Intraoperative Contrast-enhanced Ultrasound Research Articles

Survival Analysis of Patients Undergoing Intraoperative Contrast-enhanced Ultrasound in the Surgical Treatment of Malignant Glioma.

Complete resection of malignant gliomas is often challenging. Our previous study indicated that intraoperative contrast-enhanced ultrasound (ICEUS) could aid in the detection of residual tumor remnants and the total removal of brain lesions. This study aimed to investigate the survival rates of patients undergoing resection with or without the use of ICEUS and to assess the impact of ICEUS on the prognosis of patients with malignant glioma. A total of 64 patients diagnosed with malignant glioma (WHO grade HI and IV) who underwent surgery between 2012 and 2018 were included. Among them, 29 patients received ICEUS. The effects of ICEUS on overall survival (OS) and progression-free survival (PFS) of patients were evaluated. A quantitative analysis was performed to compare ICEUS parameters between gliomas and the surrounding tissues. The ICEUS group showed better survival rates both in OS and PFS than the control group. The univariate analysis revealed that age, pathology and ICEUS were significant prognostic factors for PFS, with only age being a significant prognostic factor for OS. In multivariate analysis, age and ICEUS were significant prognostic factors for both OS and PFS. The quantitative analysis showed that the intensity and transit time of microbubbles reaching the tumors were significantly different from those of microbubbles reaching the surrounding tissue. ICEUS facilitates the identification of residual tumors. Age and ICEUS are prognostic factors for malignant glioma surgery, and use of ICEUS offers a better prognosis for patients with malignant glioma.

Enhancing the Extent of Resection in Glioma Surgery Through the Integration of Intraoperative Contrast-Enhanced Ultrasound and Fluorescein Sodium

Due to the infiltrative nature and high local recurrence of gliomas, particularly high-grade gliomas, gross total resection (GTR) of a tumor is the first critical step in treatment. This study aimed to determine whether the integration of intraoperative contrast-enhanced ultrasound (CEUS) and fluorescein sodium can improve the identification of tumor boundaries and residuals, and increasethe extent of resection (EOR) to better protect neurological function. We retrospectively analysed clinical data from 87 glioma surgeries and categorised the patients into 3 groups: CEUS plus fluorescein sodium, fluorescein sodium alone and microsurgery alone. In terms of EOR, GTR was achieved in 22 (91.7%) patients in the CEUS plus fluorescein sodium group, which was significantly higher than that in other groups. In the subgroup analysis of tumors with lobulated or satellite lesions and WHO grade III or IV gliomas, CEUS plus fluorescein sodium group showed the highest GTR (86.7% and 88.9% respectively) among the groups. Logistic regression analysis of factors that may affect the GTR of tumors showed that the functional areas involvement and the presence of lobulated or satellite lesions were risk factors, whereas CEUS plus fluorescein sodium group was a protective factor. However, CEUS plus fluorescein sodium group had the longest surgery time. Intraoperative CEUS with fluorescein sodium is a real-time, straightforward, safe, and effective approach to perform surgical resection of gliomas. This approach assists surgeons in identifying tumor boundaries, residual tumors, and normal brain parenchyma, which increases the EOR.

Intraoperative contrast-enhanced ultrasound has an outcome-relevant impact on surgery of primary and metastatic liver lesions

Abstract Purpose Complete resection of the affected tissue remains the best curative treatment option for liver-derived tumors and colorectal liver metastases. In addition to preoperative cross-sectional imaging, contrast-enhanced intraoperative ultrasound (CE-IOUS) plays a crucial role in the detection and localization of all liver lesions. However, its exact role is unclear. This study was designed to evaluate the clinical and oncological impact of using CE-IOUS in the surgical treatment of these diseases. Materials and Methods Over the three-year study period, 206 patients with primary liver tumors and hepatic metastases were enrolled in this prospective, monocentric study to evaluate the impact of CE-IOUS in liver surgery. Secondary outcomes included comparing the sensitivity and specificity of CE-IOUS with existing preoperative imaging modalities and identifying preoperative parameters that could predict a strategic impact of CE-IOUS. In addition, the oncological significance of CE-IOUS was evaluated using a case-cohort design with a minimum follow-up of 18 months. Results CE-IOUS findings led to a change in surgical strategy in 34% of cases (n=70/206). The accuracy in cases with a major change could be confirmed histopathologically in 71.4% of cases (n=25/35). The impact could not be predicted using parameters assumed to be clinically relevant. An oncological benefit of a CE-IOUS adapted surgical approach was demonstrated in patients suffering from HCC and colorectal liver metastases. Conclusion CE-IOUS may significantly increase R0 resection rates and should therefore be used routinely as an additional staging method, especially in complex liver surgery.

Effectiveness of Intra-operative Contrast-Enhanced Ultrasound Assessment to Optimize Type II Endoleak Embolization.

To analyze the effectiveness of type II endoleaks (T2E) embolization using intra-operative contrast-enhanced ultrasound (CEUS). Consecutive patients treated for T2E underwent a standardized protocol with trans-arterial or trans-lumbar access, large volume embolization, onlay fusion, and intra-operative CEUS. Technical success was defined by exclusion of endoleak by CEUS. Twenty-six patients (mean age 81 ± 11years old; 89% male) were treated. The mean aneurysm sac enlargement was 11 ± 8mm from T2E diagnosis. Embolization was performed using Onyx® 18 in all patients with adjunctive coils in 13 patients (50%). After the first embolization, CEUS documented residual T2E in 13 patients (50%). Ten patients (38%) had additional embolization, which successfully eradicated the T2E in seven of them. Technical success was 50% after the first embolization attempt and 77% after additional attempts guided by CEUS (P = 0.080). There was no mortality. Median imaging follow-up was 22months. Among the 20 patients with no residual T2E on completion CEUS, 16 (80%) had sac stabilization and none required additional interventions for T2E. Of the six patients with residual T2Es on CEUS, three had sac stabilization (50%) and one required additional reintervention for T2E. There was one late aortic rupture at 56months. One in two patients treated by T2E embolization had residual endoleak on intra-operative CEUS after a first embolization attempt, decreasing to one in four patients after multiple attempts. A negative completion CEUS following embolization was associated with higher rates of sac stabilization and no need for additional T2E embolization.

Intraoperative contrast-enhanced ultrasound evaluates the hemodynamic change of cerebral revascularization in adult moyamoya disease: Preliminary results

PurposeThis study aimed to determine the feasibility of using intraoperative contrast-enhanced ultrasound (CEUS) to assess subcortical hemodynamic changes in moyamoya disease patients who had undergone combined revascularization. It also aimed to investigate the correlation between quantitative CEUS parameters and post-operative neural functional recovery. MethodsThis study included seventeen patients diagnosed with moyamoya disease, confirmed through cerebral angiography, who underwent combined revascularization. Intraoperative subcortical hemodynamics were assessed using CEUS before and immediately after cerebrovascular bypass. Hemodynamic parameters were calculated by analyzing the time-intensity curve generated from a defined region of interest in each CEUS video. Post-operative neurological symptoms, computed tomography records, and short-term modified Rankin Scale (mRS) scores were also recorded. ResultsDuring the post-operative follow-up, 29.4 % of the patients experienced new neurological symptoms, including epilepsy, dyskinesia, and language impairment. Overall, CEUS quantitative parameters suggested that blood supply improved after surgery. And certain hemodynamic parameters exhibited a stronger correlation with the mRS scores, with correlation coefficients ranging up to 0.73 (p < 0.01). However, no statistically significant differences were observed among the different functional groups. The advanced parameter of wash-out intensity (δ WOI), which signifies the rate of change at the point when blood flow is completely washed out, demonstrated a significant difference between two functional groups (p = 0.02) and exhibited a correlation with mRS scores (correlation coefficients: 0.55, p = 0.02). ConclusionsThis preliminary study suggests that quantitative intraoperative CEUS can measure subcortical hemodynamic changes. It provides a novel non-invasive method that may predict the short-term post-operative neural functional recovery of combined revascularization in moyamoya disease patients.

Intraoperative Contrast-Enhanced Ultrasonography (Io-CEUS) in Minimally Invasive Thoracic Surgery for Characterization of Pulmonary Tumours: A Clinical Feasibility Study.

The intraoperative detection of solitary pulmonary nodules (SPNs) continues to be a major challenge, especially in minimally invasive video-assisted thoracic surgery (VATS). The location, size, and intraoperative frozen section result of SPNs are decisive regarding the extent of lung resection. This feasibility study investigates the technical applicability of intraoperative contrast-enhanced ultrasonography (Io-CEUS) in minimally invasive thoracic surgery. In this prospective, monocentric clinical feasibility study, n = 30 patients who underwent Io-CEUS during elective minimally invasive lung resection for SPNs between October 2021 and February 2023. The primary endpoint was the technical feasibility of Io-CEUS during VATS. Secondary endpoints were defined as the detection and characterization of SPNs. In all patients (female, n = 13; mean age, 63 ± 8.6 years) Io-CEUS could be performed without problems during VATS. All SPNs were detected by Io-CEUS (100%). SPNs had a mean size of 2.2 cm (0.5-4.5 cm) and a mean distance to the lung surface of 2.0 cm (0-6.4 cm). B-mode, colour-coded Doppler sonography, and contrast-enhanced ultrasound were used to characterize all tumours intraoperatively. Significant differences were found, especially in vascularization as well as in contrast agent behaviour, depending on the tumour entity. After successful lung resection, a pathologic examination confirmed the presence of lung carcinomas (n = 17), lung metastases (n = 10), and benign lung tumours (n = 3). The technical feasibility of Io-CEUS was confirmed in VATS before resection regarding the detection of suspicious SPNs. In particular, the use of Doppler sonography and contrast agent kinetics revealed intraoperative specific aspects depending on the tumour entity. Further studies on Io-CEUS and the application of an endoscopic probe for VATS will follow.

Quantitative analysis using intraoperative contrast-enhanced ultrasound in adult-type diffuse gliomas with isocitrate dehydrogenase mutations: association between hemodynamics and molecular features.

The relationship between contrast-enhanced ultrasound (CEUS) hemodynamics and the molecular biomarkers of adult-type diffuse gliomas, particularly isocitrate dehydrogenase (IDH), remains unclear. This study was conducted to provide a comprehensive description of the vascularization of adult-type diffuse gliomas using quantitative indicators. Additionally, it was designed to identify any variables with the potential to intraoperatively predict IDH mutation status. This prospective study enrolled patients with adult-type diffuse gliomas between November 2021 and September 2022. Intraoperative CEUS was performed, and CEUS videos were recorded for 90-second periods. Hemodynamic parameters, including the peak enhancement (PE) difference, were calculated based on the time-intensity curve of the region of interest. A differential analysis was performed on the CEUS parameters with respect to molecular biomarkers and grades. Receiver operating characteristic curves for various parameters were analyzed to evaluate the ability of those parameters to predict IDH mutation status. Sixty patients with adult-type diffuse gliomas were evaluated. All hemodynamic parameters, apart from rising time, demonstrated significant differences between IDH-mutant and IDH-wildtype adult-type diffuse gliomas. The PE difference emerged as the optimal indicator for differentiating between IDH-wildtype and IDH-mutant gliomas, with an area under the curve of 0.958 (95% confidence interval, 0.406 to 0.785). Additionally, the hemodynamic parameters revealed significant differences across both grades and types of adult-type diffuse gliomas. Hemodynamic parameters can be used intraoperatively to effectively distinguish between IDHwildtype and IDH-mutant adult-type diffuse gliomas. Additionally, quantitative CEUS equips neurosurgeons with dynamic perfusion information for various types and grades of adult-type diffuse gliomas.

Increased blood flow of spinal cord lesion after decompression improves neurological recovery of degenerative cervical myelopathy: an intraoperative ultrasonography-based prospective cohort study.

Surgical decompression is a highly effective therapy for degenerative cervical myelopathy (DCM), but the mechanisms of neurological recovery following decompression remain unclear. This study aimed to evaluate the spinal cord blood flow status after sufficient decompression by intraoperative contrast-enhanced ultrasonography (CEUS) and to analyze the correlation between neurological recovery and postdecompressive spinal cord blood perfusion in DCM. Patients with multilevel DCM were treated by ultrasound-guided modified French-door laminoplasty using a self-developed rongeur. Neurological function was evaluated using the modified Japanese Orthopaedic Association (mJOA) score preoperatively and at 12 months postoperatively. Spinal cord compression and cervical canal enlargement before and after surgery were assessed by magnetic resonance imaging and computerized tomography. The decompression status was evaluated in real time by intraoperative ultrasonography, while the spinal cord blood flow after sufficient decompression was assessed by CEUS. Patients were categorized as favourable (≥50%) or unfavourable (<50%) recovery according to the recovery rate of the mJOA score at 12 months postoperatively. Twenty-nine patients were included in the study. The mJOA scores were significantly improved in all patients from 11.2±2.1 preoperatively to 15.0±1.1 at 12 months postoperatively, with an average recovery rate of 64.9±16.2%. Computerized tomography and intraoperative ultrasonography confirmed adequate enlargement of the cervical canal and sufficient decompression of the spinal cord, respectively. CEUS revealed that patients with favourable neurological recovery had a greater increased blood flow signal in the compressive spinal cord segment after decompression. In DCM, intraoperative CEUS can clearly reflect spinal cord blood flow. Patients with increased blood perfusion of the spinal cord lesion immediately after surgical decompression tended to achieve greater neurological recovery.

Radiofrequency Ablation of Hepatocellular Carcinomas Adjacent to the Gallbladder Without Isolation Under Contrast-Enhanced Ultrasound Monitoring: A Comparative Study with Long Term Follow-Up.

This study intends to compare the efficacy and safety between patients undergoing invasive isolation or monitoring measures and patients undergoing intra-operative contrast-enhanced ultrasound (CEUS) monitoring who underwent radiofrequency ablation (RFA) of hepatocellular carcinomas (HCC) adjacent to the gallbladder (GB). We retrospectively assessed patients with HCC adjacent to the GB who underwent ultrasound-guided RFA. They were divided into two groups: group A was monitored under intra-operative CEUS, while group B was assisted by invasive auxiliary means. The efficacy, complications and survival were followed up and compared. Thirty-eight patients with 39 HCCs were enrolled into group A and 31 patients with 35 HCCs were enrolled into group B. The technique efficacy rates were both 100% in the two groups. There were no significant differences of the cumulative 1-, 3-, and 5-year local tumor progression, tumor-free survival and overall survival between the two groups (P = 0.851, 0.081 and 0.700, respectively). There were no significant differences of major and minor complications rates between the two groups (P = 1.000, 0.994, respectively). More importantly, no GB related complications occurred in group A. Intra-operative CEUS monitoring without protective isolation of the GB might be also a potentially safe and effective method for the RFA of HCC adjacent to the GB, when compared with those assisted with invasive auxiliary means.

Fully Ultrasound-Assisted Endovascular Aneurysm Repair: Preliminary Report

Reducing fluoroscopy times and iodine contrast administration during endovascular repair (EVAR) of infrarenal aortic aneurysms remains a challenge. The purpose of this study is to evaluate the preliminary results of a fully ultrasound-assisted EVAR without iodine contrast administration. Twenty-seven consecutive patients underwent an elective intravascular ultrasound (IVUS)-assisted EVAR with final contrast-enhanced ultrasound (CEUS) control of correct aneurysm exclusion. In no case intraprocedural injection of iodine contrast medium was performed. The primary study's end points were the overall duration of the procedure, duration of fluoroscopy, cumulative radiation dose, the length of intraoperative CEUS control, and the comparison of findings between intraoperative CEUS and computed tomography (CT) scan at 1 month. Mean duration of the procedure was 130±35min. Overall duration of fluoroscopy was22±18min. Mean radiation dose was 66mGy (range 24-82). The mean length of CEUS final control was 8±2min. No type I or type III endoleak was detected either at CEUS or at angio-CT scan at 1 month from EVAR. CEUS revealed a type II endoleak in 6 patients (22%), compared to 9 type II endoleaks (33%) detected at angio-CT scan 1 month after the procedure (P=0.5). Fully ultrasound (IVUS and CEUS)-assisted EVAR is safe, feasible, and reliable, completely eliminating the need for iodine contrast medium and reducing the radiation exposure for both patients and surgeons.

Application of Intraoperative Contrast-Enhanced Ultrasound in the Resection of Brain Tumors.

To investigate the value of routine intraoperative ultrasound (IU) and intraoperative contrast-enhanced ultrasound (ICEUS) in the surgical treatment of brain tumors, and to explore the utilization of ICEUS for the removal of the remnants surrounding the resection cavity. In total, 51 patients who underwent operations from 2012 to 2018 due to different tumors in the brain were included in this study. The clinical data were evaluated retrospectively. IU was performed in all patients, among which 28 patients underwent ICEUS. The effects of IU and ICEUS on tumor resection and recurrence were evaluated. Semiquantitative analysis was performed to compare ICEUS parameters of the brain tumor with those of the surrounding tissue. In total, 36 male and 15 female patients were included in this study. The average age was 43 years (range: 14-68 years). The follow-up period was from 7 to 74 months (mean follow-up 32 months). IU was used in all patients, and no lesion was missed. Among them, 28 patients underwent ICEUS. The rate of total removal of the ICEUS group (23/28, 82%) was significantly higher than that of the IU group (11/23, 48%) (P<0.05). The recurrence rate of ICEUS and IU was 18% (5/23), and 22% (5/28), respectively, and the difference did not reach statistical significance (P>0.05). The semiquantitative analysis showed that the intensity and the transit time of microbubbles reaching the lesions were significantly different from the intensity and the transit time of microbubbles reaching the surrounding tissue (P<0.05) and reflected indirectly the volume and the speed of blood perfusion in the lesions was higher than those in the surrounding tissue. ICEUS is a useful tool in localizing and outlining brain lesions, especially for the resection of the hypervascular lesions in the brain. ICEUS could be more beneficial for identifying the remnants and improving the rate of total removal of these lesions than routine intraoperative ultrasound.

Intraoperative Ultrasound: Emerging Technology and Novel Applications in Brain Tumor Surgery.

Intraoperative ultrasound (IOUS) is becoming progressively more common during brain tumor surgery. We present data from our case series of brain tumor surgery performed with the aid of IOUS in order to identify IOUS advantages and crucial aspects that may improve the management of neurosurgical procedures for brain tumors. From January 2021 to September 2021, 17 patients with different brain tumors underwent brain tumor surgery aided by the use of IOUS. During surgery, the procedure was supported by the use of multiples ultrasonographic modalities in addition to standard B-mode: Doppler, color Doppler, elastosonography, and contrast-enhanced intraoperative ultrasound (CEUS). In selected cases, the use of IOUS during surgical procedure was combined with neuronavigation and the use of intraoperative fluorescence by the use of 5-aminolevulinic acid (5-ALA). In one patient, a preoperative ultrasound evaluation was performed through a former iatrogenic skull defect. This study confirms the role of IOUS in maximizing the EOR, which is strictly associated with postoperative outcome, overall survival (OS), and patient’s quality of life (QoL). The combination of ultrasound advanced techniques such as Doppler, color Doppler, elastosonography, and contrast-enhanced intraoperative ultrasound (CEUS) is crucial to improve surgical effectiveness and patient’s safety while expanding surgeon’s view.

Contrast-enhanced Intraoperative Ultrasound (CE-IOUS) in Patients with Pancreatic Cancer Undergoing Surgery: Early Outcomes of a Prospective Trial

Introduction: Contrast-enhanced intraoperative ultrasound (CE-IOUS) represents an important innovation in hepato-pancreato-biliary imaging. Nonetheless, there is only limited evidence regarding its use during pancreatic surgery. The purpose of the present study was to prospectively assess the potential role of CE-IOUS during pancreatic surgery for the assessment of resectability/staging of the primary tumor, along with identification of potential liver metastases. Method: The protocol of the present study has been registered at clinicaltrials.gov (identifier: NCT04683497). Thirty patients (77% males, mean age 64 years) underwent surgery for pancreatic cancer between November 2020 and July 2021. All patients underwent multidetector Computed Tomography (MDCT), Magnetic Resonance Imaging (MRI), IOUS and CE-IOUS using Sonovue©. Location of the primary tumor, relation to the main vessels, contrast medium uptake modalities, presence of liver metastases, and multifocal pancreatic involvement were evaluated. Results: Twenty-five of the included patients presented pancreatic ductal adenocarcinoma, four patients neuroendocrine tumor, and one patient acinar cell carcinoma (head:24, tail:6). Eight new liver lesions (all metastases) were identified using CE-IOUS in six patients (20%) leading to change of surgical plan (Whipple procedure with resection of segment IV in one patient, Whipple procedure with wedge resection in the second patient, and palliative surgery in four patients). All these new findings were diagnosed after contrast-enhancement; one injection was performed per lesion. Intraoperative findings regarding location and characteristics of primary tumor did not differ from those obtained with preoperative imaging. Conclusions: According to our initial experience, CE-IOUS is a safe and efficient imaging modality with direct impact on operation strategy.

The Dilemma of the Disappeared Colorectal Liver Metastasis: Systematic Review of the Systematic Reviews

Introduction: Colorectal liver metastasis (CRLM) contributes to approximately 50% of metastasis related mortality in patient with colorectal cancer. Tumour response to chemotherapy has significantly improved. As a results, a phenomenon termed “disappearing Colorectal Liver Metastases” (dCRLM) develops. The aim of this study is to evaluate if the best management of dCRLM could be recommended from the available literature. Method: English language published literature was searched with no restriction on date. Systematic reviews were the primary target for inclusion. The main outcomes were recurrence free survival (DFS), overall survival (OS) for both treated lesions and those underwent surveillance, complete pathological response (CPR) in resected dCRLM and sensitivities of different imaging modalities. Meta-analysis was conducted. Results: Out from 38 records, only 7 reviews were included. The standard contrast enhanced computed tomography (CE-CT) was inferior to high-resolution gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) in detecting CRLM after chemotherapy. Preoperative imaging is twice as likely to miss dCRLM as intraoperative imaging. Out of 919 surgically resected dCRLMs, 389 (42.3%) (IQR: 27.9-65.8%) achieved CPR. Out of 472 dCRLMs left in situ, 153 (32.4%) had recurrence (IQR: 20.5-57.8%). Conclusion: The best management for dCRLM could not be recommended due to the low quality of literature . However, trends are observed for better outcomes with surgery for patients with CPR. CPR could be induced by Hepatic artery infusion. EOB-MRI should be a preferred preoperative imaging modality for patients with CRLM and CE-IOUS could be an alternative.Tabled 1EP01A-068ComparisonResultRisk of missing CRLM after chemotherapy: CE-CT vs EOB-MRIRisk ratio: 2.26, CI (1.16-4.39), P<0.00001Risk of missing CRLM after chemotherapy: EOB-MRI vs Contrast enhanced intraoperative ultrasound (CE-IOUS)Risk ratio: 1.10,CI (0.99-1.23), P=0.08Risk of missing dCRLM: CE-IOUS vs Intraoperative ultrasound (IOUS)Risk ratio: 0.42, CI (0.16-1.07), P=0.07Risk of missing CRLM after chemotherapy: Preoperative vs intra-operative imagingRisk ratio: 2.52,CI (1.80-3.50), P<0.00001Risk of not acheiving CRR : Hepatic artery infusion (HAI) chemotherapy vs non-HAI chemotherapyRisk ratio:0.72, CI(0.51-1.01),P=0.06Risk of not achieving CPR in resected lesions: HAI chemotherapy vs non-HAI chemotherapyRisk ratio: 0.03, CI (0.00-0.20), P=0.0003DFS : resected dCRLM showed CPR vs no CPRHazard ratio: 0.40, CI (0.01-12.70), P=0.60OS : resected dCRLM showed CPR vs no CPRHazard ratio: 0.36, CI (0.03-4.12), P=0.41DFS: treated dCRLM vs dCRLM left in situHazard ratio: 0.72, CI (0.04-13.54), P=0.83 Open table in a new tab

Intraoperative Assessment of the Demarcation Line and Intersegmental/Sectional Planes in Liver Surgery

Purpose: Intraoperative assessment of demarcation line (DL) and intersegmental/sectional planes (IP) is essential to perform accurate liver resection without ischemic areas and venous congestion. DL is the most important landmark on the liver surface. The DL is normally formed by means of selective vascular occlusion or portal staining using a dye, and it can be recognized by surgeons’ eye. However, direct visualization with surgeons’ eye suffers from the failing of the evaluation due to an unclear DL, especially in patients with cirrhotic or steatotic livers. Currently, IP, which cannot be recognized by direct visualization, is now in the spotlight during parenchymal transection. Herein, we assessed the DL and IP intraoperatively by several imaging modalities. Method: The DL and IP were intraoperatively detected by means of conventional demarcation techniques and several imaging modalities as follows during liver surgery in a human and an animal model. 1. Direct visualization 2. Indocyanine green fluorescence imaging (ICG-FI) 3. Contrast-enhanced intraoperative ultrasonography (CE-IOUS) 4. Contrast-enhanced intraoperative ultrasonic cholangiography (CE-IOUSC) 5. Augmented Reality using preoperative data (AR) 6. Hyperspectral imaging (HSI) Results: The DL was detected by direct visualization, ICG-FI, and HSI. AR detected virtual DL. On the other hand, the IP was detected by ICG-FI, CE-IOUS, and CE-IOUSC. In this time, we will show the current status and issues with discussion about the strong and weak points of them. Conclusion: New technologies for assessment of DL and IP have a great potential to provide more information to surgeons in order to standardize the surgical approach and develop new surgical approaches.

PD10-11 INTRAOPERATIVE CONTRAST ENHANCED ULTRASOUND TO REDUCE UNNECESSARY URETERAL STENT PLACEMENT AFTER URETEROSCOPY

You have accessJournal of UrologyImaging/Radiology: Uroradiology I (PD10)1 Sep 2021PD10-11 INTRAOPERATIVE CONTRAST ENHANCED ULTRASOUND TO REDUCE UNNECESSARY URETERAL STENT PLACEMENT AFTER URETEROSCOPY Justin Ahn, David Bayne, Fadl Hamouche, Marshall Stoller, and Thomas Chi Justin AhnJustin Ahn More articles by this author , David BayneDavid Bayne More articles by this author , Fadl HamoucheFadl Hamouche More articles by this author , Marshall StollerMarshall Stoller More articles by this author , and Thomas ChiThomas Chi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001978.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stents are a significant source of morbidity. The decision to place one at the time of retrograde intrarenal surgery (RIRS) is often subjective. A reliable tool is needed to guide urologists and avoid unnecessary stent placement. Contrast enhanced ultrasound (CEUS) is a safe, readily adaptable technology where a microbubble contrast agent is instilled into the upper urinary tract (Figure 1). We propose an intraoperative retrograde CEUS test during RIRS to help predict post-operative ureteral drainage and the need for ureteral stent placement. METHODS: For this pilot feasibility study, we performed CEUS in patients undergoing RIRS for nephrolithiasis. After stone treatment, the renal collecting system was decompressed, then 1 ml of CEUS contrast and a 2 ml flush was instilled per ureteral catheter. For the flush, iodinated contrast was substituted for saline to permit comparison with fluoroscopic drainage. After catheter removal and 2 minutes for ureteral rest, the bladder was cycled with irrigation and then scanned with CEUS and fluoroscopy for passage of either contrast agent (Figure 1). Ureteral stent placement was determined based on preexisting standard of care. Post-operative unplanned encounters (PUE) were tracked. RESULTS: 41 renal units underwent CEUS during RIRS (Figure 2). Stent omission was successful with no PUE in 91% with CEUS drainage. Compared to those who had a stent placed based on no CEUS drainage, those who did not have a stent based on drainage had a significantly lower incidence of complications (9% vs 53%, p=0.006) Fluoroscopic drainage was discordant with CEUS drainage in 12 renal units. In all cases of discordance, drainage was seen on CEUS but not on fluoroscopy. CONCLUSIONS: CEUS is a novel means to objectively assess upper tract drainage at the time of RIRS. Our results suggest that retrograde CEUS could predict successful stent omission and may be more sensitive for predicting drainage than fluoroscopy due to low contrast volumes. Source of Funding: AUA Care Foundation © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e131-e131 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin Ahn More articles by this author David Bayne More articles by this author Fadl Hamouche More articles by this author Marshall Stoller More articles by this author Thomas Chi More articles by this author Expand All Advertisement Loading ...

Contrast-Enhanced Intraoperative Ultrasonography with Kupffer Phase May Change Treatment Strategy of Metastatic Liver Tumors - A Single-Centre Prospective Study.

AimTo compare the diagnostic performance of contrast-enhanced intraoperative ultrasonography (CE-IOUS) with Kupffer phase in metastatic liver tumours.MethodsTwenty-seven consecutive patients with liver metastasis were prospectively recruited from November 2019 to July 2020 in the Department of HPB, Beijing Hospital. MRI and Contrast Enhanced Ultrasonography (CEUS) were obtained preoperatively, and the diagnosis was made by radiologists independently and blindly. Intraoperative ultrasonography (IOUS) and CE-IOUS with Sonazoid were done by the same sophisticated surgeon and sonographer and Kupffer phase was used to detect lesions. The sensitivity and specificity to detect lesions were compared between different radiologic methods. Then, the changes in treatment strategy due to CE-IOUS with Sonazoid were analysed.ResultsTwenty-seven patients were included. In MRI, 91 lesions were detected with sensitivity 93.3% (70/75) and specificity 68.8% (11/16). In CEUS, it was 97.1% (68/70) and 86.7% (13/15) in 85 lesions. Meanwhile, in the Kupffer phase in CE-IOUS, 99 lesions were found and 8 new lesions were discovered in 7 cases, with sensitivity 97.5% (80/82) and specificity 94.1% (16/17). The four imaging methods showed no statistic significance in sensitivity and specificity in detecting lesions (Cochran’s Q 10.825, P=0.055). Treatment strategies were altered in 7 patients, 6 achieved R0 resection or ablation, and 1 patient changed from planned R0 resection to palliative surgery.ConclusionCE-IOUS may play a similar or even better role than other radiological methods in diagnosing liver metastasis. The CE-IOUS using Sonazoid demonstrated a high sensitivity and specificity for finding occult metastases intraoperatively and changing the treatment strategy.

Quantitative analysis of in-vivo microbubble distribution in the human brain

Microbubbles (MB) are widely used as contrast agents to perform contrast-enhanced ultrasound (CEUS) imaging and as acoustic amplifiers of mechanical bioeffects incited by therapeutic-level ultrasound. The distribution of MBs in the brain is not yet fully understood, thereby limiting intra-operative CEUS guidance or MB-based FUS treatments. In this paper we describe a robust platform for quantification of MB distribution in the human brain, allowing to quantitatively discriminate between tumoral and normal brain tissues and we provide new information regarding real-time cerebral MBs distribution. Intraoperative CEUS imaging was performed during surgical tumor resection using an ultrasound machine (MyLab Twice, Esaote, Italy) equipped with a multifrequency (3–11 MHz) linear array probe (LA332) and a specific low mechanical index (MI < 0.4) CEUS algorithm (CnTi, Esaote, Italy; section thickness, 0.245 cm) for non-destructive continuous MBs imaging. CEUS acquisition is started by enabling the CnTI PEN-M algorithm automatically setting the MI at 0.4 with a center frequency of 2.94 MHz–10 Hz frame rate at 80 mm—allowing for continuous non-destructive MBs imaging. 19 ultrasound image sets of adequate length were selected and retrospectively analyzed using a custom image processing software for quantitative analysis of echo power. Regions of interest (ROIs) were drawn on key structures (artery–tumor–white matter) by a blinded neurosurgeon, following which peak enhancement and time intensity curves (TICs) were quantified. CEUS images revealed clear qualitative differences in MB distribution: arteries showed the earliest and highest enhancement among all structures, followed by tumor and white matter regions, respectively. The custom software built for quantitative analysis effectively captured these differences. Quantified peak intensities showed regions containing artery, tumor or white matter structures having an average MB intensity of 0.584, 0.436 and 0.175 units, respectively. Moreover, the normalized area under TICs revealed the time of flight for MB to be significantly lower in brain tissue as compared with tumor tissue. Significant heterogeneities in TICs were also observed within different regions of the same brain lesion. In this study, we provide the most comprehensive strategy for accurate quantitative analysis of MBs distribution in the human brain by means of CEUS intraoperative imaging. Furthermore our results demonstrate that CEUS imaging quantitative analysis enables discernment between different types of brain tumors as well as regions and structures within the brain. Similar considerations will be important for the planning and implementation of MB-based imaging or treatments in the future.

A meta-analysis evaluating contrast-enhanced intraoperative ultrasound (CE-IOUS) in the context of surgery for colorectal liver metastases.

This study aimed to assess the outcomes of contrast-enhanced intraoperative ultrasound (CE-IOUS) for patients with colorectal liver metastases (CRLMs) undergoing surgery. A thorough literature search was performed in PubMed, Scopus, and Cochrane databases, in accordance with the PRISMA guidelines. The Odds Ratio, Weighted Mean Difference, and 95% Confidence Interval were evaluated, by means of Random-Effects model. Eleven articles met the inclusion criteria and incorporated 497 patients. The present study shows that CE-IOUS is associated with higher sensitivity and accuracy compared with multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), and intraoperative ultrasound (IOUS) in identifying CRLMs (p < 0.05). The positive predictive value was similar among the different modalities. Furthermore, new CRLMs were identified by CE-IOUS, thus affecting the surgical plan in 128 patients (51.8% of the patients with new CRLMs). Moreover, 91 patients (71%) underwent a more extensive hepatectomy and 15 patients (11.7%) were considered non-operable. Two alternative contrast agents, Sonazoid and Sonovue, were employed with similar sensitivity (p > 0.05). These outcomes suggest the superiority of the CE-IOUS over MDCT, MRI, and IOUS for the staging of patients with CRLMs undergoing surgery. However, they should be treated with caution given the small number of the included studies.

Emerging contrast-enhanced ultrasound applications in children.

Ultrasound contrast agent (UCA) use in radiology is expanding beyond traditional applications such as evaluation of liver lesions, vesicoureteral reflux and echocardiography. Among emerging techniques, 3-D and 4-D contrast-enhanced ultrasound (CEUS) imaging have demonstrated potential in enhancing the accuracy of voiding urosonography and are ready for wider clinical adoption. US contrast-based lymphatic imaging has been implemented for guiding needle placement in MR lymphangiography in children. In adults, intraoperative CEUS imaging has improved diagnosis and assisted surgical management in tumor resection, and its translation to pediatric brain tumor surgery is imminent. Because of growing interest in precision medicine, targeted US molecular imaging is a topic of active preclinical research and early stage clinical translation. Finally, an exciting new development in the application of UCA is in the field of localized drug delivery and release, with a particular emphasis on treating aggressive brain tumors. Under the appropriate acoustic settings, UCA can reversibly open the blood-brain barrier, allowing drug delivery into the brain. The aim of this article is to review the emerging CEUS applications and provide evidence regarding the feasibility of these applications for clinical implementation.