EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided interventions: General Aspects and EUS-guided Sampling (Short Version).

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle-based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided Interventions: General aspects and EUS-guided sampling (Long Version).

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V.

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation in clinical practice (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V - EUS-Guided Therapeutic Interventions (short version).

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III - Abdominal Treatment Procedures (Short Version).

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, safety and efficacy of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (short version; a long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III - Abdominal Treatment Procedures (Long Version).

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound (INVUS) assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, and safe and effective performance of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short Version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (long Version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Short Version).

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version/ short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Long Version).

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version).

Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS.

Initially, a set of guidelines for the use of ultrasound contrast agents was published in 2004 dealing only with liver applications. A second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some non-liver applications. Time has moved on, and the need for international guidelines on the use of CEUS in the liver has become apparent. The present document describes the third iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS) using contrast specific imaging techniques. This joint WFUMB-EFSUMB initiative has implicated experts from major leading ultrasound societies worldwide. These liver CEUS guidelines are simultaneously published in the official journals of both organizing federations (i.e., Ultrasound in Medicine and Biology for WFUMB and Ultraschall in der Medizin/European Journal of Ultrasound for EFSUMB). These guidelines and recommendations provide general advice on the use of all currently clinically available ultrasound contrast agents (UCA). They are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis and improve the management of patients worldwide.

Microwave ablation of liver metastases guided by contrast-enhanced ultrasound: experience with 125 metastases in 39 patients.

PURPOSE: The aim of our study was to evaluate the efficacy of microwave (MW) ablation of liver metastases guided by B-mode ultrasound (US) and contrast-enhanced US (CEUS). MATERIALS AND METHODS: 39 patients (17 women and 22 men) with a total of 125 liver metastases were treated with percutaneous or intraoperative CEUS-guided MW ablation. The primary tumor was colorectal cancer (n = 31), breast cancer (n = 6), carcinoid tumor (n = 1), and gastrointestinal stromal tumor (GIST) (n = 1). The median number of metastases ablated in the 45 treatment sessions was 2 (range 1 - 11). The median size (maximum diameter) of the 125 metastases was 1.5 cm (range, 0.6 - 4.0 cm). Nineteen (15 %) of the 125 metastases were bigger than 2 cm. Metastases smaller than 2 cm were treated with a single needle, metastases bigger than 2 cm were treated with 2 or 3 parallel needles. RESULTS: The 45 MW ablation sessions were performed percutaneously (n = 30), during laparotomy (n = 3), or during laparotomy combined with liver resection (n = 12). The 39 patients were followed up for at least 4 months with a median duration of 11 months (range, 4 - 20 months). The technical success rate was 100 %. The clinical effectiveness was 100 % with complete coverage of the metastasis by the avascular coagulation zone evaluated on immediate post-ablation CEUS. Local tumor progression (local recurrence) was seen in 12 (9.6 %) of the 125 treated metastases, and affected 10 (26 %) of the 39 patients. One major complication was observed in the form of a liver abscess that easily resolved after percutaneous drainage. Four minor complications were observed: Three cases of pain located at the puncture site and one case of ascites. CEUS was valuable in all phases of ablation including pre-ablation staging and procedure planning, placement of MW needles in the tumor, immediate post-ablation control of coagulation size, and finally in the long term follow-up regime. CONCLUSION: CEUS-guided MW ablation of liver metastases is an efficient and safe ablation technique with several advantages compared to other ablation modalities.

[Color Doppler ultrasound. Principles, technique and clinical use possibilities]. / Farve-Doppler-ultralyd. Princip, teknik og kliniske anvendelsesmåder.

The medical ultrasound, the Doppler frequency shift is the difference between the frequency of the transmitted and reflected ultrasound. This is due a relative movement between the reflector (most frequently the red blood cells) and the ultrasound transducer. The ultrasound apparatus registers this difference in frequency and calculates the linear rate of flow employing the Doppler equation. The Doppler analysis is presented acoustically, graphically or by means of a colour code. In pulsed Doppler technique, conventional ultrasound scanning can be combined with Doppler analysis. Important indications are: differentiation between vascular and non-vascular structure, documentation of flow and determination of the direction of flow, diagnosis and quantitation of arterial stenoses and assessment of transplants.

[Ultrasonically guided pericardiocentesis]. / Ultralydvejledt draenage af perikardiehulen.

Ultrasonically guided pericardiocentesis was performed on 25 occasions in 23 consecutive patients. Incipient cardiac tamponade was present in 22 patients and the procedure was performed for diagnostic purposes in one patient. In 21 cases, 5.7 French pig-tail catheters were employed and 1.2 mm lumbar puncture needles in four cases. In 19 out of 22 patients (86%) with incipient cardiac tamponade the ultrasonically guided pericardiocentesis was considered successful. In one patient, the catheter was misplaced in the right atrium, one patient developed pyopericardium and one patient developed transient tachycardia. In two cases, no material could be obtained. Ultrasonically guided pericardiocentesis is preferable to "blind" puncture and the procedure should be carried out by physicians with experience in interventional ultrasound.

[Laparoscopic ultrasonography of liver, biliary tract and pancreas with flexible tip transducers]. / Laparoskopisk ultralydskanning af lever, galdeveje og pancreas med styrbart lydhoved.

The scanning procedure and the ultrasound-anatomy of the liver, gall-bladder, bile ducts and pancreas are presented. Ten consecutive patients referred for laparoscopic cholecystectomy were scanned through a 10/11 mm trocar inserted periumbilically. In two cases concrements in the bile ducts were found peroperatively. The flexible-tip enables operator steering of the transducer which ensures an optimal acoustic contact. Colour and spectral Doppler were frequently used to identify vascular structures. We conclude that a flexible-tip laparoscopic ultrasound-scanner provides valuable assistance in abdominal laparoscopic procedures, and may substitute the palpation of the abdominal organs in laparoscopic abdominal surgery.

Ultrasonically guided interstitial Nd-YAG laser diffuser tip hyperthermia: an in vitro study.

Ultrasonically guided interstitial Nd-YAG laser diffuser tip hyperthermia is a new technique that involves placement of a laser fiber in solid tissue under ultrasound guidance followed by irradiation from within the area to be treated. We have previously described a diffuser tip modification of the bare laser fiber, that proved to produce spherical coagulations of predictable size. In the present paper we describe the development of an ultrasonically guided technique which permits simultaneous laser irradiation and interstitial temperature measurements under real time ultrasound monitoring. The laser lesion appeared on the ultrasound image as a hyperechoic area growing in size with time as energy was applied. Macroscopically the laser lesion emerged as a sphere with a central cavity delineated by a rim of charred tissue and beyond this a larger zone of whitish coagulation. The correlation coefficient (Pearson's r) between ultrasonically and macroscopically measured diameter of the laser lesion was calculated to r = 0.89. It is concluded that ultrasonically guided interstitial Nd-YAG laser diffuser tip hyperthermia may have a potential as a tool in the future treatment of ultrasonically visible neoplasias like liver metastases and prostate cancer.

Percutaneous radiologic gastrostomy with a simplified gastropexy technique under ultrasonographic and fluoroscopic guidance: experience in 154 patients.

PURPOSE: To evaluate the effectiveness and safety of percutaneous radiologic gastrostomy (PRG) under ultrasonographic (US) and fluoroscopic guidance using a simplified gastropexy technique. MATERIAL AND METHODS: One hundred and fifty-four (154) patients (mean age 73, range 22-93 years) were referred for PRG. Indication for PRG was neurologic disease, head/neck cancer, and other disease in 73%, 15%, and 12%, respectively. Initially, the stomach was filled with 300-500 cm3 of tap water via a nasogastric tube. The fluid-filled stomach was punctured under US guidance. A guidewire and a single T-fastener were introduced. Under fluoroscopic guidance, the tract was dilated over the guidewire until a 16F dilator with a peel-away sheath could be introduced. During dilatation, the external suture string to the T-fastener was held tight to fixate the gastric wall. A 14F balloon-retained gastrostomy tube was introduced and inflated. The T-fastener was then released, and the gastrostomy tube was retracted gently to affix the gastric wall to the abdominal wall (tube gastropexy). Technical success was assured by aspiration of gastric fluid and fluoroscopically by injection of a water-soluble contrast medium. RESULTS: The primary technical success rate was 98%. At 30-day follow-up, 3.2% had major complications and 14% minor complications. Three patients (1.9%) died of complications related to the procedure. Thirteen cases (8%) of simple tube displacement without other complications occurred. CONCLUSION: PRG guided by US and fluoroscopy is a relatively safe technique with a high success rate, provided the stomach can be properly distended with fluid. However, tube gastropexy alone does not seem to protect against early dislodgement.

Is 0.6T magnetic resonance mammography adequate in the detection of breast cancer?

PURPOSE: To evaluate whether relevant diagnostic information can be achieved when using magnetic resonance mammography (MRM) on mid-field as a supplement to conventional imaging and clinical examination in women with primary breast cancer. MATERIAL AND METHODS: 30 women (55 breasts containing 49 malignant tumors) planned for uni- or bilateral mastectomy were examined with dynamic MRM on mid-field, 0.6T. The women were examined with mammography (M) and ultrasonography (US) prior to MRM. The descriptions of the conventional examinations were evaluated retrospectively, whereas the MRM was evaluated prospectively, with knowledge of the M+US findings. Imaging findings suggesting malignancy were registered and correlated with pathology after mastectomy. A home-made rating system for evaluation of the detected lesions was tested. RESULTS: MRM detected seven additional malignant tumors, failed to detect three lesions and characterized four as gray-zone lesions according to the rating system. Sensitivity of finding the tumors with M+US was 79.0%, with a PPV for malignant tumors of 84.4%. One breast in which MRM found a malignant tumor had not initially been examined with US. Sensitivity with MRM was 91.6%, with a positive predictive value of malignant tumors of 97.7%. CONCLUSION: MRM on mid-field seems to improve the detection of cancers when used as a supplement to M+US in women with primary breast cancer. We believe that the results are fair compared to MRM on high-field, although further research and refinement are needed.

The aortic wall: an in vitro study of the double-line pattern in high-resolution US.

An in vitro study of macroscopically normal aortas from human cadavers was performed with high-resolution ultrasound (US). Rectangular pieces of 10 fresh aortas were submerged in saline solution and scanned from the intimal side. On US images a characteristic double-line pattern, consisting of an inner and an outer echogenic line separated by a relatively hypoechoic line, was seen. This configuration was initially interpreted as tunica intima, tunica media, and tunica adventitia. The thickness of each layer on the US images was measured by means of a computer-assisted procedure and on histologic specimens was measured by means of stereomicroscopy. The correlation between the two measurements was poor. Experiments in which intima and part of the media were removed did not change the US appearance. Plexiglas, metal plates, and plastic foil showed a similar double-line pattern. A needle experiment disclosed that the inner echogenic and the hypoechoic lines were displayed in front of the true water-tissue interface, which was represented by the outer echogenic line. The authors conclude that the double-line pattern is thus an artifact.

Gastric and duodenal wall thickening on abdominal ultrasonography. Positive predictive value.

In a retrospective study, 79 patients with gastric (n = 59) or duodenal (n = 20) wall thickening on conventional abdominal ultrasonograms were included. To reduce bias, patients with a microscopic diagnosis of upper GI neoplasia present at the time of scanning were excluded. The final diagnosis was based upon endoscopy, operation, upper GI series, or autopsy. Among the 59 cases of gastric wall thickening, 33 (56%) proved to be gastric cancer, one (2%) was benign neoplasia, and 17 (29%) showed nonneoplastic pathology (ulcer, gastritis, fibrosis). In eight cases (13%) no gastric pathology was present in the final diagnosis, thus producing false-positive sonographic diagnoses. Among the 20 cases of duodenal wall thickening, five (25%) proved to be duodenal cancer and seven (35%) showed nonneoplastic duodenal pathology. We concluded that gastric or duodenal wall thickening shown on abdominal sonography is a significant finding indicating upper GI pathology (malignant or nonmalignant) in a high percentage of the gastric (86%) and duodenal (60%) cases.