腹腔镜超声影像技术在腹内恶性肿瘤诊治中的价值

应用腹腔镜超声技术(LapUS)对30例怀疑为腹内恶性肿瘤患者进行分期诊断和术中应用,探讨了LapUS对腹内恶性肿瘤分期诊断和治疗中的价值。结果表明,LapUS对腹内肿瘤诊断正确率达96.7％(29/30),12例避免了不必要的剖腹探查术(占40％)。LapUS对腹内恶性肿瘤准确定位、准确分期能提供非常有价值的信息,可判断恶性肿瘤能否切除,减少了不必要的剖腹探查并能指导手术方式和切除范围。     

螺旋CT、超声内镜和术中探查对胰腺和壶腹部肿瘤诊断的相关性研究

胰腺和壶腹部肿瘤的术前诊断有时很困难,作者探讨了螺旋CT和超声内镜（EUS）在临床可疑的胰腺或壶腹部肿瘤的术前诊断价值并和术中探查的结果进行了比较。病例与方法48例可疑胰腺或壶腹部肿瘤的患者均在术前进行了螺旋CT和EUS检查。螺旋CT扫描时发现大于10mm的淋巴结则认为可能发生转移,如果血管直径突然变化及血管和软组织界面消失．则判定血管血浸。EUS检查的频率为7．5MHz和12MHz。淋巴结转移的判定标准：球型、低回声结节和边界清晰。周围血管受侵的判定标准：肿瘤位于腔内、血管轮廓异常主要血管消失区可见附属血管形成。手…     

腹腔镜在胰腺肿瘤诊断和分期中的价值

目的:总结胰腺肿瘤剖腹手术前先行腹腔镜探查的价值。方法:对12例经B超和CT诊断或怀疑为胰腺肿瘤的病人,在剖腹手术前先行腹腔镜探查,其中2例联合使用腹腔镜超声检查(LUS)。结果:1例CT诊断疑为胰头肿瘤伴少量腹水者,腹腔镜明确为原发性腹膜炎,作冲洗引流而愈。2例影像学检查见胰体尾增厚,怀疑胰腺肿瘤者,腹腔镜检查未见明显异常,再作LUS检查,1例为胰腺囊肿,另1例未见异常。9例腹腔镜检查确诊为胰腺恶性肿瘤病人中,3例明确已有远处转移,从而避免了开腹;另6例腹腔镜探查提示可以切除,结果其中1例由于肠系膜血管被肿瘤包绕而无法切除,余5例(5/9=55.6%)进行了根治性切除。腹腔镜探查在评估胰腺癌不可切除性的敏感性为75%,特异性为100%,阳性预测值为100%,阴性预测值为83.3%。结论:腹腔镜探查可发现影像学检查不能发现的腹膜转移,结合腹腔镜超声检查可提高胰腺肿瘤诊断、分期的准确性,使部分病人避免了不必要的剖腹手术。     

诊断性腹腔镜在壶腹部癌的意义评价

壶腹部癌术前使用腹腔镜结合腹腔镜超声检查，可发现一些影像学不能发现的微小转移灶，包括肝表面病灶以及腹腔内的肿大淋巴结和血管浸润等，从而综合判断肿瘤是否能够根治性切除。这项技术已经应用于临床。为了评价诊断性腹腔镜的价值和意义，作者对297例壶腹部癌病例进行了研究。     

腹腔镜检查在腹部肿瘤诊断中的应用

目的:探讨腹腔镜在腹部肿瘤诊断中的应用价值。方法:分为二组,实验组:诊断为腹部肿瘤,于剖腹术前行腹腔镜检查31例;对照组:经腹腔镜检查和活检术证实腹部肿瘤14例。结果:在实验组有4/31例(12.9%)、对照组有9/14例(64.82%)证实肿瘤在腹腔内广泛转移;全组腹腔镜检查诊断准确率为100%,避免不必要的剖腹探查13/45例(28.88%)。结论:腹腔镜检查对腹部肿瘤的诊断准确率高,有助于恶性肿瘤的准确分期,可避免许多不必要的剖腹探查,且并发症少,在腹部肿瘤的诊断中,是一个重要的辅助检查手段。     

腹腔镜超声检查和超声刀在胃肠外科诊治中的应用

目的:探讨腹腔镜超声检查技术（LUS）和腹腔镜超声刀在腹腔镜胃肠外科手术中的应用价值。方法:对50例胃肠道肿瘤等病变采用腹腔镜超声进行前瞻性肿瘤分期诊断,结合腹腔镜超声刀开展腹腔镜胃肠手术治疗。结果:经腹腔镜和腹腔镜超声分期诊断,47例肿瘤患者均明确诊断,淋巴结穿刺活检与病理结果符合率为87.5％（7/8）;其中2例转开腹手术,6例避免了剖腹探查术,39例肿瘤患者成功地完成了腹腔镜手术。本组50例患者中42例在腹腔镜下成功完成姑息性或根治性胃肠切除术。平均手术时间190min,术中出血量平均120ml（20～250ml）,系膜淋巴结清除数平均6.5个（5～12个）,术后肠蠕动恢复时间平均36h,平均住院8.5d,无手术后并发症。术后随访3～36个月,未发现复发与转移及腹壁穿刺孔或切口转移。结论:腹腔镜胃肠手术中常规使用腹腔镜超声检查可准确为病变定位,完善肿瘤分期诊断,提高肿瘤可切除性的判断率,避免了不必要的剖腹探查;术中常规使用超声刀提高了手术安全性,扩大了腹腔镜手术范围。腹腔镜胃肠道病变切除术安全可行,近期效果良好,远期效果有待观察。腹腔镜胃肠手术将成为胃肠良恶性疾病的常规手术。     

超声内镜与CT对胰腺及壶腹部周围肿瘤的术前诊断价值

目的评估超声内镜(endoscopic ultrasonography,EUS)和CT对胰腺及壶腹部周围肿瘤的术前诊断价值。方法回顾性分析33例胰腺及壶腹部肿瘤患者术前EUS、CT资料,与手术探查及术后病理结果对照,从肿瘤大小、部位等角度筛选出影响EUS准确性的因素。结果 EUS在判断胰周脂肪浸润、胆管扩张、胰周脏器侵犯、血管侵犯等方面敏感性、特异性与CT的差异无统计学意义(P>0．05);EUS在胰管扩张及淋巴结转移方面的诊断价值优于CT(P=0．039和P=0．004); EUS判断胰周脂肪浸润和胰周脏器侵及的准确性与肿瘤大小有关(P=0．015和P=0．022),判断胰管扩张的准确性与肿瘤部位有关(P<0．001)。结论 EUS对胰腺及壶腹部周围肿瘤诊断的临床价值很高,结合CT检查有助于加强对患者术前评价的认识。     

胃肠道恶性肿瘤腹腔镜分期腹腔灌洗细胞学检查的应用

腹腔镜分期最大的优点是能发现腹膜转移和表浅的肝转移、恶性淋巴结及肿瘤内生长、侵袭性腹腔镜检查可发现肿瘤有转移或内生长时,从而决定不再剖腹探查或不再行根治手术。小的超声探头的发展,使腹腔镜超声能发现小的肝内转移灶及血管侵犯。腹腔镜和腹腔镜超声的联合使用,使10％-60％的患肿瘤分期需修正、使10％-40％的患避免不必要的剖腹探查。腹腔镜检查时,膜腔灌洗简单可行．但相比于腹腔镜,其对胃肠道恶性肿瘤分期的价值很少为人所认识。腹膜腔液体发现有癌细胞、表明腹膜有早期种植,随后会有腹膜转移。本评价腹腔镜检查时腹膜腔灌洗的潜在价值。     

腹腔镜超声扫描在判断胰头癌切除中的价值

目的：探讨腹腔镜及其超声扫描技术（LUS）在判断胰头癌可切除中的价值。方法：对22例临床已确诊为胰头癌的病人在剖腹探查手术前，采用腹腔镜超声进行前瞻性的肿瘤分期，明确肝，腹膜有无微小转移，有无局部的血管侵犯（门静脉、肠系膜上动静动脉、主动脉及下腔静脉）。结果：本组发现肝表面及腹膜转移癌灶3例，肝内转移灶1例，超声引导穿刺证实为胰腺炎1例，从而避免了开腹手术，余17例中8例发现腹腔，腹膜后及网膜有肿大淋巴结与局部血管或肿瘤本身与局部血管有侵犯，其中2例发现门静脉血栓，余9例提示可术切除，17例病人进行剖腹探查，8例成功进行胰十二指肠切除术。结论：腹腔镜超声扫描可以较为准确的判断胰头癌切除的可能性，有望成为胰头癌剖腹探查术前有效的检查方法。     

胃肠道恶性肿瘤腹腔镜分期腹腔灌洗细胞学检查的应用

腹腔镜分期最大的优点是能发现腹膜转移和表浅的肝转移、恶性淋巴结及肿瘤内生长，侵袭性腹腔镜检查可发现肿瘤有转移或内生长时，从而决定不再剖腹探查或不再行根治手术。小的超声探头的发展，使腹腔镜超声能发现小的肝内转移灶及血管侵犯。腹腔镜和腹腔镜超声的联合使用，使１０％～６０％的患者肿瘤分期需修正，使１０％～４０％的患者避免不必要的剖腹探查。腹腔镜检查时，腹膜腔灌洗简单可行，但相比于腹腔镜，其对胃肠道恶性肿瘤分期的价值很少为人所认识。腹膜腔液体发现有癌细胞，表明腹膜有早期种植，随后会有腹膜转移。本文评价腹…     

Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography.

OBJECTIVE: The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region. SUMMARY BACKGROUND DATA: Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy. METHODS: A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region). RESULTS: "Occult" metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively). CONCLUSIONS: Staging laparoscopy is indispensable in the detection of "occult" intra-abdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.     

The Role of Laparoscopy and Ultrasonography in Pancreatic Head Carcinoma

Objective: The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region.Summary Background Data: Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy.Methods: A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region).Results: “Occult” metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively).Conclusions: Staging laparoscopy is indispensable in the detection of “occult” intraabdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.     

Laparoscopy with Laparoscopic Ultrasonography in the TNM Staging of Pancreatic Carcinoma

A prospective study was performed comparing laparoscopy with laparoscopic ultrasonography (LapUS), transabdominal ultrasonography (USS), computed tomography (CT), and selective visceral angiography with portal phase venography (SVA) for the assessment of resectability in 50 patients with pancreatic or periampullary cancer. The results were stratified by TNM stages. Tumor unresectability was demonstrated in 36 patients (72%). The sensitivity of LapUS for demonstrating the index lesion was 96%. Laparoscopic ultrasonography failed to predict factors precluding resection by T stage in six patients, and there were no significant differences in the ability of any modality to predict local resectability (predictive value 58–73%). Laparoscopic ultrasonography did not overestimate T stage and was significantly more specific for assessing unresectability compared with USS (100% vs. 64%, p < 0.05) and CT (100% vs. 47%, p < 0.005). No imaging investigation was able to assess the N stage accurately. Metastases were confirmed in 16 patients (32%), with LapUS proving significantly more sensitive than USS (94% vs. 29%, p < 0.001) and CT (94% vs. 33%, p < 0.005). The addition of LapUS to the laparoscopic examination did not change the M stage in any patient, as all metastases were superficially located. Laparoscopy with LapUS was the most reliable method for assessing overall tumour resectability and was significantly more predictive than CT (97% vs. 79%, p < 0.005). These results confirm that laparoscopy is indispensable for detecting occult intraabdominal metastases. LapUS reliably predicts tumor unresectability, offsetting the tendency of USS and CT to overestimate T stage. Methods of accurate N staging remain elusive, and the use of routine SVA is not justified.     

The use of laparoscopic ultrasonography in staging abdominal malignancy

The merit of intraoperative ultrasonography in abdominal surgery has been recognized for several decades and has been well documented in the literature. With the proliferation of laparoscopic abdominal surgery, laparoscopic ultrasonographic technology rapidly developed and studies have confirmed its value in staging intra-abdominal malignancy. The combination of diagnostic laparoscopy and laparoscopic ultrasonography has been shown to be consistently superior to other preoperative imaging modalities in the staging of abdominal malignancy. Consequently there has been an improvement in the management of patients with abdominal malignancy, demonstrated by reductions in nontherapeutic laparotomies, improved resectability rates, and optimization of palliation.     

Is there additional information from laparoscopic ultrasound in tumor staging?

Accurate preoperative staging of gastrointestinal malignancies is of major importance in the decision for adequate stage-related therapy. There is evidence that laparoscopy in combination with laparoscopic ultrasound is more accurate in the detection of intra-abdominal metastases than conventional preoperative imaging. Staging laparoscopy in combination with laparoscopic ultrasound is a minimally invasive technique that reveals intra-abdominal disseminated tumor spread and local tumor extent. Therefore laparoscopic ultrasound is an ideal adjunct to laparoscopy because this technique may compensate for the lack of tactile feedback with laparoscopic instruments. Color-coded Doppler imaging can be very valuable for the assessment of resectability in patients with pancreatic cancer. Current data confirm that laparoscopic ultrasound is capable of enhancing the accuracy of staging laparoscopy. Compared to standard laparoscopy, a combination of both techniques markedly increases the sensitivity of staging laparoscopy in the determination of unresectable disease. This is of major importance in the assessment of occult liver metastases and lymph node involvement. Laparoscopic ultrasonography improves the diagnostic accuracy compared to conventional imaging techniques and should be considered as integral part of staging laparoscopy.     

Magnetic resonance imaging with magnetic resonance cholangiopancreatography accurately predicts resectability of pancreatic carcinoma

Accurate preoperative staging of pancreatic malignancy aids in directing appropriate therapy and avoids unnecessary invasive procedures. We evaluated the accuracy of magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) in determining resectability of pancreatic malignancy. Twenty-one patients with suspected pancreatic malignancy underwent dynamic, contrast-en-hanced breath-hold MRI with MRCP prior to surgical evaluation. Results of this study were correlated with operative results and pathologic findings. The sensitivity, specificity, and accuracy of MRI with MRCP in detecting a mass, determining the nature of the mass, and predicting lymph node involvement and resectability were determined. MRI with MRCP correctly identified the presence of a pancreatic mass in all 21 of these patients. Following pathologic correlation, it was determined that MRI with MRCP was 81 % accurate in determining the benign or malignant nature of the pancreatic mass and 43% accurate in predicting lymph node involvement. In predicting resectability, MRI with MRCP had a sensitivity of 100%, specificity of 83%, positive predictive value of 94%, negative predictive value of 100%, and accuracy of 95%. MRI with MRCP is an accurate, noninvasive technique in the preoperative evaluation of pancreatic malignancy. Information obtained from MRI with MRCP including identification of a mass and predicting tumor resectability may be of value in staging and avoiding unnecessary invasive diagnostic procedures in patients with pancreatic cancer. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

Should cervical ultrasonography be a routine staging investigation for lung cancer patients with impalpable cervical lymph nodes?

OBJECTIVES: Detection of cervical N3 lymph nodes is currently not a routine preoperative investigation for lung cancer patients. We designed a study to assess if the frequency and accuracy of detection of metastatic cervical lymph nodes using cervical ultrasonography (US) and fine needle aspiration (FNA) justify their routine use in all lung cancer patients with impalpable cervical lymph nodes. METHODS: Fifty patients with suspected and potentially operable non-small cell lung cancer were enrolled. Patients with palpable cervical lymph nodes were excluded. In addition to routine preoperative investigations, all patients received cervical US to determine the presence of cervical lymph nodes. Nodes suspicious of harboring malignancy according to a specific set of sonographic criteria (which include shape, echogenicity, nodal architecture, and vascular patterns) were subjected to biopsy by ultrasound-guided FNA. RESULTS: Normal cervical lymph nodes were detected by cervical US in 30 patients (60%). Cervical lymph nodes suspicious of harboring malignancy were detected in 10 patients (20%). FNA confirmed cervical nodal metastasis in four of these patients (8%). The TNM staging of two patients (4%) was revised up to stage IIIb as a result, excluding them from further surgery. Cost analysis suggests this technique to be cost-effective when used as a routine preoperative investigation to exclude patients from unnecessary surgical intervention. No mortality or complications were encountered in all patients. CONCLUSIONS: Cervical US and FNA is a safe and cost-effective method of evaluating the status of impalpable cervical lymph nodes in lung cancer patients. Further study is warranted to establish the role of cervical US and FNA in lung cancer staging algorithms.     

Zum Stellenwert der laparoskopischen Sonographie für das Staging gastrointestinaler Tumoren

BACKGROUND: The objective of this study was to evaluate the impact of laparoscopic ultrasound on the staging of gastrointestinal tumors prospectively. METHODS: Between 1993 and 2000 staging laparoscopy was performed on 668 patients with various neoplasms. Laparoscopy provided adequate information regarding resectability in 366 patients. Laparoscopic ultrasonography was performed in 302 patients (45%) using an intraoperative ultrasound unit (B & K) and a semiflexible ultrasound probe (5-7.5 MHz). The results of staging laparoscopy were compared to the preoperative staging and histopathology. RESULTS: Compared to preoperative staging laparoscopic ultrasound provided additional information of therapeutic relevance in 46 of 302 cases (15%). In a group of 384 patients with tumors of the upper gastrointestinal tract, laparoscopic ultrasound was performed in 186 cases and showed occult liver metastases, M1-lymph nodes, or nonresectable disease in 26 patients. Overall, this technique improved the staging of esophageal, gastric and pancreatic cancer in 12%, 3%, and 12% of the patients, respectively. Laparoscopic ultrasound proved to be most useful in esophageal and pancreatic cancer with a rate of 52% and 20% information additional to laparoscopy. The relative contribution of laparoscopic ultrasound to the staging of gastric cancer was only 10%. CONCLUSION: Laparoscopic ultrasound improves the diagnostic accuracy of staging laparoscopy. However, routine use of this technique is only justified, if neoadjuvant therapy--particularly in controlled trials--is considered in patients with advanced gastrointestinal cancer.     

Laparoscopy and laparoscopic ultrasonography in staging carcinoma of the gastric cardia.

OBJECTIVE: To investigate the role of diagnostic laparoscopy and laparoscopic ultrasonography in the staging of carcinoma of the gastric cardia that is involving the distal oesophagus. DESIGN: Retrospective consecutive case series. SETTING: Tertiary care centre, The Netherlands. SUBJECTS: 48 patients (34 men and 14 women, median age 63 years, range 39-84) who presented with tumours of the gastric cardia that involved the distal oesophagus and in whom non-invasive staging had not shown unresectable locoregional disease or distant metastases. INTERVENTIONS: In addition to laparoscopy and laparoscopic ultrasonography, biopsy of all suspected lesions outside the area of potential resection. MAIN OUTCOME MEASURES: Number of patients in whom the findings obviated the need for exploratory laparotomy. RESULTS: There were no complications related to the laparoscopy. The investigation showed distant metastases (which were histologically verified) in 11 patients (23%, 95% confidence interval (CI) 16 to 30). These patients had non-operative palliation. Seven were identified by laparoscopy, and laparoscopic ultrasonography showed the other four. In three patients whose distant metastases had already been identified by laparoscopy, ultrasonography was omitted. Three additional patients had suspect lesions, but these were not confirmed histologically. However, these lesions were shown to be cancerous at laparotomy. One additional patient had an intra-abdominal metastasis which was missed by laparoscopy with ultrasonography. CONCLUSIONS: Laparoscopy with ultrasonography safely detected metastases that had not been shown by conventional staging investigations in 23% of 48 patients with carcinoma of the gastric cardia. The investigation should therefore be added to the standard staging procedures in patients with carcinoma of the gastric cardia that is involving the distal oesophagus.