Intraoperative Ultrasound Examination Research Articles

Prevalence of ascending aortic atheromatous plaques and risk factors in Thai cardiac surgery patients: A prospective cohort study

Cerebral embolism, a serious complication in cardiac surgery, is significantly impacted by atheromatous plaques in the ascending aorta and aortic arch. However, data on the prevalence of these plaques in Asian populations are sparse. This study aimed to evaluate the prevalence of atheromatous plaques in the ascending aorta among Thai cardiac surgery patients, thereby facilitating risk stratification and improving preoperative management. We conducted intraoperative epiaortic ultrasound examinations on 239 cardiac surgery patients. Clinically significant atheromatous plaques were defined as those exceeding 3.0 mm in thickness. The collected demographic and clinical data included sex, age, body weight, height, American Society of Anesthesiologists physical status classification, smoking status, alcohol consumption, and comorbidities. Atheromatous plaques were found in 33.5 % of the ascending aortas and 41.4 % of the aortic arches. The primary risk factors were advanced age (over 80 years; relative risk (RR) 1.444, 95 % confidence interval (CI) 1.113–1.874, P = 0.006) and carotid stenosis (RR 1.247, 95 % CI 1.04–1.495, P = 0.017). The prevalence of atheromatous plaques in Thai cardiac surgery patients was significant, with older age and carotid stenosis being major risk factors. Preoperative aortic imaging, such as computed tomography angiography or epiaortic ultrasound, should be applied to cardiac surgery candidates. In resource-limited settings, prioritizing patients of advanced age or those with carotid stenosis for imaging is advised.

Usefulness of intraoperative ultrasound examination for laparoscopic right-side colon cancer surgery: a propensity score-matched study

Complete mesocolic excision (CME) with central vascular ligation (CVL) in laparoscopic surgery for right-sided colon cancer (RSCC) requires a precise understanding of the vascular anatomy. The efficacy of intraoperative ultrasound (IUS) in the identification of blood vessels for RSCC surgery was not evaluated. The aim of this study was to compare the intraoperative and short-term outcomes of CME with CVL with or without IUS by laparoscopic surgery for RSCC. We performed IUS on 26 patients of RSCC and compared with a total of 124 patients who underwent the surgery for RSCC at our institution. Propensity score matching (PSM) was performed to reduce the confounding effects to imbalances in the use of IUS. The IUS identified the main feeding artery and the accompanying vein in all 26 cases. After PSM, the amount of intraoperative blood loss in the IUS group was significantly lower than that in the conventional group (5 ml vs. 30 ml, p = 0.035) and no significant difference of the postoperative complications was observed. The IUS reduced the risk of bleeding in the surgery for RSCC. The IUS is a safe and feasible technique that help the surgeons for anatomical understandings under real-time condition in the laparoscopic surgery of RSCC.

Results of using intraoperative ultrasound in surgery of neurodegenerative disorders of the lumbar spine

Aim. To evaluate the results of intraoperative ultrasound examination (IOUS) in surgery of degenerative diseases of the lumbar spine.Materials and methods. To evaluate the results of the use of IOUS in the surgery of degenerative diseases of the lumbar spine, an analysis of prospective examination data of 147 patients operated on for degenerative diseases of the lumbar spine in the neurosurgical department of the B.V. Petrovsky National Research Center of Surgery from 2014 to 2018. To study the accuracy of the ultrasound method for determining the level of surgical access and assessing the degree of radiation load reduction, to study the quality of ultrasound imaging of the structures of the spinal canal, a descriptive study was conducted that included 100 patients (a group of method descriptions). To determine the effectiveness of the use of IOUS, a randomized controlled trial was conducted based on a statistical comparison of the results of surgical treatment of 2 similar parallel groups of patients (control and experimental) consisting of 47 patients each, who differed only in the use of IOUS. Patients of the control group were selected from the method description group. The control and experimental groups of patients were compared according to the following criteria: the duration of surgery, the volume of intraoperative blood loss, the duration of hospitalization, the degree of root pain after surgery, the level of quality of life after surgery, the number of recurrences of herniated disc. For IOUS, we used BK Medical Pro Focus 2202 and BK Medical Flex Focus 400 ultrasound machines with neurosurgical sensors Craniotomy 8862 and Burr-Hole 8863. We performed IOUS before flavotomy, after flavotomy and after decompression of nerve structures.Results. The method of determining the level of surgical access using IOUS has a high accuracy (100 %) and allows you not to use radiography and reduce the radiation load (on average by 0.02 mSv per patient). IOUS allows to adequately visualize the structures of the spinal canal in patients with degenerative pathology of the lumbar spine: the sensitivity of the method before flavotomy is 93 %, after flavotomy – 97 %, and after decompression of nerve structures – 100 %. Due to the high sensitivity of the IOUS method, it allows optimizing surgical access, controlling the radicality of decompression of nerve structures, documenting the fact of their decompression. The use of IOUS in patients with degenerative diseases of the lumbar spine can improve the results of surgical treatment by reducing the number of recurrences of disc herniation, reducing the degree of radicular pain after surgery, reducing the duration of surgery and the volume of intraoperative blood loss.Conclusion. IOUS is a simple, harmless and widely available method of intraoperative imaging, which allows to improve the results of surgical treatment of patients with degenerative pathology of the lumbar spine.

Guideline for clinical practice of ultrasound examination in liver transplantation (2023 edition)

Liver transplantation is currently the only effective treatment for end-stage liver disease. Ultrasound examination has the advantages of non-invasive, convenient, and real-time display the intrahepatic vascular hemodynamic changes, and has become one of the preferred evaluation methods in the entire management process of liver transplantation. To further standardize the ultrasound examinations before and after liver transplantation, multiple-disciplinary experts in the field of liver transplantation, including specialists in ultrasound, liver surgery, and intervention medicine, were organized by the Chinese Medical Association Ultrasound Medicine Branch, the Chinese Medical Doctor Association Surgery Physician Branch, the Chinese Medical Doctor Association Interventional Physician Branch, and the Shanghai Medical Association Ultrasound Medicine Branch. Combined with the latest research practice in ultrasound diagnosis and treatment of liver transplantation, the ultrasound clinical practice guidelines for liver transplantation (2023 edition) was formulated. The contents of this guideline include ultrasound evaluation of liver transplantation donors and recipients, intraoperative and postoperative ultrasound examination of transplant livers, ultrasound applications in pediatric liver transplantation, and ultrasound-guided liver puncture biopsy and treatment, aiming to promote the standardized and high-quality development of liver transplantation ultrasound examination in China.

Diagnostic and Treatment Errors in Biliary Cystadenomas and Cystadenocarcinomas: Clinical Cases

Background. Biliary cystadenomas and cystadenocarcinomas are rare cystic tumors of the liver. Complicated differential diagnostics for simple cysts often leads to errors in surveillance of patients with these tumors. Cystadenoma and cystadenocarcinoma should be suspected upon detection of single or multilocular cystic neoplasms of the liver with septa and blood flow loci in the cyst wall, especially in middle-aged women. The localization of the tumor is critical. The most common localization is segment IV of the liver. Urgent intraoperative biopsy is required to determine the extent of surgery.Case description. Clinical observations with analysis of the examination and treatment data of two female patients aged 38 and 56 were presented. Both clinical observations illustrate the underestimation of the preoperative examination data that served as a ground for diagnosis of liver cysts with inadequate extent of surgery. In the first case, the resection was incomplete, and, as such, the biliary cystadenoma recurred in the resection area, the capsule of the neoplasm was ruptured and an encysted fluid collection was formed. In the second case, lack of histological examination of the excised neoplasm, due to confidence in its morphological verification as a cyst, resulted in cystadenoma recurrence in the resection zone with metastasis to the contralateral lobe of the liver.Conclusion. Hepatic cystadenomas and cystadenocarcinomas are often misdiagnosed as simple cysts. These tumors should be suspected in central localization of the tumor in the liver, especially in young women. The clinical and instrumental symptomatology and radiological semiotics of the disease require careful evaluation. The recurrence of a cystic lesion in the resection zone in a patient previously operated for a hepatic cyst serves as an additional signal for detecting biliary cystadenoma. Rational strategy for surgical management of cystic liver lesions should include hepatectomy within healthy tissues (both anatomical and atypical) with mandatory intraoperative ultrasound and urgent histological examinations.

HPB V08 Fluorescence Image Guidance (FIG) in minimally invasive liver surgery- can it help identify deep margins?

Abstract Background Despite recent advances in imaging modalities and surgical techniques in liver resection, the rate of R1 resection in liver tumours is still high. Currently, liver surgeons plan the type of liver resection based on information gathered from pre-operative cross-sectional imaging, intraoperative naked eye examination/palpation, and intra-operative ultrasound (IOUS) examination. Naked eye examination and palpation help identify superficially located tumours; however, they do not help localise deeply seated small tumours or accurately mark tumour margins. Moreover, the lack of tactile feedback in the case of laparoscopic liver surgery makes tumour identification further difficult. Currently, IOUS is the most sensitive test for detecting liver tumours – in both open and laparoscopic liver surgery. However, it does not give a real-time visual clue on transection margins. Identification and marking of the deep margin of the tumour are not possible with IOUS. We describe the use of FIG using indocyanine green (ICG) dye in localisation and identification of deep margins of a segment seven liver metastasis. Methods We present a video demonstration of the use of FIG in the identification of deep resection margins of a segment seven tumour in a 41 year-old female patient. Initially, the tumour was not visible to the naked eye owing to its location, which made the identification of the tumour and its margins with IOUS challenging. We can see in the video how ICG identified the tumour readily and helped identify the resection margins, especially the deep margin, which was challenging to identify with IOUS. The histology report confirmed that all margins were free of tumours. Results We found that FIG is a robust, objective, real-time navigation tool that can overcome some of the shortfalls associated with and help accurately identify tumour resection margins. When used along with IOUS, we believe that FIG using ICG can potentially reduce R1 resection rates in liver tumours. Conclusions We found that FIG is a robust, objective, real-time navigation tool that can overcome some of the shortfalls associated with and help accurately identify tumour resection margins. When used along with IOUS, we believe that FIG using ICG can potentially reduce R1 resection rates in liver tumours.

An impact of three dimensional techniques in virtual reality

Three dimensional (3D) imaging play a prominent role in the diagnosis, treatment planning, and post-therapeutic monitoring of patients with Rheumatic Heart Disease (RHD) or mitral valve disease. More interactive and realistic medical experiences take an advantage of advanced visualization techniques like augmented, mixed, and virtual reality to analyze the 3D models. Further, 3D printed mitral valve model is being used in medical field. All these technologies improve the understanding of the complex morphologies of mitral valve disease. Real-time 3D Echocardiography has attracted much more attention in medical researches because it provides interactive feedback to acquire high-quality images as well as timely spatial information of the scanned area and hence is necessary for intraoperative ultrasound examinations. In this article, three dimensional techniques and its impacts in mitral valve disease are reviewed. Specifically, the data acquisition techniques, reconstruction algorithms with clinical applications are presented. Moreover, the advantages and disadvantages of state-of-the-art approaches are discussed in detail.

Invited Commentary: Intraoperative Percutaneous Ultrasound Examination of the Larynx: A New Adjunct to Intraoperative Recurrent Laryngeal Nerve Monitoring.

Invited Commentary: Intraoperative Percutaneous Ultrasound Examination of the Larynx: A New Adjunct to Intraoperative Recurrent Laryngeal Nerve Monitoring.

Micronvasive behaviour of single small hepatocellular carcinoma: which treatment?

Microinvasion (MI), defined as infiltration of the portal or hepatic vein or bile duct and intrahepatic metastasis are accurate indicators of a poor prognosis for mall hepatocellular carcinomas (HCC). A previous study showed that intraoperative ultrasound (IOUS) definition of MI-HCC had a high concordance with histological findings. Aim of this study is to evaluate overall survival and recurrence patterns of patients with MI-HCC submitted to hepatic resection (HR) or laparoscopic ablation therapies (LAT). A total of 171 consecutive patients (78h; 93 LAT) with single, small HCC (< 3cm) with a MI pattern at IOUS examination were compared analyzing overall survival and recurrence patterns using univariate and multivariate analysis and weighting by propensity score. Overall recurrences were similar in the 2 groups (HR: 51 patients (65%); LAT: 66 patients (71%)). The rate of local tumor progression in the HR group was very low (5 pts; 6%) in comparison to LAT group (22 pts; 24%; p = 0.002). The overall survival curves of HR are significantly better than that of the LAT group (p = 0.0039). On the propensity score Cox model, overall mortality was predicted by the surgical treatment with a Hazard ratio 1.68 (1.08-2.623) (p = 0.022). If technically feasible and in patients fit for surgery, HR with an adequate tumor margin should be preferred to LAT in patients with MI-HCC at IOUS evaluation, to eradicate MI features near the main nodule, which are relatively frequent even in small HCC (< 3cm).

Carcinoma Camouflage

Question: A 74-year-old woman with compensated Child-Pugh A cirrhosis (Model for End-Stage Liver Disease score of 8) secondary to autoimmune hepatitis on azathioprine monotherapy was evaluated for abdominal bloating and intermittent right upper quadrant abdominal pain. She endorsed a 5-lb unintentional weight loss over the past 4 months associated with anorexia. On physical examination, she was well-appearing with a soft abdomen and no abdominal tenderness, distension, or ascites. The pertinent serology revealed an aspartate aminotransferase of 76 U/L, a total protein of 8.3 g/dL, albumin of 3.4 g/dL, hemoglobin of 12.2 g/dL, white blood cells of 3.1 × 109/L, platelets of 96,000, lactate dehydrogenase of 290 U/L, and alpha fetoprotein of 4.25 ng/mL. An abdominal ultrasound examination revealed a new hypoechoic lesion measuring 2.5 cm × 2 cm × 1.5 cm with minimal flow by Doppler. Triple phase magnetic resonance imaging (MRI) of the liver revealed a lobular 3.5 cm × 3.0 cm mass in hepatic segments 2 and 3 (Figures A and B, red arrows) as well as a 3.9 cm × 3.1 cm mass in segment 7, each T1 hypointense and T2 hyperintense with peripheral enhancement and washout including marked diffusion restriction favoring multifocal hepatocellular carcinoma with an atypical enhancement pattern. Imaging was negative for extrahepatic disease. Outside of the Milan criteria, the patient was referred to surgical oncology for further evaluation and management. The mass in segment 3 seemed to be larger via intraoperative ultrasound examination (5 cm) and was therefore resected. The mass in segment 7 underwent microwave ablation to preserve the liver parenchyma. Pathology revealed a sheetlike proliferation of large, pleomorphic, atypical vesicular lymphoid cells (Figure C) with mitotic figures and apoptotic bodies (Figure D). Immunohistologic staining was diffusely and strongly positive for CD20 (Figure E), CD10, and BCL6. Workup for viral serologies was negative (hepatitis B virus, hepatitis C virus, HIV, and Epstein–Barr virus stain from liver tissue). What is the next step in evaluation and management? What is the most likely diagnosis? Look on page 1942 for the answer and see the Gastroenterology website (www.gastrojournal.org/) for more information on submitting your favorite image to Clinical Challenges and images in GI. A referral to hematology/oncology was made for the initiation of rituximab-based chemotherapy. This patient has diffuse large B-cell lymphoma (DLBCL), germinal center B-cell type. The pathology from the resected liver segments revealed DLBCL, germinal center B-cell subtype, without double or triple-hit features after fluorescence in situ hybridization analysis. Positron emission tomography with computed tomography scans confirmed no evidence of active disease and final staging was deemed to be stage IEA with a National Comprehensive Cancer Network International Prognostic Index score of 4 (high to intermediate) secondary to age, extranodal disease, and elevated lactate dehydrogenase. Three short cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) was recommended. Echocardiogram revealed a normal ejection fraction. Unfortunately, she developed neutropenic fever during cycle 1 with extended spectrum beta lactamase urinary tract infection, urinary retention, and anasarca requiring granulocyte colony stimulating factor, antibiotics, and adjustment of diuretics. Additional chemotherapy was not advised, and she will follow-up with positron emission tomography with computed tomography scans in 2 months. DLBCL is the most common aggressive non-Hodgkin lymphoma (NHL).1Shibata J. Kurahashi S. Naito T. et al.Diffuse large B cell lymphoma primarily presenting as acute liver failure in a surviving patient.J Community Hosp Intern Med Perspect. 2019; 9: 135-139Crossref PubMed Google Scholar DLBCL may manifest as a primary hepatic lymphoma (PHL) in the late stage of disease. PHL is exceedingly rare, estimated to be present in 0.4% of extranodal NHL and 0.016% of all NHL cases.2Zhang K.J. Chen S. Chen J.L. et al.Complete response to comprehensive treatment of a primary hepatic diffuse large b cell lymphoma: a case report.Oncol Lett. 2015; 9: 1557-1660Crossref PubMed Scopus (3) Google Scholar Contributing factors include chronic viral infections (hepatitis B and C, Epstein–Barr virus, HIV), cirrhosis, autoimmune disease, and chronic use of immunosuppressants. R-CHOP is the gold standard of therapy. Chronic azathioprine use increases the risk of lymphoma; however, the association with PHL has not been reported. Imaging characteristics suggestive of PHL on MRI may consist of signal restriction in the diffusion-weighted imaging and a lower apparent diffusion coefficient.3Colagrande S. Calistri L. Grazzini G. et al.MRI features of primary hepatic lymphoma.Abdom Radiol. 2018; 43: 2277-2287Crossref PubMed Scopus (17) Google Scholar Clinicians should consider hepatic lymphoma in cirrhotic patients if there is a history of autoimmune disease, immunosuppressant use such as azathioprine, atypical enhancement pattern on MRI, and a normal alpha fetoprotein.

Observations on the Diagnostic Effects of CT Examination (Enhanced Scan) on Hemorrhage Corpus Luteum Cyst

Objective: To investigate the diagnostic effects of enhanced CT scan on hemorrhage corpus luteum cyst (HCLC). Methods: The clinical data of 24 patients with hemorrhage corpus luteum cyst diagnosed by surgery and pathology in our hospital were collected. All patients received enhanced CT scan to evaluate the diagnostic value of CT. Results: The average diameter of the cysts in this group of patients was 5.1cm by CT. Further detection of the ruptured cyst wall showed that there was a liquid low-density shadow. Some of the cysts were accompanied by signs of increased density, indicating the presence of blood clots; all patients received surgical treatment. Intraoperative ultrasound examination of the cysts had an average diameter of 5.2cm and a wall of 0.2~0.4mm. Among them, 19 cases of cysts contained "coffee-colored" liquid with varying degrees of blood clots, and 5 cases had no blood clots in the cysts but there were a lot of blood clots beside the cysts. Conclusion: The application of enhanced CT scan in patients with hemorrhage corpus luteum cyst is of great value. It can provide accurate data reference for clinical treatment and is worthy of promoting its clinical application.

Role of troponin I in choice of surgical approach after coronary artery bypass grafting (according to AMIRI-CABG Trial)

Introduction . Coronary artery bypass grafting is worldwide accepted method of treatment of ischemic heart disease. Nevertheless, intraoperative ischemic-reperfusion injury, especially when associated with graft dysfunction, could influence on surgical outcomes. There is no data about precise cut-off level of troponin I associated with graft failure after coronary artery bypass grafting. Aim – to evaluate relationship between troponin I elevation and probability of graft thrombosis. Materials and methods . During single-center non-randomized clinical trial involving 336 patients, admitted for elective coronary artery bypass grafting, role of troponin I level for surgical approach after coronary artery bypass grafting was evaluated in three groups: off-pump, n=181, on-pump, n=128 and pump-assisted (with cardiopulmonary bypass without aortic cross-clamping), n=27. Results . In patients with cardiac index >2.2, troponin I level exceeded the upper reference limit by almost 100 times: 0.5 ng/ml in off-pump group, 4.5 ng/ml in on-pump group. In patients with cardiac index 2.2 and amounted to 1.6 ng/ml in off-pump group and 13 ng/ml in on-pump group. In patients with graft thrombosis, troponin I level was 1.6 ng/ml in off-pump group and 25.8 ng/ml in on-pump group. Conclusion . Troponin I level has an important role in choice of surgical approach after coronary artery bypass grafting. Intraoperative ultrasound examination of grafts with assessment of blood flow according to Doppler sonography and visualization of the stenotic area, if any, could be recommended for early diagnosis of graft failure and choice of surgical approach after coronary artery bypass grafting.

Surgical treatment for common hepatic aneurysm. Original one-step technique.

IntroductionHepatic artery aneurysms are rare, and their treatment represents a challenge for the surgeons.Materials and methodsA new technique is presented for common hepatic artery (CHA) aneurysm: it requires minimal vascular surgical dissection and only one linear vascular stapler is applied at the bottom of aneurysm. Aneurysm exclusion is easily obtained, which allowed retrograde thrombosis. Liver blood supply is ensured to the right and left hepatic artery, through the gastroduodenal artery, and can be previously monitored, with temporary clamping of the section area, by visual control, enzyme evaluation and intraoperative ultrasound examination. We reported an open surgical treatment, with simultaneous removal of hepatic and adrenal metastases, secondary to colon cancer.ResultsThe duration of vascular surgery was 30 min and did not involve complications. Postoperative controls confirmed the efficacy of the procedure.DiscussionThis original technique can be added to the various open and endovascular techniques so far described for the treatment of a CHA aneurysm. It is advisable as open surgery, mostly in case of associated pathologies.ConclusionsThe authors believe that this “one shot” technique by vascular staple of the distal part of CHA is minimally invasive and effective to obtain the exclusion of the aneurysm.

Use of bacterial cellulose film for repair of bile duct injury in pigs.

The aim was to evaluate the use of bacterial cellulose film and bile duct autograft in repairing critical common bile duct injury in pigs. A prospective experimental analytical study was carried out on 20 Sus Domesticus, Piau suidae swine, divided into a control group (n = 10) and an experimental group (n = 10) divided into two subgroups: bacterial cellulose film E1 and bacterial cellulose film E2 to which bacterial cellulose film was randomly allocated. The control group underwent two complete critical common bile duct sections 10 mm apart, while the experimental group with a single critical common bile duct defect underwent a 10 mm section of the longitudinal shaft with edge resection. The defects in the control group were treated with end-to-end conventional anastomosis using polyglycolic 6-0 surgical thread and the experimental group with bacterial cellulose film by continuous suture using the same material. The animals were clinically evaluated throughout the experiment on days D150 (bacterial cellulose film E1), D225 (control group), and D330 (bacterial cellulose film E2) and by intraoperative ultrasound examination related to histopathological and biochemical findings. The intraoperative ultrasonography detected the changes resulting from the common bile duct anastomosis in the control group that produced a considerable incidence of ductal narrowing and obstruction to the biliary flow. In the bacterial cellulose film E2 group, there was an increase in inflammation intensity, granulomatous reaction, fibrosis, and vessels density, without producing bile duct dilation in the ultrasonography assessment. Biochemical analysis of liver enzymes yielded results in the normal range confirming preservation of liver function at the different post-surgery time points. Bacterial cellulose film, when used as a graft for bile duct repair, proved to be a biocompatible material that produced a complete healing process and biliary flow continuity.

The use of intraoperative ultrasound in patients with focal cortical dysplasia: preliminary observations

Introduction . The cessation of epileptic seizures after surgical treatment of focal epilepsy is the main objective of the surgeon. When a neurosurgeon operates focal cortical dysplasia (FCD), he/she faces difficulties with the radical removal of pathological tissue, which looks similar to healthy one. Using the neuronavigation system may not be helpful because of errors caused by displacement of brain tissues after opening the dura mater and resection of pathological foci. Intraoperative MRI examination requires significant financial expenses. One alternative is the intraoperative ultrasound (US) test, which allows one to visualize areas of pathological tissue in real time. The aim of this study is to assess the feasibility of using intraoperative US test. Materials and methods . We conducted a retrospective analysis of 20 cases of pharmacoresistant epilepsy that involved US examination during surgical operation for epilepsy caused by focal cortical dysplasia. In the preoperative period, all patients underwent EEG video monitoring in which at least three seizures were detected. In addition, three patients underwent invasive EEG video monitoring as well as preoperative and postoperative brain MRI. Based on histological verification, the distribution of patients was as follows: Ia type – 1 case (5%); Ib type – 4 cases (20%); Ic type –3 cases (15%); IIa type –3 cases (15%); IIb type – 8 cases (40%); IIIa type – 1 case (5%). Postoperative follow-up continued for 14±10 months (min – 2 months, max – 31 months). Results . Twenty (100%) patients underwent intraoperative US examination where signs of an altered cortex were found in locations similar to those revealed with preoperative MRI scans. Based on the US images, radical resection of pathological tissues was performed in these patients. In 15 (75%) patients, the seizures stopped (Engel class I). According to the US data, FCD had the following characteristics: hyperechogenicity as compared to the brain parenchyma; uneven, fuzzy, irregularly shaped contours; lack of a clear border between the white and gray matter. Conclusion . Intraoperative ultrasound is a safe, inexpensive and effective method for intraoperative imaging of FCD. The authors declare the absence of conflict of interest with respect to this publication. All authors contributed equally to this article.

Intraoperative ultrasound predictors of microinvasion of small hepatocarcinoma (

Background: Small hepatocellular carcinoma (HCC) seems to be curable by surgery or ablation. The presence of microinvasion (MI) such as portal venous, hepatic vein, bile duct infiltration, and/or intrahepatic metastasis is the best indicator of a poor prognosis (1). Previous study showed that intraoperative ultrasound (IOUS) definition of MI-HCC had a high agreement with histological findings (2). Prognoses of patients with MI-HCC were compared according to different treatments: anatomic resection (AR), non-anatomic resection NAR) and laparoscopic thermoablation (LAT). Material & Methods: A total of 174 consecutive patients with single, small HCC with a MI pattern at IOUS examination were evaluated. Among these, we compared the outcomes of the AR group (n = 58), the NAR group (n = 20) and the LAT group (n = 96) performing an analysis of the recurrence patterns during a median follow-up of 35.2 months (range: 2-163). Results: HCC recurrence was recorded in 39 patients (68 %) of the AR group, 15 patients (75 %) of the NAR group and 68 patients (71%) of the LAT group, with no significant differences (p=0.853). The incidences of number of recurrences (solitary/multiple) were similar between the three groups. In addition, the rates of local recurrences in the resection groups was very low (AR: 3.5%; NAR: 5%) in comparison to LAT group (21%; p=0.005). The disease-free survival curves of surgical resection groups are significantly better than that of the LAT group (p=0.0125). Conclusions: Patients with MI-HCC, if it is technically possible, should not be treated by LAT but instead should receive hepatic resection with a wide tumor margin to eradicate MI near the main tumor, even in HCC <3 cm. 1) Yamashita Y et al. Ann Surg Oncol 2012; 19: 2027-34 2) Santambrogio R et al. Liver Intern. 2018; 38: 312-20

OC12.04: A new advanced tool in gynecological surgery: the intraoperative ultrasound examination

OC12.04: A new advanced tool in gynecological surgery: the intraoperative ultrasound examination

Intraoperative contrast-enhanced ultrasound examination for endoleak detection after complex and infrarenal endovascular aortic repair

ObjectiveThe aim of this pilot study was to evaluate intraoperative contrast-enhanced ultrasound (iCEUS) examination for endoleak (EL) detection after complex endovascular aortic repairs (EVAR) in comparison with the standard angiographic completion control. MethodsTwenty-one patients (16 male; median age, 73 years [range, 54-81 years]) who underwent single-stage EVARs at our center between October 2016 and October 2018 were included prospectively. The procedures comprised fenestrated and/or branched EVAR (n = 14; 66%), infrarenal EVAR (n = 5; 24%), infrarenal EVAR with bilateral iliac side branch implantation (n = 1; 5%), and infrarenal EVAR with occluder implantation into the internal iliac artery (n = 1; 5%). The used endografts included 14 custom made devices (Cook, Australia Pty Ltd, Brisbane, Australia, n = 6; Vascutek Terumo, Glasgow, Scotland, n = 8) and seven standard infrarenal endografts (Medtronic Inc, Santa Rosa, Calif, n = 5; Vascutek Terumo, Glasgow, Scotland, n = 1; Cook, n = 1). All patients underwent an angiographic completion control for EL detection followed by iCEUS examination. The iCEUS examination was performed by the same examiner who was blinded to the angiography result. In addition to the comparison of the angiographic results to iCEUS examination, iCEUS examination was also compared with the computed tomography angiography (CTA) before discharge (median time to CTA, 5 days [range, 1-7 days]). ResultsAngiography detected eight type II EL, defining the EL origin in four cases. In addition to detecting all of those eight EL, iCEUS examination revealed eight more type II EL not seen on angiography (P = .002) and allowed a definition of the EL origin in all cases. CTA before discharge showed a persistence of only 5 of the 16 type II EL detected by iCEUS examination (31%, P = .002). ConclusionsAn iCEUS examination can be used as another adjunct to decrease exposure to contrast agent and radiation during EVAR, including complex procedures. A replacement of the completion angiography by iCEUS examination is conceivable for infrarenal EVAR, but also for endovascular type IV or type V repairs. Future studies with larger patient numbers will help to further validate iCEUS examination during complex EVAR.

The smart approach to surgical treatment of submucosal tumors based on preoperative EUS-typing

Background: Non-epithelial tumors of the gastrointestinal tract are in general slowly progressing tumors for which lymphogenous metastasis are not typical. The preferred techniques for removal of non-epithelial tumors are minimally invasive surgical procedures with intraluminal, laparo- and thoracoscopic approaches. Methods: From 2005 to 2017, 168 patients with non-epithelial tumors of the esophagus, stomach, and duodenum were examined, and 80 patients with non-epithelial tumors were operated at the A.V. Vishnevsky Institute of Surgery. The key method to examine patients was an endoscopic ultrasound (EUS) to determine the putative non-epithelial tumor type, as well as the source wall layer and the size of the tumor base. Laparoscopic atypical stomach resections were performed in 62 cases with laparoscopic ultrasound and/or endoscopic navigation. In 7 cases, endoscopic tunnel dissections with and without laparoscopic assistance were performed, in 11, removal of the tumor with the mucosal covering after submucosal dissection. Results: Based on an analysis of the data from preoperative endosonography, intraoperative ultrasound and histological examination of the resected specimen, a working classification of non-epithelial tumors was developed that determines what type of surgical intervention will be the most effective with maximum organ preservation. Conclusions: This classification guides the surgeon to the most effective, organ-sparing and safe intervention according to preoperative sonographic findings

IP155. Intraoperative Ultrasound Guidance for Banding of an Arteriovenous Fistula Causing High Cardiac Output Heart Failure

High output cardiac failure is a known but rare complication of arteriovenous fistula (AVF). This case report describes the use of intraoperative ultrasound examination as a guide for banding of an AVF to decrease flow volume in a patient with high cardiac output failure. The gradual decline of cardiac function before and recovery after banding is demonstrated over an 18-year period. The electronic medical record of a patient with aneurysmal AVF causing high cardiac output heart failure was reviewed. A 53-year-old obese (body mass index, 31.6 kg/m2) woman on hemodialysis via right brachiocephalic AVF since 2001 presented in 2014 for evaluation of an aneurysmal access. Her history was significant for focal segmental glomerulosclerosis, renal cell carcinoma, atrial fibrillation and nonischemic cardiomyopathy. She complained of increasing dyspnea on exertion consistent with New York Heart Association functional class III symptoms, requiring two hospital admissions over a period of 2 years. Her ejection fraction had gradually decreased to 35% (Fig 1). Her cardiac output and index were both elevated at 11.2 and 4.8 L/min/m2, respectively, while the systemic vascular resistance was remarkably low at 277 dynes/s/cm−5 consistent with high output heart failure. On examination, the AVF had a small eschar and three areas of aneurysmal degeneration. Doppler ultrasound demonstrated a flow volume of 5 L/min. She underwent open revision of the access to resect the largest aneurysm and reduce the flow volume. The aneurysm was imbricated over a 16F catheter with two running 5-0 Prolene sutures. Intraoperative ultrasound examination demonstrated persistently high volume (3 L/min; Fig 2). Next banding of a short segment with a bovine pericardial patch was performed and that decreased the flow volume to 1.2 L/min. The patient had an uneventful postoperative course and had uninterrupted use of the AVF through the other aneurysmal portions. A month later the remaining aneurysms were revised and that allowed her to avoid placement of a dialysis catheter. Her dyspnea on exertion improved with symptoms consistent with New York Heart Association functional class II, and the ejection fraction increased to 52% while left ventricular diastolic dimension decreased from 5.7 to 4.8 cm. She remains stable for more than 2 years without hospital admissions for heart failure and continues to use the access for dialysis. High cardiac output failure is a rare but significant complication of AVF. Intraoperative ultrasound is a useful tool to assess flow volume and guide banding of hemodialysis access. Reduction of flow volume can lead to sustained recovery of cardiac function.Fig 2Intraoperative ultrasound examination.View Large Image Figure ViewerDownload Hi-res image Download (PPT)