title: Potential value of contrast-enhanced intraoperative ultrasonography during partial hepatectomy for metastases: an essential investigation before resection?
abstract: OBJECTIVE
  The aim of the study was to assess the clinical value of contrast-enhanced intraoperative ultrasound (CE-IOUS) as a novel tool in the hepatic staging of patients undergoing liver resection.
  
  
  METHODS
  Sixty patients scheduled to undergo liver resection for metastatic disease were studied. Preoperative staging with contrast-enhanced CT and/or MR scans was performed within 2 to 6 weeks of operation. Following exploration, intraoperative ultrasound (IOUS) was performed using an HDI-5000 scanner (Philips) and a finger-probe with pulse inversion harmonic (PIH) capability. CE-IOUS in the PIH mode was performed in a standardized protocol (low MI: 0.02-0.04) after intravenous injection of 3-4 mL of SonoVue (Bracco spa, Milan); all detected lesions on precontrast and postcontrast scans were counted and mapped. Any alteration in surgical management was documented following CE-IOUS compared with IOUS.
  
  
  RESULTS
  Three patients were excluded due to disseminated disease on exploration. CE-IOUS was significantly more sensitive than CT/MR and IOUS in detecting liver metastases (96.1% versus 76.7% and 81.5%, respectively) (P<0.05); it altered surgical management in 29.8% (17 of 57) of cases, due to 1) additional metastases in 19.3% (11 of 57), 2) less metastases in 3.5% (2 of 57), 3) benign lesions wrongly diagnosed as metastasis on IOUS/CT in 5.3% (3 of 57), and 4) vascular proximity in 1.8% (1 of 57). Management was unchanged in 70.2% (40 of 57) despite additional lesions detected in 3.5% (2 of 57) and benign lesion wrongly diagnosed on IOUS and CT as metastasis in 1.8% (1 of 57). CE-IOUS altered combined IOUS/CT/MR staging in 35.1%.
  
  
  CONCLUSIONS
  These preliminary results suggest CE-IOUS is an essential tool prior to liver resection for metastases.
authors.affiliation: Department of Surgery, Alexandra Parade, Royal Infirmary, Glasgow, UK. gpda01@udcf.gla.ac.uk
authors.forename: Edward
authors.initials: E
authors.lastname: Leen
authors.forename: Piercarlo
authors.initials: P
authors.lastname: Ceccotti
authors.forename: Susan J
authors.initials: SJ
authors.lastname: Moug
authors.forename: Paul
authors.initials: P
authors.lastname: Glen
authors.forename: John
authors.initials: J
authors.lastname: MacQuarrie
authors.forename: Wilson J
authors.initials: WJ
authors.lastname: Angerson
authors.forename: Thomas
authors.initials: T
authors.lastname: Albrecht
authors.forename: Joachim
authors.initials: J
authors.lastname: Hohmann
authors.forename: Anja
authors.initials: A
authors.lastname: Oldenburg
authors.forename: Jorg Peter
authors.initials: JP
authors.lastname: Ritz
authors.forename: Paul G
authors.initials: PG
authors.lastname: Horgan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003287:Contrast Media; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008113:Liver Neoplasms / Q000000981:diagnostic imaging* / Q000556:secondary / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D009362:Neoplasm Metastasis / Q000000981:diagnostic imaging*; D009367:Neoplasm Staging / Q000379:methods*; D010743:Phospholipids; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D018709:Statistics, Nonparametric; D013459:Sulfur Hexafluoride; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D003287:Contrast Media; D010743:Phospholipids; C420843:contrast agent BR1; D013459:Sulfur Hexafluoride