Under Ultrasound Guidance Research Articles

Ultrasound-guided injection of the ankle joint: cadaveric investigation of the anterolateral approach.

Injection of the tibiotalar (TT) joint is commonly performed in clinical practice under ultrasound (US) guidance using an anteromedial approach. However, in some patients, this approach may be technically challenging due to post-traumatic and/or degenerative bony changes. Therefore, the aim of this cadaveric investigation was to demonstrate the feasibility of the ultrasound-guided (USG) injection of the ankle joint via the anterolateral sulcus (ALS) by confirming the dye placement/distribution inside the articular space. Likewise, the safety of the procedure has also been evaluated by measuring the distance between the needle and the intermediate dorsal cutaneous nerve of the foot. A descriptive laboratory study with eight embalmed cadaveric ankles using the Fix for Life (F4L) method was performed at the setting of an academic institution. The interventional technique and the related anatomical findings were illustrated. During the injection, the needle was advanced into the TT joint through the ALS under US guidance, i.e., in-plane anterior-to-posterior approach. With the objective to confirm its correct placement, the needle was kept in situ and-to demonstrate the location of the dye inside the articular space-all eight ankles were injected with 3 mL of green color dye. Thereafter, a layer-by-layer anatomical dissection was performed on all four cadavers. The position of the needle's tip within the ALS was confirmed in all specimens. Accurate placement of the dye inside the articular space of the ankle was confirmed in seven of the eight cadaveric ankles, with 87.5% of accuracy. Herewith, unintentional spilling of the dye within the superficial soft tissues was reported in two of the eight ankles (25.0%). The mean distance between the needle and the intermediate dorsal cutaneous nerve of the foot, measured in all eight procedures, was 3 cm. USG injection of the ALS using the in-plane, anterior-to-posterior approach can accurately place the injectate inside the articular space. This cadaveric investigation described the accuracy and potential pitfalls of USG injection of the ankle via the anterolateral approach which represents an alternative technique in patients with reduced accessibility of the anteromedial recess due to degenerative and/or post-traumatic bony changes.

Published- Comparison between supra-scapular nerve block combined with axillary nerve block and interscalene brachial plexus block for postoperative analgesia following shoulder arthroscopy

Background & objective: Inter-scalene brachial plexus block (ISB) is the gold standard for postoperative pain management in shoulder surgery. Although, this method has its side-effects and possibly complications. Supra-scapular nerve block and axillary nerve block have also been used in upper limb procedures. We compared ISB with the blockade of supra-scapular and axillary nerves (called shoulder block) for postoperative analgesia after shoulder arthroscopic surgical operation under ultrasound guidance (USG) and nerve stimulators.
 Methodology: It was a prospective, randomized, comparative study.
 Results: The VAS pain scores at different times postoperatively were not significantly different between the ISB and ShB groups (P = t 0.071, 0.28, 0.378, 0.358, 0.451 at 2, 4, 8, 16, and 24 h respectively. VAS 0 was significantly difference (P = 0.029) but still the VAS score was less than 3, so no pain killers were given.
 Conclusion: Ultrasound guided supra-scapular and axillary nerve blocks ae equally effective as inter-scalene brachial plexus block for postoperative analgesia in shoulder arthroscopic surgery with less side-effects.
 Abbreviations: ANB: Axillary Nerve Block; ISB: Interscalene Block; MAC: Minimum OR: Operating Room; REC: Research Ethics Committee; ShB: Shoulder Block; SSB: Supra-scapular Nerve Block; VAS: Visual Analogue Scale
 Citation: Elbermway MS, Elshantory SF, Aly RM, Mahran MG. Comparison between supra-scapular nerve block combined with axillary nerve block and interscalene brachial plexus block for postoperative analgesia following shoulder arthroscopy. Anaesth. pain intensive care 2022;26(5):674−680; DOI: 10.35975/apic.v26i5.2026

Intra-articular Injection of Bone Marrow Concentrate for Treatment of Patellofemoral Osteoarthritis: Preliminary Results Utilizing an Ultrasound-Guided Marrow Harvesting Technique

ObjectiveTo assess the effectiveness of intra-articular injection of bone marrow concentrate (BMC) under ultrasound (US) guidance in the treatment of patellofemoral osteoarthritis (OA), with clinical and volumetric magnetic resonance (MR) imaging follow-up. MethodsThis retrospective study included 96 consecutive patients referred for US-guided intra-articular injection of BMC for symptomatic patellofemoral OA for which conservative treatment had failed. A control group of 21 patients with symptomatic patellofemoral OA was included for comparison. Data on International Knee Documentation Committee (IKDC), Visual Analog Scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores as well as volumetric MR imaging (using T2 mapping sequence) were collected before and 12 months after injection, and the results were compared. ResultsNo technical adverse events were noted during bone marrow aspiration, BMC preparation, or intra-articular injection of BMC. No clinical adverse events were reported during long-term follow-up. All mean scores improved between baseline and 12 months after intra-articular injection of BMC (VAS 5.5 to 3.6, P < .0001; WOMAC 36.8 to 22.2, P < .0001; and IKDC 41.8 to 58.2, P < .0001). MR imaging at 1 year of follow-up after BMC treatment showed no statistically significant difference in hyaline cartilage volume compared with that at the baseline (P = .690), suggesting stabilization of the cartilage degradation process. In contrast, the group of untreated patients showed a significant decrease in the cartilage volume (P = .001), corresponding to a cartilage loss of 6.9%. ConclusionsThe results suggest that intra-articular injection of BMC under US guidance could be a promising option for the treatment of symptomatic patellofemoral OA and could promote the preservation of healthy residual cartilage volume.

PO236 / #817 TARGETED ULTRASOUND-GUIDED SHOCKWAVE THERAPY OF LOW BACK PAIN USING FOCUSED, DEFOCUSED AND RADIAL SHOCKWAVE: E-POSTER VIEWING

Extracorporeal shock wave therapy (ESWT) is supposed to alleviate myofascial pain. ESWT has fair level of detecting MTrP, short-term effect in ameliorating myofascial pain [1], can be used in the protocols of management various types of pain and spasticity, neuromusculoskeletal pathologies [1-3]. The efficacy of performance ESWT under ultrasound (US) guidance have not been studied yet. The aim of the study was to compare the effectiveness of US guidance and relevance of ESWT regimes for treatment various neuromusculoskeletal pathologies, muscle pain and dysfunction.

Ultrasound-guided cervical selective nerve block: A case series.

Cervical radiculopathy is characterized by pain, numbness, tingling, and weakness, mostly in an affected extremity, reflecting compression of a nerve in the neck is compressed or irritated where it emerges from the spinal cord. Diagnosis requires a detailed anamnesis, physical examination, and imaging. Physical therapy, exercise, medical therapy, and injections are the preferred treatments, but injections into the cervical region are only indicated if conservative treatment is ineffective. This study explored the utility of selective cervical nerve root blocks (SNRBs) performed at various levels under ultrasound guidance (USG). We evaluated patients diagnosed with cervical radiculopathy via physical examination and magnetic resonance imaging from November 2019 to March 2020. We included those who did not respond to conservative treatment and therefore received SNRBs at various levels. Sixty-three patients were evaluated over 6 months in terms of pain, functional status, and complications. We retrospectively evaluated patients with cervical herniated discs who received SNRBs at various levels between C4-7 under USG. Pain and functional status improved in month 1 and was maintained until at least month 6. SNRB injections performed under USG effectively treated pain and poor functional status in selected patients. The procedure is safe (especially) for patients who do not respond to conservative treatment.

Comparison of the effectiveness of ultrasound-guided and ultrasound-guided subgluteal nerve blocks with peripheral nerve electrical stimulation: A randomized controlled feasibility trial

AIM: The efficacy of sciatic nerve blockade with subchondral access under ultrasound guidance (USG) versus ultrasound guidance in combination with EPN (USEPN) is unknown. Data on studies of these techniques for blockade of other peripheral nerves are inconsistent. This study evaluated the feasibility of a randomized trial to compare the efficacy of sciatic nerve blockade with USG-guided sciatic access with the current practice of USEPN.&#x0D; MATERIALS AND METHODS: Forty patients were randomized into two groups in which USG or USEPN guidance was used to perform sciatic nerve blockade with sciatic access. The primary endpoint was the quality of the sensory block. The secondary endpoint was the quality of the motor block.&#x0D; RESULTS: Two groups of 20 patients each were analyzed. All patients developed successful motor and sensory blocks of the sciatic nerve when using USG and USEPN. All cases were followed. Three patients were excluded before randomization because of the unsatisfactory ultrasound imaging of the sciatic nerve.&#x0D; CONCLUSION: The results show that a prospective study of alternative techniques of sciatic nerve block by subchondral access is possible. In our pilot study, sciatic nerve block performed under USG guidance without EPN was effective in all cases.

What is the minimum effective anesthetic volume (MEAV90) of 0.2% ropivacaine required for ultrasound-guided popliteal-sciatic nerve block?

Background and Aims:Popliteal-Sciatic nerve block under Ultrasound Guidance (USG) using a local anesthetic agent like Ropivacaine is an established technique for providing analgesia and muscle relaxation for lower limb surgeries with minimal untoward events. Establishing the minimal volume of 0.2% ropivacaine required to provide intraoperative and postoperative analgesia will further reduce the drug requirements and adverse effects toward the patient.Material and Methods:This randomized prospective observational blinded study was done in a tertiary care referral hospital in South India over 9 months from August 2017 till April 2018. The block was performed on all recruited patients under ultrasound guidance with a starting volume of 16 ml 0.2% ropivacaine. Duration of time for loss of pin-prick sensation around the sole of the foot (tibial nerve) and the lateral malleolus (common peroneal nerve) was noted. If successful, the volume of the drug for subsequent patients was randomized by lottery method to either be kept the same or reduced. If the block failed, the subsequent patient recruited would have an increased volume of drug injected.Results:By Probit regression analysis using the biased coin up-and-down method we found that 9.3 ml (MEAV90) of 0.2% ropivacaine was sufficient for providing adequate analgesia. Factors such as patient age or weight had no role in efficacy of the block. There were no adverse effects such as allergy to the drug or systemic toxicity noted in the studied patients.Conclusion:9.3 ml of 0.2% ropivacaine is sufficient to provide analgesia (assessed by pin-prick) in 90% of patients undergoing popliteal-sciatic block for lower limb surgeries.

Supera Stent Implantation with Ultrasound Guidance for Complex Ostial Lesions of Superficial Femoral Artery by Retrograde Approach: The SUGAR Technique

Abstract Purpose The aim of this study was to describe a modified technique for accurate deployment of the Supera stent under ultrasound (US) guidance for complex lesions involving superficial femoral artery (SFA) ostium without jailing profunda femoral artery (PFA) by retrograde approach. Technique Retrograde pedal access was initially taken in all the cases. The stenotic or occlusive femoropopliteal lesions involving the SFA ostium were crossed retrogradely and additional contralateral common femoral artery (CFA) access was taken only if we failed to cross the lesion. In addition to fluoroscopy, extravascular US guidance was freely used whenever required throughout the procedure. After desired predilatation of the SFA lesion, US guidance (gray scale and color Doppler) was used to start deployment of the proximal few centimeters of Supera stent ensuring that the landing of first crown was exactly from the SFA ostium not extending into CFA or jailing the PFA ostium. The rest of the stent was deployed under fluoroscopic guidance. Retrograde pedal access site hemostasis was achieved by manual compression. The Supera stent implantation with Ultrasound Guidance for complex ostial lesions of superficial femoral Artery by Retrograde approach (SUGAR) technique was applied successfully in 35 patients (mean age 58.1 ± 4.4 years; 24 males) with critical limb ischemia via the distal pedal approach. No access site or remote complications were observed. Conclusion The SUGAR technique has superior advantage of utilizing a simple tool like extravascular US in addition to fluoroscopy for retrograde Supera stent deployment by allowing very precise landing at SFA ostium, bypassing the need for multiple oblique projections, unwanted radiation exposure, and extra contrast dye overload.

Comparative efficacy of supraclavicular versus infraclavicular approach of subclavian vein cannulation under ultrasound guidance: A randomised clinical trial.

Background and Aims:Subclavian vein (SCV) cannulation can be performed using either supraclavicular (SC) or infraclavicular (IC) long-axis approach under ultrasound guidance (USG). However, their relative efficacy remains debatable. The aim of this study was to compare these two approaches in terms of safety, ease, success rate, and record the incidence of complications.Methods:We studied 90 adult patients distributed into two groups of 45 each. Data regarding the time taken for first venous puncture, the time required for inserting the catheter, the total number of attempts, the incidence of guidewire misplacement, and other mechanical complications were compared using Student's t-test for quantitative data and Chi-square test for qualitative value.Results:Mean puncture time was significantly lesser in group SC than IC (P-value < 0.001). Mean catheter insertion time taken was also significantly less in group SC than IC (P-value = 0.003). The first attempt rate was higher in group SC than IC (P = 0.013). Guidewire misplacement was seen in the IC group, P = 0.001. No pneumothorax, haemothorax, or arterial puncture were noted in our study in any of the groups.Conclusion:We conclude that for right-sided SCV cannulation using USG in the long axis, the SC approach is superior to the IC approach in terms of overall ease of cannulation. It was associated with a relatively shorter procedure time, higher success rate in the first attempt, lesser incidence of guidewire misplacement, and other complications. It should be considered as an alternative approach to the IC approach in patients requiring central line insertion.

Percutaneous Peripheral Nerve Stimulation for Treatment of Brachial Plexopathy Secondary to Pancoast Tumor: A Case Report

Background: Pancoast tumors can result in significant arm and shoulder pain due to invasion of the lower brachial plexus (BP). They are usually treated by chemoradiotherapy followed by surgical resection, which may alleviate the pain. When patients respond poorly to chemoradiation and the tumor is not surgically resectable, options to treat the pain are limited. We report here successful use of percutaneous peripheral nerve stimulation (PNS) with leads inserted under ultrasound (US)-guidance for treatment of brachial plexopathy in a patient with an unresectable Pancoast tumor unresponsive to chemoradiation. Case Report: The patient was a 70-year-old woman with an unresectable poorly differentiated squamous cell carcinoma of the left lung status post chemoradiation with poor response and recently started on immune therapy who presented to her oncologist with refractory left upper extremity (LUE) pain and weakness. She was admitted for pain control, and pain management was consulted. Physical examination findings were concerning for involvement of the lower trunk of the BP, findings confirmed in imaging. Patient elected to proceed with placement of a PNS. Device was successfully placed under US guidance. Patient responded well for the first 2 weeks with significant improvement in allodynia and hyperesthesia, however, at week 3, physical examination was significantly changed and further growth of the tumor was seen on imaging. The PNS was removed at this time. Conclusion: This case demonstrates successful use of PNS to treat refractory neuropathic pain in a patient with a locally advanced Pancoast tumor. US imaging made it possible to identify the interscalene BP and accurately place the leads. The PNS achieved its desired outcome of providing pain relief in the lower trunk distribution for the full 3 weeks it was in place. Pain from Pancoast tumors can be severe, and neural blockade via PNS to interrupt pain is an option for patients with intractable pain. Additional prospective study is warranted to determine the efficacy of this technique. Key words: Brachial plexus, upper extremity, cancer pain, interventional pain management, neuromodulation, peripheral nerve stimulation

Efficacy of image-guided synovial biopsy.

A variety of benign and neoplastic lesions can affect the synovium, including pigmented villonodular synovitis (PVNS) and synovial chondromatosis. Prior to surgical resection, accurate characterization of synovial lesions is necessary for appropriate treatment planning. Additionally, recent advances in potential medical therapies for PVNS could decrease or eliminate the need for surgery in some cases. Such treatment options demand accurate characterization of synovial lesions prior to treatment. Institutional IRB approval was obtained. We identified 54 synovial biopsies performed at our institution using a comprehensive database search under ultrasound (US) or computed tomography (CT) guidance. Cases were reviewed for pre-procedure imaging, location, biopsy approach, biopsy results, post-procedure complications, and surgical pathology if synovectomy was performed. A total of 54 image-guided synovial biopsies were performed, 36 using CT guidance and 18 using US guidance. Six different anatomic locations were biopsied (the hip, knee, shoulder, elbow, ankle, and temporomandibular joint). Synovial tissue was obtained in 89% of cases (48/54). CT-guided biopsies had a positive yield of 86% (31/36) and US-guided biopsies had a positive yield of 94% (17/18). Surgical pathology was obtained in 30 of the cases and image-guided biopsy concordance was 90% (27/30). Of the patients taken for synovectomy, biopsy concordance of suspected neoplastic lesions was 100% (23/23). In cases of suspected neoplasm, the concordance between image-guided biopsy and surgical pathology was 96% (22/23). There were no reported complications. Image-guided biopsy of synovial lesions is safe and effective for establishing a definitive diagnosis prior to surgical or other intervention.

Ultrasound-Guided 125I Seed Implantation in Treatment of Abdominal Wall Metastases

Background: The treatment of abdominal wall metastasis presents a challenge, because resection can be followed by poor healing and external radiotherapy is associated with serious adverse events. This study aimed to evaluate the efficacy and safety of interstitial 125I seed implantation under ultrasound (US) guidance for treating abdominal wall metastasis. Materials and Methods: The cases of 21 patients with 28 abdominal wall metastases who received brachytherapy with 125I seeds at the department from August 2010 to March 2015 were retrospectively reviewed. 125I seeds were implanted in the abdominal wall lesions under US guidance and with the help of a treatment planning system. Follow-up was performed using computed tomography at 1 d and at 3, 6, and 12 months after implantation. The lymphocyte count before the surgery was compared with the 3-month postoperative count. The main indicators observed were changes in tumor size, side effects, and complications. Results: All 21 patients were successfully treated with 125I seed implantation under US guidance. The median follow-up since 125I seed implantation was 15 months (range 6-23 months). The response rates and local tumor control after 3, 6, and 12 months were 78.6% and 89.3%, 64.3% and 85.7%, and 52.4% and 71.4%, respectively. The mean preoperative lymphocyte count was 0.262 ± 0.117 × 109/L, which did not differ significantly from the postoperative count, which was 0.259 ± 0.094 × 109/L (p = 0.122). Procedure-related complications included fever, bleeding, and pain, but all these were Grade 1-2. No severe side effects or complications were noted. Conclusions: Percutaneous interstitial implantation of 125I seeds under US guidance is safe and feasible for abdominal wall metastases. However, its long-term efficacy requires further investigation.

A clinical trial comparing ultrasound-guided ilioinguinal/iliohypogastric nerve block to transversus abdominis plane block for analgesia following open inguinal hernia repair.

ObjectiveTo compare the efficacy of ilioinguinal/iliohypogastric (IINB) nerve block to transversus abdominis plane (TAP) block in controlling incisional pain after open inguinal hernia repair.Patients and methodsThis was a prospective randomized clinical trial of 90 patients who received either IINB (N=45) or TAP block (N=45) using 0.2% bupivacaine 15 mL under ultrasound (US) guidance based on a random assignment in the postanesthesia care unit after having an open repair of inguinal hernia. Numeric Rating Scale (NRS) scores were recorded immediately following, 4, 8, 12, and 24 hours after completion of the block. NRS scores at rest and during movement were recorded 24, 36, and 48 hours after surgery. Analgesic satisfaction level was also evaluated by a Likert-based patient questionnaire.ResultsNRS scores were lower in the IINB group compared to the TAP block group both at rest and during movement. The difference in dynamic pain scores was statistically significant (P=0.017). In addition, analgesic satisfaction was significantly greater in the IINB group than the TAP block group (mean score 2.43 vs 1.84, P=0.001). Postoperative opioid requirements did not differ between the two groups.ConclusionThis study demonstrated that compared to TAP block, local blockade of ilioinguinal and iliohypogastric nerves provides better pain control after open repair of inguinal hernia when both blocks were administered under US guidance. Greater satisfaction scores also reflected superior analgesia in patients receiving IINB.

Effects of ultrasound-guided suprascapular nerve pulsed radiofrequency on chronic shoulder pain.

Pulsed radiofrequency (PRF) therapy has become increasingly popular in the treatment of chronic shoulder pain dueto its long duration of action and non-destructive method. The aim of the study was to reveal the effects of PRF therapy ofthe suprascapular nerve (SSN) under ultrasound guidance (UG) in patients with chronic shoulder pain on both shoulder painand function. This study included 74 patients diagnosed with at least one of the following: adhesivecapsulitis, rotator cuff syndrome and impingement syndrome of shoulder. The PRF therapy of the SSN under UG was performedin those patients with a reduction of 50% or more Visual Analog Scale (VAS) score and those that reported healing inthe active range of motion (AROM) in the diagnostic SSN block. The resting, motion and sleeping shoulder pain assessmentsof the patients were done with VAS score. The shoulder joint function was assessed with the Shoulder Pain and DisabilityIndex (SPADI) questionnaire and the AROM of the joint was measured using a goniometer. In 70 of the 74 patientsa 50% or more reduction was found in the VAS score with diagnostic SSN block. After the PRF therapy of the SSN, the 15thday, 1st month, 3rd month, and 6th month follow-up VAS averages, SPADI averages and the flexion, internal rotation, externalrotation, and abduction values were statistically significantly lower than the baseline values (p<0.05). This studyis the largest series in the literature evaluating the efficacy of PRF therapy of the SSN under UG and has shown that pain canbe controlled quickly, for a long period of time, using ultrasound guided PRF therapy of the SSN in chronic shoulder pain.

Cumulative Evaluation Data: Simulation Based Learning Courses for Pediatric R1 Residents

Objectives: To utilize cumulative evaluation data of the Intensive pediatric simulation-based learning course on knowledge and practical skills for pediatric R1 residents at Saudi Commission for Health Speciality (SCFHS) in order to measure its efficacy and areas for improvement. Methods: This evaluation design is a retrospective cohort study that compares pre- post- and retention test 6 months later (knowledge and skills) of an intensive pediatric R1 simulation course. The five-day bundle courses has been conducted once per month at CRESENT and is comprised of airway management with crew resource management, central line insertion under ultrasound guidance, thoracocentesis and chest tube insertion, chest X-ray interpretation and lung ultrasound, lumbar puncture and bone marrow aspiration and biopsy and cardiac simulation course. Our evaluation data includes all pediatric R1 residents who attended the course between September 2017 and May 2018. Results: A total number of 43 trainees, 23 residents (43.5%) are males and 20 (46.5%) are females.18 (41.9%) are KfMC residents and 25 (58.1%) non-KFMC residents (Table 1). Overall, there is statistically significant improvement between the pretest and post-test knowledge and practical skills scores for all the courses. Airway management simulation course, central line catheter insertion under ultrasound guidance course and lumbar puncture course a comparative analysis for knowledge and practical skills assessment of pre-test and post-test mean scores showed significant statistical improvement with P-value &lt;0.001. Similarly, a comparative analysis for knowledge assessment of pre-test and post-test mean scores for all the five courses including pediatric cardiac simulation course and pediatric chest X-ray interpretation course showed significant statistical improvement with P-value &lt;0.001.Retention test were limited to 4 candidates did retention practical skills test and showed 100% improvement in their scores while 9 candidates did retention knowledge test for airway management course, central line insertion under ultrasound guidance course and lumbar puncture course which showed 50% less than post test but more than pretest score, 30% had equivocal as post test and 20% more than post test score. Majority enjoyed training in simulation environment Discussion: This study shows the importance and effectiveness of the pediatric simulation courses for pediatric R1 residents under SCFHS training programs. The striking results are the improvement in all assessed categories of knowledge and practical skills for all the courses, although the retention candidates were few but striking result of significant retaining the practicle skills and even retaining the knowledge as non scored similar or below pre test score. Which makes a strong argument to mandate such courses to all pediatric residents. Further research is needed to study skills’ retention more widelyand more importantly its impact on patients’ care. Although resource-intensive, the use of cumulative evaluation data helped to focus quality improvement in our courses.

PERCUTANEOUS DIRECT OZONE INJECTION – SOLID TUMOUR

This lecture defines the scope of Direct Ozone Injection into solid tumors, and introduces attendees to the ways in which Direct Ozone can be given under ULTRASOUND guidance (USG).&#x0D; &#x0D; Percutaneous USG guided Ozone injection is an exciting approach to destroying inoperable primary tumors or metastases in the liver in the treatment of hepatocellular (HCC), fewer than 40% of patients are candidates for surgery, and the rate of recurrence after curative surgery is high. Percutaneous techniques like Ozone Absolute alcohol &amp; RFA are widely used for metastatic and small primary tumors.&#x0D; &#x0D; It serves as a bridge for transplant candidates, especially in relation to small primary lesions.&#x0D; &#x0D; Percutaneous Ozone is a minimally invasive, repeatable procedure with few complications. It is performed under Ultrasound guidance. Ozone results in a higher rate of complete necrosis and requires fewer treatment sessions than percutaneous ethanol injection (PEI). Long-term survival rates are also better. Our series of 4 patients compared well than the patients treated with Trans catheter arterial chemoembolization (TACE) &#x0D; &#x0D; Cholangiocarcinoma’s with obstructive biliary system responded well with direct USG Guided Ozone Injections.

US-guided percutaneous radiofrequency versus microwave ablation for benign thyroid nodules: A prospective multicenter study.

e17593 Background: To evaluate the clinical outcomes between radiofrequency ablation (RFA) and microwave ablation (MWA) in treating benign thyroid nodules (BTNs) with a prospective multicenter study. Methods: The prospective multicenter study achieved the registration of Chinese Clinical Trial Registry (Number: ChiCTR-ONRC-13003087). From January of 2013 to December of 2015, the total number of 1,252 patients with 1351 benign thyroid nodules (BTNs) at eight participating institutions was enrolled in the multicenter study. The ablation devices were applied in the study including RFA system of VIVA RF generator (VIVA RF generator, STARmed, Goyang, Korea) and MWA system of KY-2000 2450MHz microwave system (KY-2000, Kangyou Medical, Nanjing, China). All the procedures of RFA or MWA were performed under ultrasound (US) guidance in each center. Results: The number of target nodules treated by RFA and MWA were 687 in 649 cases and 664 in 603 cases, respectively. For the estimation of efficacy, the mean maximal diameter reduction ratios (MDRRs) of RFA vs. MWA groups at the 3rd, 6th, 12th month and last follow-up were 36.4±17.3% vs. 36.0±23.0% (p = 0.765), 54.1±22.7% vs. 49.3±28.0% (p = 0.005), 64.5±22.1% vs. 57.9±40.1% (p = 0.008) and 65.5±26.0% vs. 58.2±33.5% (p = 0.028), respectively. The mean volume reduction ratios (VRRs) of RFA vs. MWA groups at the 3rd, 6th, 12th month and last follow-up were 67.6±20.3% vs. 64.4±43.5% (p = 0.143), 84.1±13.5% vs. 78.4±48.2% (p = 0.016), 89.6±20.0% vs. 82.5±49.7% (p = 0.035) and 91.3±12.6% vs. 81.1±70.4% (p = 0.045), respectively. For the estimation of safety, for all the complications and side effects encountered at the peri-ablation and follow-up period in two groups, the major, minor complication and side effect rates of RFA vs. MWA group were all no statistical significances with 4.78% vs. 6.63% (p = 0.156), 2.00% vs. 2.49% (p = 0.562) and 4.93% and 4.64% (p = 0.812), respectively. Conclusions: As a conclusion of the prospective multicenter study, both RFA and MWA under US guidance percutaneously are safe and effective techniques for selected patients with BTNs. Larger MDRR and VRR can be achieved in RFA group than the ones in MWA group at 6-month and later follow-up. Clinical trial information: ChiCTR-ONRC-13003087.

Percutaneous microwave ablation of adrenal tumours under ultrasound guidance in 33 patients with 35 tumours: A single-centre experience

Purpose: The aim of this study was to investigate the efficacy and safety of percutaneous microwave ablation (MWA) of adrenal tumours under ultrasound (US) guidance.Materials and methods: A total of 33 consecutive patients with 35 tumours were enrolled. The term ‘technical success’ is used to indicate whether the tumour was treated according to protocol and was covered completely by the ablation zone. Technical success, local tumour progression (LTP) and complications were recorded. For seven patients with eight biochemically active tumours, biochemical markers were recorded prior to and after the ablation procedure.Results: In this study, technical success was achieved in all cases. Follow-up imaging was performed on 31 patients with 33 tumours (excluding two patients who were lost to follow-up). LTP occurred for five tumours (15.2%) at a mean of 24 months of follow-up (range 3–82 months). In the subgroup analysis of tumour size and LTP, a significant difference was noted between tumours with a diameter ≤5 cm compared with those >5 cm (p < 0.01). For seven cases of metabolically active adrenal tumours, technical success was confirmed in all patients, and LTP occurred in one case of recurrent pheochromocytoma. All patients demonstrated the normalisation of abnormal biochemical markers after ablation. No major complications were observed.Conclusion: Percutaneous MWA under US guidance is effective in terms of good local control of adrenal tumours with a diameter of less than or equal to 5 cm and is capable of treating biochemically active tumours harbouring clinical syndromes.

LO088: Development of a simulation-based curriculum for ultrasound-guided internal jugular central venous catheterization

Introduction / Innovation Concept: Insertion of an internal jugular (IJ) central venous catheter (CVC) under ultrasound guidance (USG) is a complex skill that requires considerable practice in order to achieve technical proficiency. Simulation allows novices to engage in structured and high volume repetitive practice of USG IJ CVC insertion and to work through a predictable pattern of errors prior to real patient encounters. Based on earlier work on learning curves for CVC insertion, this curriculum uses a model of simulation-based high volume deliberate practice of the fundamental skills of USG CVC insertion, and was designed with careful consideration of the conditions associated with optimal learning and improvement of performance. Methods: Eight residents (post graduate year 2) from the Departments of Emergency Medicine and Anesthesiology engaged in deliberate practice of USG CVC insertion during three two-hour sessions, at 2-week intervals. Progress of the residents was monitored with direct observation and regular hand motion analysis (HMA), which was compared to performance metrics set by a local expert. Curriculum, Tool, or Material: Students reviewed online introductory ultrasound video and articles outlining internal jugular (IJ) and femoral CVC insertion prior to the first session. Session 1 focused on ultrasound skills including knobology, transducer movement, and needle tracking. This was followed by 60 minutes of deliberate practice of the skills of USG CVC insertion on both femoral and IJ models. During sessions 2/3, students practiced complete gowning and draping using sterile technique. This was followed again by deliberate practice of the skills of USG CVC insertion on both femoral and IJ models. Students received coaching and feedback throughout all sessions, with HMA assessment of USG IJ CVC insertion at the beginning and end of each session. After three training sessions, consisting of 85 total attempts, 5/8 residents surpassed the expert benchmark for probe hand motion, 6/8 for needle hand motion, and 1/8 for total procedure time, with the remaining residents approaching the expert benchmark for each metric. Conclusion: We have successfully developed a simulation-based curriculum for USG IJ CVC placement. Residents demonstrated continuous improvement in each session, approaching or exceeding the expert benchmarks by the end of the third session.

Combined Spinal Cord Stimulation and Peripheral Nerve Stimulation for Brachial Plexopathy: A Case Report

Brachial plexopathy usually results from an iatrogenic brachial plexus injury and can sometimes cause severe chronic pain and disability. There are a number of possible treatments for this condition, including medication, physical therapy, nerve blocks, and neuromodulation, but they are not always successful. Recently, combined spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) have been tried for various chronic pain diseases because of their different mechanisms of action. Here, we describe the case of a 54-year-old man who was diagnosed with brachial plexopathy 8 years ago. He underwent video-assisted thoracoscopic surgery to remove a superior mediastinal mass. However, his brachial plexus was damaged during the surgery. Although he had received various treatments, the pain did not improve. For the management of intractable severe pain, he underwent SCS 2 years ago, which initially reduced his pain from numeric rating scale (NRS) 10/10 to NRS 4 – 5/10, but the pain then gradually increased, reaching NRS 8/10, 6 months ago. At that time, he was refractory to other treatments, and we therefore applied PNS in combination with SCS. The PNS electrode was positioned on the radial nerve under ultrasound guidance. After combined PNS and SCS, his background pain disappeared, although a breakthrough pain (NRS 3 – 4/10) was caused intermittently by light touch. Furthermore, the patient’s need for analgesics decreased, and he was satisfied with the outcome of this combined treatment. We concluded that combined SCS and PNS is a very useful treatment modality, which can stimulate the target nerve both directly and indirectly, and hence, relieve pain from brachial plexopathy. Key words: Brachial plexopathy, spinal cord, peripheral nerve, stimulation, ultrasound, neuropathic