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Our Program. IOUS was used for guiding either punctures and biopsies in 5 cases 9. The procedures were punctures performed for guiding either biopsies or nodule alcoholization.
Hepato-Pancreato-Biliary (HPB) Unit
Table 5 depicts such procedures. IOUS has evolved greatly in the last 15 years. It used to be a complex method, with a limited span of indications, frequently associated with an increase in surgical time. The improvement in quality of ultrasonography equipment, with the development of transducers for this purpose, smaller and with greater resolution, has increased the importance of the method in digestive tract surgery.
In many centers, it is routinely used in liver, pancreas and bile duct diagnostic exploration. The main indications for IOUS use are: 1 detecting small hepatic primary tumors or metastases; 2 precisely staging either primary liver tumors or hepatic metastases; 3 visualizing intrahepatic vascular anatomy, in order to make segmentomies feasible; 4 identifying bilio-pancreatic ductal structures and their contents; 5 searching for nodular structures in cirrhotic livers; 6 establishing the diagnosis of pancreatic endocrine tumors; 7 as a guide for catheterizing vascular and ductal structures; 8 as a guide for localizing and puncturing both hepatic abscesses and pancreatic liquid collections; 9 as a guide for the puncture and biopsy of undiagnosed hepatic nodules; 10 in therapeutic puncturing alcoholization and instillation of chemotherapheutic agents of hepatic nodules.
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In the present series, the main purpose for IOUS was searching for metastatic hepatic nodules in patients with gastric, intestinal and pancreatic malignancies. The goal of the examinations was the intraoperative detection of unidentified non-palpable nodules. The image-utilizing methods for routine liver examination are ultrasonography and CT. Nevertheless, these procedures cannot detect hepatic metastases, either single or multiple, particularly those that are small.
The problems associated with the examination technique were artifacts, the patient's physical type, anatomic variations, allergy to contrast, and, in particular, the size of the lesions. It is estimated that approximately 20 percent of metastases are preoperatively identified.
IOUS is useful principally in the detection of minute and deeply located lesions in the hepatic parenchima. The method can lead to a precise detection and location of lesions, as well as their spatial relationships with intrahepatic vascular structures. Two out of 39 cases in the hepatobiliary group had a diagnosis of chronic hepatic disease cirrhosis. In both of them, intraoperative IOUS detected nodules previously not observed. The discovery of left lobe tumoral involvement changed the surgical plan, which resulted in the avoidance of right hepatectomy.
In its place, alcoholization of nodules was performed. These nodules, four in number, were less than 1. In chronic hepatic disease, the parenchimal heterogeneity has seen as an additional difficulty for preoperative detection of small nodules. For this reason, IOUS has been utilized in examining cirrhotic patients for nodules smaller than 5. IOUS allows for the clear identification of portal branches and hepatic veins.
Thus, the tridimensional nature of tumoral and vascular structures are easily recognized by the surgeon. Through this method, as well as guided puncture techniques, a new surgical procedure such as subsegmentectomy was developed. Hepatic resections have become a more common procedure. However, most patients with cellular hepatocarcinoma have associated cirrhosis. In these patients, a wide resection is a risky procedure, due to the hepatic failure which could occurr.
Thus, IOUS plays a important role in guiding more economic resections. Also benign lesions like cavernous hemangiomas, adenomas and nodular focal hyperplasy have been benefited by these segmental or subsegmental resections, leading to the avoidance of unnecessary lobectomies. IOUS is helpful in performing subsegmentectomies because it allows the visualization of intrahepatic vascular structures which have no anatomical expression on the hepatic surface. In the group of patients with bile disease, cases of bile duct dilation, malignancies, and lithiasis have been evaluated.
The gallbladder has usually been adequately studied through preoperative ultrasonography. In recent years, IOUS has been used to explore either intrahepatic and intrahepatic biliary ducts. Recent studies have suggested that intraoperative cholangiograpy be replaced by IOUS. Cholangiography is a technique used to detect common duct calculi with sensitivity and specificity of approximately 90 to 95 percent.
Nevertheless, it has some technical limitations and interpretation problems due to bubble formation.
Use of Ultrasound Expands Across Surgical Specialties
It also has the disadvantage of prolonging surgical time, because of the procedure itself and the additional time needed for the development of the film. On the other hand, IOUS is a non-invasive, simple and fast method. The results in the detection of biliary calculi have been similar for both methods.
In the case of cholangiocarcinoma seen in this series, IOUS was useful in staging and establishing anatomical relationships, similarly to what has been previously discussed for hepatic masses. In this series, there was an agreement between the preoperative examinations and preoperative IOUS in In the cases of liver and bile duct diseases, a Bismuth et al. Clarke et al. In the group of patients investigated for suspected pancreatic disease, the main indication for IOUS was the search for endocrine tumors. In the eight cases with suspected endocrine tumors, IOUS supplied additional information in three, as compared to other preoperative examinations.
In two of these cases, a solid nodule was identified through the method. In the other, a preoperatively-diagnosed solid nodule, was found to be a cyst. In the four cases of non-endocrine pancreatic disease, two were suspected of being tumorous.
Hepatobiliary & Pancreatic Surgery - Jersey Shore University Medical Center
In both, IOUS showed a normal pancreas. In another case, in which the preoperative examinations results were normal, IOUS showed a mass in the head of pancreas. Various authors have emphasized the importance of IOUS as a routine diagnostic procedure for the identification of endocrine tumors. Due to the small dimensions of theses nodules, the preoperative diagnosis is usually difficult or inconclusive. Thus, the intraoperative location of tumor, by palpation and IOUS, is very important. The contribution of IOUS is particularly important in the study of multiple endocrine tumors.
The complementary character of conventional sonography, and IOUS plus palpation, gives the surgeon increased safety in the resection of small nodules. In the present study, IOUS provided additional data, as compared to other preoperative examinations As for the other indications for IOUS, the findings of this study agree with those from literature, in terms of its use for the detection of pancreatic anatomic alterations, identification of the Wirsung duct, evaluation of texture, and the observation of peripancreatic vascular structures.
The method is useful for the diagnosis of tumors and chronic pancreatitis.
Segmental Anatomy of the Hepatic Parenchyma
Its accuracy surpasses that seen in other preoperative examinations. Interventional ultrasonography has been very useful in guiding several percutaneous techniques. Its main indications are related to procedures in which needles and catheters are necessary, such as in the drainage of abscesses, aspiration of cysts, injection of alcohol and chemotherapeutic agents, and biopsy procedures. These operative procedures can also be done with IOUS. In the present series, intraoperative IOUS was used in five cases, guiding biopsies and alcoholizations of hepatic nodules, and drainage of hepatic abscesses.
In these cases, the purpose was performing diagnostic and therapeutic punctures on inflammatory and neoplasic hepatic lesions that, due to their localization, were not readily accessible by visualization or palpation.
A decrease in operative time and an increase in surgical safety were additional advantages. Although the present study deals only with hepatic operative procedures, other authors have mentioned the use of IOUS in pancreatic operations, such as the internal drainage of pseudocysts and the catheterization of a dilated Wirsung duct. IOUS is an additional procedure in surgical operations, which leads to an increase in operative time. However, by allowing a rapid identification of small lesions, a more precise staging of tumors, guiding resections that would otherwise be performed blindly, and by making associated surgical procedures feasible, the end result is actually a shorteningg of overall operative time.
This contributes to a better prognosis. The injection of CO 2 into the hepatic artery was not associated with harmful side effects. The new IOUS apparatus, equipped with a color doppler, had brought an advancement to the technique. It allows the rapid identification of the arterial and venous vasculature, which makes possible the differentiation between blood vessels and other channel-like structures.
The improved recognition of the hepatobiliary and pancreatic anatomy has made surgical dissections in these areas easier. Laparoscopic surgery represents a major advance in surgical technique in the last decade. Specially designed transducers which allow monitoring these procedures had been developed.