Ultrasonographic localization of occult pulmonary nodules during video-assisted thoracic surgery.

The aim of our study was to evaluate the role of ultrasonography in the localization of pulmonary nodules during video-assisted thoracic surgery (VATS). Ultrasonography was performed in 35 patients for the localization of pulmonary nodules during VATS. Indication for VATS was excisional biopsy of undetermined nodules in 22 patients, single or multiple metastasectomy in 12 patients and resection of primitive pulmonary cancer in 1 patient with reduced pulmonary reserve. A laparoscopic probe with flexible head and multi-frequency transducer (5-7.5 MHz) was used. Intraoperative ultrasonography localized 37 of 40 nodules preoperatively detected by CT and/or by positron emission tomography in 35 patients. Furthermore, ultrasonography localized two nodules not visualized at spiral CT. Eighteen nodules were not visible or palpable at thoracoscopic examination and were found by intraoperative sonography only. In 6 patients in whom thoracotomy was performed, manual palpation did not reveal more lesions than ultrasonography. In our experience, ultrasonography was very helpful when lesions were not visible or palpable during thoracoscopy, showing high sensitivity (92.5%) in finding pulmonary nodules. Since it is not possible to determine preoperatively whether a localization technique will be necessary during the operation or not, and ultrasonography is a non-invasive technique, we think that, at present, this technique can be considered as the first-instance localization technique during thoracoscopic resection of pulmonary nodules.

[CT angiography for the evaluation of adult orthotopic liver transplantation arterial complications].

PURPOSE: In this study we compared duplex Doppler sonography, conventional angiography and CT angiography for the evaluation of hepatic arterial complications following orthotopic liver transplantation (OLT). MATERIAL AND METHODS: CT angiography, with Maximum Intensity Projection (MIP) and Volume Rendering reconstructions, was performed in 11 patients with well-grounded suspect of hepatic artery stenosis or thrombosis after routine duplex Doppler examination. Eight patients underwent conventional angiography. RESULTS: CT detected three out of four duplex doppler false positives and confirmed the diagnostic suspect in four cases. In two cases it showed a shift of the blood flow towards the splenic artery with hepatic hypoperfusion. In one case a wrong delay rendered the study unuseful. In seven out of eight patients conventional angiography confirmed CT angiography findings. DISCUSSION. The follow up of OLT arterial complications is now performed with duplex doppler sonography; this technique has a satisfactory sensitivity and specificity, but far from 100%. Therefore in some patients the diagnosis of arterial obstruction might be delayed, with the risk of serious complications; in other cases with ultrasonographic false positive findings, useless angiographic examinations are performed. In our experience CT angiography proved to be a precious tool, which might be included in the diagnostic algorithm of arterial complications after OLT. Particularly CT angiography seems to be suitable for the cases of discordance between clinical and duplex doppler findings, to improve the overall diagnostic accuracy. CONCLUSION: In our experience CT-angiography proved to be accurate and satisfactory as a second step examination after duplex-doppler in the diagnostic algorythm of adult OLT arterial complications.

[Intraoperative echography in the localization of pulmonary nodules during video-assisted thoracic surgery]. / Ecografia intraoperatoria nella localizzazione delle lesioni nodulari polmonari durante chirurgia toracica video assistita.

PURPOSE: One of the major limitations of thoracoscopic resection of lung nodules is localization of the target, especially when the lesion is deep or very small: we investigated the efficacy of US as a technique for intraoperative localization. MATERIAL AND METHODS: We examined 11 patients who underwent diagnostic and/or curative thoracoscopic resection of benign or malignant, primary or metastatic lung nodules. The study was preceded by a preliminary phase in which we examined with US 5 patients that underwent thoracotomy. A multifrequency laparoscopic US probe with a deflectable linear headpiece mounted on a portable Esaote-Hitachi Spazio US unit was used. RESULTS: The US exploration of the lung requires the complete collapse of the parenchyma and is therefore particularly difficult in patients with severe chronic obstructive pulmonary disease (COPD). In the patients examined during thoracotomy US showed all the lesions but one 7-mm nodule in an emphysematous patient in whom complete parenchyma collapse could not be achieved. Also in the patients examined during thoracoscopy US detected all the targets (13/13), even a 13-mm metastatic nodule which had been visualized preoperatively by PET only. The smallest lesion found was a 4-mm fibrosarcoma metastasis. The mean time to achieve adequate lung collapse was about 40 minutes from selective exclusion of the affected lung. DISCUSSION: Thoracoscopic US has been recently introduced for the intraoperative localization of pulmonary nodules. In our experience this technique is helpful in localizing the targets, assessing the extent of surgical resection and studying possible vascular involvement. Considering the easy execution, the low cost, the lack of contraindications and complications of the technique and its accuracy when performed under optimal technical conditions, we think there are enough reasons to investigate this approach further. CONCLUSIONS: Intraoperative US proved to be a useful technique of easy execution, even though it is heavily operator-dependent and limited in patients with severe COPD.

[Nonobstructive residual mucocele of the cystic duct. Reassessment of complications in our 13 years' experience with liver transplantation]. / Mucocele del dotto cistico residuo non ostruttivo. Rivalutazione della complicanza negli ultimi 13 anni della nostra esperienza nei trapianti del fegato.

PURPOSE: We reassessed the incidence of mucocele of the residual cystic duct in our series of orthotopic liver transplantation (OLT) patients. MATERIAL AND METHODS: We examined a series of 283 liver transplants with end-to-end choledocho-choledocal anastomosis (263 patients, 163 men and 80 women, 24-65 years old), performed at the II Surgical Department of the University of Bologna from May 1986 to April 1999 and subsequently followed-up in our Institute. All patients were examined with gray-scale and color Doppler US and some also underwent CT and CT cholangiography. RESULTS: An anechoic ovoidal structure just before the portal vein and in proximity of the main bile duct was found in 13 patients. US and CT findings, the latter when available, led us to make a diagnosis of nonobstructive mucocele of the cystic duct. The radiological diagnosis was eventually confirmed by clinical and surgical findings. DISCUSSION AND CONCLUSIONS: In our series the incidence of this complication was 4.5%, a slightly higher value than those reported in the literature. Cystic duct mucocele cannot be considered an uncommon complication and should thus be more carefully searched for by operators. In our experience this complication never required reoperation for cholestasis.