Percutaneous ultrasound-guided cholangiography using microbubbles to evaluate the dilated biliary tract: initial experience

Clinical application of fly-thru in diagnosis of biliary obstructive diseases: feasibility, reproducibility, and diagnostic value

PURPOSE

To evaluate the feasibility, reproducibility, and diagnostic value in biliary obstructive diseases using Fly-Thru (FT) technique.

METHODS

In this single-center prospective study, patients with biliary obstruction who underwent both abdominal ultrasound and FT examinations were recruited between January 2013 and January 2023. 3D FT images (3D-FT) were reconstructed with FT volumetric data. Image quality was subjectively assessed by two radiologists independently. 3D-FT was used to determine the degree of biliary obstruction and compared with ultrasound-guided percutaneous transhepatic cholangiography (PTC). Diagnostic confidence level, diagnostic accuracy and diagnostic duration of the two radiologists using 2D-ultrasound (2D-US) alone and 2D-US combined with 3D-FT were recorded respectively and compared.

RESULTS

100 consecutive patients were enrolled (mean age: 59.6 ± 13.2 years; 52 men). All 3D-FT images were successfully reconstructed and most (75% and 66%) 3D-FT images were considered clear and highly useful for diagnosis with a good agreement (Kappa = 0.653). Benign lesions and malignancies presented differently in both 2D-US and 3D-FT imaging. 3D-FT was not inferior to PTC in determining the degree of biliary obstruction (p = 0.101), with the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, and positive predictive value as 90.5%, 26.7%, 1.23, 0.36, 77.6%, 50.0% respectively. Combined with 2D-US, 3D-FT significantly increased the diagnostic confidence level and diagnostic accuracy of biliary obstructive diseases (all p < 0.01), especially for radiologists with less experience.

CONCLUSION

Application of 3D-FT in diagnosis of biliary obstructive diseases was considered feasible and reproducible, with satisfactory diagnostic value and clinical importance.

Contrast-enhanced ultrasound-guided percutaneous transhepatic cholangiodrainage is a safe and effective procedure for patients with malignant biliary obstruction and stage 3 chronic kidney disease

OBJECTIVES

This study aimed to validate the efficacy and safety of contrast-enhanced ultrasound-guided percutaneous transhepatic cholangiodrainage (CEUS-PTCD) as a biliary drainage procedure in patients with malignant biliary obstruction and stage 3 chronic kidney disease (CKD3).

MATERIALS AND METHODS

Between January 2019 and December 2023, 634 patients who underwent CEUS-PTCD were retrospectively enrolled in this study. During the procedure, imaging parameters such as the maximum diameter of the dilated bile duct, presence of ascites, detailed findings from CEUS, and clinical outcomes were meticulously recorded. Laboratory results, including serum bilirubin levels, liver function tests, and estimated glomerular filtration rate (eGFR), were evaluated in one day before and three days after procedure. The aforementioned parameters were compared using the paired-sample t test and the Wilcoxon test.

RESULTS

A total of 66 (10.41 %) patients with malignant biliary obstruction and CKD3 were included in the final analysis (median age: 66, range: 30-89 years, 46 males and 20 females). Procedure records indicated that 23 patients (34.8 %) had a maximum biliary duct dilation diameter of ≤ 4 mm, while 5 patients (7.6 %) exhibited mild ascites. Additionally, 24 patients (36.4 %) had ultrasound contrast agent entry into both the biliary duct and bloodstream. All patients successfully achieved external bile drainage following CEUS-PTCD, with no significant complications observed during or after the intervention. Post-procedure, there was a statistically significant reduction in all previously elevated serum bilirubin and liver enzyme levels (P-values were less than 0.05). Furthermore, no statistically significant alterations in eGFR were observed prior to or following CEUS-PTCD across all patients (P = 0.295), including comparisons between groups with and without the ultrasound contrast agent into the bloodstream (P = 0.254).

CONCLUSION

CEUS-PTCD is a safe and effective biliary drainage procedure for patients with malignant biliary obstruction and CKD3.

Intracavitary Applications for CEUS in PTCD

Intracavitary contrast-enhanced ultrasound is widely accepted as a highly informative, safe, and easily reproducible technique for the diagnosis, treatment, and follow-up of different pathologies of the biliary tree. This review article describes the diverse applications for CEUS in intracavitary biliary scenarios, supported by a literature review of the utilization of the method in indications like biliary obstruction by various etiologies, including postoperative strictures, evaluation of the biliary tree of liver donors, and evaluation of the localization of a drainage catheter. We also provide pictorial examples of the authors' personal experience with the use of intracavitary CEUS in cases of PTCD as a palliative intervention. Intracavitary CEUS brings all the positive features of US together with the virtues of contrast-enhanced imaging, providing comparable accuracy to the standard techniques for diagnosing biliary tree diseases.

Ultrasound-guided percutaneous transhepatic biliary drainage for distal biliary malignant obstructive jaundice

The main cause of distal biliary malignant obstructive jaundice (DBMOJ) is the stricture of the extrahepatic biliary tract by malignant tumors, including pancreatic head and uncinate process cancer, low-grade cholangiocarcinoma, duodenal cancer, papillary duodenal cancer and other malignant tumors. The most effective treatment is radical pancreaticoduodenectomy. However, preoperative obstructive jaundice can affect the patient's liver function and blood coagulation function, increase local inflammation and oedema, and make surgery more difficult. Patients with severe obstructive jaundice require preoperative biliary drainage, which can be achieved by various methods, including ultrasound endoscopic biliary drainage (EUS-EBD) and endoscopic retrograde biliary drainage (ERBD). The latter is mainly divided into endoscopic nasobiliary drainage and endoscopic biliary stent. Some patients underwent percutaneous transhepatic biliary drainage (PTBD) when ERBD and EUS-EBD failed. In this study, we aimed to identify PTBD in DBMOJ and to further investigate the role of the puncture pathway in DBMOJ. The relationship between PTBD and bile duct internal diameter was confirmed by analysing and collating clinical data. In this study, DBMOJ was grouped according to bile duct internal diameter and liver function was used as an indicator to examine the improvement in liver function with PTBD in patients undergoing DBMOJ. Analysis of puncture complications showed that PTBD puncture was safe. DBMOJ with different bile duct internal diameters had different rates of liver function improvement after PTBD. The right-side approaches had significantly lower alanine aminotransferase (ALT) and alanine transaminase (AST) than the left-side approaches. This study showed that PTBD for DBMOJ is associated with a low complication rate and good reduction of jaundice. Liver function recovery was faster in patients with DBMOJ treated with PTBD in the right-sided approach compared with the left-sided approach. PTBD is an effective tool to be used in patients who have failed ERBD and EUS-EBD.

Ultrasound contrast agent assisted ultrasonography guidance percutaneous nephrostomy for non-hydronephrotic kidney

BACKGROUND

Given the limited success rate and considerable challenges associated with conventional ultrasonography (US) guidance for percutaneous nephrostomy (PCN) in non-hydronephrotic kidneys, this study proposed a solution with ultrasound contrast agent to enhance the success rate and mitigate the difficulties.

MATERIALS AND METHODS

From January 2017 to August 2023, a total of thirteen patients diagnosed with non-hydronephrotic kidney were included in the study. Following routine ultrasonography examination, no significant dilatation of the renal collecting system was observed. US-guided percutaneous nephrostomy PCN was performed with the assistance of ultrasound contrast agent (UCA). The patients were subsequently monitored to assess the improvement of symptoms and postoperative recovery.

RESULTS

The success rate was found to be 100% for all patients (13/13) and kidneys (20/20). The average volume of UCA solution used was 19 ± 6.7 mL (range, 11-35 mL), while the mean duration of the operation was 18.92 ± 8.96 min (range, 7-36 min). A majority of the patients (12/13) underwent a single puncture procedure. Throughout the follow-up period, no serious complications were observed, and surgery resulted in significant alleviation of symptoms in all patients.

CONCLUSION

The use of UCA-assisted US guidance PCN has been shown to be effective in achieving urinary diversion and alleviating associated clinical symptoms in non-hydronephrotic kidneys. In comparison to traditional methods, this approach demonstrates a high success rate and safety profile, while also offering a simplified operative procedure. Consequently, it presents a novel method and concept for managing non-hydronephrotic kidneys afflicted by urine leakage.

Percutaneous ultrasound-guided cholecystocholangiography with microbubbles combined with liver biopsy for the assessment of suspected biliary atresia

BACKGROUND

Percutaneous ultrasound (US)-guided cholecystocholangiography is effective in diagnosing biliary atresia for infants with a gallbladder >1.5 cm in length on US. However, whether it is still effective for other types of gallbladders needs further clarification.

OBJECTIVE

To evaluate the diagnostic performance and safety of percutaneous US-guided cholecystocholangiography combined with liver biopsy in children with suspected biliary atresia and with different types of gallbladders on US.

MATERIALS AND METHODS

Sixty-five infants were referred for percutaneous US-guided cholecystocholangiography with microbubbles and liver biopsy after an equivocal (n=39) or highly suspected (n=26) US diagnosis of biliary atresia. Two radiologists evaluated US and percutaneous US-guided cholecystocholangiography images in consensus. One pathologist independently evaluated liver specimens. We used the unpaired t-test, Mann-Whitney U test and chi-square test to analyze the data.

RESULTS

Of the 65 infants, 59 (90.8%) underwent a successful percutaneous US-guided cholecystocholangiography, with both sensitivity and specificity of 100%. All six infants for whom puncture failed had contracted gallbladders. The sensitivity and specificity of liver biopsy in the diagnosis of biliary atresia were 89.7% (26/29) and 83.3% (30/36), respectively. When percutaneous US-guided cholecystocholangiography and liver biopsy were combined, all infants gained correct diagnosis, and in 35 infants (97.2%, 35/36) biliary atresia could be excluded without intraoperative cholangiography. Twenty-two of 65 infants (33.8%) had fluid collections around the liver related to puncture. None of these complications needed treatment.

CONCLUSION

Percutaneous US-guided cholecystocholangiography combined with liver biopsy appears safe and effective for excluding or confirming biliary atresia in cholestatic infants with a dilated gallbladder on US.

Comparison of contrast-enhanced ultrasound versus conventional ultrasound-guided percutaneous nephrolithotomy in patients with nondilated collecting system: a randomized controlled trial

OBJECTIVE

To compare the safety, effectiveness, and feasibility of contrast-enhanced ultrasound (CEUS) versus conventional ultrasound-guided percutaneous nephrolithotomy (PCNL) in patients with nondilated collecting system.

METHODS

Between July 2018 and July 2020, 160 kidney stone patients with nondilated collecting system planned for PCNL were randomly assigned into two groups, CEUS with retrograde ureteral contrast injection and conventional ultrasound with retrograde ureteral normal saline injection. Patient's demographics, the success rate of puncture, success rate of a single-needle puncture, number of punctures, puncture time, perioperative outcomes, stone-free rate, and incidence of complications were compared.

RESULTS

The success rate of a single-needle puncture for CEUS-guided PCNL was higher than that in the conventional ultrasound group (88.5% vs. 73.7%, p = 0.02). Patients performed with CEUS-guided PCNL required less needle passes (p = 0.02), shorter needle puncture time (p = 0.031), and shorter channel establishment time (p = 0.04) than those guided with conventional ultrasound. The postoperative hemoglobin decrease in the CEUS-guided PCNL group was less than that of the control group (p = 0.02). There was no significant difference in operating time, length of hospital stays, kidney function change, and complications between the two groups (p > 0.05). The 1-month stone-free rate was 94.9% in the CEUS group and 90.8% in the control group (p > 0.05).

CONCLUSIONS

Compared with conventional ultrasound, CEUS-guided PCNL may facilitate ultrasound-guided PCNL for patients without hydronephrosis, and benefited with a higher success rate of a single-needle puncture, less needle passes, shorter puncture time, and lower postoperative Hb drop.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1800016981 KEY POINTS: • Compared with conventional ultrasound, CEUS-guided PCNL is a safe and efficacious procedure for kidney stone patients with nondilated collecting system. • Compared with conventional ultrasound, CEUS-guided PCNL benefited with a higher success rate of a single-needle puncture, less needle passes, shorter puncture time, and lower postoperative Hb drop. • CEUS-guided PCNL associated with the more accurate needle puncture and acceptable complications.

Intra-cavitary contrast-enhanced ultrasound for diagnosis of duodenal fistula: A case report and review of the relevant literature

BACKGROUND

Duodenal stump fistula is a rare complication after subtotal gastrectomy (Billroth Ⅱ anastomosis). Its clinical symptoms vary with the size of the fistula and the patency of abdominal drainage. Failure in timely diagnosis will lead to serious abdominal infection, massive hemorrhage, and other complications, even life-threatening events.

CASE SUMMARY

A patient developed abdominal pain 6 months after subtotal gastrectomy (Billroth Ⅱ anastomosis) for gastric cancer. Emergency enhanced CT examination showed thickening of the abdominal wall and adjacent abdominal soft tissue, and gas accumulation was also observed. The gas was suspected to be associated with the duodenal stump, and no obvious mass shadow was observed. The abdominal drainage tube was pulled out, and ultrasound guided percutaneous intra-cavitary contrast-enhanced ultrasound displayed the fistula opening and fistula tract dynamically, and guided real-time placement of a catheter for drainage.

CONCLUSION

Intra-cavitary contrast-enhanced ultrasound can accurately diagnose the intestinal fistula, indicate the direction of fistula in real time, accurately locate and guide catheterization, and provide diagnostic and treatment assistance in clinical practice.

Update in Contrast-Enhanced Ultrasound

BACKGROUND

The aim of modern medicine is to safely classify diseases for successful therapy without invasive measures. Sonography, computed tomography (CT), and magnetic resonance imaging (MRI) are potent imaging techniques. However, without contrast medium, the informative value of the 3 native methods is limited. The advantages of sonography are: no radiation exposure or previously known physically harmful interactions with tissue, proportionate disappearance of a contrast agent risk, no (probably irreversible) contrast agent deposits, and no risk of renal insufficiency. But, is that enough to compete with of even exceed CT and MRI?

SUMMARY

In this review, the state of the art of contrast-enhanced ultrasound (CEUS) in the abdominal cavity is presented. The remarkable diagnostic possibilities can unfortunately only be demonstrated here in a small number of impressive, typical case studies underpinned by the literature, so that, from one's own perspective, the full spectrum of CEUS can be used by oneself or initiated. Within the limits of physics, the real-time dynamics of CEUS enable conclusions to be drawn, so that with the current technology, sonography, including expansion by contrast, can be considered superior to other imaging methods. It is not uncommon for CEUS to have the value of a control and reference method.

KEY MESSAGES

Sonography very often enables reliable diagnostics. The introduction of a contrast agent in sonography has led to a quantum leap similar to that of other imaging techniques. Already natively, the real-time representation of dynamic events leads to a certain superiority, i.e., complete observation of the inflow and outflow phases of the contrast medium and the resulting diagnostic; tissue-specific differentiation options provide a unique selling point. Further advantages of the first-choice imaging diagnostic method are: a lack of radiation exposure, repeatability of the examination at any time, local independence, a negligible allergy rate compared to the contrast agents of other methods, and a lack of kidney and thyroid exposure or excluded deposits.

Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) in the Liver - Update 2020 - WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS), first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications.The 2012 guideline requires updating as previously the differences of the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including the United States Food and Drug Administration (FDA) approval as well as the extensive Asian experience, to produce a truly international perspective.These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCA) and are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis to improve the management of patients.

Guidelines and Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound (CEUS) in the Liver-Update 2020 WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast-enhanced ultrasound, first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology. The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications. The 2012 guideline requires updating as, previously, the differences in the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including U.S. Food and Drug Administration approval and the extensive Asian experience, to produce a truly international perspective. These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCAs) and are intended to create standard protocols for the use and administration of UCAs in liver applications on an international basis to improve the management of patients.

Intracavitary contrast-enhanced ultrasonography in children: review with procedural recommendations and clinical applications from the European Society of Paediatric Radiology abdominal imaging task force

Contrast-enhanced ultrasonography (US) has become an important supplementary tool in many clinical applications in children. Contrast-enhanced voiding urosonography and intravenous US contrast agents have proved useful in routine clinical practice. Other applications of intracavitary contrast-enhanced US, particularly in children, have not been widely investigated but could serve as a practical and radiation-free problem-solver in several clinical settings. Intracavitary contrast-enhanced US is a real-time imaging modality similar to fluoroscopy with iodinated contrast agent. The US contrast agent solution is administered into physiological or non-physiological body cavities. There is no definitive list of established indications for intracavitary US contrast agent application. However, intracavitary contrast-enhanced US can be used for many clinical applications. It offers excellent real-time spatial resolution and allows for a more accurate delineation of the cavity anatomy, including the internal architecture of complex collections and possible communications within the cavity or with the surrounding structures through fistulous tracts. It can provide valuable information related to the insertion of catheters and tubes, and identify related complications such as confirming the position and patency of a catheter and identifying causes for drainage dysfunction or leakage. Patency of the ureter and biliary ducts can be evaluated, too. US contrast agent solution can be administered orally or a via nasogastric tube, or as an enema to evaluate the gastrointestinal tract. In this review we present potential clinical applications and procedural and dose recommendations regarding intracavitary contrast-enhanced ultrasonography.

Contrast-enhanced ultrasound-guided celiac plexus neurolysis in patients with upper abdominal cancer pain: initial experience

OBJECTIVES

The purpose of this study was to determine the efficacy and safety of contrast-enhanced ultrasound (CEUS)-guided celiac plexus neurolysis (CPN) in patients with upper abdominal cancer pain.

METHODS

Thirty-five patients with upper abdominal cancers tortured by intractable upper abdominal pain underwent CEUS-guided CPN with ethanol. The pain alleviation and opioid intake were observed and evaluated during a 3-month follow-up after CPN. The dispersion of alcohol around the aorta was evaluated on 3D-CEUS. Complications were assessed during CPN and at follow-up.

RESULTS

All of the 35 patients' CPN was successfully achieved. Pain relief was observed in 28 (80%), 20 (57.1%), 27 (77.1%), 20 (57.1%), and 10 (29.4%) patients immediately, 1 day, 1 month, 2 months, and 3 months after CPN, respectively. The agent dispersion around the aorta on CEUS images of 28 patients who showed pain relief was at least 90° of the circumference around the aorta. The median duration of pain alleviation was 2.7 months (95% confidence interval [CI], 2.5-2.9). Less than half of the patients had minor complications including irritant pain at the puncture site (8 of 35; 22.9%), diarrhea (4 of 35; 11.4%), nausea and vomiting (3 of 35; 8.6%), and post-procedural hypotension (1 of 35; 2.9%).

CONCLUSIONS

CEUS-guided CPN is a safe and effective method to alleviate refractory upper abdominal pain in patients with upper abdominal cancers. CEUS image allows the visualization of puncture path and observation of drug dispersion. The pain relief is relevant to the dispersion of neurolytic agent around the aorta.

KEY POINTS

• CEUS-guided celiac plexus neurolysis (CPN) is feasible and easy. • It allows direct visualization of the diffusion of the neurolytic agent in the retroperitoneal anatomic space. • CEUS-guided CPN improves safety of CPN by clearly delineating the needle path.

Postsurgical Management of Dilated Biliary Tract in Children: Ultrasound-Guided Percutaneous Transhepatic Cholangial Drainage and Subsequent Percutaneous Ultrasound Cholangiography

OBJECTIVE. The purpose of this study was to evaluate the feasibility of ultrasound (US)-guided percutaneous transhepatic cholangial drainage (PTCD) and consequent percutaneous US cholangiography in managing the dilated biliary tracts of children who have undergone hepatobiliary surgery. SUBJECTS AND METHODS. Sixteen children (11 boys, five girls; age range, 3-144 months) who underwent hepatobiliary surgery from December 2016 to October 2018 and had US evidence of biliary dilatation were included. All patients had undergone US-guided PTCD because of elevated postoperative serum bilirubin levels or bile duct infection. Immediately after the PTCD procedure, diluted sulphur hexafluoride microbubbles dispersion was injected through the PTCD tube to evaluate the anastomosis and the intrahepatic bile duct tree. Laboratory results, including those of serum bilirubin measurement, liver function tests, and routine blood tests, were evaluated before and after PTCD. Nine of 16 patients also underwent percutaneous transhepatic cholangiography (PTC). The percutaneous US cholangiography findings were evaluated and compared with the PTC findings. RESULTS. Liver enzyme levels decreased after PTCD with a statistically significant difference from the values before PTCD. Percutaneous US cholangiography showed that the anastomosis in 6 of the 16 patients (37.5%) was patent and depicted the morphologic featuresof intrahepatic bile duct tree in five of these patients. In the other 10 patients, the anastomosis was completely obstructed, and percutaneous US cholangiography depicted the morphologic features of intrahepatic bile duct tree in eight patients. In the nine patients who underwent PTC, the percutaneous US cholangiographic findings were the same as the PTC findings. CONCLUSION. US-guided PTCD is helpful in relieving jaundice and inflammation in children who have undergone hepatobiliary surgery and have biliary dilatation. Findings at consequent percutaneous US cholangiography are comparable to those of PTC in depicting the anastomosis in these patients.

Contrast-Enhanced Ultrasound Guidance for Interventional Procedures

Since its introduction, contrast-enhanced ultrasound (CEUS) has gained an important role in the diagnosis and management of abdominal and pelvic diseases. Contrast-enhanced ultrasound can improve lesion detection rates as well as success rates of interventional procedures when compared to conventional ultrasound alone. Additionally, CEUS enables the interventionalist to assess the dynamic enhancement of different tissues and lesions, without the adverse effects of contrast-enhanced computed tomography, such as exposure to ionizing radiation and nephrotoxicity from iodinated contrast material. This review article describes the various applications and advantages of the use of CEUS to enhance performance of ultrasound-guided interventions in the abdomen and pelvis.

How Pre-operative Sentinel Lymph Node Contrast-Enhanced Ultrasound Helps Intra-operative Sentinel Lymph Node Biopsy in Breast Cancer: Initial Experience

We aimed to evaluate the value of sentinel lymph node contrast-enhanced ultrasound (SLN-CEUS) and surface tracing for the biopsy of intra-operative sentinel lymph nodes (SLNs). Between June 2015 and December 2017, a total of 453 patients with early invasive breast cancer were recruited. Patients received an intradermal injection of microbubble contrast agent around the areola on the day before surgery. The locations and sizes of lymphatic channels (LCs) and SLNs were marked on the body surface using gentian violet. Then, injection of double blue dye was performed half an hour before surgery. We compared the pathway of LCs and the location of SLNs obtained from SLN-CEUS and blue dye during surgery. Among the 453 patients, the mean numbers of LCs and SLNs detected by SLN-CEUS were 1.42 and 1.72, respectively, and the coincidence rate was 98.2% compared with blue dye during surgery. The median distance from the SLN to skin measured by pre-operative CEUS and blue dye was 1.95 ± 0.69 and 2.03 ± 0.87 cm (p = 0.35). There were three SLN enhancement in our research, including homogeneous enhancement, inhomogeneous enhancement and no enhancement, with the sensitivity, specificity, positive predictive value and negative predictive value of SLN-CEUS for the diagnosis of SLNs being 96.82%, 91.91%, 87.54% and 98.01%, respectively. SLN-CEUS with skin marking can identify the pathway of LCs and the location of the SLN before surgery, measure the distance from the SLN to skin and determine if the SLN is metastatic. SLN-CEUS can be used as an effective complement to the blue dye method.

Intra-Cavitary Contrast-Enhanced Ultrasound: A Novel Radiation-Free Method for Detecting Abscess-Associated Penetrating Disease in Crohn's Disease

BACKGROUND AND AIM

Penetrating disease is a common condition complicating Crohn's disease [CD]. Establishing the presence of a fistula and the anatomical definition of the fistulous tracts are essential for deciding on appropriate treatment strategies. We aimed to assess the diagnostic accuracy of intra-cavitary contrast-enhanced ultrasound [IC-CEUS] for the detection of a fistulous tract associated with abscesses in CD patients.

METHODS

In this prospective cohort study, consecutive CD patients suspected of having an intra-abdominal abscess, who were referred for US-guided aspiration were recruited. IC-CEUS was performed by injecting diluted contrast agent [SonoVue] into the abscess cavity immediately following the ultrasound-guided needle abscess aspiration and drainage. The diagnostic accuracy of IC-CEUS in demonstrating the presence of fistulous tracts was compared with that of computed tomography enterography/magnetic resonance enterography [CTE/MRE], using surgical and gross pathological findings as the reference standard.

RESULTS

Thirty-one patients who underwent IC-CEUS and subsequent surgery were included in the final analysis. IC-CEUS demonstrated fistulous/sinus tracts in 26 of 31 participants with a sensitivity and specificity of 86.7 % (95% confidence interval [CI], 68.4-95.6%) and 100% [95% CI, 5.5-100.0%], respectively. Moreover, IC-CEUS correctly demonstrated fistulous/sinus tracts in 13 participants without delineation of fistulous/sinus tracts on CTE/MRE. Combining IC-CEUS and CTE/MRE, the fistula/sinus tract was clearly demonstrated in 29 patients [93.5%, 29/31]. The mean duration of the IC-CEUS procedure was 8.6 min [range 5.0-12.0]. No severe adverse events occurred during the IC-CEUS procedure.

CONCLUSION

In this pilot study, IC-CEUS accurately delineated the anatomical definition of fistulous/sinus tracts associated with intra-abdominal abscesses in CD patients. As a radiation-free and safe technique, IC-CEUS may be used as an alternative/adjunctive method to CTE/MRE for detecting penetrating disease in patients with CD.

Comparison of Endoscopic Ultrasonography Guided Biliary Drainage and Percutaneous Transhepatic Biliary Drainage in the Management of Malignant Obstructive Jaundice After Failed ERCP

AIMS

The aim of this study is to compare the efficacy and safety of endoscopic ultrasonography guided biliary drainage and percutaneous transhepatic biliary drainage in the management of malignant obstructive jaundice after failed ERCP.

METHODS

We performed a prospective study on 66 consecutive patients with malignant obstructive jaundice admitted to our hospital between January 2014 and January 2016 [corrected]. Patients were performed endoscopic ultrasonography-guided biliary drainage in 36 cases (group A) and percutaneous transhepatic biliary drainage in 30 cases (group B) according to the results of the draw. Data on the following variables were compared between the 2 groups: the technical success rate, the clinical success rate, complications, length of hospital stay, and hospital costs.

RESULTS

There was statistically significant difference in the clinical success rate (88.89% vs. 66.67%; χ=4.84), complications (5.56% vs. 23.33%; χ=4.39), length of hospital stay (11.54±3.73 d vs. 15.68±6.56 d; t=8.17) and hospital costs (23.52±8.44 thousand yuan vs. 32.81±6.06 thousand yuan; t=16.28) (P<0.05) between group A and group B. The technical success rate was higher in groups A than that in group B, although the difference did not reach statistical significance (94.44% vs. 86.67%; χ=1.20; P>0.05).

CONCLUSIONS

In the treatment of malignant obstructive jaundice, endoscopic ultrasonography guided biliary drainage is safer and more effective than percutaneous transhepatic biliary drainage when performed by experienced practitioners after failed ERCP. Its more widespread use is recommended.

Use of Ultrasound Contrast Agents in Relation to Percutaneous Interventional Procedures: A Systematic Review and Pictorial Essay

The aim of this article is to provide an inventory of the use of contrast-enhanced ultrasound (CEUS) in relation to percutaneous interventional procedures. The article is structured into a systematic literature review followed by a clinical part relating to percutaneous CEUS-guided procedures. A literature search identified 3109 records. After abstract screening, 55 articles were analyzed and supplemented with pictorial material to explain the techniques. In conclusion, the best-evidenced indications for CEUS-guided interventions are biopsy and ablation of inconspicuous or B-mode-invisible tumors, intraprocedural ablation control and follow-up, as well as percutaneous transhepatic cholangiography and drainage procedures.

Contrast-enhanced ultrasound (CEUS) in abdominal intervention

The introduction of ultrasound contrast agents has rendered contrast-enhanced ultrasound (CEUS) a valuable complementary technique to address clinically significant problems. This pictorial review describes the use of CEUS guidance in abdominal intervention and illustrates such application for a range of clinical indications. Clinical application of CEUS discussed include commonly performed abdominal interventional procedures, such as biopsy, drainage, nephrostomy, biliary intervention, abdominal tumor ablation and its subsequent monitoring, and imaging of vascular complications following abdominal intervention. The purpose of this article is to further familiarize readers with the application of CEUS, particularly its specific strength over alternative imaging modalities, in abdominal intervention.

Contrast-enhanced ultrasound examination of the gallbladder and bile ducts: A pictorial essay

The gallbladder and bile ducts are usually assessed initially with conventional gray-scale ultrasound (US). Contrast enhanced US (CEUS) is used when a diagnosis cannot be reached with conventional US. CEUS is easy to learn and perform. US contrast agents can be safely administered in patients with renal function impairment. In this pictorial essay the physics, examination technique and indications of CEUS for examining the gallbladder and bile ducts are reviewed. Gallbladder indications include elucidating normal variants, differentiating sludge from neoplastic lesions, benign and malignant pathology, infection, wall rupture and hemobilia. In the biliary tree CEUS is used for studying benign and malignant tumors, including metastases and cholangiocarcinoma, as well as intrabiliary injection.

Intraoperative ultrasonography of the biliary tract using saline as a contrast agent: a fast and accurate technique to identify complex biliary anatomy

BACKGROUND

Intraoperative assessment of biliary tract anatomy is relevant for a number of benign and malignant hepatobiliary diseases. During biliary reconstruction, drainage of all relevant bile ducts is imperative to prevent atrophy of undrained segment, cholangitis and secondary biliary cirrhosis. Intraoperative cholangiography, though widely used for intraoperative imaging of the biliary tract, involves heavy equipment use, radiation risk and has a limited role in the evaluation of isolated segmental bile ducts.

METHODS

We evaluated the use of a novel technique of intraoperative ultrasonography of the biliary tract using normal saline as a contrast agent. It involves injecting saline in any part of the biliary system while performing real-time intraoperative 2-dimensional ultrasonography.

RESULTS

This procedure was carried out in intraoperative situations to delineate complex biliary anatomy involving segmental bile ducts. Excellent image quality was obtained in the form of opacification and demarcation of the liver segment to which the duct belongs. The flow of saline microbubbles was clearly visible on real-time ultrasound images, leading to accurate identification of the duct.

CONCLUSION

Intraoperative ultrasonography with saline as a contrast agent can accurately identify small isolated segmental bile ducts and help in surgery of the biliary tract. It is a simple and inexpensive technique that can be performed with minimal resources.

Adhesive Capsulitis of the Shoulder: Evaluation With US-Arthrography Using a Sonographic Contrast Agent

Adhesive capsulitis (AC) is a painful and disabling disorder, which caused restricted motion and chronic pain of shoulder. Intracavitary contrast-enhanced ultrasound has been recently applied to assess obstructive bile duct diseases, tubal patency, vesicoureteric reflux and so on. The aim of this study was to detect the value of US-arthrography by injecting the contrast agent SonoVue into glenohumeral joint compared with US in diagnosing AC. Utrasound (US) and US-arthrography images of 45 patients with AC were compared with that of 45 control subjects without AC with MRI as a gold standard. Patients with AC had a significantly thickened coracohumeral ligment (CHL, 3.1 mm) and inferior capsule (3.5 mm) on US, and a decreased volume of axillary recess (1.14 ml) on US-arthrography compared with the control subjects (1.59 ml). Filling defect (91.1%) and synovitis-like abnormality (75.6%) in the joint on US-arthrography were more sensitive than that of rotator interval abnormality (71.1%), thickened CHL more than 3 mm (64.4%), thickened inferior capsule more than 3.5 mm (66.7%) on US respectively for diagnosis of AC. Consequently, US-arthrography was more effective method than US for assessment of AC. Filling defects of joint cavity and synovitis-like abnormality in the joint are characteristic US-arthrography findings for diagnosing AC.

Contrast-enhanced US-assisted Percutaneous Nephrostomy: A Technique to Increase Success Rate for Patients with Nondilated Renal Collecting System

Purpose To perform a single-center study of contrast material-enhanced ultrasonography (US)-assisted percutaneous nephrostomy (PCN) for patients with nondilated renal collecting system. Materials and Methods An international review board approved this retrospective study with waiver of informed consent for participation, and the study was approved by the Ethical Committee. From November 2011 to September 2015, 47 patients (mean age, 51.9 years ± 16.2 [standard deviation]; range, 18-80 years) with clinical necessity of urinary drainage, urinary diversion, or provision of access to the collecting system and with nondilated renal collecting system who underwent contrast-enhanced US-assisted PCN for 48 kidneys were included. US contrast agent was injected through the puncture needle and the drainage catheter to confirm successful PCN. The technical success rate and complications were evaluated. Relative frequencies with 95% confidence intervals (CIs) were calculated. Results The technical success rate was 100% (47 of 47, 95% CI: 93.8%, 100%) per patient and 100% (48 of 48, 95% CI: 94.0%, 100%) per kidney. For each kidney, the mean number of needle passes was 1.4 ± 0.5 (range, 1-3). The mean duration of the complete procedure was 18.9 minutes ± 4.8 (range, 8-30 minutes). The mean dose of contrast agent was 12.9 mL ± 3.2 (range, 8-25 mL). No major complications were observed. After a follow-up of 1-30 days (mean, 18.4 days ± 10.3), only four patients (four of 47, 8.5%, 95% CI: 2.37%, 20.4%) had minor complications, including one perirenal hematoma seen at US 9 days after the procedure and three patients with transient macroscopic hematuria that lasted 1-2 days. Conclusion Contrast-enhanced US-assisted PCN in patients with nondilated renal collecting system is valuable with high technical success rate. ^© RSNA, 2017.

Contrast-enhanced US-guided Interventions: Improving Success Rate and Avoiding Complications Using US Contrast Agents

Ultrasonography (US) is an established modality for intervention. The introduction of microbubble US contrast agents (UCAs) has the potential to further improve US imaging for intervention. According to licensing, UCAs are currently approved for clinical use in restricted situations, but many additional indications have become accepted as having clinical value. The use of UCAs has been shown to be safe, and there is no risk of renal toxic effects, unlike with iodinated or gadolinium contrast medium. Broadly speaking, UCAs can be injected into the bloodstream (intravascular use) or instilled into almost any accessible body cavity (endocavitary use), either in isolation or synchronously. In microvascular applications, contrast-enhanced US (CEUS) enhances delineation of necrotic areas and the vascularized target to improve real-time targeting. The ability of CEUS to allow true assessment of vascularity has also been used in follow-up of devascularizing intervention. In macrovascular applications, real-time angiographic images can be obtained with CEUS without nephrotoxic effects or radiation. In endocavitary applications, CEUS can achieve imaging similar to that of iodinated contrast medium-based fluoroscopy; follow-up to intervention (eg, tubography and nephrostography) can be performed at the bedside, which may be advantageous. The use of UCAs is a natural progression in US-guided intervention. The aim of this article is to describe the indications, contraindications, and techniques of using UCAs as an adjunctive tool for US-guided interventional procedures to facilitate effective treatment, improve complication management, and increase the overall success of interventional procedures. Online supplemental material is available for this article. ^©RSNA, 2016.

The effect of percutaneous ultrasound-guided subacromial bursography using microbubbles in the assessment of subacromial impingement syndrome: initial experience

OBJECTIVE

The purpose of this study was to determine the feasibility and the value of percutaneous ultrasound-guided subacromial bursography (PUSB) with contrast-enhanced ultrasound (CEUS) for assessment of rotator cuff tears.

METHODS

Between January 2012 and September 2014, 2-D US and PUSB were prospectively performed in 135 patients with suspected rotator cuff tears from among 2,169 patients with clinically diagnosed subacromial impingement syndrome. Sixty-three patients who had undergone arthroscopy were included. The PUSB findings were compared with those from 2-D US using the McNemar test, with arthroscopy as a standard.

RESULTS

Of a total of 19 full-thickness tears (FTTs), 2-D US correctly diagnosed 12 and PUSB correctly diagnosed 18 (P = 0.031). With regard to partial-thickness tears, 2-D US correctly diagnosed 31 and PUSB 35 of a total of 41 tears (P = 0.375).Accuracy in diagnosing FTTs was 81.0 % for 2-D US and 98.4 % for PUSB. 2-D US and PUSB yielded sensitivity of 63.2 % and 94.7 %, respectively, for full-thickness tears, with specificity of 88.6 % and 100.0 %, respectively.

CONCLUSIONS

PUSB is a safe and feasible procedure, with greater sensitivity and specificity than 2D US in diagnosing FTTs As such, PUSB improves the value of ultrasound for assessing rotator cuff pathology.

KEY POINTS

• PUSB allows new application of CEUS and offers a new form of bursography. • PUSB appears to facilitate diagnosis of full -thickness rotator cuff tears. • PUSB outlines the rotator cuff tears more clearly than 2-D US.

Endocavitary contrast-enhanced ultrasound: a technique whose time has come?

Endocavitary use of contrast agents in sonography (US) is a relatively new method in diagnostic imaging, competing against gray-scale US, fluoroscopy, and endoscopy. This article describes established indications, demonstrates the techniques of evolving applications, and discusses their potential benefits. These benefits include the ability to obtain precise information about the placement of drains and the extent of fluid collections, and to accurately identify the location and features of strictures in various organs, and those of complications of fluid collections or abscesses, without resorting to ionizing radiation.

Feasibility of percutaneous contrast ultrasound-guided cholecystography in dogs

Differentiating hepatocellular disease versus biliary obstruction can be challenging in dogs presented for icterus. The purpose of this prospective study was to determine the feasibility of percutaneous contrast ultrasound-guided cholecystography in dogs. Ten normal dogs weighing 7.6-13.0 kg (median 9.8 kg) were recruited. All dogs were considered normal based on complete blood count, serum chemistry profile, ultrasound examination, and percutaneous radiographic cholecystography. Percutaneous contrast ultrasound-guided cholecystography was performed using 0.5 ml of commercially available contrast agent and two conventional ultrasound machines for simultaneous scanning at two different locations. Two observers independently evaluated the time to initial detection of contrast in the proximal duodenum and duration of contrast enhancement via visual monitoring. Dynamic contrast enhancement was calculated using time-intensity curves. Mean (± SD) and median (range) of time to initial detection were 8.60 s (± 3.35) and 8.0 s (2.0-11.0), respectively, and mean and median duration were 50.45 s (± 23.24) and 53.0 s (20.0 - 70.0), respectively. Mean, median, and range of peak intensity were 114.1 mean pixel value (MPV) (SD ± 30.7), 109.2 MPV, and 79.7-166.7, respectively, and mean, median, and range of time to peak intensity were 26.1 s (SD ± 7.1 s), 24.0 s, and 19.0-41.0 s, respectively. Findings indicated that percutaneous contrast ultrasound-guided cholecystography is a feasible technique for detecting and quantifying patency of the bile duct in normal dogs. Future studies are needed to assess the diagnostic utility of this technique for dogs with biliary obstruction.

Demonstration of an occult biliary-arterial fistula using percutaneous contrast-enhanced ultrasound cholangiography in a transplanted liver

We present a case of a biliary-arterial communication as a consequence of the placement of an internal-external biliary drainage catheter in a liver transplant patient diagnosed on contrast-enhanced ultrasound using a novel application by injecting microbubble contrast into the catheter tube. We postulate that this method may be sensitive in identifying occult communications between the biliary tree and the vascular compartment when a catheter drain is positioned, and there is hemobilia or unexplained sepsis.

Ultrasound-guided endoscopic biliary drainage: a useful drainage method for biliary decompression in patients with biliary obstructions

BACKGROUND

Endoscopic retrograde cholangiopancreatography with fluoroscopy guidance is a well-established technique for providing biliary drainage in patients with biliary obstructions. However, fluoroscopic facilities may not always be available and fluoroscopy carries a risk of radiation exposure.

AIM

We retrospectively compared the procedure success rate and efficacy of ultrasound-guided endoscopic biliary drainage (UG-EBD) and fluoroscopy-guided endoscopic biliary drainage (FG-EBD) in patients with biliary obstructions.

METHODS

Patients who had received either UG-EBD or FG-EBD were included in the study. Main outcome measurements included the procedure success rate, procedure time, and clinical response.

RESULTS

A total of 125 patients who had undergone UG-EBD (n = 63) and FG-EBD (n = 62) were identified. The total procedure success rate was 93.7 % in the UG-EBD group and 96.8 % in the FG-EBD group without statistical difference. Also, no significant difference was found in the procedure success rate of lower or upper/middle obstructions of the common bile duct (CBD) between the 2 groups. The mean procedure time was not different between the 2 groups [UG-EBD group 24.54 (9.52) min vs. FG-EBD group 21.74 (8.77) min, p = 0.09]. There were no differences in the normalization of clinical and laboratory parameters and immediate complication between the 2 groups.

CONCLUSIONS

Endoscopic biliary drainage (EBD) under US-guidance and under fluoroscopy guidance is equally effective and safe for patients with lower or upper/middle obstructions of the CBD. The UG-EBD technique is especially suitable for special patients, such as critically ill patients, pregnant woman, etc.

Intra-biliary contrast-enhanced ultrasound for evaluating biliary obstruction during percutaneous transhepatic biliary drainage: a preliminary study

OBJECTIVES

The aimed of this study was to investigate the value of intra-biliary contrast-enhanced ultrasound (IB-CEUS) for evaluating biliary obstruction during percutaneous transhepatic biliary drainage (PTBD).

MATERIALS AND METHODS

80 patients with obstructive jaundice who underwent IB-CEUS during PTBD were enrolled. The diluted ultrasound contrast agent was injected via the drainage catheter to perform IB-CEUS. Both conventional ultrasound and IB-CEUS were used to detect the tips of the drainage catheters and to compare the detection rates of the tips. The obstructive level and degree of biliary tract were evaluated by IB-CEUS. Fluoroscopic cholangiography (FC) and computer tomography cholangiography (CTC) were taken as standard reference for comparison.

RESULTS

Conventional ultrasound displayed only 43 tips (43/80, 53.8%) of the drainage catheters within the bile ducts while IB-CEUS identified all 80 tips (80/80, 100%) of the drainage catheters including 4 of them out of the bile duct (P<0.001). IB-CEUS made correct diagnosis in 44 patients with intrahepatic and 36 patients with extrahepatic biliary obstructions. IB-CEUS accurately demonstrated complete obstruction in 56 patients and incomplete obstruction in 21 patients. There were 3 patients with incomplete obstruction misdiagnosed to be complete obstruction by IB-CEUS. The diagnostic accuracy of biliary obstruction degree was 96.3% (77/80).

CONCLUSION

IB-CEUS could improve the visualization of the drainage catheters and evaluate the biliary obstructive level and degree during PTBD. IB-CEUS may be the potential substitute to FC in the PTBD procedure.

Advances in the investigation of obstructive jaundice

The causes of obstructive jaundice are varied, and timely, accurate methods of investigation are essential to avoid the development of complications. Imaging, invasive or non-invasive, should be carefully selected depending on the suspected underlying pathology in order to determine the degree and level of obstruction along with tissue acquisition and staging where relevant. Several imaging techniques will also allow subsequent therapeutic interventions to be carried out. This article reviews advances in the investigation of obstructive jaundice, highlighting recent developments, many of which at present remain restricted to large centres of expertise, but are likely to become more widespread in use as research progresses and local experience continues to improve.