诊断性腹腔镜的临床应用价值

目的 探讨诊断性腹腔镜在临床的应用价值。方法 回顾性分析1994年2月至2000年10月进行的75例诊断性腹腔镜检查。结果 对28例不明原因腹水,24例腹外伤、急腹症,9例不明原因腹内肿块,6例性质不明肝脏肿块,6例肿瘤待查及2例膈肌病变,除2例不明原因腹水患诊断未明外,余皆在腹腔镜下得到明确诊断及相应的有效治疗。总诊断明确率为97．4％。有3例发生并发症,发生率4．0％。结论 诊断性腹腔镜检查是一种较安全、有效的检查方法。在评估腹腔内病变,如肝脏疾病,不明原因腹水,腹腔内肿瘤的诊断、转移病灶的发现和恶性病变的分期,某些腹外伤及急腹症方面有其独特而重要的作用,     

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.     

Bacteremia after diagnostic conventional laparoscopy and minilaparoscopy: a prospective study in 100 patients

BACKGROUND/GOALS: Diagnostic laparoscopy under sedoanalgesia is a valuable tool in the work-up of liver diseases and is helpful as a staging procedure. The rate of bacteremia caused by this procedure is unknown, in particular when performed as minilaparoscopy. STUDY: A 100 consecutive patients having undergone diagnostic laparoscopy carried out either conventionally (group I, n=50) or as minilaparoscopy (group II, n=50) were prospectively enrolled in this study. Blood cultures were drawn before and within 5 minutes after the procedure. Risk factors for bacteremia were evaluated. RESULTS: Bacterial growth occurred in 4 blood cultures drawn immediately after laparoscopy. No patient developed fever or other signs of infection in the follow-up. Risk factors predisposing to bacteremia could not be identified. CONCLUSIONS: Conventional diagnostic laparoscopy under sedoanalgesia and minilaparoscopy are associated with a low rate of bacteremia as in diagnostic upper endoscopy.     

Video-assisted Thoracoscopy for Spontaneous Pneumothorax after Pneumonectomy

In this paper, we present 3 patients who had previously undergone pneumonectomy and then presented with a spontaneous pneumothorax. The indication for pneumonectomy was tuberculosis and NSCLC in 2 and 1 patient, respectively. The interval between the surgery and development of pneumothorax was 2, 4, and 11 years. On admission, 2 of the 3 patients were in extreme respiratory distress requiring urgent chest tube insertion. In all patients we undertook elective video-assisted thoracoscopy with complete preparation for cardiopulmonary support on the side. Bullectomy and/or diathermy ablation for apical bullae and blebs were performed concomitantly with total parietal pleurectomy. The postoperative course was uneventful in the patients, and they remain on routine follow-up for up to 6-12 months without any complaints. Our experience suggests that emphysematous changes in the remaining lung should be carefully inspected during long-term follow-up after pneumonectomy. Video-assisted thoracoscopic (VAT) pleurectomy appears to be a good option for the management of spontaneous pneumothorax only if it is performed by a dedicated multidisciplinary team with various cardiopulmonary support facilities on the side.     

Experience with diagnostic laparoscopy in a hepatology training program

Laparoscopy is an underutilized endoscopic procedure in the United States even though it has proven to be an important diagnostic modality. Among factors that may account for the unpopularity of this procedure are lack of experience and proper training in many gastroenterology fellowship programs, a perceived notion that there is a relatively high complication rate, and the preference for radiologic imaging techniques for establishing a diagnosis. We reviewed, over an 11-month period, our experience with laparoscopy in a large teaching center to better assess its safety when performed by trainees. The major and minor complication rates were 0.9% and 2.9%, respectively, with no fatalities. These findings compare favorably with the general experience.     

Pneumothorax following transbronchial biopsy. Low diagnostic yield with routine chest roentgenograms

A chest roentgenogram is commonly obtained after a transbronchial biopsy to exclude a pneumothorax. We hypothesized that these routine chest roentgenograms rarely demonstrate a pneumothorax in patients who have neither symptoms nor fluoroscopic findings of lung collapse. To test this hypothesis, we studied 305 consecutive patients undergoing bronchoscopy with fluoroscopically guided TBB. No patient without symptoms and fluoroscopic findings suggesting lung collapse had a pneumothorax demonstrated on the post-biopsy chest roentgenogram. At the University of Virginia, routine chest roentgenograms failed to demonstrate a single unsuspected pneumothorax among all patients undergoing TBB during a period of nearly six years. Given this low incidence of unsuspected pneumothorax, we conclude that routine chest roentgenograms have a low diagnostic yield and may not be necessary in all patients after fluoroscopically guided TBB.     

Pneumothorax derived from bronchiolitis obliterans after marrow transplantation

Long-term survival has become achievable after bone-marrow transplantation, but various pulmonary diseases due to chronic graft-vs.-host disease have been recognized. Particularly, bronchiolitis obliterans is a life-threatening complication with no effective remedy. Bilateral pneumothorax associated with bronchiolitis obliterans is rare, but it requires careful attention. In a 42-year old man with intractable pneumothorax after bone marrow transplantation and surgical procedures, extensive thoracolysis was effective as an acute treatment for this disease.     

Irritable bowel syndrome in women having diagnostic laparoscopy or hysterectomy

We identified irritable bowel syndrome (IBS) in 47.7% of 86 women having diagnostic laparoscopy for chronic pelvic pain, 39.5% of 172 women having elective hysterectomy, and 32.0% of 172 controls age-matched for the hysterectomy group (P=NS). Constipation and pain subtype IBS were more common in hysterectomy patients than controls (P < 0.05). In laparoscopy patients, dyspareunia was more common in those with IBS than in those without it (P < 0.05). In the hysterectomy group, more IBS patients had chronic pelvic pain (P < 0.005), and abnormal menses (P < 0.01). Chronic pelvic pain was more frequently the only prehysterectomy diagnosis in IBS patients (P < 0.05), and IBS was present more often when pain was a reason for hysterectomy (P < 0.01). One year after laparoscopy, IBS patients gave lower overall status ratings (P < 0.01) and lower pain improvement ratings (P < 0.05) than non-IBS patients. In women who had a hysterectomy for pain, there was less pain improvement one year later in those with the pain subtype of IBS than in non- IBS patients (P < 0.05). IBS is associated with gynecologic symptoms and affects the symptomatic outcome of diagnostic laparoscopy and hysterectomy.     

Pneumothorax

Pneumothorax represents a common clinical problem. An overview of relevant and updated information on epidemiology, pathophysiology, and management of spontaneous (primary and secondary), catamenial, and traumatic (iatrogenic and noniatrogenic) pneumothorax is given.