Page 20 - World's Most Popular Laparoscopic Journal

Amitabh Thakur

at the Cleveland Clinic. Patient records were retros- guided needle biopsy; in nine, the tissue obtained was
pectively reviewed for age, sex, pathologic diagnosis, nondiagnostic and in the one patient in whom the biopsy
conversion to laparotomy, and perioperative complications. revealed lymphoma, the tissue was considered inadequate
A total of 30 cases were reviewed. In this group, 67% for subclassification. Eleven patients were considered
were males and 33% were females; mean age was 48 poor candidates for image-guided biopsy as the enlarged
years. Ten patients underwent mesenteric lymph node lymph nodes were present in unsuitable locations (7) or
sampling and 20 (67%) underwent retroperitoneal tumor small (4). In five patients presenting with chronic right
resection. 8 lower abdominal pain and having normal imaging studies,
Data collected from patient charts, which included mesenteric lymph nodes were identified at diagnostic
demographics, conversion rates, ability to obtain laparoscopy. In one patient who was empirically started
adequate tissue for pathologic evaluation, and treatment on antitubercular therapy upon identification of
based on biopsy results were evaluated. Preoperatively, mesenteric nodal mass, a biopsy became necessary four
all patients underwent a CT of the abdomen which was months later when the response was found to be poor.
used for evaluation of the location and extent of the 4. The diagnostic features of 11 cases hospitalized for
adenopathy and operative planning. If deemed abdominal tuberculosis in the Pediatric Surgery
appropriate by radiology, CT/US-guided biopsies were Department of Fattouma Bourguiba Hospital in Monastir
attempted prior to any consideration of surgical for a 6-year period (2001-2006) were evaluated
intervention. In multiple cases, pathology was retrospectively. The diagnosis of abdominal tuberculosis
determined based on such core biopsies. If image guided was substantiated histopathologically by laparoscopy in
biopsy was unsuccessful in establishing a diagnosis then all cases. The epidemiological and clinical characteristics
surgical intervention was recommended. Preoperatively, along with the laboratory, radiological and histological
10
all patients were carefully examined in order to evaluate data were studied.
The diagnosis was suspected according to the
for any palpable lymphadenopathy which may have been
approached much more easily, such as in the axillary or epidemiological, clinical, biological and radiological
findings. The final diagnosis was established by abdominal
inguinal regions. CT scans were also carefully reviewed laparoscopy and a histological study. The epidemio-
with staff radiologists in order to optimize our operative logical data included age, sex, BCG vaccination, raw
approach. Surgical plans were discussed at length with milk intake, and family or personal history of tuberculosis
the patients and consent was obtained. or immunodeficiency. The general signs (fever, weight
3. Between October 2000 and November 2005, 28 patients loss, night sweating, anorexia, abdominal pain and bowel
with abdominal lymphadenopathy underwent laparo- movement disorder) and the clinical signs (abdominal
scopic biopsy at PD Hinduja Hospital, Mumbai, India. swelling, abdominal mass, ascites and lymph nodes)
Preoperative radiological imaging studies had identified were noted. The laboratory tests done were erythrocyte
a nodal mass in 20, a solitary node in 1, a cold abscess sedimentation rate (ESR) and C-reactive protein (CRP)
in 1, and a mesenteric cystic lesion in 1 patient. In five (to screen for an inflammatory syndrome) with blood
patients with chronic right lower abdominal pain and cell counts (to search for hyperleukocytosis). The
normal ultrasonographic findings, mesenteric nodes were bacteriological tests included a skin test (Mantoux test),
identified and biopsied during diagnostic laparoscopy. 9 Mycobacterium tuberculosis search in biological liquids
There were nine men and 19 women with a median (sputum, pleural effusion, ascites liquid), and polymerase
age of 27 years (range 6-77 years). The presenting chain reaction (PCR). A chest X-ray was taken for all
features included chronic abdominal pain (7), pain, patients to search for a pulmonary localization. In all
weight loss and fever (10), pain and weight loss (3), cases, the abdominal imaging included an ultrasound
abdominal lump (2), pyrexia of unknown origin (5), and examination to search for ascites and abnormal lymph
backache (1). None of these patients had palpable nodes, explore palpable abdominal masses and rule out
peripheral lymph nodes suitable for biopsy. In 23 patients, any surgical emergencies. A computerized tomography
preoperative ultrasound scan and/or computerized tomo- (CT) scan was performed in only five cases.
graphy scan had identified the site of lymphadenopathy. All operations were carried out under general
One patient was shown to have a lesion suspected to be endotracheal anesthesia with the patients placed in
a mesenteric cyst. Ten patients had an earlier image- modified Lloyd-Davis, left lateral, right lateral or

140
JAYPEE