Continuous Ultrasound Guidance Research Articles

Assessing the educational value and content of YouTube videos for ultrasound-guided subclavian vein catheterization.

The European Society of Anaesthesiology (ESA) published a guideline regarding continuous ultrasound guidance for central venous catheters in 2020. YouTube has been a popular educational platform since its inception. The purpose of the present study was to evaluate the adequacy of videos on ultrasound-guided subclavian vein catheterization posted on YouTube based on this guideline. YouTube was scanned using the keywords associated with ultrasound-guided subclavian vein catheterization and 46 of the 106 most-watched videos were included in the study. The videos were divided into three groups, as individual, manufacturer, and academic according to their sources, and were evaluated as poor, satisfactory, and good in terms of the overall content. The videos were then evaluated based on ESA's six-title guide for more specific informational content. A total of 46 videos were reviewed and 52.2% (n = 24) were found to be prepared by individuals. Among the videos, the rate of videos describing only venipuncture (poor) was 23.9% (n = 11), 73.9% (n = 34) of videos described the verification of the guidewire location with venipuncture, and 2.2% of videos described all the recommendations suggested by the guide (n = 1). At the end of the catheterization procedure, 4.3% (n = 2) stated that the catheter location should be confirmed by using ultrasound, 15.2% (n = 7) recommended chest-X-ray, and 80.4% (n = 37) did not suggest any. Manufacturer and academic videos can be watched due to their high-quality scores, but it may be practical to prepare training videos with guidelines both for educators and students to have global access to the renewed guideline information.

Reliable Visualization of the Treatment Effect of Transperineal Focal Laser Ablation in Prostate Cancer Patients by Magnetic Resonance Imaging and Contrast-enhanced Ultrasound Imaging

BackgroundTransperineal focal laser ablation (TPLA) treatment for prostate cancer (PCa) is an experimental focal ablative therapy modality with low morbidity. However, a dosimetry model for TPLA is lacking. ObjectiveTo determine (1) the three-dimensional (3D) histologically defined ablation zone of single- and multifiber TPLA treatment for PCa correlated with magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS) and (2) a reliable imaging modality of ablation zone volumetry. Design, setting, and participantsThis was a prospective, multicenter, and interventional phase I/II pilot study with an ablate-and-resect design. TPLA was performed in 12 patients with localized prostate cancer divided over four treatment regimens to evaluate potential variation in outcomes. InterventionTPLA was performed approximately 4 wk prior to robot-assisted radical prostatectomy (RARP) in a daycare setting using local anesthesia. Outcome measurements and statistical analysisFour weeks after TPLA, ablation zone volumetry was determined on prostate MRI and CEUS by delineation and segmentation into 3D models and correlated with whole-mount RARP histology using the Pearson correlation index. Results and limitationsTwelve office-based TPLA procedures were performed successfully under continuous transrectal ultrasound guidance using local perineal anesthesia. No serious adverse events occurred. A qualitative analysis showed a clear demarcation of the ablation zone on T2-weighted MRI, dynamic contrast-enhanced MRI, and CEUS. On pathological evaluation, no remnant cancer was observed within the ablation zone. Ablation zone volumetry on CEUS and T2-weighted MRI compared with histology had a Pearson correlation index of r = 0.94 (95% confidence interval [CI] 0.74–0.99, p < 0.001) and r = 0.93 (95% CI 0.73–0.98, p < 0.001), respectively. ConclusionsCEUS and prostate MRI could reliably visualize TPLA ablative effects after minimally invasive PCa treatment with a high concordance with histopathological findings and showed no remnant cancer. Patient summaryThe treatment effects of a novel minimally invasive ablation therapy device can reliably be visualized with radiological examinations. These results will improve planning and performance of future procedures.

Successful Hysteroscopic Management of Cesarean Scar Defect Pregnancy

A 30-year-old multipara of 2 with history of 1 cesarean delivery, presented to the emergency department (ED) with one day of pelvic pain and vaginal bleeding. A positive β-human chorionic gonadotropin (β-hCG) blood test (215 mUI/mL) had been obtained 20 days prior. Upon admission, she was hemodynamically stable, and the physical exam showed no cervical changes or active bleeding. Transvaginal Ultrasound (TVUS) performed in the ED revealed a gestational sac (GS) implanted in the uterine isthmus, with a 6.7 mm embryo without cardiac activity. She was admitted for further evaluation. Formal TVUS (Figure 1) revealed an apparent cesarean scar defect (CSD) containing a 6 mm embryo without cardiac activity. Trophoblast tissue extended towards the defect, and the myometrial residual thickness (MRT) measured 1.4 mm. Adnexa appeared normal. Serial β-hCG levels were obtained, resulting on 2,177 on admission, 1,972 on the second, and 1,924 mUI/mL on the fourth day. Based on these findings, diagnosis of CSD pregnancy was made. Hysteroscopic management (Figure 2) was decided and successfully performed under regional anesthesia and continuous ultrasound guidance. Complete resection of the GS occupying the CSD was achieved using a bipolar resectoscope. Post-procedure, the patient received a prophylactic dose of Methotrexate (100 mg IM), an etonogestrel implant was inserted, and was discharged without incidents the day following surgery. The pathology report confirmed the diagnosis. On follow-up 12 days after surgery, patient was asymptomatic, β-hCG levels resulted 7.4 mIU/mL, and on a 6-month follow-up visit, was discharged to primary healthcare. Reasonable evidence supports hysteroscopic management of CSD pregnancy, with the benefit of direct visualization (1, 2, 3). Other techniques, like use of a double balloon catheter have been described (4). Hysteroscopy was chosen despite of the MRT (5), with staged laparoscopic repair due to an unclear fertility desire.

284 Collaboration With a Bioengineering Senior Design Course to Develop a Novel Medical Device Facilitating Vessel Cannulation Under Continuous Ultrasound Guidance

Critically ill patients in the emergency department (ED) and intensive care unit (ICU) often require invasive vascular access for monitoring and treatment. The Seldinger technique has remained the standard for vessel cannulation since it was developed over 50 years ago. The current procedure requires fine motor control at several steps including needle stabilization during guidewire insertion. Ultrasound has been incorporated into the procedure but the current technique does not allow for real time visualization of guidewire advancement.

Ultrasound-Guided Partial Plantar Fascia Release with the Use of a Fine Cutting Device for the Treatment of Persistent Plantar Fasciitis: A Case Series

Plantar fasciitis is a common cause of musculoskeletal discomfort. Minimally invasive interventions are preferred as second-line treatments following failure of conservative management. We report on a novel technique of ultrasound-guided percutaneous release of the medial third of the plantar fascia with the use of a fine cutting device for the treatment of persistent plantar fasciitis. This is a retrospective case series of all patients treated with the technique between 2013 and 2015. Patients had failed conservative management for a minimum of 6 months. The procedure was performed in an outpatient setting under local anesthesia. Under continuous ultrasound guidance, release of the medial third of the plantar fascia from the calcaneus was performed using an ophthalmic V-Lance knife through a medial stab wound entry point. Fifteen patients (six men and nine women) with an average age of 54.7 years were included. The mean (standard deviation [SD]) visual analogue scale score for pain improved significantly, from 66.0 (SD, 18.8) preoperatively to each consecutive follow-up point: 29.3 (SD, 25.2) at 2 weeks, 30.0 (SD, 27.8) at 4 weeks, and 34.0 (SD, 26.1) at 12 weeks (P < .001). The mild increase in visual analogue scale score between 4 and 12 weeks was statistically significant (P = .018). Average duration of required analgesia was 5.5 days and average time required to return to usual activities was 5.7 days. Two patients suffered with refractory neuropathic pain over the lateral border of the foot without any obvious abnormality. Ultrasound-guided percutaneous release with the use of a fine cutting device could be an alternative option for the treatment of persistent plantar fasciitis. The technique is not without complications, and a mild but statistically significant decline in pain levels from early to short term has been detected. Therefore, the long-term outcomes of this technique need to be investigated before we can advocate its routine use.

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance is effective, quick, and safe

ObjectivesThe aim of this study was to assess the feasibility, performance, and complications of a non-surgical, minimally-invasive procedure of deep contraceptive implant removal under continuous ultrasound guidance.MethodsThe ultrasound-guided procedure consisted of local anesthesia using lidocaine chlorhydrate 1% (10 mg/mL) with a 21-G needle, followed by hydrodissection using NaCl 0.9% (9 mg/mL) and implant extraction using a Hartmann grasping microforceps. The parameters studied were the implant localization, success and complication rates, pain throughout the intervention, volumes of lidocaïne and NaCl used, duration of the procedure, and size of the incision. Between November 2019 and January 2021, 45 patients were referred to the musculoskeletal radiology department for ultrasound-guided removal of a deep contraceptive implant and were all retrospectively included.ResultsAll implants were successfully removed en bloc (100%). The mean incision size was 2.7 ± 0.5 mm. The mean duration of the extraction procedure was 7.7 ± 6.3 min. There were no major complications (infection, nerve, or vessel damage). As a minor complication, 21 patients (46.7%) reported a benign superficial skin ecchymosis at the puncture site, spontaneously regressing in less than 1 week. The procedure was very well-tolerated, with low pain rating throughout (1.0 ± 1.5/10 during implant extraction).ConclusionsMinimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, effective, and safe. In the present cohort, all implants were successfully removed, whatever the location, with short procedural time, small incision size, low pain levels, and no significant complications. This procedure could become a gold standard in this indication.Key Points• Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, which led to a success rate of 100% whatever the location (even close to neurovascular structures), with only a small skin incision (2.7 ± 0.5 mm).• The procedure was safe, quick, without any major complications, and very well tolerated in terms of pain.• This minimally invasive ultrasound-guided procedure could become the future gold standard for the removal of deep contraceptive implants, as an alternative to surgical extraction, even for implants in difficult locations such as subfascial ones or those close to neurovascular structures.

MP46-07 PRELIMINARY RESULTS OF IN VIVO FOCAL TRANSPERINEAL LASER ABLATION TREATMENT OF THE PROSTATE: CORRELATION OF mpMRI AND CEUS IMAGING TO HISTOLOGY IN RADICAL PROSTATECTOMY SPECIMEN

You have accessJournal of UrologyProstate Cancer: Localized: Ablative Therapy (MP46)1 Sep 2021MP46-07 PRELIMINARY RESULTS OF IN VIVO FOCAL TRANSPERINEAL LASER ABLATION TREATMENT OF THE PROSTATE: CORRELATION OF mpMRI AND CEUS IMAGING TO HISTOLOGY IN RADICAL PROSTATECTOMY SPECIMEN Luigi van Riel, Rob van Kollenburg, Theo de Reijke, Dilara Savci-Heijink, Marc Engelbrecht, Harrie Beerlage, Ton van Leeuwen, Martijn de Bruin, and Jorg Oddens Luigi van RielLuigi van Riel More articles by this author , Rob van KollenburgRob van Kollenburg More articles by this author , Theo de ReijkeTheo de Reijke More articles by this author , Dilara Savci-HeijinkDilara Savci-Heijink More articles by this author , Marc EngelbrechtMarc Engelbrecht More articles by this author , Harrie BeerlageHarrie Beerlage More articles by this author , Ton van LeeuwenTon van Leeuwen More articles by this author , Martijn de BruinMartijn de Bruin More articles by this author , and Jorg OddensJorg Oddens More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002067.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Focal ablative techniques are an alternative for standard radical therapy of localized prostate cancer (PCa). Soractelite™ transperineal laser ablation (TPLA) using the Echolaser device, with four independent laser sources, is such a novel minimal invasive treatment. We conducted a study in patients planned for radical prostatectomy (RP) to determine the histological ablative efficacy in correlation with CEUS and mpMRI. The size of ablation zone on RP specimens was correlated to CEUS imaging and MRI following TPLA. Furthermore, safety and feasibility of TPLA using a (multi)fiber setup in men with localized PCa will be evaluated. METHODS: A prospective, multicenter and interventional phase I/II pilot study using Soractelite™ with an ablate-and-resect principle was designed that aims to include 15 patients. Patients underwent TPLA procedures, using a single fiber delivering 1800J at 3W under local anesthesia, with continuous ultrasound guidance approximately 4 weeks before RP. Imaging (grayscale US, CEUS and mpMRI) was performed prior to TPLA and RP. Whole-mount H&E-stained slides of RP specimens were digitized. The ablation zone was annotated on imaging and histology, and segmented into 3D models. RESULTS: Three outpatient clinic based TPLA procedures were performed successfully and discharged the same day. The ablation zone on T2-weighted, DCE and CEUS imaging and histology (figure 1) was clearly demarcated upon qualitative analysis and the 3D shape seems to be ellipsoid on MRI and CEUS. This closely matches the annotated ablation zone on histology. Currently, quantitative data, regarding 3D segmentation of T2-weighted, DCE, CEUS and histopathology, is being analyzed to be presented. CONCLUSIONS: TPLA is a feasible office-based minimal invasive focal treatment of PCa and it can be performed safely under local anesthesia, in these preliminary results. Multiple laser fiber configurations will be investigated with ongoing enrollment. The ablation zone is clearly demarcated on CEUS imaging and on MRI T2-weighted and DCE imaging. The histopathological defined 3D ablation zone closely matches the ablation zone seen on imaging. Source of Funding: This study was funded by STW and CfC © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e815-e816 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luigi van Riel More articles by this author Rob van Kollenburg More articles by this author Theo de Reijke More articles by this author Dilara Savci-Heijink More articles by this author Marc Engelbrecht More articles by this author Harrie Beerlage More articles by this author Ton van Leeuwen More articles by this author Martijn de Bruin More articles by this author Jorg Oddens More articles by this author Expand All Advertisement Loading ...

Radiofrequency Ablation: A Novel Treatment Option for Neck Recurrence in Medullary Thyroid Carcinoma

Abstract Background: Medullary thyroid carcinoma (MTC) is an aggressive cancer with cervical lymph node metastases typically found at presentation. The recurrence rate after resection is high (~ 50%)(1), and patients often need multiple surgeries. Radiofrequency ablation (RFA) has been used in treatment of recurrent thyroid cancer when surgery is contraindicated or declined by patients in both Asia and Europe (2). We present the first case of an MTC recurrence treated successfully with RFA in North America. Clinical Case: A 43-year-old female with sporadic metastatic MTC, status post total thyroidectomy and multiple neck surgeries, presented with elevated calcitonin level of 630 pg/mL (normal: &amp;lt; 10 pg/mL). Neck ultrasound showed left tracheoesophageal groove mass, measuring 12 mm X 12 mm X 17 mm, consistent with metastatic MTC on cytopathology with calcitonin washout of 16590 pg/mL (normal: &amp;lt; 10 pg/mL). She had no dysphagia, shortness of breath or hoarseness of voice. Computed tomography (CT) scan of chest confirmed presence of mass, in proximity with left recurrent laryngeal nerve. Serial imaging showed rapid enlargement, with concern for impending aerodigestive tract invasion. Surgical intervention had a high risk of vocal cord paralysis due to the lesion’s location. A multidisciplinary tumor board agreed that thermal ablation aimed at shrinking the mass, as a bridge to systemic therapy, would be the best option. RFA was performed as an outpatient with conscious sedation, after informed consent and observing standard aseptic techniques. Under continuous ultrasound guidance, D5W was injected into left tracheoesophageal groove behind the mass and a continuous infusion of D5W at 15 mL/hr was maintained to protect the nerve from thermal injury. Using a trans-isthmic approach, an 18 G monopolar RFA probe with 5 mm active tip was advanced into the malignant mass and ablation was performed with 35 W power until the entire mass was hyperechoic. Vocal response was monitored throughout the procedure and voice remained normal after RFA. A neck ultrasound at her 6 months follow-up showed ablated lesion measuring 7 mm X 11 mm X 10 mm, representing a 68.6% reduction in volume. Repeat CT scan thorax showed disappearance of mass in left neck region. Conclusion: RFA is a minimally invasive and effective treatment for recurrent cervical MTC lesions, and a viable alternative to surgery, as shown in our case. Future studies should focus on long term follow-up and comparison with surgery with regards to safety and efficacy.

The value of real-time ultrasound-guidance for definite placement of a right supraclavicular subclavian central venous catheter.

Central venous catheters (CVC) are widely used in critically ill patients and in those undergoing major surgery. Significant adverse events, such as pneumothorax and hemothorax, can be caused by needle insertion during CVC insertion. CVC misplacement is less often described, yet equally important, as it can lead to deleterious complications.Here, we describe a case in which misplacement of a guidewire following infraclavicular puncture of the right axillary vein was detected by continuous ultrasound employing the right supraclavicular fossa view. Utilizing this ultrasound view, the insertion approach to the vessel was changed and correct CVC placement could be achieved.While ultrasound guidance is widely accepted for vessel puncture, this case demonstrates the value of continuous ultrasound guidance for the entire process of CVC insertion: vessel puncture, correct guidewire advancement, catheter placement, and exclusion of complications such as pneumothorax. It also shows that there should be a high index of suspicion for guidewire misplacement, even after successful venipuncture.In conclusion, ultrasound protocols covering the complete CVC insertion process should be implemented into current clinical practice.

S1857 EUS-Guided Fine Needle Core Liver Biopsy With a Modified 1-Pass 1-Actuation Wet Suction in Non-Alcoholic Fatty Liver Disease

INTRODUCTION: Liver biopsy is currently the benchmark in the assessment of hepatic disease, particularly in visualizing the histologic degree of fibrosis. However, the invasive nature of traditional sampling methods can pose danger to the patient. The emergence of EUS-guided liver biopsy (EUS-LB) provides the endoscopist the option to offer a treatment modality with advantages such as reduced pain, increased safety due to continuous ultrasound guidance, the ability to take multiple samples with a widened view of the organ, and can be performed in the outpatient setting. CASE DESCRIPTION/METHODS: A 56-year old female with multiple co-morbidities such as obesity, hypertension and diabetes mellitus type 2 presented with right upper abdominal discomfort and worsening fatigue. She denies alcohol use. Physical examination displayed mild hepatomegaly with some tenderness to palpation. AST and ALT levels were moderately elevated. In conjunction with the patient presentation, elevated LFT’s and radiographic findings, nonalcoholic fatty liver disease (NAFLD) was suspected. EUS-guided liver biopsy was selected for this patient. A linear EUS endoscope is advanced into the duodenum at the location of the duodenal bulb. In this position, the left hepatic lobe is located from the proximal stomach or right hepatic lobe. First, open the 19-gauge needle and remove the stylit. After, flush the needle with normal saline. Then, a needle trajectory of approximately 5 cm is chosen, avoiding large vessels. The needle travels through the duodenal wall and into the liver and one pass is made through liver tissue. Withdraw the needle as saline is placed into the syringe at 20 cc suction. Suction is stopped once the sample is obtained. Once the specimen has been collected, it is directly placed into formalin from the needle. DISCUSSION: We have shown the efficacy of EUS-MLB. It has been shown to accurately predict fibrosis in patients with fatty liver disease and several studies cite a range of diagnostic yields ranging from 91 to 100%. However, some potential pitfalls include the similar visual nature of the liver and spleen on EUS, a misidentified spleen can result in an adverse bleeding complication. Additionally, tissue sample yield can be dependent on the endoscopist’s technical skill with this complex procedure.Figure 1.: EUS displaying increased areas of hepatic echogenicity suggestive of NAFLD.Figure 2.: 19-gauge needle advancing through the liver using one pass to obtain optimal viable tissue sample.Figure 3.: Live view of parenchymal tissue obtained via EUS.

Fetoscopic Balloon Dilation and Cricotracheal Resection for Laryngeal Atresia in CHAOS.

View Supplementary Video 1 Laryngoscope, 131:660–662, 2021

The role of ultrasound imaging in the management of partial placental retention after third trimester livebirth

Objectives To evaluate the impact of different ultrasound signs in the management and the role of ultrasound guidance in the surgical evacuation of partial placental tissue retention. Methods This is an observational cohort study and retrospective case assessment of 82 patients with clinical symptoms of partial placental retention following a third trimester singleton livebirth between January 2013 and May 2019. The ultrasound signs were recorded using a standardized protocol and the outcome of the management strategy and the use of ultrasound guidance during any surgical procedure was evaluated. Results Out of the 64 patients who had a vaginal birth, 25 (39.1%) had a manual removal of the placenta at delivery. Fifteen patients were confirmed as not having retained placental tissue and did not require further treatment. Four patients were referred after failed surgical management and four after failed conservative management. All surgical procedures were vacuum aspiration and forceps removal under continuous ultrasound guidance. A significantly lower gestational age at delivery (p < .05), shorter interval between delivery and ultrasound diagnosis (p < .05) and lower number of patients presenting with heavy bleeding was found in the conservative compared to the surgical management subgroups (p < .05). The incidence of feeding vessels was significantly (p < .05) higher in the surgical than in the conservative management subgroups and associated with increased myometrial vascularity. Six patients developed intra-uterine adhesions. In four of these cases, ultrasound examination showed a hyperechoic mass surrounded by normal myometrial vascularity and no feeding vessel. Conclusions Ultrasound imaging accurately differentiated between patient with and without partial placental retention after third trimester livebirth. Ultrasound-guided vacuum aspiration is safe and efficient in these cases.

Percutaneous sclerotherapy with polidocanol under the guidance of ultrasound for venous malformations in children - A retrospective cohort study from a single tertiary medical center.

This study reports our experience, the therapeutic outcomes and complications of percutaneous sclerotherapy (PS) with polidocanol to treat venous malformations (VMs) in children.A retrospective analysis was conducted of pediatric patients with VMs who underwent PS using polidocanol under continuous ultrasound (US) guidance between January 2015 and January 2018 at our department. Medical records were reviewed to record demographic information, lesion characteristics, treatment sessions, therapeutic outcomes and complications. χ2 analysis was employed to evaluate the effects of these characteristics on outcomes.Hundred treatment sessions were performed for lesions in 47 patients. The mean age of the patients was 4.1 ± 3.6 years (mean ± SD). The female to male ratio was almost 2:1 (female 32, male 15). The location of the VMs included the head and neck in 16 cases (34.0%), upper extremity in 11 cases (23.4%), lower extremity in 10 cases (21.3%), and trunk and perineum in 10 cases (21.3%). The majority of the lesions were focal in 36 cases (76.6%), while 11 (23.4%) were diffuse. Seventeen patients (36.2%) underwent single PS session, 14 patients (29.8%) underwent 2 sessions, 10 patients (21.3%) underwent 3 sessions and 6 patients (12.7%) underwent ≧4 sessions. The mean PS session per patient was 2.1 ± 1.1. The mean follow-up duration was 11.4 ± 7.6 months. After the last PS session, 8 patients (17.0%) had excellent outcomes, 27 (57.4%) had good outcomes, 10 (21.3%) had fair outcomes, and 2 (4.3%) had poor outcomes. Focal lesions were more likely to have good or excellent outcomes than diffuse lesions (χ2 = 4.522, P = .033). No other lesion characteristic significantly affected the outcomes (good or excellent outcomes), including lesion location (χ2 = 2.011, P = .570) or lesion size (χ2 = 1.045, P = .307). After the PS procedure, temporary local swelling occurred in 81 sessions (81.0%), local pain occurred in 15 sessions (15.0%), fever occurred in 27 (27.0%) sessions, and transient local numbness occurred in four sessions (4.0%).PS with polidocanol under the guidance of US appears to be safe and effective for the treatment of VMs in children, especially for focal lesions.

1147: The role of ultrasound in the management of third stage of second trimester delivery

The use of intraoperative sonographic guidance for second trimester elective dilation and curettage (D & E) procedure reduces the incidence of uterine perforation. Nevertheless, the role of intraoperative sonographic guidance during curettage procedure following second trimester medical induction has not been evaluated. We aim to evaluate the effect of intraoperative sonographic guidance during curettage procedure following second trimester uterine evacuation. A retrospective cohort study performed in a Gynecology department at a tertiary university-affiliated medical center including patients undergoing second trimester medical induction up to 23 6/7 weeks estimated gestational age who underwent uterine curettage after delivery of the fetus. Women undergoing curettage procedure under continuous ultrasound guidance were compared with those undergoing curettage without ultrasound guidance One hundred ninety four patients underwent a curettage without intraoperative sonographic guidance, while 79 underwent the procedure utilizing intraoperative sonographic guidance. The overall rate of composite adverse outcome was higher among those undergoing curettage under intraoperative sonographic guidance as compared with no sonographic guidance (39.2% vs. 20.6%, P=0.002). Placental morbidity (12.6% vs. 5.6%, P=0.04) and infectious complications (7.5% vs. 2.5%. P=0.05) were more frequent among those undergoing curettage using intraoperative sonographic guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with an adverse outcome (P=0.001). Procedure time was longer when ultrasound guidance was used; 9:52 min. vs. 6:58 min. (P< 0.001). Intraoperative ultrasonography guidance during curettage after second trimester uterine evacuation is associated with a higher complication rate than no guidance.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1262 The Role of Ultrasound in the Management of Third Stage of Second Trimester Delivery: A Retrospective Cohort Study

Study Objective The use of intraoperative sonographic guidance for second trimester elective dilation and curettage (D & E) procedure reduces the incidence of uterine perforation. Nevertheless, the role of intraoperative sonographic guidance during curettage procedure following second trimester medical induction has not been evaluated. We aim to evaluate the effect of intraoperative sonographic guidance during curettage procedure following second trimester uterine evacuation. Design A retrospective cohort study. Setting A Gynecology department at a tertiary university‐affiliated medical center. Patients or Participants Patients undergoing second trimester medical induction up to 23 6/7 weeks estimated gestational age who underwent uterine curettage after delivery of the fetus. Interventions Women undergoing curettage procedure under continuous ultrasound guidance were compared with those undergoing curettage without ultrasound guidance. Measurements and Main Results One hundred ninety four patients underwent a curettage without intraoperative sonographic guidance, while 79 underwent the procedure utilizing intraoperative sonographic guidance. The overall rate of composite adverse outcome was higher among those undergoing curettage under intraoperative sonographic guidance as compared with no sonographic guidance (39.2% vs. 20.6%, P=0.002). Placental morbidity (12.6% vs. 5.6%, P=0.04) and infectious complications (7.5% vs. 2.5%. P=0.05) were more frequent among those undergoing curettage using intraoperative sonographic guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with an adverse outcome (P=0.001). Procedure time was longer when ultrasound guidance was used; 9:52 min. vs. 6:58 min. (P Conclusion Intraoperative ultrasonography guidance during curettage after second trimester uterine evacuation is associated with a higher complication rate than no guidance.

Long-term outcome following laser therapy of benign cystic-solid thyroid nodules.

ObjectiveLaser therapy (LT) is considered a safe and effective procedure for inducing thyroid nodule necrosis, fibrosis and shrinkage. Little is known about long-term efficacy of LT in benign complex thyroid nodules, which we report here.Design and methodsOne hundred and ten euthyroid outpatients (28 men and 82 women; median age 48 years (range 17–82)) with a recurrent cytologically benign cystic (≥2 mL cyst volume) thyroid nodule causing local discomfort were assigned to LT. LT was performed after complete cyst aspiration and under continuous ultrasound (US) guidance. Nineteen patients (17 within 6 months) had surgery after LT. The median follow-up for the remaining 91 patients was 45 months (range: 12–134).ResultsThe overall median nodule volume in the 110 patients decreased from 9.0 mL (range: 2.0–158.0) to 1.2 mL (range: 0.0–85.0) (P < 0.001) at the final evaluation, corresponding to a median reduction of 85% (range: −49 to 100%). Remission of the cystic part (volume ≤1 mL) was obtained in 82 of 110 (75%) patients after LT. The median cyst volume decreased from 6.3 mL (range: 2.0–158.0) to 0.0 mL (range: 0.0–85.0) (P < 000.1), corresponding to a median reduction of 100% (range: −49 to 100%). These results correlated with a significant decrease in pressure as well as cosmetic complaints. Side effects were restricted to mild local pain.ConclusionUS-guided aspiration and subsequent LT of benign recurrent cystic thyroid nodules results in a satisfactory long-term clinical response in the majority of patients. LT constitutes a clinically relevant alternative to surgery in such patients.

Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer

BackgroundIntraoperative ultrasound guided (IUG) breast conserving surgery (BCS) is being increasingly embraced by breast surgeons worldwide. We aimed to compare the efficacy of IUG-BCS for palpable and nonpalpable breast cancer with respect to margin status, re-excision rate, tissue sacrifice and cost-time analysis. MethodsIntraoperative localization protocol includes intraoperative ultrasound prior to excision to localize the lesion and guide the initial resection. The excised specimen was then examined visually and by palpation and the specimen and cavity was examined with ultrasound. Frozen sections were obtained routinely from a portion of all six faces of the resected specimen, and shaved cavity margins were sent for permanent histology. ResultsOf the 208 patients, 57.2% had nonpalpable tumors. The sensitivity of ultrasound localization was 100%. Negative margins were achieved in 92.43% of nonpalpable and 91.01% of palpable lesions at initial procedure. The involved margins were correctly identified by the surgeon via specimen sonography in 95.4% of cases. Final positive margin rate was 2.4%. Calculated resection ratio and time analysis revealed nothing significant. ConclusionIUG-BCS is an invaluable and effective modality for obtaining clear surgical margins with optimum resection volumes and reducing re-operations. Furthermore, by means of this algorithm, in case of shaving cavity margins of the tumor bed for permanent analysis, frozen section evaluation might be omitted.

Factors related to recurrence of the benign non-functioning thyroid nodules after percutaneous microwave ablation

Purpose: To determine the factors affecting the recurrence of the solitary benign thyroid nodules (BTN) after microwave ablation (MWA).Materials and methods: Between January 2013 and January 2015, a total of 110 patients with at least one solid thyroid nodule (solid component ≥ 80%) were enrolled. MWA was performed under continuous ultrasound (US) guidance. Before and during the follow-up, the thyroid nodule volume, thyroid function and cosmetic complaints were evaluated. Recurrence is defined by the new blood flow in the total ablation area or/and > 50% increase in nodule volume.Results: Almost all thyroid nodules were significantly decreased in size after MWA. After 12 months, the average volume of thyroid nodules was decreased from 12.6 ± 15.1 to 3.2 ± 5.7 ml. Of the total 110 patients, 16 cases had recurrence 12 months after MWA, and these patients had a larger initial volume than that of the non-recurrence patients (11.6 ± 14.9 vs. 23.9 ± 12.5, p < 0.01). The recurrence group also demonstrated more irregular blood vessels (1.8 8 ± 1.1 vs. 2.8 5 ± 1.3, p < 0.05), and a lower energy (1575.5 ± 674.3 J/ml vs. 1172.3 ± 454.2 J/ml, p < 0.01). In addition, 81.2% (13/16) of the patients in the recurrence group were adjacent to the vital structures, which is significantly higher than that of the non-recurrence group 28.7% (27/94) (p < 0.01).Conclusions: The US-guided MWA results in a satisfactory long-term outcome of the patients with a benign solitary thyroid nodule. We identified three risk factors for recurrence: initial volume, vascularity and the energy per 1 ml reduction in nodular volume.

Non-Responding Knee Pain with Osteoarthritis, Meniscus and Ligament Tears Treated with Ultrasound Guided Autologous, Micro-Fragmented and Minimally Manipulated Adipose Tissue

Background: Chronic knee pain from advanced osteoarthritis is often associated with tears in the fibro-cartilaginous meniscus and cruciate ligaments. The result is substantial pain and impairments and loss of daily function, thus limiting activity and quality of life. These often include pain, loss of range of 116 motion, inability to elevate the leg, pain increased with activity and gradual worsening over time. This represents a challenging clinical picture for which few non-surgical options are available. Most patients failing to respond to current methods of care are offered arthroplasty. Current therapies are focused on the relief of the symptoms but cannot repair the damage nor stop the degenerative process. Objective: This is a case study of the first subject in a continuing IRB to reach a 2.5 year end-point. Our intention was to investigate the potential benefits of using autologous, minimally manipulated fat graft in subjects with advanced osteoarthritis and meniscus pathology who had failed to obtain benefit from previous, standards of care. Study description: 73 YO male, end stage bone-on-bone right knee pain. First subject to reach the 2 1/2 year follow up after Lipogems® precision ultrasound guided injections. Material and Methods: Micro-fragmented fat was obtained using a minimal manipulation technology in a closed system, Lipogems®, without the addition of enzymes or other additives. Fat graft was injected under continuous ultrasound guidance. Results: VAS pain, KOOS function, range of motion and quadriceps strength improved after treatment. Conclusion: Autologous, micronized, and minimally manipulated adipose tissue resulted in significant improvement in pain, function and quality of life. No adverse events were reported.

Guidelines on transfusion for fetuses, neonates and older children.

Guidelines on transfusion for fetuses, neonates and older children.