[Diagnostic laparoscopy. Its current indications]. / La laparoscopie diagnostique. Ses indications actuelles.

Operative laparoscopy and laparoscopic surgery are quite topical today, but not so much diagnostic laparoscopy. In fact, the wide distribution and great accuracy of new noninvasive exploratory techniques has revolutionized strategy for the diagnosis of abdominal diseases. It has been said that these techniques have now superseded laparoscopy, which should be abandoned. The reply should be that, indeed, laparoscopy has lost many of its classic indications, but that it still retains other important ones. The results obtained with a very close integration of laparoscopy and ultrasonography should particularly be emphasized, as they provide a decrease in risks and an improvement of diagnoses.

Prelaparoscopic echography used to detect abdominal adhesions.

Through the use of echography after establishing the pneumoperitoneum, it is possible to recognize the presence of intra-abdominal adhesions and the distribution of gas. Using this method, the laparoscopist is able to form a picture of the intra-abdominal situation with regard to the site of the adhesions and the pneumoperitoneal chambers. This enables him to choose the best site for the insertion of the trocar both for the avoidance of possible incidents, and for optimal inspection. This method has been successfully employed in 39 patients with large abdominal surgical scars. Laparoscopy confirmed the echographic findings in almost all the cases. Thus, in 38% of cases the laparoscopic "inspection site" chosen was atypical with respect to the usual sites for the insertion of the laparoscope, but always proved to be the most suitable.

Laparoscopy in staging, follow-up, and restaging of ovarian carcinoma.

Laparoscopy was systematically employed for the study of 143 cases of primary ovarian tumor in the various phases of staging, treatment, follow-up, and restaging. We found that laparoscopy allowed a more precise staging if used before laparotomy. Verification of response at any time in the course of therapy was readily achieved by laparoscopy.

Laparoscopy in abdominal staging of esophageal carcinoma. Report of 369 cases.

Three hundred sixty-nine patients with cancer of the esophagus (280) and of the cardia (89) underwent laparoscopy, which revealed single or multiple metastases to the liver, peritoneum, omentum, stomach, and lymph nodes in 52 patients (14%) and a metastasis to the gastric wall or to the regional lymph nodes in 36 patients (9.7%). Laparoscopic false negative findings in our series of 250 cases submitted to laparotomy was only 4.4% (2.8% for the liver, 1.2% for the peritoneum, and 0.4% for the omentum). Cirrhosis was diagnosed in 14.3% and severe portal hypertension in 6.7% of our series. Laparoscopy is a very effective procedure in pretherapy staging of esophageal cancer.

Primary and metastatic tumors of the liver associated with cirrhosis. A study based on laparoscopy and autopsy.

In a series of 2,538 cases of cirrhosis seen at laparoscopy there were 140 primary liver carcinomas and 19 cases of metastases to a cirrhotic liver out of a total of 167 extrahepatic neoplasms associated with cirrhosis. In an autopsy series of 1,073 cases of cirrhosis there were 190 primary liver carcinomas and 22 cases of metastases to a cirrhotic liver out of a total of 98 extrahepatic neoplasms. In another autopsy series of 498 cases of cirrhosis there were 71 primary liver carcinomas and 18 cases of metastases to a cirrhotic liver out of a total of 58 extrahepatic neoplasms. The laparoscopy series showed a predominance (31.8%) of esophageal tumors associated with cirrhosis, but these tumors rarely gave rise to liver metastases (3.7%); in the autopsy series there was a predominance (35.3%) of tumors of the portal territory, giving rise to metastases in cirrhotic livers in 35.2% of cases.

Laparoscopy in the diagnosis of primary carcinoma of the gallbladder. A study of 98 cases.

Ninety-eight cases of carcinoma of the gallbladder were studied by laparoscopy from 1968 to 1982. The gallbladder was completely explored in 48 patients. Hard white plaques of the gallbladder wall were noted in 30 patients. Local metastases were found in 89 patients. A diagnosis of malignancy by biopsy was made in 90% of cases although only three biopsies were taken from the gallbladder itself. Laparoscopy is useful in identifying those rare cases where radical surgical intervention may improve survival.

Laparoscopic splenic biopsy.

The authors report their experiences with 1243 laparoscopic splenic biopsies performed between 1968 and 1982 at the Laparoscopy Center of the Regional Hospital in Padua. We may conclude that: The risk of laparoscopic splenic biopsy in minimal and fears regarding its performance are unjustified. The diagnostic value of splenic biopsy is evident if a comparison is made, in the different groups, between the percentage and the accuracy of the diagnoses made with the single macroscopic and the histological examinations, respectively. As well as the staging and follow-up of malignant lymphomas, examination of the spleen in clinically suspected splenopathy is a new and interesting indication for laparoscopy, for it is now possible to take one or more biopsies.

[Depletive treatment of uncompensated liver cirrhosis with high doses of spirolactone only]. / Trattamento depletivo della cirrosi epatica scompensata con solo spironolattone ad alte dosi

In most regimens proposed for the depletive management of cirrhosis of the liver, spirolactone is associated with other diuretics. Treatment of 28 patients with uncompensated forms by means of spirolactone only, using high, protracted doses determined essentially in accordance with the depletion obtained, is described. The disappearance of signs of water retention was gradual and unattended by difficulties. Normalisation of the urinary Na/K ratio preceded the diuretic response; Increased diuresis led to a slight increase in urinary potassium/day. Higher doses were used in patients with lower urinary Na/K ratios. Here a critical diuretic response was only obtained around the 5th day. Transient low blood sodium and chlorine and high blood potassium were noted; the last parameter was not related to the drug dose, nor to changes in Bun; No marked changes in blood uric acid, calcium, ammonium, bilirubin or sugar were observed.

[The value of laparoscopy in the study of portal hypertension]. / L'importanza della laparoscopia nello studio dell'ipertensione portale

Up to now, laparoscopy has always been considered as only marginally importan in the study of portal hypertension whereas in fact it should become one of the fundamental examinations in this field. The technique not only contributes, by direct liver exploration, to a more precise judgment regarding the underlying disease, with the possibility of earlier recognition of pre-hepatic, intra-hepatic and post-hepatic forms of portal hypertension, but also makes it possible to detect the earliest signs of hypertension. Further, and most important, laparoscopy extends investigation of the collateral circulation to the sector of the small peritoneal vessels which are inaccessible with other techniques, demonstrating alterations are of decisive importance in the economy of the collateral circulation. On the basis of these new elements, together of course with radiological and fibro-endoscopic data, it is possible to divide cases of portal hypertension into three groups depending on the type of collateral circulation operative on each occasion. These types present differing anatomcfunctional features and clinical physiognomy, a factor of great practical importance especially for the purpose of establishing indications for the portacaval anastomosis of choice, and possibly prophylactic intervention.