Laparoscopy For Ascites And Peritoneal Malignancyresults

The benefit of laparoscopic evaluation is highlighted especially in patients with ascitic fluid collections that are found clinically to be unassociated with other signs of malignancy. The majority of these collections are from benign sources. Chuet al16 recently reviewed 129 patients having malignant ascites of unknown origin. Seventy-eight (60.5%) were found to have visual manifestations of peritoneal car-cinomatosis on laparoscopic evaluation. Peritoneal biopsy revealed malignancy in 67 of 76 cases which were biopsied and showed that a majority of these were adenocarcinoma followed by lymphoma and mesothelioma. In 14% of the lap-aroscopic studies, no definitive diagnosis could be made whereas peritoneal tuberculosis accounted for 20% of the cases and cirrhosis in 5%. Overall, laparos-copy with peritoneal biopsy was able to establish the cause of ascites in 86% of cases. Approximately 75% of women who present with malignant ascites of un known origin have a gynecologic cause of the fluid collection while another 10% have associated gastrointestinal malignancy. In men, gastrointestinal cancer accounts for the predominant cases of malignant ascites. Even though rigorous lap-aroscopy may be performed, a small percentage may still have no identifiable cause for the ascitic collection.17 It is important to note that ascitic fluid can result from certain treatment regimens utilized in the management of cancer. This is especially true with fluorouracil and N-phosphonacetyl-L-asparate.18

The use of laparoscopy must be considered paramount for the complete assessment of patients who present with intra-abdominal malignancy with or without ascites. Most intra-abdominal cancers may be associated with ascitic collections and small implants on the peritoneal surface. In addition, extra-abdominal malignancies such as breast and melanoma may have significant intra-abdominal presentations with both ascites and peritoneal implants.

The benefit of laparoscopy is realized both in the ability to make a diagnosis when cancer is unsuspected as well as the direct evaluation of the abdominal cavity in patients who have diffuse carcinomatosis. Utilizing both fluid for cytology and biopsy of tumor nodules, the surgeon-laparoscopist can play a major role in treatment planning. Although the visual effect of diffuse peritoneal cancer is usually not subtle, interpretation is important and proper biopsy techniques are mandatory in order not to worsen an already advanced situation. Recent addition of intra-abdominal ultrasound and isotopic markers may enhance the visual and histologic information to be garnered from laparoscopy.19

References

1. Kelling G. Ueber Oesophagoskopie, Gastroskopie und Kolioskopie. Munch Med Wochenschr 1902; 49:21-4.

2. McClay EF, Howell SB. Intraperitoneal therapy in the management of patients with ovarian cancer. Hematol Oncol Clin North Am 1992; 6:915.

3. Stuart GC, Nation JG, Snider DD et al. Intraperitoneal interferon in the management of malignant ascites. Cancer 1993; 71:2027.

4. Fernandez-Cruz L, Margarona E, Llovera J et al. Pancreatic ascites. Hepato-gastroenterology 1993; 40:150.

5. Antman K, Schiff PB, Pass HI. Benign and malignant mesothelioma. In: Devita VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology 5th edition, Philadelphia: Lippincott-Raven Pub 1997; 1870.

6. Lentz SS, Schray MF, Wilson TO. Chylous ascites after whole-abdomen irradiation for gynecologic malignancy. Int J Radiat Oncol Biol Phys 1990; 19:435.

7. Hallman JR, Geisinger KR. Cytology of fluids from pleural, peritoneal and peri-cardial cavities in children: A comprehensive survey. Acta Cytol 1994; 38:209.

8. Marincola FM, Schwartzentruber DJ. Malignant ascites. In: Devita VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology 5th Edition, Philadelphia: Lippincott-Raven Pub 1997; 2599.

9. Salky BA, Bauer JJ, Gelernt IM et al. The use of laparoscopy in retroperitoneal pathology. Gastrointest Endosc 1988; 34:227.

10. Dorsay DA, Greene FL, Baysinger CL. Hemodynamic changes during laparoscopic cholecystectomy monitored with transesophageal echocardiography (TEE). Surg Endosc 1995; 9:128-134.

Easter DW, Furumoto NL. Diagnostic techniques in abdominal evaluation. In: Greene FL, Rosin RD, eds. Minimal Access Surgical Oncology. Oxford: Radcliffe Med Press Ltd. 1995; 7-8.

John TG, Greig JD, Carter DC, Garden OJ. Carcinoma of the pancreatic head and periampullary region: Tumor staging with laparoscopy and laparoscopic ultrasonography. Ann Surg 1995; 221:156.

Bessler M, Whelan RL, Halverson A et al. Is immune function better preserved after laparoscopic versus open colon resection? Surg Endosc 1994; 8:881. Bhargava DK. Peritoneal tuberculosis: Laparoscopic patterns and its diagnostic accuracy. Am J Gastroenterol 1992; 87:109-112.

Savalgi RS, Rosin RD. Port-site metastasis. In: Greene FL, Rosin RD, eds. Minimal Access Surgical Oncology Oxford: Radcliffe Med Press, Ltd 1995; 158-165. Chu CM, Lin SM, Peng SM et al. The role of laparoscopy in the evaluation of ascites of unknown origin. Gastrointest Endosc 1994; 40:285. Muggia FM, Baranda J. Management of peritoneal carcinomatosis of unknown primary tumor site. Semin Oncol 1993; 20:268.

Kemeny N, Seiter K, Martin D et al. A new syndrome: Ascites, hyperbilirubine-mia and hypoalbuminemia after biochemical modulation of fluorouracil with N-phosphonacetyl-L-aspartate (PALA). Ann Intern Med 1991; 115:946. Stellato TA. Diagnostic laparoscopy for benign and malignant disease. In: Greene FL, Ponsky JL, eds. Endoscopic Surgery. Philadelphia: W.B. Saunders 1994; 290-299.

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