Operative ultrasound establishes resectability of metastases by major hepatic resection

Intraoperative abdominal ultrasonography

BACKGROUND

Ultrasonography during abdominal surgery has been reported since the 1960s, but its use did not become widespread until the recent availability of high-frequency, high-resolution transducers. This review discusses the application of intraoperative ultrasonography to open and laparoscopic abdominal surgery.

METHODS

A literature search (Medline) was undertaken. All papers pertaining to the subject matter that were located were included in the review.

RESULTS

Intraoperative ultrasonography influences surgical strategy in up to 50 per cent of liver resections for malignancy. It is the single most sensitive technique for the detection of occult hepatic metastases at the time of primary colorectal resection. In pancreatic surgery, intraoperative ultrasonography is of value in the localization of islet cell tumours and in the assessment of resectability of adenocarcinoma. The technique may also have a role in staging laparoscopy, and in the operative management of kidney and gastrointestinal diseases.

CONCLUSION

Ultrasonography is an ideal operative tool as it is safe, reproducible and requires no special patient preparation or positioning. It should be regarded as an essential component of major hepatobiliary and pancreatic procedures. The recent availability of flexible laparoscopic probes is likely to lead to a similar impact on minimal access surgery.

Improved survival after resection of colorectal liver metastases

BACKGROUND

The goal of this study was to determine if staging with intraoperative ultrasound (IOUS), assessment of porta hepatis lymph nodes, and evaluation of resection margins can improve selection of patients likely to benefit from resection of colorectal liver metastases.

METHODS

A retrospective evaluation was performed on patients undergoing celiotomy with intent to resect colorectal liver metastases. Patients were considered unresectable if extrahepatic disease was identified by peritoneal exploration or if IOUS demonstrated greater than four lesions or the inability to achieve negative margins. Tumor-negative margins were confirmed by pathologic evaluation. Actuarial 5-year survival was calculated using the method of Kaplan and Meier.

RESULTS

Median follow-up is 25 months. Of the 151 patients undergoing operative exploration, 107 (71.0%) underwent liver resection (all margins tumor negative). Three operative deaths occurred in this group (2.8%). The disease of 30 patients (19.8%) was considered unresectable due to extrahepatic involvement, and that of 14 patients (9.2%) was demonstrated by IOUS to be unresectable. Five-year actuarial survival was 44% for the resected group and 0% for the unresectable patients (p < 0.0001).

CONCLUSIONS

IOUS, portal node assessment, and pathologic margin evaluation improves the selection of patients likely to benefit from resection of colorectal liver metastases.

Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography

OBJECTIVE

The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region.

SUMMARY BACKGROUND DATA

Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy.

METHODS

A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region).

RESULTS

"Occult" metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively).

CONCLUSIONS

Staging laparoscopy is indispensable in the detection of "occult" intra-abdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.

Operative ultrasonography during hepatobiliary and pancreatic surgery

On the basis of our experience with operative ultrasonography during hepatobiliary and pancreatic surgery, its indications, benefits, and disadvantages are summarized. High-resolution operative ultrasound scanning of the liver, biliary tract, and pancreas was performed during 357, 735, and 242 operations, respectively. The benefits of operative ultrasonography were categorized as acquisition of diagnostic information otherwise not available, replacement for or complement to operative radiography, and guidance of surgical procedures. Operative ultrasonography provided beneficial information during 73 of 82 hepatic operations (89.0%), 57 of 69 noncalculous biliary operations (82.6%), and 177 of 242 pancreatic operations (73.1%). Operative ultrasonography was significantly superior (sensitivity 93.3%) to other screening tests for diagnosing liver metastasis from colorectal carcinoma evaluated in 189 patients, and it detected previously unrecognized metastatic tumors in 18 patients (9.5%). For screening common bile duct calculi during 666 operations, operative ultrasonography and operative cholangiography were comparable in all indices of accuracy except for a higher predictability of a positive test of operative ultrasonography (94.8% versus 71.7%). For diagnosing portal vein invasion of pancreatic carcinoma, operative ultrasonography provided better overall accuracy than preoperative studies (89.7% versus 64.1%). On the basis of operative ultrasound findings, previously planned surgical procedures were altered in 32 of 82 hepatic operations (39.0%) and 24 of 145 pancreatic operations for chronic pancreatitis (16.6%). Operative ultrasound guidance of various surgical procedures was performed during 88 hepatic and 84 pancreatic operations, including 40 ultrasound-guided hepatectomies and 42 pancreatotomies. Operative ultrasonography has a number of advantages, such as safety and speed in performance, wide application, high diagnostic accuracy, and ability of guiding procedures. Its disadvantages are the limitation of the fields of view in certain applications, the need for special equipment, and a slow learning curve.