Comparison Between Transgastric、Transumbilical And Laparoscopic Peritoneoscopy For Patients With Ascites Of Unknown Origin

Background and objectivesAscites is a consequence or combination of many different underlying diseases, such as tuberculous peritonitis, cancerous, cirrhosis, congestive heart failure, nephrosis ascites. The origin of ascites can be identified in the majority of patients by clinical and conventional laboratory and/or image examinations, but occasionally it cannot be determined without further investigation. Thus, we define ascites of unknown origin as the cause of ascites that cannot be determined after conventional examination. Selective peritoneum biopsy and laparotomy peritoneoscopy can be used for these patients, but these methods may cause trauma or have a low diagnostic rate. Laparscopic peritoneoscopy has become an useful even gold standard method to identify the cause of ascites of unknown origin.Natural orifice transluminal endoscopic surgery (NOTES) is a newly minimally invasive technique that gives access to the abdominal cavity via transgastric, transvaginal, transcolonic or transvesical routes. NOTES peritoneoscopy, liver biopsy, appendectomy, cholecystectomy, splenectomy, gastrojejunostomy, oophorectomy, tubal ligation have been performed successfully in animal experiments and some human researches, which proved NOTES have advantages over standard surgical methods, such as improved cosmesis, decreased incidence of wound infection, decreased need for sedation, decreased incidence of incisional hernia and so on.There are some reseaches about transgastric peritoneoscopy and transumbilical peritoneoscopy, which proved feasible and safe of these two new techniques. They can be used for patients with ascites of unknown origin. But till now, these is lack of clinical researches on comparison between transgastric, transumbilical and laparoscopic peritoneoscopy. In order to investigate the advantages and disadvantages of these three peritoneoscopies, we design this research.Materials and Methods1. During Jun.2010to Jan.2013, patients with ascites of unknown origin were included. In order to identify the cause, they were suggested to peform peritoneoscopy. They were divided into3groups on carefully discussion with the patients and on informed consent. These3groups were named as transgastric group, transumbilical group and laparoscopic group. This research was approved by the Nanfang Hospital institutional review board. Informed consent was obtained from all the patients.2. All the patients were fasting for12hours before the procedure. They were given a pre-operative dose of a broad spectrum intravenous antibiotic30min before the procedure. Transgastric group and transumbilical group were peformed in a sterile endoscopic room, laparoscopic group was performed in an operative room.All the patients were under general anesthesia with endotracheal intubation.3. Transgastric peritoneoscopy(TGP):A forward-viewing and sterile endoscope was inserted perorally into the stomach. Access to the peritoneal cavity was created as follows:a styliform incision was created by the percutaneous endoscopic gastrostomy needle in the anterior wall of the stomach. Then a needle-knife was used to enlarge the incision. The incision was dilated with a12-mm dilation balloon. Then the endoscope was advanced into the peritoneal cavity, which was insufflated with carbon dioxide to creat pneumoperitoneum.The peritoneal cavity was then examined endoscopically. Forcep biopsy was performed when necessary and diagnosis was confirmed pathologically. The gastric wall incision was closed with hemo static clips.4. Transumbilical peritoneoscopy(TUP):A1.2-cm incision was created below the umbilicus, then a1.2-cm trocar was placed into the incision. A forward-viewing and sterile endoscope was inserted through the trocar into the peritoneal cavity, which was insufflated with carbon dioxide to creat pneumoperitineum. The peritoneal cavity was then examined endoscopically. Forcep biopsy was performed when necessary and diagnosis was confirmed pathologically. The abdominal incision was sutured after peritoneoscopy.5. Laparoscopic peritoneoscopy(LP):A1.2-cm incision was created below the umbilicus, then a1.2-cm trocar was placed into the incision. A carbon dioxide pneumoperitineum(13-15mmHg) was induced by using Veress needle. A forward viewing laparoscope was inserted through the trocar into the peritoneal cavity. Another two5-mm trocar were inserted from the abdominal wall into the peritoneal cavity to be the main trocar and the assistant trocar in order to perform exploration and biopsy. The abdominal incisions were sutured after peritoneoscopy.6. Observation datas:diagnostic finding, complication, incision time, operating time, exploration range, postoperative pain score, postoperative WBC change, cost of the procedure were compared between the3groups respectively.7. Statistical Analysis:All analyses were performed using the software SPSS19.0. The incision time,operating time,exploration range, postoperative pain score, postoperative WBC change and operation fees of the three peritoneoscopy groups were compared using Kruskal Wallis as well as Mann Whitney nonparametric tests for general and pairwise comparison respectively. The relationship between exploration range and peritoneal adhesion were analyzed by Spearman nonparametric correlation. Categorical data such as gender was compared using Fisher’s exact probability. Two-sided P<0.05was considered significant.Results1.23patients with ascites of unknown origin were included in this research.8patients were included in the transgastric group,7patients in the transumbilical group,8patients in the laparoscopic group. The demographic datas of3groups were comparable.2. All the23patients were confirmed diagnosis after the procedure.16had tuberculous peritonitis,4had peritoneal metastatic carcinoma,1had primary peritoneal mesothelioma,1had cirrhosis and1had T lymphocytic hyperplasia.3. All the procedures were performed successfully.One patient in TGP group had intraoperative bleeding when balloon dilated was performed, it was treated successfully.5patients(2in TGP group,2in LP group,1in TUP group) got mild fever after the operation. No any other intraoperative or postoperative complication was recorded.4. The incision time of TGP group was longer than that of LP group and TUP group(27.88±3.36min vs11.63±0.91min and9.71±0.57min, P=0.000),but there was no statistical difference between LP group and TUP group(P=0.139).5. The operating time of TGP group was also longer than that of LP group and TUP group(102.50±11.76min vs57.88±7.03min and48.71±3.99min, P=0.002),but there was no statistical difference between LP group and TUP group(P=0.451). 6. The exploration range of LP group was wider than that of TGP group and TUP group(9.00vs6.38±0.99and6.57±0.95, P=0.016),but there was no statistical difference between TGP group and TUP group(P=0.906).7. There was a negative correlation between exploration range and peritoneal adhesion in the TGP group and TUP group, meaning more severe the adhesion was, more limited range the peritoneoscopy could reach(r=-0.910,P=0.002and r=-0.828,P=0.021respectively). However, exploration range in LP group was not limited by peritoneal adhesion(r=1).8. When comparing postoperative pain score and WBC change, there was no statistical differences between the3groups.(P=0.071and P=0.431respectively).9. The cost of TGP group was the most expensive one, followed by LP group, TUP group was the cheapest(12808.50±442.58vs4807.50±374.21and2636.14±144.50,P=0.000).ConclusionsTuberculosis and peritoneal carcinomatosis were found to be the two major causes of ascites of unknown origin in our peritoneoscopic examinations. Transgastric and transumbilical peritoneoscopy with selective biopsy are feasible and safe, and have the same diagnostic rate as laparoscopic peritoneoscopy. There were no differences in complications, postoperative pain score and WBC change between the three peritoneoscopic examinations. The exploration range was limited in TGP and TUP due to peritoneal adhesion. The incision and operation time was the longest in TGP and the cost was the most expensive. But TGP left no scar on the abdominal wall and would be suitable for patients with strong requirements of cosmesis. The incision and operation time was the shortest in TUP and the cost was the cheapest. In addition, it left only one unnoticeable scar in the abdomen and is worthy of clinical application.