LUS: Laparoscopic Ultrasound
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1 LUS: Laparoscopic Ultrasound Dr. Bjørn Skjoldbye Herlev Hospital Copenhagen University Training Course for Advanced Oncologic Laparoscopy St. Petersburg - February 14, 2006
2 Equipment Laparoscopy LUS (B&K 8666, multidirectional flexible tip) Abdominal US Biopsies RF-treatment
3 LUS with flexible tip
4 LUS Transducer 10 mm Port
5 Equipment Surgical US-Scanner
6 ProFocus and LUS
7 PiP: Picture in Picture
8 Principles of US-guided biopsy 2D-image Target in image Target on line Insersion of the biopsy needle
9 LUS-guided intervention
10 LUS-guided TRU-cut Biopsy
11 LUS-guided biopsy
12 Percutaneous Biopsy c.pancreatis
13 LUS Guided Biopsy
14 US-contrast Adding an edge to LUS Requirements: I.v access Equipment capable of Contrast Harmonic Contrast Media for infusion
15 SonoVue T=0 2.4 ml bolus i.v.
16 LUS: Hepato-biliary applications Tumors Classification - Resectability Cystic-Solid Differentiation Fluid Collections Abscess Fistulas Biliary Obstruction Biliary Stones Parenchymal Evaluation
17 Gall-Bladder
18 Cholecystitis & Gall bladder with stones
19 Fatty liver (bright liver) & Focal Fatty Sparring
20 Simple cyst vs complex malignant cyst
21 Abscess & Fistula
22 Klatskin Tumor
23 Pancreatic Cancer 5 yr survival: 0.5% Wipples: max 25% Distant metastasis or carcinosis: 50% alive < 6m 80-90% non-resectable at time of diagnosis Only 40-60% resectable pre-operatively are resectable at time of operation
24 Pancreatic tumor and endoprotesis
25 Lymph Adenitis & Dilated Common Bile Duct
26 Pancreatic cancer - Surgical approach Wipple s operation Palliative surgery Endoprotesis (stenting)
27 LAP 27,4 CT vs. LAP & LUS CT LAP LUS resection % resectable Callery MP et al. J AM Coll Surg 1997;185:33-39
28 Catheline JM et al. Surg Endosc 1999; 13: Diagnostic Sensitivity Sens. % Pancreatic tumor Glandular Met. Liver Met. Peritoneal carcinose Vascular Encasement UL CT EUS LAP LUS
29 Surgical treatment of Pancreatic Wipples operation is only potentially curative treatment of pancreatic cancer Succesful outcome of Wipples operation require radical surgery Preoperative staging is required to avoid uneccessary surgery Cancer
30 Criteria for non-resectability Liver metastases Carcinosis Lymph node metastases Vascular encasement Invasion of neighbouring organs
31 Anatomy
32 Intra-hepatic bileduct dilatation
33 US-Signs to be noted ascites encasement Gallbladder
34 Invasive growth in sup. mes. Vein
35 Non-resectable c.pancreatis
36 Lymph Node Metastasis
37 Enlarged pancreatic gland
38 Method Combined Laparoscopy & LUS
39 Carcinosis
40 Ascites
41 Carcinosis - Biopsy
42 Staging pancreatic cancer with Laparoscopy and Laparoscopic Ultrasound
43 Liver metastasis
44 Liver metastasis
45 Gastric tube Endoprotesis
46 Double duct dilatation Portal Thrombosis and collateral flow
47 Doppler Imaging Dilated pancreatic duct
48 Sub-centimeter Liver Metastases
49 Tumor enchasement of a.hepatica
50 Sentinel Node Lymph Nodes
51 Retroperitoneum
52 LAP-LUS-CFM (Doppler)
53 Portal Thrombosis
54 Material Perampullary/pancreatic cancers patients possible resectability (CT and US) m/f: 64/46 Median age: 63 years (range 37-79)
55 Aim Avoid unnecessary exploration in non-resectable disease Evaluate Non- and minimally invasive techniques in diagnosis, staging and treatment Evaluate clinical impact and diagnostic value of LAP/LUS
56 Results 42% LUS-resectable were in fact resectable with curative intend. 55% (61/110) avoided uneccesary laparotomy. 3% Benign or n.a.
57 Reasons for non-resectability Vascular involvement Liver met.s 2 4 Lymph node met.s
58 Predictive values of CT & LAP/LUS Tabel 10 Oversigt over prædiktive værdier fra forskellige studier. Gengivet efter Brooks et al. 6 Referenc e N Predictive value of CT (%) Andren- Sandberg et al Predictive value of laparoscopy (%) Bemelman et al (LUS) Conlon et al Callery et al (LUS) Durup Scheel-Hincke et al (LUS) Fernandez-Del Castillo et al (angiography) John et al (LUS) Reddy et al Brooks et al (LUS in 55%) Present series * 41 (LAPLUS) *95% SG: 15-65%. Beregnet på 6/15 patienter. Hos 71/110 patienter var der ikke taget stilling mht. operabilitet. Se hovedteksten. 55
59 Conclusion LAP+LUS is an essential modality in preoperative staging of pancreatic surgery Further improvement in staging accuracy necessary through supplementary investigations Better CT? EUS with biopsy? Contrast enhanced US? PET-CT?
60 LAP-LUS guided treatment LAP-LUS guided (RF) tumor ablation
61 Treatment of Liver-mets? RADIOFREQUENCY ABLATION (RFA) Dispersive Electrode Pad I RF- Electrode Generator
62 Laparoscopic Guided RFA
63 RFA I
64 RFA II
65 Liver Metastasis After RFA
66 Clinical Aim US-contrast Improved detection of subtle Lmets Characterization of liver lesions Guiding Biopsies Per-operative Therapeutic Feed-Back Follow-up; Recurrency vs non-malignant sequela
67 Detection of liver metastasis before and after PIUS No of patients 11 No. Of Patients RT lobe LT lobe RT Lobe LT lobe Skjoldbye B, Høgholm M, et al. Improved detection and biopsy of solid liver lesions using PIUS and constrast agent infusion. 2002;Ultrasound Med Biol; 28:
68 Typical Enhancement Pattern of focal liver lesions after SonoVue (i.v.) TYPE Arterial- Portal- Late- Haemangioma Peripheral/ Centripital Iso- Globular echoic FNH Spoke & wheel Hyperor Iso-echoic Central Scar Adenoma Internal vasc. Nearly Iso- Iso-hypo enhancement Echoic echoic HCC Strong vasc. Slightly enhancement hypoechoic hypoechoic Metastasis; Hyper-vascular Peri. enhancm. Centr. necrosis Slightly hypoechoic Strongly hypoechoic Metastasis; Hypo-vascular Poor enhancement Slightly hypoechoic Strongly hypoechoic
69 Haemangioma
70 LUS contranst enhanced biopsy
71 Metastasis
72 Late Phase Detection of Barely Visible Liver Metastasis
73
74 HCC & US Contrast
75 RFA Treatment of HCC & US Contrast
76 LUS Contrast & RFA Before During treatment After
77 Summary LUS LAP equals IUS Laparotomy LUS provide in depth information LUS require dedicated equipment High resolution imaging & Doppler Biopsy US-contrast Contrast-LUS may add advantages Detection of lesions Characterization of lesions Treatment control
78 What you get is what you see and there is nothing more to it.. Tina Turner
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