软式腹腔内镜检查对原因不明腹水的诊断研究
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摘要
目的：应用软式腹腔内镜对原因不明腹水患者进行腹腔探查，使用经脐经腹路径腹腔探查法及经胃人体自然腔道腹腔探查法（natural orifice transluminal endoscopicsurgery，NOTES）两种方式，探索软式腹腔内镜检查对原因不明腹水的诊断价值。
方法：对2007年4月至2011年10月我院消化内科收治的121例渗出性腹水患者进行回顾性分析研究，所有患者经过腹腔穿刺液常规监测、细胞学检查、肿瘤标志物等实验室检查以及各种影像学检查（包括B超、CT和MRI等）、PPD试验及胃肠镜检查难以明确诊断。其中2例患者在外院行试验性抗结核治疗1个月以上无效。对这些经常规检查手段仍不能确诊者，运用软式内镜进行腹腔探查，观察腹水性状并取样送化验，全面仔细探查腹膜及腹腔内各脏器，发现病变后取活组织并送病理检查，以病理学检查结果为疾病的最终确诊依据，评价此种诊断方式的效果。
结果：本组121例患者中，经腹腔内镜检查及病理活检明确诊断者117例，诊断不明者4例，确诊率96.7%。在明确诊断的117例中，发现恶性肿瘤56例（47.86%），结核性腹膜炎27例（23.08%），肝硬化13例（11.11%），嗜酸性小肠炎5例（4.27%），其他脏器炎症16例（13.68%）。腹腔内镜下观察淡黄色腹水共67例（55.37%），草绿色腹水35例（28.93%），红色腹水16例（13.22%），白色浑浊腹水3例（2.48%）。56例腹腔肿瘤中，腹膜恶性间皮瘤9例，腹膜转移癌共47例，其中卵巢转移癌13例（27.66%），原发性肝癌腹腔转移11例（23.40%），胃癌腹腔转移6例（12.77%），结肠癌腹腔转移4例（8.51%），胆管细胞癌腹腔转移3例（6.38%），十二指肠乳头癌腹腔转移2例（4.26%），胰腺癌腹腔转移1例（2.13%），肺癌腹腔转移1例（2.13%），鼻咽癌腹腔转移1例（2.13%），肿瘤来源不明5例（10.64%）。术后患者切口愈合良好，24小时后可进饮食,患者创伤小。目前已探索出两种软式内镜腹腔探查方法，分别为经脐路径腹腔内镜探查法与经胃NOTES腹腔内镜探查法。
结论：1、软式内镜腹腔检查对原因不明腹水的诊断具有很大价值。2、经脐腹腔内镜检查和经胃NOTES腹腔内镜检查是新的、可靠和微创的腹腔疾病诊断方法。
Objective: To investigate value of peritoneoendoscopy with sofe endoscope in thediagnosis of ascites with unknown origin. The peritoneoendoscopy was performed by usingtwo ways: transumbilical peritoneoendoscopy and the transgastric natural-orificetransluminal endoscopic surgery(NOTES).
Methods: A total of121patients with exudative ascites which was not able to bediagnosed by routine methods were diagnosed by peritoneoendoscopy and histologicalexamination of biopsies at our hospital from April2007to October2011．The data of clinicalmanifestations，gastroscopy，colonoscopy，abdominal ultrasonography，abdominal computedtomography， magnetic resonance imaging， ascitic cytology and transgastricperitoneoendoscopy via NOTES were, retrospectively, analyzed．
Results: Definite diagnosis was made in117of121patients (96.7%)，of which56（47.86%）were malignant tumors，27（23.08%）were tuberculosis peritonitis，13（11.11%）were hepatic cirrhosis,5(4.5％)were eosinophilic enteritis, and16(13.68%) wereinflammation of other organs．
In56patients with peritoneal malignant tumors, malignant mesothelioma of peritoniumaccounted for16.1%(9patients) and peritoneal metastatic cancers83.0%(47patients). Ofpatients with peritoneal metastatic cancers oophoroma was diagnosed in13patients（27.66%）, peritoneal metastatic from hepatic carcinoma in11patient（s23.40%）, peritonealmetastatic from gastric cancers in6patients（12.77%）, peritoneal metastatic from coloncarcinoma in4patients（8.51%）, peritoneal metastatic from cholangiocarcinoma in3patients（6.38%）carcinoma, peritoneal metastatic from duodenal papilla carcinoma in2patients（4.26%）, peritoneal metastatic from pancreatic carcinoma in1patients（2.13%）, peritonealmetastatic from lung cancer in1patient （2.13%）, and peritoneal metastatic fromnasopharyngeal carcinoma in1patient（2.13%）. In5patients（10.64%） with ascites, nodefinite diagnosis was made. There was no complications and no visible scar on the abdominalwall.
Conclusion:1. Peritoneoendoscopy with sofe endoscope combined with histologicalexamination of biopsies has important value in the diagnosis of ascites of unknown causes, and
2. transumbilical peritoneoendoscopy and NOTES peritoneoendoscopy are new, easy,reliable and minimal invasive methods for diagnosis of peritoneal diseases.
方法：对2007年4月至2011年10月我院消化内科收治的121例渗出性腹水患者进行回顾性分析研究，所有患者经过腹腔穿刺液常规监测、细胞学检查、肿瘤标志物等实验室检查以及各种影像学检查（包括B超、CT和MRI等）、PPD试验及胃肠镜检查难以明确诊断。其中2例患者在外院行试验性抗结核治疗1个月以上无效。对这些经常规检查手段仍不能确诊者，运用软式内镜进行腹腔探查，观察腹水性状并取样送化验，全面仔细探查腹膜及腹腔内各脏器，发现病变后取活组织并送病理检查，以病理学检查结果为疾病的最终确诊依据，评价此种诊断方式的效果。
结果：本组121例患者中，经腹腔内镜检查及病理活检明确诊断者117例，诊断不明者4例，确诊率96.7%。在明确诊断的117例中，发现恶性肿瘤56例（47.86%），结核性腹膜炎27例（23.08%），肝硬化13例（11.11%），嗜酸性小肠炎5例（4.27%），其他脏器炎症16例（13.68%）。腹腔内镜下观察淡黄色腹水共67例（55.37%），草绿色腹水35例（28.93%），红色腹水16例（13.22%），白色浑浊腹水3例（2.48%）。56例腹腔肿瘤中，腹膜恶性间皮瘤9例，腹膜转移癌共47例，其中卵巢转移癌13例（27.66%），原发性肝癌腹腔转移11例（23.40%），胃癌腹腔转移6例（12.77%），结肠癌腹腔转移4例（8.51%），胆管细胞癌腹腔转移3例（6.38%），十二指肠乳头癌腹腔转移2例（4.26%），胰腺癌腹腔转移1例（2.13%），肺癌腹腔转移1例（2.13%），鼻咽癌腹腔转移1例（2.13%），肿瘤来源不明5例（10.64%）。术后患者切口愈合良好，24小时后可进饮食,患者创伤小。目前已探索出两种软式内镜腹腔探查方法，分别为经脐路径腹腔内镜探查法与经胃NOTES腹腔内镜探查法。
结论：1、软式内镜腹腔检查对原因不明腹水的诊断具有很大价值。2、经脐腹腔内镜检查和经胃NOTES腹腔内镜检查是新的、可靠和微创的腹腔疾病诊断方法。
Objective: To investigate value of peritoneoendoscopy with sofe endoscope in thediagnosis of ascites with unknown origin. The peritoneoendoscopy was performed by usingtwo ways: transumbilical peritoneoendoscopy and the transgastric natural-orificetransluminal endoscopic surgery(NOTES).
Methods: A total of121patients with exudative ascites which was not able to bediagnosed by routine methods were diagnosed by peritoneoendoscopy and histologicalexamination of biopsies at our hospital from April2007to October2011．The data of clinicalmanifestations，gastroscopy，colonoscopy，abdominal ultrasonography，abdominal computedtomography， magnetic resonance imaging， ascitic cytology and transgastricperitoneoendoscopy via NOTES were, retrospectively, analyzed．
Results: Definite diagnosis was made in117of121patients (96.7%)，of which56（47.86%）were malignant tumors，27（23.08%）were tuberculosis peritonitis，13（11.11%）were hepatic cirrhosis,5(4.5％)were eosinophilic enteritis, and16(13.68%) wereinflammation of other organs．
In56patients with peritoneal malignant tumors, malignant mesothelioma of peritoniumaccounted for16.1%(9patients) and peritoneal metastatic cancers83.0%(47patients). Ofpatients with peritoneal metastatic cancers oophoroma was diagnosed in13patients（27.66%）, peritoneal metastatic from hepatic carcinoma in11patient（s23.40%）, peritonealmetastatic from gastric cancers in6patients（12.77%）, peritoneal metastatic from coloncarcinoma in4patients（8.51%）, peritoneal metastatic from cholangiocarcinoma in3patients（6.38%）carcinoma, peritoneal metastatic from duodenal papilla carcinoma in2patients（4.26%）, peritoneal metastatic from pancreatic carcinoma in1patients（2.13%）, peritonealmetastatic from lung cancer in1patient （2.13%）, and peritoneal metastatic fromnasopharyngeal carcinoma in1patient（2.13%）. In5patients（10.64%） with ascites, nodefinite diagnosis was made. There was no complications and no visible scar on the abdominalwall.
Conclusion:1. Peritoneoendoscopy with sofe endoscope combined with histologicalexamination of biopsies has important value in the diagnosis of ascites of unknown causes, and
2. transumbilical peritoneoendoscopy and NOTES peritoneoendoscopy are new, easy,reliable and minimal invasive methods for diagnosis of peritoneal diseases.
引文
[1]阮继刚等.腹腔镜用于不明原因腹水的检查[J].《宁夏医学院学报》2005年3期，217-218
[2]张顺财.消化系统疾病诊断与鉴别诊断学[M].北京:科学技术出版社,2004，120.
[3] Zhang M, Jiang X, Zhang M, et al. The role of18F-FDG PET/CT in the evaluation ofascites of undertermined origin [J] Nucl Med,2009,50:506-512.
[4]宋喜秀.肝病腹膜炎腹水检查的评估[J].国外医学消化分册，1983，2：106-108.
[5]李建华，毛玉莲，赵玉洲，等.胸、腹水癌性鉴定观察[J].河南医学，1982,2:5-6
[6]刘长虹，袁梦彪.腹水诊断现状与进展[J],中华医学研究杂志，2004,4（3），221-223
[7] Yeh HC. Ultrasongraphy in ascites [J]. Radiology,1977,124(3):783.
[8] Seltzer SE. Analysis of the tetheed-bowel sign on abdominal CT as a predictor ofmalignant ascites [J]. Gastrointest Radiol,1987,12(3):245.
[9]张炳远.腹腔镜技术对不明原因腹水的诊断价值[J].青岛大学医学院学报，2003,39（3）,231-232
[10]安子元，徐大毅，安照源.腹膜活检的方法及诊断价值(附302例腹膜疾病的诊断)[J].中华消化内镜杂志，1996(16).
[11]张兴荣，马述春，胡和平，陈伟忠，张忠兵，朱梁，刘苏，蔡洪培.腹膜细胞刷检在恶性腹水中的诊断价值[J].第二军医大学学报1998(2).
[12]克力木，张成，陈勇，等.腹腔镜探查诊断不明原因腹水83例分析[J].中国实用外科杂志.2010，29（10）：861－862.
[13]黄志强.现代腹腔镜外科学[M].北京:人民军医出版社,1994，197.
[14]徐海燕，朱小林，代云俊，房殿春.腹腔镜对不明原因腹水的诊治价值[J].胃肠病学和肝病学杂志2010,19(7).
[15]张明金，陈尚传，吴建斌.不明原因腹水的腹腔镜探查(附32例报告)[J].腹腔镜外科杂志2010，15（1）：45－46.
[16].陈勇，克力木.腹腔镜探查在结核性腹膜炎诊断中的价值[J].新疆医学,2009,38(2):15-18.
[17] Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: anovel approach to diagnostic and therapeutic interventions in the peritoneal cavity [J].Gastrointest Endosc,2004,60:114-117.
[18] ASGE/SAGES. Working Group on Natural Orifice Translumenal EndoscopicSurgery White Paper October2005[J]. Gastrointest Endosc,2006,63(2):199-203.
[19] Jagannath SB, Kantsevoy SV, Vaughn CA, et al. Peroral transgastric endoscopicligation of fallopian tubes with long-term survival in a porcine model [J].Gastrointest Endosc,2005,61:449-453.
[20] Wagh MS, Merrifield BF, Thompson CC. Endoscopic transgastric abdominalexploration and organ resection: initial experience in a porcine model [J]. ClinGastroenterol Hepatol,2005,3:892-896.
[21] Park PO, Bergstrom M, Ikeda K, et al. Experimental studies of transgastricgallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos)[J].Gastrointest Endosc,2005,61:601-606.
[22] Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy withsurvival in a porcine model [J]. Gastrointest Endosc,2005,62:287-292.
[23] Fritscher-Ravens A, Mosse CA, Ikeda K, et al. Endoscopic transgastriclymphadenectomy by using EUS for selection and guidance [J]. GastrointestEndosc,2006,63:302-306.
[24] Wagh MS, Merrifiedl BF, Thompson CC. Survival studies after endoscopictransgastric oophorectomy and tubectomy in a porcine model [J]. GastrointestEndosc,2006,63:473-478.
[25] Kantsevoy SV, HU B, Jagannath SB, et al. Transgastric endoscopic splenectomy: is itpossible [J]. Surg Endosc,2006,20:522-525.
[26] Ryou M, Fong DG, Paird, et al. Dual-port distal pancreatectomy using a prototypeendoscope and endoscopic stapler: a natural orifice transluminal endoscopic surgery(NOTES) survival study in a porcine model [J]. Endoscopy,2007,39(10):881-887.
[27]. Whiteford MH, Denk PM, Swanstr M LL. Feasibility of radical sigmoid colectomyperformed as natural orifice translumenal endoscopic surgery (NOTES) usingtransanal endoscopic microsurgery [J]. Surg Endosc,2007,21(10):1870-1874.
[28] Clayman RV, Box GN, Abraham JB, et al. Transvaginal single-port NOTESnephrectomy: initial laboratory experience [J]. J Endourol,2007,21(6):640-644.
[29] Mintz Y, Horgan S, Cullen J, et al. Dual-lumen natural orifice translumenalendoscopic surgery (NOTES): a new method for performing a safe anastomosis [J].Surg Endosc,2007, Nov20[Epub ahead of print].
[30]宋洋，张定国，朱惠明.腹腔内镜检查对不明原因腹水的诊断价值[J].中华消化内镜杂志，2009，26（7）169-172.
[31] Baron TH. Natural orifice transluminal endoscopic surgery [J]. Br J Surg,2007,94(1):1-2.
[32] Giday SA, Kantsevoy SV, Kalloo A. Principle and history of natural orificetransluminal endoscopic surgery [J]. Minimally Invasive Ther Allied Technology,2006,15:373-377.
[33]张志宏，腹腔镜检查对结核性腹膜炎的诊断意义[J].中华消化杂志，1985，5：87-88．
[34] Fritscher-Ravens A, Mosse CA, Ikeda K, et al. Endoscopic transgastriclymphadenectomy by using EUS for selection and guidance [J]. GastrointestEndosc,2006,63:302-306.
[35] Kallo A, Singh VK, Jagnnath SB, et al. Flexible transgastricpeitoneoscopy: a novel approach to diagnostic and therapeuticinterventions in the peritoneal cavity [J]. Gastrointestinal Endoscopy,2004,60(1):114-117.
[36] Narula V, Happel L, Volt K, et al. Transgastric endoscopic peritoneoscopy does notrequire decontamination of the stomach in humans [J]. Surg Endosc,2009,23:1331-1336.
[2]张顺财.消化系统疾病诊断与鉴别诊断学[M].北京:科学技术出版社,2004，120.
[3] Zhang M, Jiang X, Zhang M, et al. The role of18F-FDG PET/CT in the evaluation ofascites of undertermined origin [J] Nucl Med,2009,50:506-512.
[4]宋喜秀.肝病腹膜炎腹水检查的评估[J].国外医学消化分册，1983，2：106-108.
[5]李建华，毛玉莲，赵玉洲，等.胸、腹水癌性鉴定观察[J].河南医学，1982,2:5-6
[6]刘长虹，袁梦彪.腹水诊断现状与进展[J],中华医学研究杂志，2004,4（3），221-223
[7] Yeh HC. Ultrasongraphy in ascites [J]. Radiology,1977,124(3):783.
[8] Seltzer SE. Analysis of the tetheed-bowel sign on abdominal CT as a predictor ofmalignant ascites [J]. Gastrointest Radiol,1987,12(3):245.
[9]张炳远.腹腔镜技术对不明原因腹水的诊断价值[J].青岛大学医学院学报，2003,39（3）,231-232
[10]安子元，徐大毅，安照源.腹膜活检的方法及诊断价值(附302例腹膜疾病的诊断)[J].中华消化内镜杂志，1996(16).
[11]张兴荣，马述春，胡和平，陈伟忠，张忠兵，朱梁，刘苏，蔡洪培.腹膜细胞刷检在恶性腹水中的诊断价值[J].第二军医大学学报1998(2).
[12]克力木，张成，陈勇，等.腹腔镜探查诊断不明原因腹水83例分析[J].中国实用外科杂志.2010，29（10）：861－862.
[13]黄志强.现代腹腔镜外科学[M].北京:人民军医出版社,1994，197.
[14]徐海燕，朱小林，代云俊，房殿春.腹腔镜对不明原因腹水的诊治价值[J].胃肠病学和肝病学杂志2010,19(7).
[15]张明金，陈尚传，吴建斌.不明原因腹水的腹腔镜探查(附32例报告)[J].腹腔镜外科杂志2010，15（1）：45－46.
[16].陈勇，克力木.腹腔镜探查在结核性腹膜炎诊断中的价值[J].新疆医学,2009,38(2):15-18.
[17] Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: anovel approach to diagnostic and therapeutic interventions in the peritoneal cavity [J].Gastrointest Endosc,2004,60:114-117.
[18] ASGE/SAGES. Working Group on Natural Orifice Translumenal EndoscopicSurgery White Paper October2005[J]. Gastrointest Endosc,2006,63(2):199-203.
[19] Jagannath SB, Kantsevoy SV, Vaughn CA, et al. Peroral transgastric endoscopicligation of fallopian tubes with long-term survival in a porcine model [J].Gastrointest Endosc,2005,61:449-453.
[20] Wagh MS, Merrifield BF, Thompson CC. Endoscopic transgastric abdominalexploration and organ resection: initial experience in a porcine model [J]. ClinGastroenterol Hepatol,2005,3:892-896.
[21] Park PO, Bergstrom M, Ikeda K, et al. Experimental studies of transgastricgallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos)[J].Gastrointest Endosc,2005,61:601-606.
[22] Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy withsurvival in a porcine model [J]. Gastrointest Endosc,2005,62:287-292.
[23] Fritscher-Ravens A, Mosse CA, Ikeda K, et al. Endoscopic transgastriclymphadenectomy by using EUS for selection and guidance [J]. GastrointestEndosc,2006,63:302-306.
[24] Wagh MS, Merrifiedl BF, Thompson CC. Survival studies after endoscopictransgastric oophorectomy and tubectomy in a porcine model [J]. GastrointestEndosc,2006,63:473-478.
[25] Kantsevoy SV, HU B, Jagannath SB, et al. Transgastric endoscopic splenectomy: is itpossible [J]. Surg Endosc,2006,20:522-525.
[26] Ryou M, Fong DG, Paird, et al. Dual-port distal pancreatectomy using a prototypeendoscope and endoscopic stapler: a natural orifice transluminal endoscopic surgery(NOTES) survival study in a porcine model [J]. Endoscopy,2007,39(10):881-887.
[27]. Whiteford MH, Denk PM, Swanstr M LL. Feasibility of radical sigmoid colectomyperformed as natural orifice translumenal endoscopic surgery (NOTES) usingtransanal endoscopic microsurgery [J]. Surg Endosc,2007,21(10):1870-1874.
[28] Clayman RV, Box GN, Abraham JB, et al. Transvaginal single-port NOTESnephrectomy: initial laboratory experience [J]. J Endourol,2007,21(6):640-644.
[29] Mintz Y, Horgan S, Cullen J, et al. Dual-lumen natural orifice translumenalendoscopic surgery (NOTES): a new method for performing a safe anastomosis [J].Surg Endosc,2007, Nov20[Epub ahead of print].
[30]宋洋，张定国，朱惠明.腹腔内镜检查对不明原因腹水的诊断价值[J].中华消化内镜杂志，2009，26（7）169-172.
[31] Baron TH. Natural orifice transluminal endoscopic surgery [J]. Br J Surg,2007,94(1):1-2.
[32] Giday SA, Kantsevoy SV, Kalloo A. Principle and history of natural orificetransluminal endoscopic surgery [J]. Minimally Invasive Ther Allied Technology,2006,15:373-377.
[33]张志宏，腹腔镜检查对结核性腹膜炎的诊断意义[J].中华消化杂志，1985，5：87-88．
[34] Fritscher-Ravens A, Mosse CA, Ikeda K, et al. Endoscopic transgastriclymphadenectomy by using EUS for selection and guidance [J]. GastrointestEndosc,2006,63:302-306.
[35] Kallo A, Singh VK, Jagnnath SB, et al. Flexible transgastricpeitoneoscopy: a novel approach to diagnostic and therapeuticinterventions in the peritoneal cavity [J]. Gastrointestinal Endoscopy,2004,60(1):114-117.
[36] Narula V, Happel L, Volt K, et al. Transgastric endoscopic peritoneoscopy does notrequire decontamination of the stomach in humans [J]. Surg Endosc,2009,23:1331-1336.