscopy 772 (30.89%) had ascites; liver cirrhosis underlay it in 57.78%, peritoneal carcinosis in 26.29%, primary and metastatic carcinoma, respectively, in 12.95%, tuberculous peritonitis in 1.42%, more rarely other diseases. Liver cirrhosis, malignant tumours and the other hepatic affections with concomitant ascites in their course can certainly be diagnosed laparoscopically. Laparoscopy with oriented biopsy of peritoneum and liver is of decisive importance in differentiating peritoneal carcinosis from tuberculosis. In peritoneal carcinosis the diagnosis (as based in clinical and laboratory findings) coincided perfectly with the laparoscopic and histologic one in 24.5%, partially in 45.5%. In 30% there was no congruence at all. Laparoscopy and the test methods associated with it contributed to the accurate diagnosis of peritoneal carcinosis in 75.5% of the patients. Ovarian carcinoma (20.9%) and cancer of the stomach (16.3%) underlay peritoneal carcinosis most frequently, other diseases by far more seldom.     

What is the role of diagnostic laparoscopy in a gastroenterology unit?

Background Diagnostic laparoscopy is known to be a relatively safe invasive procedure. However, its use has decreased owing to the development of imaging techniques, and fewer gastroenterologists now practice diagnostic laparoscopy. Our aim was to examine the role of diagnostic laparoscopy in a gastroenterology unit in the era of advanced imaging techniques. Methods We retrospectively reviewed 855 diagnostic laparoscopy cases. Its safety and efficacy were evaluated for various indications. Results No mortality was observed, and complications were noted in ten patients (1.2%). Among the indications were evaluation of chronic liver disease (n = 673), liver tumor (n = 15), ascites of unknown origin and peritoneal disease (n = 142), and staging of intra-abdominal malignancy (n = 25). In patients with chronic liver disease, 461 were diagnosed as having chronic viral hepatitis, based on clinical data including imaging studies, but the diagnosis was changed to cirrhosis after a laparoscopic exam in 69 patients (15.0%). In patients with ascites of unknown origin and peritoneal disease, the diagnostic yield was 87.2% (123/141). In 24 (19.5%) of the 123 patients, the diagnosis changed or the less probable diagnosis was confirmed after laparoscopic examination. The confirmed diagnoses were mainly primary peritoneal disease, including peritoneal tuberculosis, in 17 patients, peritoneal metastatic carcinoma in five, and mesothelioma in two. Conclusions Diagnostic laparoscopy in a gastroenterology unit is safe and useful, especially for confirmation of liver cirrhosis and primary peritoneal disease evaluation.     

Advanced gastric cancer: characteristics at presentation and therapeutic possibilities]

OBJECTIVE: To analyse the presentation forms and prognosis of patients with advanced gastric cancer at the time of diagnosis. DESIGN: Retrospective cohort study. PATIENTS AND METHODS: We studied all patients with gastric cancer (n=2,334) and synchronic metastases diagnosed in Lugo and A Coru?a hospitals between 1975 and 1993. We estimated survival probability using the Kaplan-Meier method, and prognostic factors with Cox's regression models. RESULTS: Metastases were detected at the time of diagnosis in 585 (25.1%) patients, with the liver (346; 14.8%) and peritoneum (61; 6.9%) being the most frequently involved sites. The liver was exclusively affected in 213 (9.1%) cases, the peritoneum in 70 (3.3%), and another intraabdominal site in 121 (5.2%). Patients with peritoneal metastases were older (p=0.05), more commonly had a diffuse type of cancer according to Lauren's tumor classification (p<0.001), and underwent surgery more frequently (p=0.01). Curative resection was possible for only 11 (5.2%), 7 (10%), and 25 (20.7%) patients with metastases in only the liver, peritoneum, or another site, respectively, but in all cases survival probability was significantly enhanced. No surgery (HR=2.92), and simultaneous involvement of the liver and peritoneum (HR=1.62) were factors associated with a higher mortality rate. CONCLUSIONS: Patients with gastric cancer and metastases in only one intraabdominal organ show characteristic forms of presentation. Furthermore, in all cases candidacy for surgery should be carefully evaluated, as prognosis may improve in selected patients.     

The spectrum of tuberculosis in dialysis patients

Patients receiving dialysis therapy are known to be at increased risk of tuberculosis (TB). The aim of this study was to evaluate the frequency, clinical characteristics and course of TB disease in dialysis patients treated at our institution. Medical records of 330 regular haemodialysis (n=219) and continuous ambulatory peritoneal dialysis (n=111) patients (172 male, 158 female; mean age 55+/-16 y) who were cared for at our tertiary university hospital between December 2002 and January 2006 were retrospectively evaluated. Nine cases of TB (2.7%) occurred, in the following locations: vertebra (n=3), miliary (n=3), lymph nodes (n=1), peritoneum (n=2; one as peritionitis, 1 as an abscess). Four of these 9 patients died during the follow-up (mean time from diagnosis to death, 7 months); none of the deaths appeared to be caused by the disease itself. The incidence of TB disease in patients receiving renal replacement therapy is high, and occurs primarily in extrapulmonary sites.     

Sharma's parachute sign a new laparoscopic sign in abdomino pelvic tuberculosis

AimsTo demonstrate a new laparoscopic sign “Sharma's Parachute sign” in abdominopelvic tuberculosis in women with infertility.MethodsA total of 104 women who were diagnosed to have abdominopelvic tuberculosis, on endometrial sampling or on laparoscopy were enrolled in this ongoing study on tuberculosis in infertility. A new laparoscopic “Sharma's parachute sign” was looked for in these cases on laparoscopy.ResultsThe mean age, pairty and duration of infertility was 27.6 years, 0.58 and 4.1 years respectively. Menstrual dysfuction were common especially hypomenorrhoea (34.61%), oligomenorrhoea (36.53%) along with constitutional symptoms and abdomino pelvic pain or lump. Diagnosis of abdominopelvic tuberculosis was made by identification of acid fast bacilli (AFB) on microscopy or culture of endometrial aspirate or peritoneal biopsy or positive gene Xpert or positive polymerase chain reaction (PCR) or histopathological demonstration of epithelioid granuloma on endometrial or peritoneal biopsy, various laparoscopic findings on pelvic and abdominal organs were tubercles and shaggy areas (white deposits, caseous nodules encysted ascites, abdominal and pelvic adhesions, tubal findings (hydrosalpinx, pyosalpinx, beaded or calcified tubes). A new “Sharma's parachute sign”in which ascending colon was totally adherent to anterior abdominal wall with its mesocolon looking like an open parachute with small caseous nodule was seen in 11 (10.5%) cases.ConclusionDiagnostic laparoscopy is an important investigation for abdominopelvic tuberculosis showing various adhesions including new parachute sign.     

Effect of hyaluron derivate gel in prevention of postsurgical peritoneal adhesions--an experimental study in pigs

BACKGROUND/AIMS: The aim of this study was to assess the efficacy of a hyaluronic acid derivate gel in reducing adhesions in pigs undergoing laparoscopic abdominal cavity surgery. METHODOLOGY: 20 domestic female pigs underwent laparoscopy in general anesthesia. 4 defined serosal defects have been made (hepatoduodenal ligament, parietal, anterior stomach wall and jejunal mesentery). The defects have been covered with 20 mL Hyalobarrier Gel in 10 randomly selected pigs. 2 weeks postoperatively the pigs got reoperated for evaluation of potential adhesions. RESULTS: 17 pigs remained for evaluation. 2 pigs died during introduction of anesthesia, one at the end of the operation. None of the pigs died due to a reaction to the gel. We found adhesions in 33% of the gel group (n=3 out of 9) and in 87.5% in the group without gel (7 out of 8): p < 0.05. Most of the adhesions have been found at the parietal defect (7 out of 17 at all). CONCLUSIONS: The hyaluronic acid gel was highly efficacious and reduced the number and extent of adhesions throughout the abdomen following laparoscopic peritoneal surgery significantly.     

Peritoneal tuberculosis: 27 cases in the suburbs of northeastern Paris]

SETTING: Peritoneal tuberculosis did not disappear from France during the 1990s. OBJECTIVE: To determine the characteristics of peritoneal tuberculosis in the north-eastern suburbs of Paris. METHOD: A retrospective study of cases diagnosed with peritoneal tuberculosis between 1990 and 1998 in five suburban hospitals in the north-east region of Paris. RESULTS: Twenty-seven cases of adult peritoneal tuberculosis were diagnosed. There were nine women and 18 men, with a mean age of 37.5 years, 88.9% of whom were foreign born. General and digestive symptoms--abdominal pain and/or ascites--were present in 96.3% of the cases. The mean delay in treatment was 30 days. Peritoneal involvement was isolated in 25.9% of cases, and associated with pulmonary tuberculosis in 40.7% or hepatic tuberculosis in 25.9%. Co-infection with HIV (human immunodeficiency virus) was present 14.8% of cases. Culture of ascites fluid, laparoscopy and/or laparotomy (n = 17), with directed biopsy, aided in the formal diagnosis of peritoneal tuberculosis in 59.2%. One relapse and one case of multiresistance were observed. The mean duration of treatment was 9 months (range 6-12 months). Three patients received treatment with corticosteroids, and 91.2% of the patients achieved cure without sequelae. CONCLUSION: Peritoneal tuberculosis is not rare in the Paris region. The diagnosis should be suspected in case with ascites and fever, and can be confirmed by laparoscopy with sampling for bacteriology and histology. The methods of treatment need to be standardised.     

Diagnostic non invasif d’une tuberculose péritonéale

Tuberculous peritonitis was suspected in a 33-year-old man, without significant past medical history or risk factor for tuberculosis, who presented with constitutional manifestations including fatigue and weight loss, fever for several weeks and inflammatory ascites. Echo-guided percutaneous biopsy of the thickened omentum showed numerous epithelioid granulomas, avoiding laparoscopic peritoneal biopsies. Recovery was uneventful under antituberculous treatment.     

114例术后伤口脓肿分支杆菌感染的临床病理学分析

目的 探讨术后切口脓肿分支杆菌感染的临床病理学特征,评价其诊断价值。方法 １１４例手术切口感染均为污染的手术器械消毒所致,经细菌培养及菌种鉴定证实为脓肿分支杆菌。回顾性分析感染组织的病理学特征。结果 １１４例术后切口感染中累及皮肤和皮下脂肪组织９５例（８３．３％）,深层肌肉组织２１例（１８．４％）,腹腔脏器、腹和肠系膜３例（２．６％）,局部区域淋巴结１３例（１１．４％）。病理改变主要为肉芽肿性病变     

89例X线胸片误诊肺结核的CT分析

目的探讨X线胸片误诊肺结核的原因及CT对肺结核的诊断价值。方法对X线胸片误诊而经临床确诊并具有完整临床、影像资料的肺结核病例89例进行X线胸片和CT对照回顾性分析。结果(1)X线胸片下肺叶病灶占44.9%,CT显示下叶基底段病灶最多,占32.0%。(2)胸部CT发现X线胸片漏检早期肺结核病灶11.8%、肺内隐匿部位病灶43.3%和早期粟粒性结核6例。(3)胸部CT对肺结核血行播散及支气管播散、支气管壁增厚、胸膜增厚及粘连、纵隔淋巴结肿大及钙化的显示率明显高于X线胸片。结论CT检查对肺结核诊断及鉴别诊断具有重要价值,建议在X线胸片诊断不明确时及时作CT检查。     

对200例不明原因腹腔积液患者腹膜活检的临床分析

目的 探讨超声引导下腹膜穿刺活检对不明原因腹腔积液患者的临床诊断价值.方法 选取我院近5年来资料完整的不明原因腹腔积液患者207例,行腹膜活检者200例,总体腹膜活检率为96.6％.其中女117例,年龄17～81岁,平均(58.6±21.7)岁.男83例,年龄20～83岁,平均年龄(53.4±23.1)岁.均经超声...     

Bladder perforation during laparoscopic donor nephrectomy

We present two cases of bladder perforation during laparoscopic donor nephrectomy at our institution. Neither of the surgeries was otherwise complicated, and the diagnoses were made post-operatively. The kidneys were extracted through a Pfannenstiel incision and used blunt dissection to penetrate the peritoneum. Both patients had previous tubal ligations, adhesions from which may have increased the chance of injury. We believe that this is a previously unreported complication that merits attention. Care should be taken with the peritoneal incision and dissection as the bladder may be susceptible to injury.     

血红素氧合酶-1在胃癌腹膜转移中的表达及意义

目的 探讨血红素氧合酶-1(hemeoxygenase-1,HO-1)在胃腺癌及腹膜转移灶、细胞系及耐药细胞系中的表达及意义.方法 用免疫组化法检测68例胄腺癌组织及其腹膜转移灶、转移灶旁无瘤腹膜组织中HO-1的表达,以及46例无腹膜转移的胃腺癌组织中HO-1的表达.Western印迹法检测胃腺癌腹膜转移组织及耐药细胞系HO-1的表达.结果 胃腺癌及其腹膜转移灶HO-1的阳性表达率分别为39.7%(27/68)和41.2%(28/68),显著高于癌旁无瘤腹膜组织[0%(0/68),P<0.01],亦显著高于无腹膜转移胃癌组织[21.7%(10/46),P<0.05].低分化转移灶HO-1表达水平显著高于中、高分化转移灶(P<0.05).Western印迹法检测胃癌腹膜转移患者的转移灶HO-1表达水平显著高于其癌旁无瘤腹膜组织(P<0.05).HO-1在耐药细胞系GC9811-P的表达水平较其亲本细胞系明显上调(P<0.05).结论 HO-1在胃腺癌腹膜转移过程中表达增高,HO-1可能参与胃癌腹膜转移发生.高表达HO-1与胃癌腹膜转移组织的恶性程度有关,其信号转导通路可能存在于组织的上皮细胞,并可能与多药耐药有关.     

血红素氧合酶-1在胃癌腹膜转移中的表达及意义

目的 探讨血红素氧合酶-1(hemeoxygenase-1,HO-1)在胃腺癌及腹膜转移灶、细胞系及耐药细胞系中的表达及意义.方法 用免疫组化法检测68例胄腺癌组织及其腹膜转移灶、转移灶旁无瘤腹膜组织中HO-1的表达,以及46例无腹膜转移的胃腺癌组织中HO-1的表达.Western印迹法检测胃腺癌腹膜转移组织及耐药细胞系HO-1的表达.结果 胃腺癌及其腹膜转移灶HO-1的阳性表达率分别为39.7%(27/68)和41.2%(28/68),显著高于癌旁无瘤腹膜组织[0%(0/68),P<0.01],亦显著高于无腹膜转移胃癌组织[21.7%(10/46),P<0.05].低分化转移灶HO-1表达水平显著高于中、高分化转移灶(P<0.05).Western印迹法检测胃癌腹膜转移患者的转移灶HO-1表达水平显著高于其癌旁无瘤腹膜组织(P<0.05).HO-1在耐药细胞系GC9811-P的表达水平较其亲本细胞系明显上调(P<0.05).结论 HO-1在胃腺癌腹膜转移过程中表达增高,HO-1可能参与胃癌腹膜转移发生.高表达HO-1与胃癌腹膜转移组织的恶性程度有关,其信号转导通路可能存在于组织的上皮细胞,并可能与多药耐药有关.