Intraoperative Ultrasonography Research Articles

Feasibility and potential of intraoperative ultrasound in arthroscopy of femoroacetabular impingement

ABSTRACT This study aimed to evaluate the feasibility of using ultrasound for monitoring osteochondroplasty intraoperatively, determine the factors that interfere with ultrasound imaging and assess its influence on surgeon performance. Intraoperative ultrasonography was performed during osteochondroplasty in 39 cases of arthroscopy. The femoral head–neck junction (FHNJ) was evaluated using ultrasonography. Another 39 cases, which underwent conventional arthroscopy, were included in the control group. The C-arm was used in this group at the end of osteochondroplasty to confirm that no residual cam lesion remained. Pre- and postoperative Dunn radiographs and computed tomography (CT) scans were analyzed to determine the feasibility of ultrasound. Residual cam deformity was noted in eight cases under ultrasound. The FHNJ was not detected owing to ultrasound interference by air in three cases. No difference in the α angle measured in Dunn radiographs and the residual cam deformity rate of CT at the 1:00, 2:00 or 3:00 position was found between both groups. However, the α angle at the 3:00 position was greater in the ultrasound group than in the control group (44.4 ± 4.3° versus 41.3 ± 5.1°, P < 0.05), suggesting that more bone was preserved at 3:00 in the ultrasound group. No difference was found in the mean operation time. None of the patients experienced complications, such as wounds or intra-articular infections. Ultrasound is a safe method for assessing FHNJ during arthroscopy. It did not change the risk of residual cam deformity but positively affected the surgeon’s performance by reducing unnecessary bone removal.

Role of intraoperative Doppler Ultrasound in brain surgery

Role of intraoperative Doppler Ultrasound in brain surgery

Thoracic root-related intradural extramedullary cavernoma presenting with subarachnoid hemorrhage: illustrative case.

Just 5% of all cavernomas are located in the spine. Thoracic root-related subtypes are the rarest, with a total of 14 cases reported in the literature to date. Among them, only 4 presented with subarachnoid hemorrhage (SAH). A 65-year-old female presented after an ictus of headache with no neurological deficits. Computed tomography (CT) demonstrated sulcal SAH, with the remainder of the workup nondiagnostic for etiology. Three weeks later, she re-presented with acute thoracic back pain and thoracic myelopathy. CT and magnetic resonance imaging suggested dubiously a T9-10 disc herniation with spinal cord compression. Surgical decompression and resection were then planned. Intraoperative ultrasound (IUS) demonstrated an intradural extramedullary lesion, confirmed to be cavernoma. Complete resection was achieved, and the patient was discharged a few days postoperatively to inpatient rehabilitation. Although spine imaging is deemed to be low yield in the evaluation of cryptogenic SAH, algorithms can be revisited even in the absence of spine-related symptoms. Surgeons can be prepared to change the initial surgical plan, especially when preoperative imaging is unclear. IUS is a powerful tool to assess the thecal sac after its exposure and to help guide this decision, as in this rare entity.

297 Impact of Navigated Intraoperative Ultrasound on Brain Shift and Gross Tumor Resection

INTRODUCTION: Intraoperative imaging and neuronavigation aid in achieving maximum tumor resection. However, tissue removal during surgery can cause brain shift, which alters the relative anatomy and “de-calibrates” the standard approaches. While intraoperative MRI (iMRI) is the gold-standard to correct for brain shift, it is expensive, time-consuming, and logistically difficult. As an alternative, we investigated an approach which combines intraoperative ultrasound (ioUS) technology with preoperative imaging to allow for real-time compensation of brain shift and assessment of extent of resection (EOR). METHODS: We prospectively enrolled patients undergoing neurosurgical tumor resection at Massachusetts General Hospital beginning April 2023. Patients were registered with Brainlab Ultrasound Navigation prior to surgery. ioUS sweeps were acquired before cortex incision, mid-resection, and post-resection with bkActiv and fused to preoperative MRIs. Four points around the tumor were longitudinally tracked to assess brain shift. Data included sweep duration, image processing speed, extent of brain shift as determined by intraoperative markers, and EOR assessed from the ioUS compared with postoperative MRIs. RESULTS: Seven patients were enrolled (average age 62 ± 15, 75% male) with frontal (n = 5), temporal (n = 1), and occipital (n = 1) gliomas (n = 4) and metastases (n = 3). All patients exhibiting total resection as determined by ioUS also demonstrated total resection on post-operative MRI, evaluated independently by a neuroradiologist. The average time of scan and image processing (n = 19) was 5.7 ± 1.9 and 27.8 ± 6.5 seconds respectively. CONCLUSIONS: Navigated ioUS offers accurate and efficient assessment of EOR during surgery for tumor resections. Furthermore, when brain shift is detected, navigated ioUS can allow for compensation and continued utilization of navigation via the acquisition of a brand new, navigable, intraoperatively acquired dataset.

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

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

ICG-Enhanced Compression Anatomical Segment 7 Segmentectomy in Laparoscopic and Robotic Approach.

Minimally invasive anatomical resection (AR) for posterosuperior lesions is technically challenging.1,2 The Glissonean approach or puncture technique is generally selected.3,4 The tumor-feeding portal pedicle compression AR (C-AR) is an established procedure in open surgery.5 This technique has benefited from the association with indocyanine green (ICG) fluorescence, used to enhance the anatomical area to be resected.6 Recently, C-AR via the minimal access approach has been reported.7 Herein, we report the first cases of laparoscopic and robotic segment 7 (S7) segmentectomy using the ICG-enhanced compression technique. Two cases of CHILD-class A hepatocellular carcinoma (HCC) in segment 7 with a liver stiffness less than 7 kPa treated by laparoscopic and robotic anatomical S7 segmentectomies were reported. Using the intraoperative ultrasound (IOUS), the tumor-bearing portal pedicle and the level targeted for compression were identified. The right hemiliver was adequately mobilized to allow handling of the organ during dissection. Using the grasper and the probe itself, the S7 Glissonean pedicle was transparenchymally compressed under real-time IOUS control. To further enhance the visibility of the discolored S7, ICG was administered intravenously, obtaining the compressed area to be resected as a non-stained one. Dissection was performed under intermittent Pringle maneuver up to exposing the right hepatic vein, dividing the Glissonean pedicle to segment 7 and then completing the resection. Pathologic findings demonstrated a 4.9 cm and 7.3 cm HCC with a R0-resection margin (> 1 cm in both). Postoperative complications were nil. The patients were discharged 6 days after surgery. This preliminary experience shows that the C-AR is a feasible and reliable technique in laparoscopic and robotic approach for posterosuperior lesions. Further studies are needed to investigate its applicability and standardization.

Real-Time Ultrasound-Guided Posterolateral Thoracic Discectomy: 2-Dimensional Operative Video.

Symptomatic thoracic disk herniations can be challenging to treat. Various surgical approaches have been reported in the literature, but the ideal approach is still a topic of controversy. We present a step-by-step surgical video highlighting the utilization of continuous, real-time intraoperative ultrasound (IOUS) guidance for thoracic discectomy through a posterolateral approach. The background and rationale for the procedure and a detailed presentation of the sequence of surgical steps are detailed in the operative video. We believe that real-time IOUS can be used not only to gain an understanding of the ventral anatomy and to verify decompression after discectomy but it can also be used in a real-time fashion to guide the maneuvers for discectomy itself. Advantages of using real-time IOUS include real-time monitoring of the spinal cord during mobilization of the disk-osteophyte complex and direct visualization of the dura-disk herniation interface, which may enhance the safety of surgery. The patient consented to the procedure and the publication of her image.

Cystic Echinococcosis of the Liver: Correlation Between Intra-Operative Ultrasound and Pre-Operative Imaging.

Background: Imaging plays an essential role in the management of hepatic hydatid cysts (HCE). The objective of our study was to determine the correlation between pre-operative ultrasound, computed tomography (CT), and intra-operative ultrasound (IOUS) in studying the characteristics and complications of HCE. Patients and Methods: This was a prospective, descriptive, and analytical study conducted in the General Surgery Department of Habib Bourguiba Hospital in Sfax. The study included patients with HCE who underwent conservative surgery between April 2017 and June 2022. Results: We enrolled 49 patients with 94 cysts. At the end of our study, IOUS allowed for better detection of HCE (98.8%) regardless of the number of cysts per patient. IOUS and CT were accurate in studying the location of cysts (κ = 1), whereas pre-operative abdominal ultrasound was less efficient (κ = 0.870). IOUS was the best examination for detecting exocysts (κ = 0.961), studying daughter cysts (κ = 0.823), and exploring vascular relations, but it was less effective (κ = 0.523) in detecting calcifications. Regarding classifications, ultrasound and CT had similar results. However, IOUS was most reliable in differentiating between CE3b and CE4 types (κ = 0.653). Ultrasound, CT, and IOUS were not sensitive in detecting latent HCE suppurations and cystobiliary fistulas. Conclusions: Performing IOUS is essential to prevent recurrences and reduce post-operative morbidity.

Intraoperative Extravascular Ultrasound in the Identification of Flow-Limiting Dissections after Balloon Angioplasty in the Femoropopliteal Segment.

Background: The BIO REACT study is designed to investigate the incremental value of Extravascular UltraSound (EVUS) added to conventional angiography, compared to conventional angiography only for the identification of Flow-Limiting Dissections (FLD) and to evaluate the safety and efficacy of the REsponse Adapted Combination Therapy (REACT) for the treatment of femoropopliteal lesions. Methods: The primary endpoints were the specificity and sensitivity of EVUS added to angiography for the detection of FLD. Secondary endpoints were primary patency of the REACT therapy within 12 months, fCD-TLR, freedom from MAE, major target limb amputations (mTLA) and survival rates within 24 months. Results: A total of 150 patients were included. EVUS added to angiography had an overall sensitivity of 29% and specificity of 93% for the detection of FLD. There was no PSVR cut-off offering a clinically acceptable trade-off between meaningful sensitivity and specificity values for the detection of FLD. At 12 months, treatment with the REACT resulted in primary patency and fCD-TLR of 81.6% and 94.3%, respectively. In addition, freedom from MAE was 94.3% at 12 months. At 24 months, the survival rate was 94.0%. No mTLA was reported up to the 24-month follow-up. Conclusions: The addition of DUS to angiography showed limited value for detecting FLD in femoropopliteal artery disease.

Automatic hepatic tumor segmentation in intra-operative ultrasound: a supervised deep-learning approach.

Training and evaluation of the performance of a supervised deep-learning model for the segmentation of hepatic tumors from intraoperative US (iUS) images, with the purpose of improving the accuracy of tumor margin assessment during liver surgeries and the detection of lesions during colorectal surgeries. In this retrospective study, a U-Net network was trained with the nnU-Net framework in different configurations for the segmentation of CRLM from iUS. The model was trained on B-mode intraoperative hepatic US images, hand-labeled by an expert clinician. The model was tested on an independent set of similar images. The average age of the study population was 61.9 ± 9.9 years. Ground truth for the test set was provided by a radiologist, and three extra delineation sets were used for the computation of inter-observer variability. The presented model achieved a DSC of 0.84 (), which is comparable to the expert human raters scores. The model segmented hypoechoic and mixed lesions more accurately (DSC of 0.89 and 0.88, respectively) than hyper- and isoechoic ones (DSC of 0.70 and 0.60, respectively) only missing isoechoic or >20mm in diameter (8% of the tumors) lesions. The inclusion of extra margins of probable tumor tissue around the lesions in the training ground truth resulted in lower DSCs of 0.75 (). The model can accurately segment hepatic tumors from iUS images and has the potential to speed up the resection margin definition during surgeries and the detection of lesion in screenings by automating iUS assessment.

Enucleation of a solitary pancreatic tail insulinoma: a case report and review of the literature

Introduction: Insulinomas are the most common pancreatic neuroendocrine tumors. They secrete insulin and result in endogenous hyperinsulinaemic hypoglycemia. The diagnosis of insulinoma was classically based on the fulfillment of Whipple’s triad; hypoglycaemia (plasma glucose <50mg/dL), neuroglycopaenic symptoms, and the prompt relief of such symptoms with the administration of glucose. Preoperative localization of the insulinoma will help to plan the type of surgery necessary, either enucleation or pancreatic resection, and also decide on the approach, either open or laparoscopic. Case description: A 53-year-old farmer presented with neuroglycopenia symptoms with biochemical evidence of endogenous hyperinsulinaemic hypoglycemia during the mixed meal test. Imaging evidence in the form of CT and MRI showed a benign, approximately 1cm, solitary pancreatic tail insulinoma. Intraoperative ultrasonography confirmed the findings and the patient underwent enucleation of the tumor. Histology revealed a grade 2 pancreatic neuroendocrine tumor with confirmation of an insulinoma on immunohistochemistry. Conclusion: Pancreatic insulinomas, a rare pancreatic tumor, the commonest of the pNET present with neuroglycopenia. Diagnosis entails biochemical confirmation of endogenous hyperinsulinaemic hypoglycemia on a 72-hour prolonged fasting test. Noninvasive imaging in the form of CT as the first line, followed by MRI is used for localization and assessment of resectability. EUS and ASVS are additional invasive imaging in diagnostic difficulty. Enucleation and intraoperative ultrasonography is the treatment of choice for small, benign, pancreatic insulinomas.

Preoperative and Intraoperative Scrotal Duplex Ultrasound in the Assessment of Varicocele: A Comparative Study

Background: This study aimed to compare the accuracy of preoperative and intraoperative scrotal duplex ultrasound (SDU) in assessing varicocele, a common cause of male subfertility.Methods and Results: The study was conducted on 20 male patients scheduled for subinguinal varicocelectomy at a tertiary care hospital from March 2022 to March 2023. We used Grey-Scale US and Doppler US to evaluate testicular size, vein diameter, arterial flow parameters, and retrograde flow. We found that the preoperative scrotal duplex was a good and accurate method for assessing the grading of varicocele, and there was no significant difference in vein diameter or venous reflux between preoperative and intraoperative assessments. However, we observed a significant increase in the number of veins and testicular volume during intraoperative SDU compared to preoperative scrotal SDU.Conclusion: SDU is a reliable tool for determining testicular volume and provides objective, accurate, and reproducible measurements of testicular volume.

Ultrasound principles and instrumentation

Ultrasound (US) is a fundamental and inexpensive tool both for the prompt diagnosis and for the study of diverse medical conditions. Its widespread use is partly due to the availability of US devices in the daily practice of physicians. US can be performed in real-time and is instrumental in the generation of clinical algorithms for the management of situations like trauma. It also constitutes a primary approach for the study of oncological diseases, and a guidance tool for interventions such as percutaneous drainages. In addition, and specifically for HPB surgeons, US is an essential tool in the operating room: intraoperative (either open or laparoscopic) US is necessary for the accurate determination of the stage, location, number, and margins of tumors within the liver, pancreas, or biliary tree. On another note, reading and understanding US images are skills that require time and training, which should be taught during surgical residencies. However, this is not customary in most residencies globally. This chapter offers a concise yet comprehensive elucidation of the basic principles of ultrasonography, the instruments required to perform an ultrasonic assessment of a patient, and the basic ultrasound controls.

Management of intraoperatively identified small bile duct stones in patients undergoing cholecystectomy

IntroductionThe management of CBDS (common bile duct stones) in patients with co-existing gallbladder stones has been debated. Guidelines recommend patients with CBDS identified on imaging should be offered duct clearance; however, this is based on low-quality evidence. This study aimed to investigate the natural history of small CBDS identified using IOUS (intraoperative ultrasound) in patients undergoing cholecystectomy. This may provide evidence to support a short-term expectant management approach in such patients.MethodsPatients with CBDS diagnosed on IOUS during cholecystectomy were identified from a database of consecutive patients undergoing surgery. Patients with CBDS identified were divided into small stone (SS, ≤5 mm) and large stone (LS, >5 mm) groups. Intraoperative CBDS management, postoperative investigations, postoperative bile duct clearance, re-admissions, complications, length of stay (LOS) and follow-up are described.ResultsFifty-nine of 427 patients had CBDS identified on IOUS. In the SS group (n=51), 46 patients underwent short-term expectant management rather than immediate/planned bile duct clearance. Following short-term expectant management, 41/46 patients (89.1%) did not require postoperative endoscopic retrograde cholangiopancreatography and at >3 year follow-up, none has since presented with residual CBDS. Median LOS was 0 days in the short-term expectant management group and 2 days in the immediate/planned bile duct clearance group, P=0.039.ConclusionsThis study reports the natural history of small CBDS identified on IOUS in patients undergoing cholecystectomy. Such patients were safely treated with short-term expectant management associated with a reduced hospital LOS. This provides rationale for undertaking further research to establish this as a preferred management strategy.

Laparoscopic median arcuate ligament section for median arcuate ligament compression syndrome initially detected as splenic infarction: a case report

BackgroundMedian arcuate ligament compression syndrome (MALS) causes upper abdominal pain and at times hemodynamic abnormalities in the pancreaticoduodenal region.Herein, we present a case of a 70 year-old man, initially diagnosed with splenic infarction and was successfully treated laparoscopically.Case presentationA 70-year-old man with abdominal pain admitted to our hospital. Abdominal-enhanced computed tomography revealed a poorly contrasted area in the spleen and stenosis at the root of the celiac artery. Arterial dilatation was observed around the pancreaticoduodenal arcade, however, no obvious aneurysm formation or arterial dissection was observed. Abdominal-enhanced magnetic resonance imaging indicated the disappearance of the flow void at the root of the celiac artery. The patient had no history of atrial fibrillation and was diagnosed with splenic infarction due to median arcuate ligament compression syndrome. We performed a laparoscopic median arcuate ligament section with five ports. Intraoperative ultrasonography showed a retrograde blood flow in the common hepatic artery and the celiac artery. After releasing the compression, the antegrade blood flow from the celiac artery to the splenic artery, and the common hepatic artery were visualized using intraoperative ultrasonography. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 9. Postoperative computed tomography a month after surgery revealed no residual stenosis of the celiac artery or dilation of the pancreaticoduodenal arcade. Furthermore, the poorly contrasted area of the spleen improved.ConclusionsReports indicate that hemodynamic changes in the abdominal visceral arteries due to median arcuate ligament compression are related to the formation of pancreaticoduodenal aneurysms. In this case, median arcuate ligament compression syndrome caused splenic infarction by reducing blood flow to the splenic artery.

Transcortical transcatheter ultrasound-assisted technique for deep-seated brain tumors. Technical note.

Surgery of deep-seated brain tumors can be challenging. Several methods have been described to facilitate transcortical approaches, including ultrasound-assisted resection. Ultrasound-guided placement of a standard ventricular catheter is a widely reported technique and has been used to approach these lesions via the transcortical route. We describe how we usually perform this useful technique to assist and enhance the transcortical resection of some deep-seated brain tumors. Standard electromagnetic frameless navigation (S8 Neuronavigation System, Medtronic, Minneapolis, USA) was employed to focus the craniotomy and to plan the trajectory of the ventricular catheter. After dural opening, an ultrasound device (Arietta 850, Hitachi-Aloka Medical, Tokyo, Japan) was used for intraoperative ultrasound (IOUS) assessment. A ventricular catheter was placed from the cortex to the lateral wall of the tumor under direct real-time IOUS visualization to guide the further transcortical dissection. Transcortical transcatheter ultrasound-assisted technique involved minimal time and infrastructure requirements. There were no major technical difficulties during its use, providing confidence and improving subcortical white matter dissection by guiding the route to the tumor. Recent improvement of IOUS image-quality devices offers several attractive options for real-time navigation. The combination of conventional neuronavigation systems with real-time IOUS assessment during the intradural step provides a higher degree of control by improving the execution of the surgery. We hope this description may be a useful tool for some selected cases and contribute to the further enhancement and improvement of this widely used technique.

Real-Time Intraoperative Ultrasound Using a Minimally Invasive Transducer During Anterior Cervical Spine Surgery.

Intraoperative ultrasound (IOUS) during anterior cervical surgery is hindered by large transducer size and small operative corridor. We hypothesized that a linear (minimally invasive) transducer designed for transsphenoidal surgery can visualize the spinal cord, nerve roots, and surrounding structures during anterior cervical approaches, facilitating intraoperative assessment of central and foraminal decompression. IOUS was used to evaluate 26 levels in 17 patients (15 anterior cervical discectomy and fusion, 1 corpectomy, 1 arthroplasty) with a linear probe (7 × 6-mm end-fire transducer, 150-mm length, 12-15 MHz). After pin-based distraction, discectomy, and posterior longitudinal ligament resection, IOUS assessed adequacy of cord decompression and, following proximal foraminotomy or uncinectomy, nerve root decompression. If indicated, additional decompression was completed. Criteria for adequate central and foraminal decompression were visualization of subarachnoid space around the cord and cerebrospinal fluid pulsatility along the root sleeve/absence of nerve root compression distal to the root sleeve, respectively. IOUS successfully visualized the cord, nerve roots, and surrounding structures in all 26 levels and influenced management in 11 levels (42.3%). IOUS indicated persistent cord and nerve root compression in 2 and 7 levels, respectively. Planned uncinectomy was aborted in 2 levels after IOUS demonstrated adequate nerve root decompression with intervertebral distraction/proximal foraminotomy alone. IOUS identified persistent nerve root compression after initial proximal foraminotomy in 4 levels and uncinectomy in 2 levels. An unplanned uncinectomy was performed in 1 level after IOUS showed persistent nerve root compression after multiple iterations of proximal foraminotomy. At follow-up (mean 3.1 months), the mean improvement in Numeric Rating Scale neck and arm pain, Neck Disability Index, and modified Japanese Orthopedic Association was 4.0%, 3.2%, 3.7%, and 0.7%, respectively. The neural elements and their relationships to surrounding bone/soft tissue can be visualized using a minimally invasive IOUS transducer during anterior cervical surgery without having to remove pin-based distraction. This allows surgeons to intraoperatively verify the extent of central and foraminal decompression.

Intraoperative ultrasonography in microsurgical resection of vestibular schwannomas via retrosigmoid approach: surgical technique and proof-of-concept illustrative case series.

Intraoperative ultrasonography (ioUS) is an established tool for the real-time intraoperative orientation and resection control in intra-axial oncological neurosurgery. Conversely, reports about its implementation in the resection of vestibular schwannomas (VS) are scarce. The aim of this study is to describe the role of ioUS in microsurgical resection of VS. ioUS (Craniotomy Transducer N13C5, BK5000, B Freq 8MHz, BK Medical, Burlington, MA, USA) is integrated into the surgical workflow according to a 4-step protocol (transdural preresection, intradural debulking control, intradural resection control, transdural postclosure). Illustrative cases of patients undergoing VS resection through a retrosigmoid approach with the use of ioUS are showed to illustrate advantages and pitfalls of the technique. ioUS allows clear transdural identification of the VS and its relationships with surgically relevant structures of the posterior fossa and of the cerebellopontine cistern prior to dural opening. Intradural ioUS reliably estimates the extent of tumor debulking, thereby helping in the choice of the right moment to start peripheral preparation and in the optimization of the extent of resection in those cases where subtotal resection is the ultimate goal of surgery. Transdural postclosure ioUS accurately depicts surgical situs. ioUS is a cost-effective, safe, and easy-to-use intraoperative adjunctive tool that can provide a significant assistance during VS surgery. It can potentially improve patient safety and reduce complication rates. Its efficacy on clinical outcomes, operative time, and complication rate should be validated in further studies.

P410 Intraoperative Ultrasonography of the Small Bowel in the evaluation of resection margins during surgery for Crohn's Disease

Abstract Background Histological involvement of surgical resection margins in Crohn’s Disease (CD) is considered an important risk factor for disease recurrence after surgery. The extent of resection is currently left to preoperative investigations and surgeon's experience. Aim of the study is to evaluate usefulness of intra-operative ultrasonography (IOUS) of the small bowel to best identify the surgical site of resection and reduce the risk of histological involvement of resection margins. Methods Consecutive patients who underwent surgery for CD (ileocaecal or ileal resections for first or repeated surgery) from April 2022 to April 2023 were prospectively enrolled (IOUS group). All patients underwent to IOUS through a small mini-laparotomy with a linear wireless probe performed by an expert gastroenterologist and the location of the proximal ileal resection was decided considering the absence of intraoperative small bowel ultrasonographic signs of CD (wall thickness, mucosal, submucosal and muscular layer thickness, echogenicity of the wall stratification and mesenteric fat). A control group from the historical cohort of patients undergoing the same surgical procedures was included; for whom the site of the proximal ileal resection was decided only on the basis of the absence of macroscopic signs of disease as usually assessed. To minimize the selection bias, a propensity score analysis was performed identifying a subgroup of the historical cohort (non-IOUS group) matched for location of disease and repeated surgery. The primary endpoint was histological involvement of the resection margins, judged positive in case of granulomas or signs of active ulcerative inflammation. Results 27 patients (59% male, mean age 39.3 y [SD 16.5], mean BMI 21.24 [SD 2.03]) were consecutively enrolled in the IOUS group. A 1:1 propensity score matching analysis was performed identifying 27 patients included in the non-IOUS group . The two groups were homogeneous in terms of gender, age, smoking, BMI, behavior of disease and surgical technique (laparoscopic or open technique). IOUS group presented a lower rate of histological positive margins compared to the non-IOUS group (18.5% vs 48.1% p = 0.021). No significant differences were found in terms of mean duration of surgery between the two groups (254.2 min vs 225 min [49.3-77.8]; p = 0.11) or in terms of mean length of surgical specimen (24.1 cm vs 34.1 cm [SD 13.5 -23.1]; p = 0.058) Conclusion IOUS of the small bowel appears to be a useful tool for IBD-surgeon in order to obtain a lower rate of histologically positive margins with a comparable duration of the surgery and no significant difference in length of the intestinal specimen.

European Society of Pediatric Radiology survey of perioperative imaging in pediatric liver transplantation: (2) intraoperative imaging

BackgroundLiver transplantation is the state-of-the-art curative treatment for end-stage liver disease. Imaging is a key element in the detection of intraoperative and postoperative complications. So far, only limited data regarding the best radiological approach to monitor children during liver transplantation is available.ObjectiveTo harmonize the imaging of pediatric liver transplantation, the European Society of Pediatric Radiology Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra- and postoperative phase. This paper reports the responses related to intraoperative imaging.Materials and methodsAn online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted, and 22 institutions from 11 countries returned the survey.ResultsIntraoperative ultrasound (US) is used by all sites to assess the quality of the vascular anastomosis in order to ensure optimal perfusion of the liver transplant. Vessel depiction is commonly achieved using color Doppler (95.3%). Additional US-based techniques are employed by fewer centers (power angio mode, 28.6%; B-flow, 19%; contrast-enhanced US, 14.3%). Most centers prefer a collaborative approach, with surgeons responsible for probe handling, while radiologists operate the US machine (47.6%). Less commonly, the intraoperative US is performed by the surgeon alone (28.6%) or by the radiologist alone (23.8%). Timing of US, imaging frequency, and documentation practices vary among centers.ConclusionIntraoperative US is consistently utilized across all sites during pediatric liver transplantation. However, considerable variations were observed in terms of the US setup, technique preferences, timing of controls, and documentation practices. These differences provide valuable insights for future optimization and harmonization studies.