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L u c ia n a M e n d e s d e O liv e ira C e rri, G io v a n n i G u id o C e rriI
I
In tra o p e ra tiv e u ltra s o n o g ra p h y o f liv e r,
b ile d u c ts a n d p a n c re a s
T h e u s e o f in tra o p e ra tiv e u ltra s o n o g ra p h y (IG U S ) to e v a lu a te liv e r, b ile d u c ts a n d p a n c re a tic d is e a s e , a s c o m p a re d to th e re s u lts o f p re o p e ra tiv e u ltra s o n o g ra p h y a n d C T , is d is c u s s e d . F o rty -tw o p a tie n ts w h o u n d e rw e n t a b d o m in a l s u rg e ry fo r s u s p e c te d h e p a to b ilia ry a n d /o r p a n c re a tic d is e a s e w e re s tu d ie d . T h e in tra o p e ra tiv e s tu d y w a s c a rrie d o u t w ith a p o rta b le a p p a ra tu s (A lo k a 5 0 0 , J a p a n ), u s in g 5 .0 M H z a n d 7 ~ 5 M H z lin e a r s te rile tra n s d u c e rs . T h e m a in in d ic a tio n s fo r IG U S w e re th e s e a rc h fo r a n d /o r e v a lu a tio n o f p rim a ry h e p a tic m a s s e s ,h e p a tic a b s c e s s e s o r m e ta s ta s e s , o b s tru c tiv e ja u n d ic e , o r n e u ro e n d o c rin e tu m o rs . In 1 5 c a s e s (3 8 .5 p e rc e n t) fro m th e h e p a to b ilia ry g ro u p a n d in 7 c a s e s (5 8 .3 p e rc e n t) fro m th e p a n c re a tic g ro u p , a d iffe re n c e b e tw e e n p re o p e ra tiv e a n d in tra o p e ra tiv e fin d in g s w a s o b s e rv e d . T h e m a in d iffe re n c e w a s o b s e rv e d in re la tio n to th e n u m b e r a n d s iz e o f h e p a tic a n d p a n c re a tic le s io n s . T h e re la tio n s h ip b e tw e e n th e le s io n s a n d th e v a s c u la r s tru c tu re s w a s e v a lu a te d th ro u g h IG U S . T h e m e th o d w a s a ls o u s e d to g u id e s u rg ic a l p ro c e d u re s s u c h a s b io p s ie s , th e a lc o h o liz a tio n o f n o d u le s , a n d th e d ra in a g e o f a b s c e s s e s . IG U S p la y s a n im p o rta n t ro le in d e te c tin g s m a ll h e p a tic a n d p a n c re a tic n o d u le s , in th e a s s e s s m e n t o f a n a to m ic a l re la tio n s h ip s b e tw e e n th e le s io n s a n d th e v a s c u la r s tru c tu re s , a n d in th e p e rfo rm a n c e o f in te rv e n tio n is t p ro c e d u re s .
U N IT E R M S : D ia g n o s is . Im a g e /c la s s ific a tio n . U ltra s o n o g ra p h y /m e th o d s . In tra o p e ra tiv e p e rio d . L iv e r/U ltra s o n o g ra p h y . P a n c re a s / U ltra s o n o g ra p h y . B ile d u c ts /U ltra s o n o g ra p h y .
IN T R O D U C T IO N
T
h e f ir s t e f f o r ts to u s e in tr a o p e r a tiv e( lO U S ) to o k p la c e in 1 9 6 1 . u ltr a s o n o g r a p h yA t th a t ti m e , u ltr a s o n o g r a p h y w a s a n u n id im e n s io n a l p r o c e d u r e , u s e d in n e u r o s u r g e r y . II n th e s a m e y e a r , S c h le g e l e t a l.2u s e d th e m e th o d f o r lo c a liz in g k id n e y s to n e s . H a y a s h i e t a 1 .3r e p o r te d c a s e s o f g a llb la d d e r c a lc u li, in w h ic h th e d ia g n o s is w a s a c h ie v e d b y m e a n s o f a s p e c ia l la p a r o s c o p e w ith a n a tta c h e d tr a n s d u c e r .
A d re s s fo r c o rre s p o n d e n c e : G io v a n n i G u id o C e rri
R u a J a g u a rib e , 5 6 7 , V ila B u a rq u e S a o P a u lo /S P - B ra s il- C E P 0 1 2 2 4 -0 0 1
I n B r ita in in 1 9 6 3 , K n ig h t a n d N e w e l4 r e p o r te d th e u s e o f I O U S in th e e x p lo r a tio n o f th e c o m m o n d u c t, d u r in g c h o le c y s te c to m y f o r g a lls to n e s .4 I n 1 9 6 5 , E is e m a n e t a l.5
c a r r ie d o u t 9 3 in tr a o p e r a tiv e u ltr a s o n o g r a p h ic e x p lo r a tio n s f o r b ile d u c t e v a lu a tio n . T h e y f ir s t u s e d a n o r m a l tr a n s d u c e r , w h ic h w a s f u r th e r im p r o v e d b y s ig n if ic a n tly r e d u c in g its d im e n s io n s , in o r d e r to in s e r t it in to th e c o m m o n d u c t. I n th is s tu d y , th e y f o u n d 1 8 c o m m o n d u c t c a lc u li. T w o f a ls e - p o s itiv e a n d tw o f a ls e - n e g a tiv e c a s e s w e r e o b s e r v e d .
N e v e r th e le s s , I O U S d id n o t a c h ie v e th e d e s ir e d r e s u lts . T h u s , th e e q u ip m e n t w a s n o t im p r o v e d , a n d f u r th e r r e s e a r c h f o r th e d e v e lo p m e n t o f th e te c h n iq u e w a s n o t c a r r ie d o u t. O n ly in 1 9 7 8 , w ith th e a p p e a r a n c e o f te m p o r a l ( B m o d e ) a p p a r a tu s , d id s o m e g r o u p s s ta r t to p e r f e c t th e m e th o d ." T h e p io n e e r s in h e p a to b ilia r y a n d p a n c r e a tic s u r g e r y w e r e S ig e l e t a I .7 in th e U n ite d
g . . ... P.. $ '.1 H ;t.A H ? ;,. ...:-:« «••••••
S ta te s , L a n e a n d C o u p la n dx in A u s tr a lia , a n d M a k u u c h il)
in J a p a n .
M o r e r e c e n tly , la D S h a s b e e n u s e d a s a
c o m p le m e n ta r y te c h n iq u e d u r in g a n u m b e r o f s u r g ic a l
p r o c e d u r e s , s u c h a s h e p a to b ilia r y a n d p a n c r e a tic o p e r a tio n s .
T h is te c h n iq u e h a s b e e n la r g e ly u s e d in h e p a tic o p e r a tio n s ,
s in c e th e liv e r is a b u lk y o r g a n a n d its d e e p e r a r e a s a r e n o t
w ith in th e r e a c h o f d ir e c t s u r g ic a l e x p lo r a tio n . T h e
e v a lu a tio n o f th e h e p a tic v a s c u la tu r e is o f g r e a t in te r e s t,
s in c e la D S a J lo w s its o b s e r v a tio n w ith o u t a r tif a c ts ,
d if f e r e n tin g f r o m m o s t v a s c u la r r a d io lo g ic e x a m in a tio n s ,
w h ic h r e q u ir e c o m p le x a n d e x p e n s iv e d e v ic e s , n o t a lw a y s
a v a ila b le in r e g u la r o p e r a tin g r o o m f a c ilitie s .
T h e r o le o f la D S in th e s tu d y o f liv e r c o n d itio n s is to
d e te c t a n d e s ta b lis h th e e x te n t o f le s io n s , p a r tic u la r ly w h e n
th e y a r e m in u te a n d d e e p ly lo c a te d . T h is r o le is o f f u r th e r
im p o r ta n c e w h e n o n e r e m e m b e r s th a t c o m p le m e n ta r y
in tr a o p e r a tiv e h e p a tic a s s e s s m e n ts , a p a t1 f r o m in s p e c tio n
a n d p a lp a tio n , a r e p r a c tic a lly n o n e x is te n t o r in a c c u r a te , a s
a r e f o r e x a m p le c h o la n g io g r a p h y a n d p o r to g r a p h y . T h e
e v a lu a tio n o f le s io n s , a n d th e ir r e la tio n s h ip to v a s c u la r
s tr u c tu r e s , is d e c is iv e f o r s u r g ic a l s tr a te g y .6 . Ill. II
T h e p a n c r e a s is a r e la tiv e ly s m a ll o r g a n , f a ir ly
a c c e s s ib le to p a lp a tio n . I t is c r o s s e d b y th e m a in p a n c r e a tic
d u c t a n d th e c o m m o n b ile d u c t. O p a c if ic a tio n a n d
C h o le d o c h a l c y s t w ith c a lc u li
F ig u re 1 - G re a t d ila tio n o f c h o le d o c h u s w ith m u ltip le c a lc u li.
p o r to g r a p h y p r o v id e s o m e in f o r m a tio n ( u s u a lly in d ir e c t) o n
th e e x is te n c e o f d is e a s e in th e s e s tr u c tu r e s . A s a r e s u lt,
u ltr a s o n o g r a p h y h a s p la y e d a n im p o l1 a n t r o le in p r o v id in g
d a ta o n p a n c r e a tic p a r e n c h im a . I n a d d itio n , it c a n b e a g u id e
to th e c a th e te r iz a tio n o f p a n c r e a tic d u c t w h e n n e c e s s a r y ,
a n d is h e lp f u l in e v a lu a tin g v a s c u la r s tr u c tu r e s a s w e i1.(,.1 2
I n tr a o p e r a tiv e e v a lu a tio n h a s p la y e d a c o m p le m e n ta r y
r o le , to th e te c h n iq u e s a lr e a d y u s e d b y s u r g e o n s f o r th e s tu d y
o f b ile d u c ts : n a m e ly , c h o la n g io g r a p h y a n d c h o le d o
-c h o s -c o p y .6
E n th u s ia s m f o r la D S is e x p la in e d b y its a b ility to
p r o v id e in f o r m a tio n o n o r g a n p a r e n c h im a a n d v a s c u la tu r e .
F u r th e r m o r e , th e te c h n iq u e is n o n - in v a s iv e , lo w - c o s t, f a s t
a n d e a s ily e x e c u te d , w ith th e a d v a n ta g e o f n o t p r o lo n g in g
o p e r a tiv e tim e s ig n itic a n tly .1 3 .1 4 la D S h a s a ls o th e a d v a n ta g e
o f s u r p a s s in g th e lim ita tio n s o f p e r c u ta n e o u s te c h n iq u e s b y
e lim in a tin g th e in te r f e r e n c e o f th e a b d o m in a l w a ll, r ib s a n d
th e p r e s e n c e o f a ir in th e b o w e l. D u e to th e d ir e c t c o n ta c t
b e tw e e n th e tr a n s d u c e r a n d th e o r g a n u n d e r e x a m in a tio n ,
th e m e th o d a llo w s th e u s e o f a h ig h - f r e q u e n c y b e a m , w h ic h
a ls o le a d s to b e tte r r e s o lu tio n a n d b e tte r q u a lity im a g e s .
T h is e x p la in s th e r e s u lts o f v a r io u s s tu d ie s , w h ic h h a v e
s h o w n a h ig h e r s e n s itiv ity in th e d e te c tio n o f s m a ll h e p a tic
a n d p a n c r e a tic tu m o r s b y la D S w h e n c o m p a r e d to
p r e o p e r a tiv e u ltr a s o n o g r a p h y , C T , a n d a n g io g r a p h y . 1 5
In s u lin o m a
F ig u re 2 - T h e n o d u le is b e tte r v is u a liz e d b y in te rp o s in g a s u rg ic a l g lo v e fille d w ith s a lin e s o lu tio n . (*)
C E R R I, L .M .O . &C E R R I, G .G . -In tra o p e ra tiv e u ltra s o n o g ra p h y o f liv e r,
b ile d u e ls a n d p a n c re a s
Table 1
Comparison between pre and postoperative findings (liver and bile duct.)
P a tie n t
1.
2 .3.
4.
5.
6.
7.
8.
9 .1 0 .
1 1 .
12.
1 3 .
1 4 .
15.
16.
17.
18.
19.
20.
2 1 .
22.
23.
2 4 .
25
26.
27.
28.
2 8 .
29.
3 0 .
3 1 .
3 2 .
33.
3 4 .
35.
3 6 .
37.
38.
39.
P re o p e ra tive U S /C T
D iffu se h e p a tic n o d u le s
C h o le d o ch a l cyst w ith ca lcu li
H e p a tic n o d u le in rig h t lo b e (se g m e n t V II)
N o rm a l live r
C h o le d o ch a l d ila tio n
N o rm a l live r
N o rm a l live r
N o rm a l live r
M a ss in g a llb la d d e r
R ig h t h e p a tic lo b e m a ss,
w ith in va sio n o f le ft lo b e (se g m e n t IV )
4 so lid n o d u le s in th e rig h t h e p a tic lo b e
N o rm a l live r
H e p a tic a b sce sse s
N o rm a l live r
C h ro n ic h e p a tic d ise a se
H e p a tic n o d u le
H e p a tic a b sce sse s
H e p a tic A b sce sse s
H e p a tic m e ta sta tic n o d u le s
M a ss in rig h t a n d le ft h e p a tic lo b e s
(se g m e n ts V a n d IV ) +C h ro n ic C a lcu lu s
C h o le cystitis
N o rm a l live r
N o rm a l live r
N o rm a l live r
F a tty live r
T h re e h e p a tic n o d u le s
N o rm a l live r
N o rm a l live r
N o d u le in rig h t h e p a tic lo b e (se g m e n t V II)
N o d u le in rig h t h e p a tic lo b e (se g m e n t V II)
L e ft h e p a tic lo b e M a ss
L e ft in tra h e p a tic b ile d u ct d ila tio n w ith ju n ctio n a l a m p u ta tio n
C o m p le x le sio n in le ft h e p a tic lo b e
N o rm a l live r
P a p illa ry tu m o r
N o rm a l live r
N o rm a l live r
N o rm a l live r
C h ro n ic live r d ise a se . S o lid n o d u le
in se g m e n t V II. C yst in se g m e n t V II
C h ro n ic live r d ise a se . L e ft lo b e m a ss
L e ft h e p a tic lo b e m a ss
IG U S
S a m e fin d in g s
S a m e fin d in g s
T w o n o d u le s, o n e in rig h t lo b e (se g m e n t V II), th e o th e r in le ft lo b e (se g m e n t II)
S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s
M a ss in g a llb la d d e r, h ila r lym p h a d e n o p a th y, d ila tio n o f in tra h e p a tic b ile d u ct.
R ig h t h e p a tic lo b e m a ss w ith n o in va sio n o f le ft lo b e ; d e via tio n in m id d le h e p a tic ve in
S a m e fin d in g s, p lu s o n e 1 cm so lita ry n o d u le in se g m e n t V II.
S a m e fin d in g s
H e p a tic m e ta sta se s
S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s
L ive r: sa m e p re o p e ra tive fin d in g s. B ile d u ct: C h o le ste ro lo sis
S a m e fin d in g s
C h ro n ic live r d ise a se
S a m e fin d in g s
S e ve ra l sm a ll h e p a tic cysts
S a m e fin d in g s
N o rm a l live r. H ila r Iym p h a d e n o p h a ty
S a m e fin d in g s
T w o n o d u le s in se g m e n t V II
T w o n o d u le s in se g m e n t V II
L e ft h e p a tic lo b e m a ss. M a ss in se g m e n t V II,
clo se to rig h t h e p a tic ve in o p e n in g .
S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s
P a p illa ry tu m o r. B ile d u ct d ila tio n .
.S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s
S a m e fin d in g s, p lu s 3 m o re sm a ll so lid
n o d u le s in le ft lo b e
C h ro n ic live r d ise a se . L e ft lo b e m a ss. S o lid n o d u le in rig h t lo b e (se g m e n t V I)
S a m e fin d in g s
Hepatic metastases of carcinoma of the colon
Figure3 - Solid nodule with necrotic center, deviating right suprahepatic vein.
Figure 4 -Solid mass in head of pancreas. Duodenum (8).
Table 2
Comparison between pre and intraoperative findings. (Pancreas.)
Patient number
1.
2.
3.
4
5.
6.
7.
8.
9.
10.
11.
12.
Preoperative US/CT
Normal pancreas
Mass in pancreas head and
dilation of Wirsung duct
Normal pancreas
Solid nodule in the transition between
head and body of the pancreas
Solid nodule in pancreatic body
Normal pancreas
Two solid nodules
Normal pancreas
Normal pancreas
Pancreatic nodule
Peripancreatic mass
Pancreatic tumor
IGUS
Same findings
Normal pancreas. Dilation of Wirsung duct
Same findings
Two solid hipoecogenic nodules in the same area
Same findings
Solid mass in the head of the pancreas
Two hipoecogenic solid nodules and 1 cystic nodules
Same findings
Solid hipoecogenic nodule in the head of the pancreas
Chronic pancreatitis, with no nodules
Same findings
Normal pancreas
CERRI, L.M.O. & CERRI, G.G. - Intraoperative ultrasonography of liver, bile ducts and pancreas
Table 3
A greem ent betw een preoperative exam inations and laus (liver and bile duct.)
Table 4
A greem ent betw een preoperative exam inations and laus. (Pancreas.)
A g re e m e n t
D iffe re n c e
T o ta l
2 4 c a s e s (6 1 .5 % )
1 5 c a s e s (3 8 .5 % )
3 9 c a s e s (1 0 0 % )
A g re e m e n t
D iffe re n c e
T o ta l
5 c a s e s (4 1 .7 % )
7 c a s e s (5 8 .3 % )
1 2 c a s e s (1 0 0 % )
In s u lin o m a
Figure 6 -T w o s o lid h y p o e c h o g e n ic n o d u le s o f 0 .7 a n d 1 .5 c m
id e n tifie d in p a n c re a tic ta il.
TableS
A greem ent betw een findings of preoperative exam inations and laus. (Liver, B ile duct and pancreas.)
2 9 c a s e s (5 6 .8 % )
2 2 c a s e s (4 3 .2 % )
5 1 c a s e s (1 0 0 % )
s a l i n e s o l u t i o n . I n c a s e o f s u p e r f i c i a l l e s i o n s , a w a t e r - f i l l e d
s u r g i c a l g l o v e w a s u t i l i z e d f o r b e t t e r f o c u s i n g . I n c a s e o f
n o n - p a l p a b l e o r i n a c c e s s i b l e l e s i o n s , a I O U S - g u i d e c l
p u n c t u r e w a s p e r f o r m e d . A g re e m e n t
D iffe re n c e
T o ta l
H e p a tic m e ta s ta s e s
Figure 5 -M u ltip le s m a ll h y p o e c h o g e n ic h e p a tic n o d u le s .
PA TIEN TS A N D M ETH O D S
F o r t y - t w o p a t i e n t s w h o u n d e r w e n t a b d o m i n a l s u r g e r y
w i t h a t e n t a t i v e d i a g n o s i s o f h e p a t o b i l i a r y a n d p a n c r e a t i c
d i s e a s e b e t w e e n 1 9 9 1 a n d 1 9 9 4 a t t h e H o s p i t a l d a s
C l f n i c a s , F M U S P , w e r e s t u d i e d . O n e p a t i e n t u n d e r w e n t
t h e o p e r a t i o n t w i c e w i t h I O D S . T h e p a t i e n t s w e r e 1 3 t o
8 2 y e a r s - o l d ( a v e r a g e 4 6 .5 y e a r s ) . T w e n t y - o n e w e r e f e m a l e
a n d 2 1 m a l e . T h e y w e r e d i v i d e d i n t w o g r o u p s , a c c o r d i n g
t o t h e d i a g n o s i s o f h e p a t o b i l i a r y o r p a n c r e a t i c d i s e a s e . I n
8 c a s e s , b o t h t h e h e p a t o b i l i a r y ' a n d p a n c r e a t i c a r e a s w e r e
e x a m i n e d . A l l p a t i e n t s u n d e r w e n t u l t r a s o n o g r a p h y a n d /
o r C T i n t h e p r e o p e r a t i v e p e r i o d .
A l l i n t r a o p e r a t i v e e x a m i n a t i o n s w e r e c a r r i e d o u t b y
t h e a u t h o r , u s i n g p o r t a b l e e q u i p m e n t , m o d e l 5 0 0 ( A l o k a ,
T o k y o , J a p a n ) , w i t h s t e r i l e l i n e a r 5 .0 a n d 7 .5 M H z
t r a n s d u c e r s . R e c o r d i n g s w e r e t a k e n w i t h a v i d e o p r i n t e r .
T h e e x a m i n a t i o n w a s s t a n d a r d i z e d b y l o n g i t u d i n a l l y
a n d t r a n s v e r s a l l y s c a n n i n g t h e o r g a n u n d e r s t u d y . T h e
c o n t a c t b e t w e e n t r a n s d u c e r a n d t h e o r g a n t o b e e x a m i n e d
w a s e s t a b l i s h e d b y u t i l i z i n g p e r i t o n e a l f l u i d a n d s t e r i l e
Table 6 IOUS-guided procedures
Patient
1 .
2 .
3 .
4 .
5 .
Procedure
Guidance for drainage of multiple bilobar hepatic abscesses.
Guidance for drainage of residual abscess in right hepatic lobe (Segment VIII).
Puncture/biopsy of solid area of mixed lesion of left hepatic lobe (Segment IV).
Puncture/biopsy and alcoholization of hypoechogenic nodule in left hepatic lobe (Segment VII).
Puncture/biopsy and alcoholization of hyperechogenic, non-palpable nodule in right hepatic lobe (Segment VI).
RESULTS
T h ir ty - n in e e x a m in a tio n s f o r th e in v e s tig a tio n o f
h e p a to b ilia r y d is e a s e w e r e c a r r ie d o u t. I n th is g r o u p o f
p a tie n ts , th e s u r g ic a l in d ic a tio n s w e r e : p r im a r y h e p a tic
tu m o r s ; h e p a tic a b s c e s s e s ; h ig h a n d lo w o b s tr u c tiv e
ja u n d ic e ; g a ll b la d d e r tu m o r s ; s e a r c h in g f o r h e p a tic
m e ta s ta s is f r o m g a s tr ic a n d c o lo n ic m a lig n a n c ie s ; a n d
n e u r o e n d o c r in e tu m o r s . I n th e 1 2 p a tie n ts w h o u n d e r w e n t
s u r g e r y f o r p a n c r e a tic d is e a s e , th e m a in p u r p o s e o f th e
e x a m in a tio n s w a s to s e a r c h f o r n e u r o e n d o c r in e tu m o r s .
Figure7 - 1.3 cm cyst in pancreatic body.
A COMPARISON
BETWEEN
PREOPERATIVE
EXAMINATIONS
AND IOUS
(Tables 1 and 2)I n 2 4 c a s e s ( 6 1 .5 p e r c e n t) f r o m th e h e p a to b ilia r y
g r o u p , th e r e w a s a n a g r e e m e n t b e tw e e n p r e o p e r a ti v e a n d
in tr a o p e r a tiv e f in d in g s . I n 1 5 c a s e s ( 3 8 .5 p e r c e n t) , th e
r e s u lts f r o m I O U S w e r e d if f e r e n t.
T h e m o s t f r e q u e n t d iv e r g e n c ie s in th is g r o u p w e r e
r e la te d to th e n u m b e r o f p r e o p e r a tiv e id e n tif ie d le s io n s .
I n s ix c a s e s ( 1 6 .7 p e r c e n t) , a la r g e r n u m b e r o f le s io n s
Hepatic abscesses
Figure 8 -Image of fluid content, with a thickened wall.
CERRI, L.M.O. & CERRI, G.G. -Intraoperative ultrasonography of liver, bile ducts and pancreas
Figure 9 -A fte r p u n c tu re , th e re w a s a re d u c tio n in th e s iz e o f th e a b s c e s s . N e e d le (a rro w ).
w a s d e t e c t e d b y I O U S . T h e d i a m e t e r o f t h e s e l e s i o n s r a n g e d f r o m 0 . 4 t o 1 . 5 c m . O t h e r a l t e r a t i o n s i d e n t i f i e d b y I O U S , n o t d i s c o v e r e d b y p r e o p e r a t i v e f i n d i n g s , w e r e r e l a t e d t o t h e s o l i d o r c y s t i c n a t u r e o f l e s i o n s , s i z e o f l e s i o n s , h i l a r l y m p h a d e n o p a t h y , a n d d i l a t i o n o f t h e i n t r a h e p t a i c b i l e d u c t .
I n t h e g r o u p o f p a t i e n t s w h o u n d e r w e n t p a n c r e a t i c p r e o p e r a t i v e i n v e s t i g a t i o n , ' a g r e e m e n t b e t w e e n p r e o p e r a t i v e a n d i n t r a o p e r a t i v e f i n d i n g s w a s o b s e r v e d i n 5 c a s e s ( 4 1 . 7 p e r c e n t ) . I n 7 c a s e s ( 5 8 . 3 p e r c e n t ) , I O U S s h o w e d d i f f e r e n t r e s u l t s . T h e d e t e c t i o n o f p a n c r e a t i c n o d u l e s o f 0 . 9 t o 1 . 2 c m w a s t h e m a i n c o n t r i b u t i o n o f t h e i n t r a o p e r a t i v e s t u d y o f t h e p a n c r e a s . T a b l e s 3 a n d 4 g i v e t h e r e s u l t s f o r b o t h t h e a g r e e m e n t a n d d i f f e r e n c e s b e t w e e n p r e o p e r a t i v e a n d i n t r a o p e r a t i v e m e t h o d s i n t h e h e p a t o b i l i a r y a n d p a n c r e a t i c g r o u p s . T a b l e 5 s u m m a r i z e s t h e r e s u l t s o f t h e t w o g r o u p s .
IOUS-GUIDED
SURGICAL
PROCEDURES
I O U S w a s u s e d f o r g u i d i n g e i t h e r p u n c t u r e s a n d b i o p s i e s i n 5 c a s e s ( 9 . 8 p e r c e n t ) . T h e p r o c e d u r e s w e r e
H e p a tic m e ta s ta s e s o f c a rc in o m a o f th e c o lo n .
Figure 10 -T h ro u g h IG U S a n o th e r 0 .8 e m s o lid , h y p o e e h o g e n ie n o d u le w a s fo u n d , n e x t to th e a b o v e m e n tio n e d .
p u n c t u r e s p e r f o r m e d f o r g u i d i n g e i t h e r b i o p s i e s o r n o d u l e a l c o h o l i z a t i o n . D r a i n a g e o f p a r e n c h i m a t o u s c o l l e c t i o n s , i n a c c e s s i b l e t o t h e s u r g e o n 's v i s i o n a n d / o r p a l p a t i o n , w e r e a l s o p e r f o r m e d . T a b l e 5 d e p i c t s s u c h p r o c e d u r e s .
DISCUSSION
I O U S h a s e v o l v e d g r e a t l y i n t h e l a s t 1 5 y e a r s . I t u s e d t o b e a c o m p l e x m e t h o d , w i t h a l i m i t e d s p a n o f i n d i c a t i o n s , f r e q u e n t l y a s s o c i a t e d w i t h a n i n c r e a s e i n s u r g i c a l t i m e . T h e i m p r o v e m e n t i n q u a l i t y o f u l t r a s o n o g r a p h y e q u i p m e n t , w i t h t h e d e v e l o p m e n t o f t r a n s d u c e r s f o r t h i s p u r p o s e , s m a l l e r a n d w i t h g r e a t e r r e s o l u t i o n , h a s i n c r e a s e d t h e i m p o r t a n c e o f t h e m e t h o d i n d i g e s t i v e t r a c t s u r g e r y . I n m a n y c e n t e r s , i t i s r o u t i n e l y u s e d i n l i v e r , p a n c r e a s a n d b i l e d u c t d i a g n o s t i c e x p l o r a t i o n . 1 6
T h e m a i n i n d i c a t i o n s f o r I O U S u s e a r e : I)d e t e c t i n g s m a l l h e p a t i c p r i m a r y t u m o r s o r m e t a s t a s e s ; 2 ) p r e c i s e l y s t a g i n g e i t h e r p r i m a r y l i v e r t u m o r s o r h e p a t i c m e t a s t a s e s ; 3 ) v i s u a l i z i n g i n t r a h e p a t i c v a s c u l a r a n a t o m y , i n o r d e r t o m a k e s e g m e n t o m i e s f e a s i b l e ; 4 ) i d e n t i f y i n g b i l i o - p a n c r e a t i c d u c t a l s t r u c t u r e s a ~ d t h e i r c o n t e n t s ; 5 ) s e a r c h i n g f o r n o d u l a r
Lym phom a
Figure 11 -G anglionar m ass in hepatic hilus, com pressing the
portal system .
stru c,tu res in cirrh o tic liv ers; 6 ) estab lish in g th e d iag n o sis o f p an creatic' en d o crin e tu m o rs; 7 ) as a g u id e fo r cath eterizin g v ascu lar an d d u ctal stru ctu res; 8 ) as a g u id e fo r lo calizin g an d p u n ctu rin g b o th h ep atic ab scesses an d p an creatic liq u id co llectio n s; 9 ) as a g u id e fo r th e p u n ctu re an d b io p sy o f u n d iag n o sed h ep atic n o d u les; 10) in th erap eu tic p u n ctu rin g (alco h o lizatio n an d in stillatio n o f ch em o th erap h eu tic ag en ts) o f h ep atic n o d u les. I?
In th e p resen t series, th e m ain p u rp o se fo r IO U S w as search in g fo r m etastatic h ep atic n o d u les in p atien ts w ith g astric, in testin al an d p an creatic m alig n an cies. T h e g o al o f th e ex am in atio n s w as th e in .trao p erativ e d etectio n o f u n id en tified n o n -p alp ab le n o d u les.
T h e im ag e-u tilizin g m eth o d s fo r ro u tin e liv er ex am in atio n are u ltraso n o g rap h y an d C T . N ev erth eless, th ese p ro ced u res can n o t d etect h ep atic m etastases, e,ith er sin g le o r m u ltip le, p articu larly th o se th at are sm all. T h e p ro b lem s asso ciated w ith , th e ex am in atio n tech n iq u e w ere artifacts, th e p atien t's p h y sical ty p e, an ato m ic v ariatio n s, allerg y to co n trast, an d , in p articu lar, th e size o f th e lesio n s.
A ll th ese facto rs red u ce'th e sen sitiv ity o f b o th o f IO U S an d C T . It is estim ated th at ap p ro x im ately 2 0
p ercen t o f m etastases are p reo p erativ ely id en tified . IO U S
C ellular hepatocarcinom a
Figure 12 -T he three sm all (0.5 cm ) solid nodules in the left
hepatic lobe w ere only identified by IG U S .
is u sefu l p rin cip ally in th e d etectio n o f m in u te an d d eep ly lo cated lesio n s in th e h ep atic p aren ch im a. T h e m eth o d can lead to a p recise d etectio n an d lo catio n o f lesio n s, as w ell as th eir sp atial relatio n sh ip s w ith in trah ep atic v ascu lar stru ctu res.I?I~ T h e h ig h reso lu tio n o f IO U S allo w s fo r th e d ifferen tiatio n o f lesio n s w ith b en ig n featu res lik e cy sts an d h em an g io m as, fro m m etastatic-lo o k in g n o d u les, w h ich are freq u en tly h y p o eco g en ic an d d isp lay a targ et co n fig u ratio n . I? 2 0
T w o o u t o f 3 9 cases in th e h ep ato b iliary g ro u p h ad a d iag n o sis o f ch ro n ic h ep atic d isease (cirrh o sis). In b o th o f th em , in trao p erativ e IO U S d etected n o d u les p rev io u sly n o t o b serv ed . B o th p atien ts h ad a U S /C T d iag n o sed n o d u le in th e rig h t h ep atic lo b e. T h e d isco v ery o f left lo b e tu m o ral in v o lv em en t ch an g ed th e su rg ical p lan , w h ich resu lted in th e av o id an ce o f rig h t h ep atecto m y . In its p lace, alco h o lizatio n o f n o d u les w as p erfo rm ed . T h ese n o d u les, fo u r in n u m b er, w ere less th an 1.0cm in d iam eter.
In ch ro n ic h ep atic d isease, th e p aren ch im al h etero g en eity h as seen as an ad d itio n al d ifficu lty fo r p reo p erativ e d etectio n o f sm all n o d u les. F o r th is reaso n , IO U S h as b een u tilized in ex am in in g cirrh o tic p atien ts fo r n o d u les sm aller th an 5 .0 cm y .2 1 T h e m eth o d h as also
C E R R I, L.M .O . & C E R R I, G .G . -Intraoperative ultrasonography of liver, bile ducts and pancreas
p ro v ed to b e u sefu l in ev alu atin g tu m o ral in trav ascu lar
g ro w th in th e h ep atic an d p o rtal v ein sy .2 2
la D S allo w s fo r th e clear id en tificatio n o f p o rtal
b ran ch es an d h ep atic v ein s. T h u s, th e trid im en sio n al n atu re
o f tu m o ral an d v ascu lar stru ctu res are easily reco g n ized
b y th e su rg eo n . T h ro u g h th is m eth o d , as w ell as g u id ed
p u n ctu re tech n iq u es, a n ew su rg ical p ro ced u re su ch as
su b seg m en tecto m y w as d ev elo p ed y .2 3
H ep atic resectio n s h av e b eco m e a m o re co m m o n
p ro ced u re. H o w ev er, m o st p atien ts w ith cellu lar
h ep ato carcin o m a h av e asso ciated cirrh o sis. In th ese
p atien ts, a w id e resectio n is a risk y p ro ced u re, d u e to th e
h ep atic fai lu re w h ich co u ld o ccu rr. T h u s, la D S p lay s a
im p o rtan t ro le in g u id in g m o re eco n o m ic resectio n s. A lso
b en ig n lesio n s (lik e cav ern o u s h em an g io m as, ad en o m as
an d n o d u lar fo cal h y p erp lasy ) h av e b een b en efited b y
th ese seg m en tal o r su b seg m en tal resectio n s, lead in g to
th e av o id an ce o f u n n ecessary lo b ecto m ies. la D S is
h elp fu l in p erfo rm in g su b seg m en tecto m ies b ecau se it
allo w s th e v isu alizatio n o f in trah ep atic v ascu lar
stru ctu res w h ich h av e n o an ato m ical ex p ressio n o n th e
h ep atic su rfaceY . 1 4 .2 2 -2 4
In th e g ro u p o f p atien ts w ith b ile d isease, cases o f
b ile d u ct d ilatio n , m alig n an cies, an d lith iasis h av e b een
Figure 13 - H y p e rre frin g e n t im a g e in th e c e n te r o f th e le s io n
c o rre s p o n d s to n e e d le tip .
ev alu ated . T h e g allb lad d er h as u su ally b een ad eq u ately
stu d ied th ro u g h p reo p erativ e u ltraso n o g rap h y .C > ' 2 5
In recen t y ears, la D S h as b een u sed to ex p lo re eith er
in trah ep atic an d in trah ep atic b iliary d u cts. R ecen t stu d ies
h av e su g g ested th at in trao p erativ e ch o lan g io g rap y b e
rep laced b y la D S . C h o lan g io g rap h y is a tech n iq u e u sed
to d etect co m m o n d u ct calcu li w ith sen sitiv ity an d
sp ecificity o f ap p ro x im ately 9 0 to 9 5 p ercen t. N ev erth eless,
it h as so m e tech n ical lim itatio n s an d in terp retatio n
p ro b lem s d u e to b u b b le fo rm atio n . It also h as th e
d isad v an tag e o f p ro lo n g in g su rg ical tim e, b ecau se o f th e
p ro ced u re itself an d th e ad d itio n al tim e n eed ed fo r th e
d ev elo p m en t o f th e film . O n th e o th er h an d , la D S is a
n o n -in v asiv e, sim p le an d fast m eth o d . T h e resu lts in th e
d etectio n o f b iliary calcu li h av e b een sim ilar fo r b o th
m eth o d s.2 C > .2 7
In th e case o f ch o lan g io carcin o m a seen in th is series,
la D S w as u sefu l in stag in g an d estab lish in g an ato m ical
relatio n sh ip s, sim ilarly to w h at h as b een p rev io u sly
d iscu ssed fo r h ep atic m asses.
In th is series, th ere w as an ag reem en t b etw een th e
p reo p erativ e ex am in atio n s an d p reo p erativ e la D S in 6 1 .5
p ercen t o f th e cases. In th e cases o f Ii v el' an d b i Ie d u ct
d iseases, a 3 8 .5 p ercen t d ifferen ce w as fO lllld . B ism u th et
Figure 14 -A t th e m o m e n t o f a lc o h o liz a tio n , th e n o d u le b e c o m e s
h y p e re c h o g e n ic .
S a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 4 (4 ): 1 1 9 6 -1 2 0 7 ,1 9 9 6 C E R R I, L .M .O . & C E R R I, G .G . -In tra o p e ra tiv e u ltra s o n o g ra p h y o f liv e r,
a l.2 X r e p o r te d a 6 7 p e r c e n t a g r e e m e n t a n d a 3 3 p e r c e n t
d if f e r e n c e b e tw e e n I O U S a n d o th e r im a g e - u tiliz in g
p r e o p e r a tiv e e x a m in a tio n s . C la r k e e t a l.2 9 f o u n d u p to 3 5
p e r c e n t a d d itio n a l le s io n s w ith I O U S , a s c o m p a r e d to o th e r
p r e o p e r a tiv e m e th o d s .
I n th e g r o u p o f p a tie n ts in v e s tig a te d f o r s u s p e c te d
p a n c r e a tic d is e a s e , th e m a in in d ic a tio n f o r I O U S w a s
th e s e a r c h f o r e n d o c r in e tu m o r s . I n th e e ig h t c a s e s w ith
s u s p e c te d e n d o c r in e tu m o r s , I O U S s u p p lie d a d d itio n a l
in f o r m a tio n in th r e e , a s c o m p a r e d to o th e r p r e o p e r a tiv e
e x a ll1 in a tio n s . I n tw o o f th e s e c a s e s , a s o lid n o d u le
w a s id e n tif ie d th r o u g h th e m e th o d . I n .th e o th e r , a
p r e o p e r a tiv e ly - d ia g n o s e d s o lid n o d u le , w a s f o u n d to
b e a c y s t.
I n th e f o u r c a s e s o f n o n - e n d o c r in e p a n c r e a tic d is e a s e ,
tw o w e r e s u s p e c te d o f b e in g tu m o r o u s . I n b o th , I O U S
s h o w e d a n o r m a l p a n c r e a s . I n a n o th e r c a s e , in w h ic h th e
p r e o p e r a tiv e e x a m in a tio n s r e s u lts w e r e n o r m a l, I O U S
s h o w e d a m a s s in th e h e a d o f p a n c r e a s .
V a r io u s a u th o r s h a v e e m p h a s iz e d th e im p o r ta n c e o f
I O U S a s a r o u tin e d ia g n o s tic p r o c e d u r e f o r th e id e n
ti-f ic a tio n o f e n d o c r in e tu m o r s . D u e to th e s m a ll d im e n s io n s
o f th e s e s n o d u le s , th e p r e o p e r a tiv e d ia g n o s is is u s u a lly
d if f ic u lt o r in c o n c lu s iv e . T h u s , th e in tr a o p e r a tiv e lo c a tio n
o f tu m o r , b y p a lp a tio n a n d I O U S , is v e r y im p o r ta n t. T h e
c o n tr ib u tio n o f I O U S is p a r tic u la r ly im p o r ta n t in th e s tu d y
o f m u ltip le e n d o c r in e tu m o r s . T h e c o m p le m e n ta r y
c h a r a c te r o f c o n v e n tio n a l s o n o g r a p h y , a n d I O U S p lu s
p a lp a tio n , g iv e s th e s u r g e o n in c r e a s e d s a f e ty in th e
r e s e c tio n o f s m a ll n o d u le s . I ll.3 1 1 .3 1
I n th e p r e s e n t s tu d y , I O U S p r o v id e d a d d itio n a l
d a ta ', a s c o m p a r e d to o th e r p r e o p e r a tiv e e x a m in a tio n s
( 3 5 .5 p e r c e n t o f th e c a s e s o f n e u r o e n d o c r in e tu m o r s ) .
A c c o r d in g to lite r a tu r e , th e s e n s itiv ity o f p r e o p e r a tiv e
U S /C T in d e te c tin g n e u r o e n d o c r in e tu m o r s is f a ir ly
v a r ia b le , r a n g in g f r o m 3 0 to 8 0 p e r c e n t.:w T h e s e n s itiv ity
o f I O U S is 9 0 p e r c e n t, th u s s u r p a s s in g th e o th e r
p r e o p e r a ti v e m e th o d s . 1 2 .2 1 1 .3 1
A s f o r th e o th e r in d ic a tio n s f o r I O U S , th e f in d in g s
o f th is s tu d y a g r e e w ith th o s e f r o m lite r a tu r e , in te r m s
o f its u s e f o r th e d e te c tio n o f p a n c r e a tic a n a to m ic
a lte r a tio n s , id e n tif ic a tio n o f th e W ir s u n g d u c t, e v a lu a tio n
o f te x tu r e , a n d th e o b s e r v a tio n o f p e r ip a n c r e a tic
v a s c u la r s tr u c tu r e s . T h e m e th o d is u s e f u l f o r th e
d i a g n o s i s o f tu m o l's a n d c h r o n i c p a n c r e a ti ti s . I ts
a c c u r a c y s u r p a s s e s th a t s e e n in o th e r p r e o p e r a tiv e
e x a m in a tio n s .fl
.7 S ie g e l e t a l.7 r e p o r te d th a t I O U S w a s h e lp f u l in 6 9 p e r c e n t o f s u r g e r y c a s e s f o r p a n c r e a titis
a n d in 6 9 p e r c e n t o f s u r g ic a l p r o c e d u r e s f o r tu m o r s .
I n te r v e n tio n a l u ltr a s o n o g r a p h y h a s b e e n v e r y u s e f u l
in g u id in g s e v e r a l p e r c u ta n e o u s te c h n iq u e s . I ts m a in
in d ic a tio n s a r e r e la te d to p r o c e d u r e s in w h ic h n e e d le s a n d
c a th e te r s a r e n e c e s s a r y , s u c h a s in th e d r a in a g e o f
a b s c e s s e s , a s p ir a tio n o f c y s ts , in je c tio n o f a lc o h o l a n d
c h e m o th e r a p e u tic a g e n ts , a n d b io p s y p r o c e d u r e s . T h e s e
o p e r a tiv e p r o c e d u r e s c a n a ls o b e d o n e w ith lO U S Y - I ll.2 X
I n th e p r e s e n t s e r ie s , in tr a o p e r a tiv e I O U S w a s u s e d
in f iv e c a s e s , g u id in g b io p s ie s a n d a lc o h o liz a tio n s o f
h e p a tic n o d u le s , a n d d r a in a g e o f h e p a tic a b s c e s s e s . I n th e s e
c a s e s , th e p u r p o s e w a s p e r f o r m i n g d ia g n o s tic a n d
th e r a p e u tic p u n c tu r e s o n in f la m m a to r y a n d n e o p la s ic
h e p a tic le s io n s th a t, d u e to th e ir lo c a liz a tio n , w e r e n o t
r e a d ily a c c e s s ib le b y v is u a liz a tio n o r p a lp a tio n . A d e c r e a s e
in o p e r a tiv e tim e a n d a n in c r e a s e in s u r g ic a l s a f e ty w e r e
a d d itio n a l a d v a n ta g e s .
A lth o u g h th e p r e s e n t s tu d y d e a ls o n ly w ith h e p a tic
o p e r a tiv e p r o c e d u r e s , o th e r a u th o r s h a v e m e n tio n e d th e
u s e o f I O U S in p a n c r e a tic o p e r a tio n s , s u c h a s th e in te r n a l
d r a i n a g e o t' p s e u d o c y s ts a n d th e c a th e te r iz a ti o n o f a d iIa te d
W ir s u n g d u c t. I n tr a o p e r a tiv e U S h a s b e e n a ls o u s e f u l in
b ile d u c t s u r g e r y , in c a th e te r iz in g a n d d r a in in g b ile d u c ts ,
a n d in p e r f o r m in g p u n c tu r e /b io p s y o f tu m o r s .3 2
I O U S is a n a d d itio n a l p r o c e d u r e in s u r g ic a l
o p e r a tio n s , w h ic h le a d s to a n in c r e a s e in o p e r a tiv e tim e .
H o w e v e r , b y a llo w in g a r a p id id e n tif ic a tio n o f s m a ll
le s io n s , a m o r e p r e c is e s ta g in g o f tu m o r s , g u id in g
r e s e c tio n s th a t w o u ld o th e r w is e b e p e r f o r m e d b lin d ly , a n d
b y m a k in g a s s o c ia te d s u r g ic a l p r o c e d u r e s f e a s ib le , th e e n d
r e s u lt is a c tu a lly a s h o r te n in g o f o v e r a ll o p e r a tiv e tim e .
T h e a p p e a r a n c e o f c o n tr a s t d y e s in a s s o c ia tio n w ith
I O U S , a s p r o p o s e d b y T a k a d a e t a l.,3 3 o p e n s g o o d
p e r s p e c tiv e s f o r lo c a tin g e v e n s m a lle r tu m o r s . T h is
c o n tr ib u te s to a b e tte r p r o g n o s is . T h e in je c tio n o f C O 2 in to th e h e p a tic a r te r y w a s n o t a s s o c ia te d w ith h a r m f u l
s id e e f f e c ts .
T h e n e w I O U S a p p a r a tu s , e q u ip p e d w ith a c o lo r
d o p p le r , h a d b r o u g h t a n a d v a n c e m e n t to th e te c h n iq u e . I t
a llo w s th e r a p id id e n tif ic a tio n o f th e a r te r ia l a n d v e n o u s
v a s c u la tu r e , w h ic h m a k e s p o s s ib le th e d if f e r e n tia tio n
b e tw e e n b lo o d v e s s e ls a n d o th e r c h a n n e l- lik e s tr u c tu r e s .
T h e im p r o v e d r e c o g n itio n o f th e h e p a to b i Ii a r y a n d
p a n c r e a tic a n a to m y h a s m a d e s u r g ic a l d is s e c tio n s in th e s e
a r e a s e a s ie r .
L a p a r o s c o p ic s u r g e r y r e p r e s e n ts a m a jo r a d v a n c e in
s u r g ic a l te c h n iq u e in th e la s t d e c a d e . S p e c ia lly d e s ig n e d
tr a n s d u c e r s w h ic h a llo w m o n ito r in g th e s e p r o c e d u r e s h a d
b e e n d e v e lo p e d . S o m e o f th e m a r e s till in th e e a r ly p h a s e s
o f u tiliz a tio n . T h is r e p r e s e n ts a m a jo r c o n tr ib u tio n o f
I O U S , a s m o r e s a f e ty a n d a n im p r o v e d v is u a liz a tio n i l l
la p a r o s c o p ic s u r g e r y a r e p r o v id e d Y I n o u r o p i n io n , T O U S
w ill s o o n b e c o m e a r o u tin e p r o c e d u r e a s s o c ia te d w ith th e s e
te c h n iq u e s .
C E R R I, L .M .O . & C E R R I, G .G . - In tr a o p e r a tiv e u ltr a s o n o g r a p h y o f liv e r ,
b ile d u c ts a n d p a n c r e a s
CONCLUSIONS
4 .
I.
rO D S plays
an im portant
role in detecting
sm all
hepatic nodules,
either prim ary
or m etastatic.
5.
2.
rO D S
is an im portant
technique
in precisely
identifying
hepatic
lesions
and their
anatom ical
vascular
relationships.
6.
3.
rO D S should be routinely
used in cirrhotic
patients
w ith hepatic
tum ors,
for the purpose
of detecting
nodules
difficult
to diagnose
preoperatively
and
difficult
for the
surgeon
to see
because
of the
heterogeneity
of the hepatic parenchim a.
rO D S w as found to be an im portant
procedure
in the
detection
of m inute pancreatic
tum ors.
rO D S has better
sensitivity
than preoperative
U S/
C T
in detecting
hepatobiliary
and
pancreatic
alterations.
rO D S
h as
been
useful
in
associ
ati on
w i t h
intraoperative
procedures,
such
as biopsies,
the
alcoholization
of nodules,
and
the
drai nage
of
abscesses.
RESUMO
E
d iscu tid a a u tiliza ya o d a u ltra -so n o g ra fia in tra -o p e ra to ria n a a va lia ya o d o ffg a d o , via s b ilia re s e p a n cre a s e co m p a ra d o s o s re su lta d o s co m o s d e u ltra -so m e to m o g ra fia co m p u ta d o riza d a p re -o p e ra to rio s. F o ra m e stu d a d o s 4 2 p a cie n te s su b m e tid o s a ciru rg ia a b d o m in a l p o r su sp e ita d e d o e n ya h e p a to b ilia r e /o u p a n cre cltica . 0 e stu d o in tra -o p e ra to rio fo i re a liza d o co m a p a re lh o p o rta til (A lo ka 5 0 0 , Ja p a o ), u tiliza n d o -se tra n sd u to re s lin e a re s e ste re is d e 5 .0 M H z e 7 .5 M H z. A s p rin cip a is in d ica yo e s d a u ltra -so n o g ra fia in tra -o p e ra to ria fo ra m : a va lia r m a ssa s h e p a tica s p rim a ria s, a b sce sso s h e p a tico s, icte rfcia o b stru tiva , p e sq u isa d e m e ta sta se s h e p a tica s e p e sq u isa d e tu m o r n e u ro e n d o crin o . E m 1 5 ca so s (3 8 ,5 % ) d o g ru p o h e p a to b ilia r e e m se te ca so s (5 8 ,3 % ) d o g ru p o p a n cre a tico h o u ve d ive rg e n cia e n tre o s a ch a d o s p re e in tra -o p e ra to rio s. A p rin cip a l d ive rg e n cia fo i q u a n to a o n u m e ro e d im e n sa o d a s le so e s h e p a tica s e p a n cre a tica s. A u ltra -so n o g ra fia in tra -o p e ra to ria p e rm itiu e sta b e le ce r re la yo e s a n a to m ica s d a le sa o co m e stru tu ra s va scu la re s. E ste m e to d o d e e xa m e ta m b e m fo i u tiliza d o p a ra g u ia r p ro ce d im e n to s in te rve n cio n ista s co m o b io p sia e a lco o liza ya o d e n o d u lo s e d re n a g e m d e a b sce sso s. C o n clu i-se q u e a u ltra -so n o g ra fia in tra -o p e ra t-o ria te m p a p e l im p -o rta n te n a d e te cya -o d e p e q u e n -o s n -o d u l-o s h e p a tic-o s e p a n cre a tic-o s, n -o e sta b e le cim e n t-o d e re la c;o e s a n a to m ica s d e le so e s co m e stru tu ra s va scu la re s e n a re a liza c;a o d e p ro ce d im e n to s in te rve n cio n ista s.REFERENCES
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