Value of intraoperative ultrasound with conventional probes and its usefulness in surgical and therapeutic management of patients

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Novo Amado, M. Fraga Sánchez, J. González Ramírez, G. Calvo Arrojo, C. Vidal Cameán, J.M. Crespo Teijeiro" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A.M." "apellidos" => "Novo Amado" "email" => array:1 [ 0 => "albanovo.amado@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Fraga Sánchez" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "González Ramírez" ] 3 => array:2 [ "nombre" => "G." "apellidos" => "Calvo Arrojo" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Vidal Cameán" ] 5 => array:2 [ "nombre" => "J.M." "apellidos" => "Crespo Teijeiro" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Lucus Augusti, Lugo, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valor de la ecografía intraoperatoria realizada con sondas convencionales y su utilidad en el manejo quirúrgico y terapéutico de los pacientes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2234 "Ancho" => 1645 "Tamanyo" => 114108 ] ] "descripcion" => array:1 [ "en" => "Bar graph showing the matches between the intraoperative ultrasound scan and the histological findings, and pie chart showing the matches between the intraoperative ultrasound scan and the preoperative imaging modalities." ] ] ] "textoCompleto" => "IntroductionThe intraoperative ultrasonography (IOUS) is a dynamic imaging modality that provides real time accurate information while performing surgical procedures.<a class="elsevierStyleCrossRefs" href="#bib0100">1,2</a>Although when it was first introduced it was only limited to the study of the liver and the bile duct,<a class="elsevierStyleCrossRefs" href="#bib0100">1,3</a> it has progressively found more indications and today it is used in the study of any solid organs.<a class="elsevierStyleCrossRef" href="#bib0115">4</a> It provides valuable information that even some times changes the therapeutic attitude to be followed with the patients.<a class="elsevierStyleCrossRefs" href="#bib0100">1,2</a>It is no different from conventional ultrasound scans except for the fact that the probe is in direct contact with the surface of the organ we wish to study, which allows us to avoid the usual artifacts occurring in conventional studies.<a class="elsevierStyleCrossRef" href="#bib0100">1</a> So it is a rather easy imaging modality to use, although it requires a wide knowledge of the anatomy of the organ studied and special aseptic measures before performing any surgical procedures.<a class="elsevierStyleCrossRef" href="#bib0115">4</a>Although there are probes specifically designed for this type of exploration,<a class="elsevierStyleCrossRefs" href="#bib0100">1,4,5</a> the IOUS scan may be performed using conventional units with covers for the probe and the device in order to guarantee the necessary asepsis, like we do in our center.This procedure requires certain technical complexities and adequate planning so that the radiologist does not waste his/her time in the operating room and nothing interferes with his/her normal activity. To this end we need to know at what time during the surgery should the radiologist intervene and how much time will the radiologist put into planning and reviewing the patient's clinical history and all prior imaging modalities.<a class="elsevierStyleCrossRef" href="#bib0115">4</a>Since it is widely used in the study of different organs, we decided to show both the effectiveness and the applications of IOUS scans in the surgical and therapeutic management of different conditions.Material and methodsWe retrospectively reviewed 135 consecutive patients who underwent IOUS scans from January 2011 through June 2016.Due to the retrospective nature of our work, we did not need the approval from the ethics committee. The necessary data were gathered by reviewing digitalized clinical histories.The IOUS scans were performed in patients eligible for surgery with curative intent without contraindications for the intervention, and with the following indications:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Characterization of lesions of undetermined significance due to mismatches among different preoperative imaging modalities (lesions non accessible to percutaneous biopsies).</li><li class="elsevierStyleListItem" id="lsti0010">•Identification of small sized-lesions that may be misdiagnosed using conventional imaging modalities.</li><li class="elsevierStyleListItem" id="lsti0015">•Anatomical location and determination of loco-regional or vascular invasions.</li><li class="elsevierStyleListItem" id="lsti0020">•Guidelines for the management of diagnostic (biopsy) or therapeutic (radiofrequency ablation) procedures.</li></ul>Our center is a clinical hospital with 850 beds and 21 operating rooms where we perform around 13,500interventions/year. In all cases, the unit that ordered the IOUS scan was the General Surgery Unit.The patients’ only inclusion criterion was having had one IOUS scan performed within the selected time interval. All IOUS scans were performed by one radiologist with over 10 years of experience doing conventional ultrasound scans with the Logiq7 Pro unit (GE Healthcare, Chicago, USA). Most IOUS scans were performed using one 3.5MHz convex probe (141 cases), and a minority of cases using one 10MHz linear probe (4 cases).In order to guarantee sterile conditions while performing the IOUS scan, Ultracover plastic covers (Ecolab/Microtek Medical, Columbus, USA) were used for the ultrasound unit, the probe, and the power cable (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The IV contrast used to perform the IOUS scan was sulfur hexafluoride (Sonovue, Bracco, Milan, Italy) in the hepatic IOUS scans performed due to clinical suspicion of metastasis (81), or hemangioma (2) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The aspects assessed in each case were the anatomical region studied; the patients’ underlying conditions; the reasons behind the IOUS order; the preoperative imaging modalities; the role of the IOUS scan in the management of the patient; the histological findings, and the degree of match showed by the IOUS with respect to these and other preoperative test findings.The final diagnosis was established through the histological analysis of the surgical pieces in the resection of intraoperative biopsies.ResultsAnatomical region studiedThe hepatic ultrasound scan was the most widely used study with 133 explorations, which amounts to 91.7 per cent of all ultrasound scans performed, followed, in order of frequency, by pancreatic (n=4), and thoracic ultrasound scans (n=3), with 2.7 per cent and 1.3 per cent, respectively, of all ultrasound scans performed. “Other ultrasound scans” were excluded because they were performed in one (1) case only such as the ultrasound scans performed in the axillary, pelvic, occipital, parotid, and thyroid regions, and a combination of hepatic and pancreatic ultrasound scans (4 per cent of the total).The explorations of superficial organs such as the parotid gland, or the thyroid gland were ordered by surgeons after a series of technical difficulties during the surgery (location of the lesion or approach used).Underlying conditionsThe patients’ underlying conditions are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Reasons behind the intraoperative ultrasound scans orderEight (8) categories were used as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Preoperative imaging modalitiesAll patients had, at least, one prior imaging modality before the surgery. Fifty-seven (57) per cent had undergone prior computed tomography (CT) scans, and magnetic resonance imaging (MRI), and 21 per cent, CT scans only. Thirteen (13) per cent of the patients underwent not only CT scans, and MRIs but also one (1) ultrasound scan prior to the surgery. Five (5) per cent underwent CT scans and ultrasound scans, or ultrasound scans only, and 4 per cent underwent MRIs, or MRIs plus ultrasound scans.Role of the intraoperative ultrasound scan in the management of the patientIn order to assess what the role of the IOUS scans in the management of the patient, all cases were grouped into three (3) categories:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">•In 12 per cent of the patients (n=18) the role of the IOUS scan was merely diagnostic. In these cases no surgery with curative intent was performed, since the results were conclusive of benign lesion (10 cases), or a diagnosis of malignant lesion (8 cases) was achieved, which made these patients non eligible for surgical resection.</li><li class="elsevierStyleListItem" id="lsti0030">•In 7.5 per cent of the patients (n=11) the IOUS scan diagnosed a malignant lesion with invasion of adjacent structures, which made them unresectable, which is why the lesions were biopsized.</li><li class="elsevierStyleListItem" id="lsti0035">•In 80 per cent of the patients (n=116) the IOUS scan confirmed the diagnosis, found the lesion within the organ, and ruled out the presence of other lesions, which is why they decided to go on with the surgery with curative intent.</li></ul>HistologyIn all those cases where a tissue sample was obtained following resection or biopsy of the lesion (n=130), the histological findings were:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040">•In 107 cases (82.4 per cent) the results confirmed neoplastic origin, out of which 88 were metastases, and 19 were primary tumors.</li><li class="elsevierStyleListItem" id="lsti0045">•In 11 cases (8.4 per cent) the condition was not neoplastic: four (4) hemangiomas; three (3) abscesses; two (2) hydatid cysts; one (1) complicated hepatic cyst; and one (1) case of chronic pancreatitis.</li><li class="elsevierStyleListItem" id="lsti0050">•In 10 cases (7.7 per cent) the histological findings were normal and no precise diagnosis was achieved, although malignancy was ruled out.</li><li class="elsevierStyleListItem" id="lsti0055">•In 1.5 per cent of the cases (two patients) the results were unspecific. The results showed presence of fibrosis; necrosis; vascular thrombosis; and calcifications, but here malignancy could not be ruled out.</li></ul>In 15 cases no histological sample was obtained for several reasons, whether because there was a prior histological diagnosis, because they looked like typically benign lesions in the IOUS scans (hemangiomas), because radiofrequency ablations were performed, or because the patient died during the intervention.MatchThe findings from the IOUS scan matched the histological findings in 124 cases (95.4 per cent), but did not match them in 6 cases (4.6 per cent) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). When it comes to these 6 cases we should bear in mind that:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0060">•In four (4) cases the treatment responses of hepatic metastasis was assessed, and also in three (3) patients with underlying colon carcinoma, and in one (1) patient with cholangiocarcinoma, for which they had received prior chemotherapy. In all of them, the histological findings did not match the findings from the IOUS scans, and in suspicious cases of lesion, the histological findings were normal–one (1) unspecific finding, and one (1) metastasis undetected by the IOUS scan.</li><li class="elsevierStyleListItem" id="lsti0065">•In the case of one (1) patient with suspicion of hepatic metastasis of vesicular carcinoma, the IOUS scan confirmed the lesion, but the histological findings said the tissue looked normal.</li><li class="elsevierStyleListItem" id="lsti0070">•In one (1) suspicious case of hepatocarcinoma according to the IOUS scan, the histological findings gave unspecific results.</li></ul><elsevierMultimedia ident="fig0015"></elsevierMultimedia>In 111 cases (76 per cent), the diagnoses achieved by the IOUS scan matched the suspicious preoperative imaging modalities, but in 34 cases (24 per cent) they did not, which was decisive for the management of the patient, since it completely changed the therapeutic attitude toward such patient.<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075">•In 16 cases, the diagnoses achieved by the IOUS scan indicated resection of the lesion and preoperative unsuspected tumor lesion.</li><li class="elsevierStyleListItem" id="lsti0080">•In 3 cases, the diagnoses achieved by the IOUS scan indicated presence of hemangiomas in oncological patients with suspicion of metastasis, which is why they did not require resection.</li><li class="elsevierStyleListItem" id="lsti0085">•In 15 cases, the diagnoses achieved by the IOUS scan confirmed presence of unresectable lesion given the disease had spread.</li></ul>DiscussionThe hepatic ultrasound scan is still the main application of all IOUS scans (91.7 per cent in our series). One of its main utilities is to confirm the absence or presence of liver disease in patients who are eligible for surgery with curative intent in whom metastasectomy procedures are intended; also it is useful to assess the hepatic segments that will remain untouched during the surgery.<a class="elsevierStyleCrossRef" href="#bib0120">5</a>Although the future of surgery is minimally invasive surgery and there are different devices available that allow us to perform laparoscopic IOUS scans,<a class="elsevierStyleCrossRef" href="#bib0125">6</a> most centers do not have access to them because of the costs, but they can be performed using conventional units as long as all the necessary asepsic measures are observed, and by trained personnel.The use of contrast-enhanced ultrasound scans allows us to continuously assess the organ vascularization, and detect small-sized lesions.<a class="elsevierStyleCrossRefs" href="#bib0130">7–11</a> The contrast can be used pre or perioperatively, helps characterize the lesions, puts them into context with other neighboring vascular structures, and rules out invasion.<a class="elsevierStyleCrossRefs" href="#bib0155">12–15</a> In our series, ultrasound contrast agents were used in patients with suspicion of hemangioma or metastasis because all of them already had an indication for the intervention of the primary tumor and, since there were mismatches among the different preoperative imaging modalities, these contrast agents were ordered to see if resection was or not indicated.The preoperative use of the new chemotherapy agents available has turned unresectable metastases into resectable ones. However, their use causes alterations of the hepatic parenchyma such as sinusoidal congestion, and steatohepatitis, which complicates the assessment of the parenchyma through imaging modalities.<a class="elsevierStyleCrossRef" href="#bib0165">14</a> This is why, in these patients, the IOUS scans are especially useful, allowing us to detect a greater number of metastases (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>During the last few years, the IOUS applications have grown and IOUS scans are used in more and more organs for the identification of atypical lesions that need surgical therapy<a class="elsevierStyleCrossRefs" href="#bib0110">3,4</a>; in our center we have also been using IOUS scans for quite a while because of their availability, their cost-effectiveness, and because they do not involve ionizing radiation, which means that they are harmless both for the patient and the radiology team.<a class="elsevierStyleCrossRefs" href="#bib0100">1–4</a>Even in some studies published, IOUS scans have altered scheduled surgical acts in 5–28 per cent of the cases.<a class="elsevierStyleCrossRefs" href="#bib0165">14–19</a> In our study, these changes affected 24 per cent of the cases, meaning that the IOUS findings changed the ways of the therapeutic attitude.However, the IOUS findings should not be taken in isolation, but together with all the information available (preoperative tests; explorations; and surgical palpations) for better results.This work has some limitations given its retrospective nature, and its small, unselected and not very representative sample of the population.In sum, the IOUS scan performed using conventional probes has proven to have a positive effect in the management of patients, in the surgical planning, and in the clinical outcomes. IOUS scans help us establish the right diagnosis of noncharacterizable lesions using preoperative imaging modalities, locate and outline the extent of a lesion within a given organ, and ultimately facilitate the performance of intraoperative procedures, including centers that do not have specific probes for this purpose.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this investigation.Confidentiality of dataThe authors declare that no patient data appears in this article.Right to privacy and informed consentThe authors declare that no patient data appear in this article.FinancingAll authors confirm that they have received no funding while conducting this paper.Authors<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0090">1.Manager of the integrity of the study: ANA and JGR.</li><li class="elsevierStyleListItem" id="lsti0095">2.Study idea: ANA and JGR.</li><li class="elsevierStyleListItem" id="lsti0100">3.Study design: ANA, JGR and MFS.</li><li class="elsevierStyleListItem" id="lsti0105">4.Data mining: ANA, MFS, GCA and CVC.</li><li class="elsevierStyleListItem" id="lsti0110">5.Data analysis and interpretation: ANA, JGR, MFS, GCA, CVC and JMCT.</li><li class="elsevierStyleListItem" id="lsti0115">6.Statistical analysis: ANA, JGR and MFS.</li><li class="elsevierStyleListItem" id="lsti0120">7.Reference: ANA, MFS, GCA, CVC and JMCT.</li><li class="elsevierStyleListItem" id="lsti0125">8.Writing: ANA, JGR, MFS and JMCT.</li><li class="elsevierStyleListItem" id="lsti0130">9.Critical review of the manuscript with intellectually relevant remarks: ANA, JGR, MFS, GCA, CVC and JMCT.</li><li class="elsevierStyleListItem" id="lsti0135">10.Approval of final version: ANA, JGR, MFS, GCA, CVC and JMCT.</li></ul>Conflict of interestsThe authors declare no conflict of interests associated with this article whatsoever." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres942188" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec915112" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres942189" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec915113" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Anatomical region studied" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Underlying conditions" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Reasons behind the intraoperative ultrasound scans order" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Preoperative imaging modalities" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Role of the intraoperative ultrasound scan in the management of the patient" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Histology" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Match" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0075" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Financing" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Authors" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-29" "fechaAceptado" => "2017-06-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec915112" "palabras" => array:3 [ 0 => "Ultrasound" 1 => "Intraoperative ultrasound" 2 => "Diagnostic accuracy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec915113" "palabras" => array:3 [ 0 => "Ecografía" 1 => "Ecografía intraoperatoria" 2 => "Utilidad diagnóstica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo prove both the reliability and the applications presented by intraoperative ultrasonography (IOUS) in surgical and therapeutic management of diverse pathologies and the possibility of doing it by using conventional equipment. Material and methodsSingle-center retrospective study of 145 IOUS performed by using conventional equipment in 135 patients between January 2011 and June 2016. We assessed the organs studied by ultrasound, underlying conditions of patients, preoperative imaging and the degree of matching them with the histological findings. The functions of the intraoperative ultrasound were assessed in each case. Results91.7 per cent of the scans performed were hepatic, being other locations varied but less common. They had a high concordance with the histological results of the lesions analyzed (95.4 per cent) and in 24 per cent of the cases their results did not coincide with those of the preoperative imaging tests, being decisive for the management of the patients. ConclusionDespite the limitations of our study, IOUS has proven to be a reliable and safe diagnostic test with advantages over conventional imaging techniques. It contributes to get a correct diagnosis in those lesions not characterized by the preoperative imaging tests, to locate and delimit the extension of a lesion within an organ and facilitate the performance of diagnostic procedures (intraoperative biopsy) even in centers where we do not have specific probes." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoDemostrar la fiabilidad y las aplicaciones que presenta la ecografía intraoperatoria (EIO) en el manejo quirúrgico y terapéutico de diversas patologías, así como la posibilidad de utilización de equipos convencionales para su realización. Material y métodosEstudio retrospectivo unicéntrico de 145 EIO realizadas con equipos convencionales a 135 pacientes entre enero de 2011 y junio de 2016. Se valoraron los órganos estudiados mediante EIO, las enfermedades de base de los pacientes y las pruebas de imagen preoperatorias, y se analizó el grado de concordancia de la EIO con las mismas y con los resultados histológicos en los casos en que se obtuvo muestra de tejido, así como las funciones que desempeñó la EIO en el tratamiento de los pacientes. ResultadosEl 91,7% de las ecografías realizadas fueron hepáticas, siendo otras localizaciones variadas menos frecuentes. Estas presentaron una alta concordancia con los resultados histológicos de las lesiones analizadas (95,4%), y en el 24% de los casos sus resultados no coincidieron con los de las pruebas de imagen preoperatorias, siendo determinantes para el tratamiento de los pacientes. ConclusiónA pesar de las limitaciones de nuestro estudio, la EIO ha demostrado ser una prueba fiable con ventajas frente a las pruebas de imagen convencionales. Ayuda a llegar a un diagnóstico en aquellas lesiones no caracterizables mediante las pruebas de imagen preoperatorias, a localizar y delimitar la extensión de una lesión dentro de un órgano, y facilita la realización de procedimientos diagnósticos (biopsia intraoperatoria) incluso en centros donde no se dispone de sondas específicas." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Novo Amado AM, Fraga Sánchez M, González Ramírez J, Calvo Arrojo G, Vidal Cameán C, Crespo Teijeiro JM. Valor de la ecografía intraoperatoria realizada con sondas convencionales y su utilidad en el manejo quirúrgico y terapéutico de los pacientes. Radiología. 2017;59:516–522." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 865 "Ancho" => 1500 "Tamanyo" => 216704 ] ] "descripcion" => array:1 [ "en" => "Placing of sterile covers on the conventional ultrasound unit used. Unit and probe with the sterile covers ready to go. Radiologist performing an intraoperative ultrasound scan in the operating room." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1125 "Ancho" => 1500 "Tamanyo" => 181928 ] ] "descripcion" => array:1 [ "en" => "Typical behavior of hypovasular hepatic metastasis. Basal intraoperative ultrasound scan and after the administration of a contrast enhancement agent. Hepatic focal lesion in the transition of segments IVa and VIII that happens to be a hypoechoic and hypo-uptake lesion with respect to the remaining hepatic parenchyma after the administration of contrast." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2234 "Ancho" => 1645 "Tamanyo" => 114108 ] ] "descripcion" => array:1 [ "en" => "Bar graph showing the matches between the intraoperative ultrasound scan and the histological findings, and pie chart showing the matches between the intraoperative ultrasound scan and the preoperative imaging modalities." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1255 "Ancho" => 1400 "Tamanyo" => 171415 ] ] "descripcion" => array:1 [ "en" => "Patient with sigma tumor (left upper computed tomography – CT scan, arrowhead) who received neoadjuvant treatment with chemotherapy, and whose preoperative study confirms presence of hepatic steatosis (right upper CT scan) without any evidence of focal lesions suggestive of metastasis. The patient is candidate to surgery with curative intent (sigmoidectomy procedure), and during surgery the surgeon performs hepatic palpation finding suspicious nodularities. One intraoperative ultrasound scan (below) is urgently ordered that confirms the presence of one hepatic, focal lesion that is later biopsized and confirm the presence of adenocarcinoma metastasis." ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Underlying conditions \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of cases \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Tumors (92 per cent)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Colorectal cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Hepatobiliary carcinomas</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatocarcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vesicle cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cholangiocarcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neuroendocrine cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pancreatic cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breast cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Infections (5 per cent)</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Abscesses</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Occipital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hydatid cysts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complicated hepatic cyst \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Chronic inflammation (3 per cent)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic hepatopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic cholecystitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic pancreatitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1594689.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "The subcategory “Other Neoplasms” includes thyroid cancer; parotid gland cancer; uterine cancer; ovary cancer; renal cancer; melanomas; and sarcomas, because there was one (1) case of each only." ] ] ] "descripcion" => array:1 [ "en" => "Underlying conditions of patients who underwent intraoperative scans grouped into three (3) different categories." ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reason for ordering IOUS scans \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of cases \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of hepatic metastasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Assessment of the response to therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of malignant lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of benign lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; 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Valor de la ecografía intraoperatoria realizada con sondas convencionales y su utilidad en el manejo quirúrgico y terapéutico de los pacientes

A.M. Novo Amado

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albanovo.amado@gmail.com

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, M. Fraga Sánchez, J. González Ramírez, G. Calvo Arrojo, C. Vidal Cameán, J.M. Crespo Teijeiro

Servicio de Radiodiagnóstico, Hospital Universitario Lucus Augusti, Lugo, Spain

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which allows us to avoid the usual artifacts occurring in conventional studies&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> So it is a rather easy imaging modality to use&#44; although it requires a wide knowledge of the anatomy of the organ studied and special aseptic measures before performing any surgical procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although there are probes specifically designed for this type of exploration&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> the IOUS scan may be performed using conventional units with covers for the probe and the device in order to guarantee the necessary asepsis&#44; like we do in our center&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This procedure requires certain technical complexities and adequate planning so that the radiologist does not waste his&#47;her time in the operating room and nothing interferes with his&#47;her normal activity&#46; To this end we need to know at what time during the surgery should the radiologist intervene and how much time will the radiologist put into planning and reviewing the patient&#39;s clinical history and all prior imaging modalities&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Since it is widely used in the study of different organs&#44; we decided to show both the effectiveness and the applications of IOUS scans in the surgical and therapeutic management of different conditions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We retrospectively reviewed 135 consecutive patients who underwent IOUS scans from January 2011 through June 2016&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Due to the retrospective nature of our work&#44; 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Ultracover plastic covers &#40;Ecolab&#47;Microtek Medical&#44; Columbus&#44; USA&#41; were used for the ultrasound unit&#44; the probe&#44; and the power cable &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The IV contrast used to perform the IOUS scan was sulfur hexafluoride &#40;Sonovue&#44; Bracco&#44; Milan&#44; Italy&#41; in the hepatic IOUS scans performed due to clinical suspicion of metastasis &#40;81&#41;&#44; or hemangioma &#40;2&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The aspects assessed in each case were the anatomical region studied&#59; the patients&#8217; underlying conditions&#59; the reasons behind the IOUS order&#59; the preoperative imaging modalities&#59; the role of the IOUS scan in the management of the patient&#59; the histological findings&#44; and the degree of match showed by the IOUS with respect to these and other preoperative test findings&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The final diagnosis was established through the histological analysis of the surgical pieces in the resection of intraoperative biopsies&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Anatomical region studied</span><p id="par0105" class="elsevierStylePara elsevierViewall">The hepatic ultrasound scan was the most widely used study with 133 explorations&#44; which amounts to 91&#46;7 per cent of all ultrasound scans performed&#44; followed&#44; in order of frequency&#44; by pancreatic &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; and thoracic ultrasound scans &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#44; with 2&#46;7 per cent and 1&#46;3 per cent&#44; respectively&#44; of all ultrasound scans performed&#46; &#8220;Other ultrasound scans&#8221; were excluded because they were performed in one &#40;1&#41; case only such as the ultrasound scans performed in the axillary&#44; pelvic&#44; occipital&#44; parotid&#44; and thyroid regions&#44; and a combination of hepatic and pancreatic ultrasound scans &#40;4 per cent of the total&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The explorations of superficial organs such as the parotid gland&#44; or the thyroid gland were ordered by surgeons after a series of technical difficulties during the surgery &#40;location of the lesion or approach used&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Underlying conditions</span><p id="par0120" class="elsevierStylePara elsevierViewall">The patients&#8217; underlying conditions are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Reasons behind the intraoperative ultrasound scans order</span><p id="par0125" class="elsevierStylePara elsevierViewall">Eight &#40;8&#41; categories were used as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Preoperative imaging modalities</span><p id="par0130" class="elsevierStylePara elsevierViewall">All patients had&#44; at least&#44; one prior imaging modality before the surgery&#46; Fifty-seven &#40;57&#41; per cent had undergone prior computed tomography &#40;CT&#41; scans&#44; and magnetic resonance imaging &#40;MRI&#41;&#44; and 21 per cent&#44; CT scans only&#46; Thirteen &#40;13&#41; per cent of the patients underwent not only CT scans&#44; and MRIs but also one &#40;1&#41; ultrasound scan prior to the surgery&#46; Five &#40;5&#41; per cent underwent CT scans and ultrasound scans&#44; or ultrasound scans only&#44; and 4 per cent underwent MRIs&#44; or MRIs plus ultrasound scans&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Role of the intraoperative ultrasound scan in the management of the patient</span><p id="par0135" class="elsevierStylePara elsevierViewall">In order to assess what the role of the IOUS scans in the management of the patient&#44; all cases were grouped into three &#40;3&#41; categories&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">In 12 per cent of the patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#41; the role of the IOUS scan was merely diagnostic&#46; In these cases no surgery with curative intent was performed&#44; since the results were conclusive of benign lesion &#40;10 cases&#41;&#44; or a diagnosis of malignant lesion &#40;8 cases&#41; was achieved&#44; which made these patients non eligible for surgical resection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">In 7&#46;5 per cent of the patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41; the IOUS scan diagnosed a malignant lesion with invasion of adjacent structures&#44; which made them unresectable&#44; which is why the lesions were biopsized&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">In 80 per cent of the patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>116&#41; the IOUS scan confirmed the diagnosis&#44; found the lesion within the organ&#44; and ruled out the presence of other lesions&#44; which is why they decided to go on with the surgery with curative intent&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Histology</span><p id="par0155" class="elsevierStylePara elsevierViewall">In all those cases where a tissue sample was obtained following resection or biopsy of the lesion &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>130&#41;&#44; the histological findings were&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">In 107 cases &#40;82&#46;4 per cent&#41; the results confirmed neoplastic origin&#44; out of which 88 were metastases&#44; and 19 were primary tumors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">In 11 cases &#40;8&#46;4 per cent&#41; the condition was not neoplastic&#58; four &#40;4&#41; hemangiomas&#59; three &#40;3&#41; abscesses&#59; two &#40;2&#41; hydatid cysts&#59; one &#40;1&#41; complicated hepatic cyst&#59; and one &#40;1&#41; case of chronic pancreatitis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">In 10 cases &#40;7&#46;7 per cent&#41; the histological findings were normal and no precise diagnosis was achieved&#44; although malignancy was ruled out&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">In 1&#46;5 per cent of the cases &#40;two patients&#41; the results were unspecific&#46; The results showed presence of fibrosis&#59; necrosis&#59; vascular thrombosis&#59; and calcifications&#44; but here malignancy could not be ruled out&#46;</p></li></ul></p><p id="par0180" class="elsevierStylePara elsevierViewall">In 15 cases no histological sample was obtained for several reasons&#44; whether because there was a prior histological diagnosis&#44; because they looked like typically benign lesions in the IOUS scans &#40;hemangiomas&#41;&#44; because radiofrequency ablations were performed&#44; or because the patient died during the intervention&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Match</span><p id="par0185" class="elsevierStylePara elsevierViewall">The findings from the IOUS scan matched the histological findings in 124 cases &#40;95&#46;4 per cent&#41;&#44; but did not match them in 6 cases &#40;4&#46;6 per cent&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; When it comes to these 6 cases we should bear in mind that&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">In four &#40;4&#41; cases the treatment responses of hepatic metastasis was assessed&#44; and also in three &#40;3&#41; patients with underlying colon carcinoma&#44; and in one &#40;1&#41; patient with cholangiocarcinoma&#44; for which they had received prior chemotherapy&#46; In all of them&#44; the histological findings did not match the findings from the IOUS scans&#44; and in suspicious cases of lesion&#44; the histological findings were normal&#8211;one &#40;1&#41; unspecific finding&#44; and one &#40;1&#41; metastasis undetected by the IOUS scan&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">In the case of one &#40;1&#41; patient with suspicion of hepatic metastasis of vesicular carcinoma&#44; the IOUS scan confirmed the lesion&#44; but the histological findings said the tissue looked normal&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">In one &#40;1&#41; suspicious case of hepatocarcinoma according to the IOUS scan&#44; the histological findings gave unspecific results&#46;</p></li></ul></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">In 111 cases &#40;76 per cent&#41;&#44; the diagnoses achieved by the IOUS scan matched the suspicious preoperative imaging modalities&#44; but in 34 cases &#40;24 per cent&#41; they did not&#44; which was decisive for the management of the patient&#44; since it completely changed the therapeutic attitude toward such patient&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">In 16 cases&#44; the diagnoses achieved by the IOUS scan indicated resection of the lesion and preoperative unsuspected tumor lesion&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">In 3 cases&#44; the diagnoses achieved by the IOUS scan indicated presence of hemangiomas in oncological patients with suspicion of metastasis&#44; which is why they did not require resection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">In 15 cases&#44; the diagnoses achieved by the IOUS scan confirmed presence of unresectable lesion given the disease had spread&#46;</p></li></ul></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0225" class="elsevierStylePara elsevierViewall">The hepatic ultrasound scan is still the main application of all IOUS scans &#40;91&#46;7 per cent in our series&#41;&#46; One of its main utilities is to confirm the absence or presence of liver disease in patients who are eligible for surgery with curative intent in whom metastasectomy procedures are intended&#59; also it is useful to assess the hepatic segments that will remain untouched during the surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Although the future of surgery is minimally invasive surgery and there are different devices available that allow us to perform laparoscopic IOUS scans&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> most centers do not have access to them because of the costs&#44; but they can be performed using conventional units as long as all the necessary asepsic measures are observed&#44; and by trained personnel&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The use of contrast-enhanced ultrasound scans allows us to continuously assess the organ vascularization&#44; and detect small-sized lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7&#8211;11</span></a> The contrast can be used pre or perioperatively&#44; helps characterize the lesions&#44; puts them into context with other neighboring vascular structures&#44; and rules out invasion&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12&#8211;15</span></a> In our series&#44; ultrasound contrast agents were used in patients with suspicion of hemangioma or metastasis because all of them already had an indication for the intervention of the primary tumor and&#44; since there were mismatches among the different preoperative imaging modalities&#44; these contrast agents were ordered to see if resection was or not indicated&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The preoperative use of the new chemotherapy agents available has turned unresectable metastases into resectable ones&#46; However&#44; their use causes alterations of the hepatic parenchyma such as sinusoidal congestion&#44; and steatohepatitis&#44; which complicates the assessment of the parenchyma through imaging modalities&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> This is why&#44; in these patients&#44; the IOUS scans are especially useful&#44; allowing us to detect a greater number of metastases &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0255" class="elsevierStylePara elsevierViewall">During the last few years&#44; the IOUS applications have grown and IOUS scans are used in more and more organs for the identification of atypical lesions that need surgical therapy<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">3&#44;4</span></a>&#59; in our center we have also been using IOUS scans for quite a while because of their availability&#44; their cost-effectiveness&#44; and because they do not involve ionizing radiation&#44; which means that they are harmless both for the patient and the radiology team&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Even in some studies published&#44; IOUS scans have altered scheduled surgical acts in 5&#8211;28 per cent of the cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">14&#8211;19</span></a> In our study&#44; these changes affected 24 per cent of the cases&#44; meaning that the IOUS findings changed the ways of the therapeutic attitude&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">However&#44; the IOUS findings should not be taken in isolation&#44; but together with all the information available &#40;preoperative tests&#59; explorations&#59; and surgical palpations&#41; for better results&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">This work has some limitations given its retrospective nature&#44; and its small&#44; unselected and not very representative sample of the population&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">In sum&#44; the IOUS scan performed using conventional probes has proven to have a positive effect in the management of patients&#44; in the surgical planning&#44; and in the clinical outcomes&#46; IOUS scans help us establish the right diagnosis of noncharacterizable lesions using preoperative imaging modalities&#44; locate and outline the extent of a lesion within a given organ&#44; and ultimately facilitate the performance of intraoperative procedures&#44; including centers that do not have specific probes for this purpose&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical disclosures</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Protection of human and animal subjects</span><p id="par0355" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Confidentiality of data</span><p id="par0360" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Right to privacy and informed consent</span><p id="par0365" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Financing</span><p id="par0290" class="elsevierStylePara elsevierViewall">All authors confirm that they have received no funding while conducting this paper&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Authors</span><p id="par0295" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">1&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study&#58; ANA and JGR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">2&#46;</span><p id="par0305" class="elsevierStylePara elsevierViewall">Study idea&#58; ANA and JGR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">3&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Study design&#58; ANA&#44; JGR and MFS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">4&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Data mining&#58; ANA&#44; MFS&#44; GCA and <span class="elsevierStyleSmallCaps">C</span>V<span class="elsevierStyleSmallCaps">C</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">5&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; ANA&#44; JGR&#44; MFS&#44; GCA&#44; CVC and JMCT&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">6&#46;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; ANA&#44; JGR and MFS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">7&#46;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Reference&#58; ANA&#44; MFS&#44; GCA&#44; CVC and JMCT&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">8&#46;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Writing&#58; ANA&#44; JGR&#44; MFS and JMCT&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">9&#46;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks&#58; ANA&#44; JGR&#44; MFS&#44; GCA&#44; CVC and JMCT&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">10&#46;</span><p id="par0345" class="elsevierStylePara elsevierViewall">Approval of final version&#58; ANA&#44; JGR&#44; MFS&#44; GCA&#44; CVC and JMCT&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interests</span><p id="par0350" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests associated with this article whatsoever&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To prove both the reliability and the applications presented by intraoperative ultrasonography &#40;IOUS&#41; in surgical and therapeutic management of diverse pathologies and the possibility of doing it by using conventional equipment&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Single-center retrospective study of 145 IOUS performed by using conventional equipment in 135 patients between January 2011 and June 2016&#46; We assessed the organs studied by ultrasound&#44; underlying conditions of patients&#44; preoperative imaging and the degree of matching them with the histological findings&#46; The functions of the intraoperative ultrasound were assessed in each case&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">91&#46;7 per cent of the scans performed were hepatic&#44; being other locations varied but less common&#46; They had a high concordance with the histological results of the lesions analyzed &#40;95&#46;4 per cent&#41; and in 24 per cent of the cases their results did not coincide with those of the preoperative imaging tests&#44; being decisive for the management of the patients&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Despite the limitations of our study&#44; IOUS has proven to be a reliable and safe diagnostic test with advantages over conventional imaging techniques&#46; It contributes to get a correct diagnosis in those lesions not characterized by the preoperative imaging tests&#44; to locate and delimit the extension of a lesion within an organ and facilitate the performance of diagnostic procedures &#40;intraoperative biopsy&#41; even in centers where we do not have specific probes&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Demostrar la fiabilidad y las aplicaciones que presenta la ecograf&#237;a intraoperatoria &#40;EIO&#41; en el manejo quir&#250;rgico y terap&#233;utico de diversas patolog&#237;as&#44; as&#237; como la posibilidad de utilizaci&#243;n de equipos convencionales para su realizaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo unic&#233;ntrico de 145 EIO realizadas con equipos convencionales a 135 pacientes entre enero de 2011 y junio de 2016&#46; Se valoraron los &#243;rganos estudiados mediante EIO&#44; las enfermedades de base de los pacientes y las pruebas de imagen preoperatorias&#44; y se analiz&#243; el grado de concordancia de la EIO con las mismas y con los resultados histol&#243;gicos en los casos en que se obtuvo muestra de tejido&#44; as&#237; como las funciones que desempe&#241;&#243; la EIO en el tratamiento de los pacientes&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El 91&#44;7&#37; de las ecograf&#237;as realizadas fueron hep&#225;ticas&#44; siendo otras localizaciones variadas menos frecuentes&#46; Estas presentaron una alta concordancia con los resultados histol&#243;gicos de las lesiones analizadas &#40;95&#44;4&#37;&#41;&#44; y en el 24&#37; de los casos sus resultados no coincidieron con los de las pruebas de imagen preoperatorias&#44; siendo determinantes para el tratamiento de los pacientes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A pesar de las limitaciones de nuestro estudio&#44; la EIO ha demostrado ser una prueba fiable con ventajas frente a las pruebas de imagen convencionales&#46; Ayuda a llegar a un diagn&#243;stico en aquellas lesiones no caracterizables mediante las pruebas de imagen preoperatorias&#44; a localizar y delimitar la extensi&#243;n de una lesi&#243;n dentro de un &#243;rgano&#44; y facilita la realizaci&#243;n de procedimientos diagn&#243;sticos &#40;biopsia intraoperatoria&#41; incluso en centros donde no se dispone de sondas espec&#237;ficas&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Novo Amado AM&#44; Fraga S&#225;nchez M&#44; Gonz&#225;lez Ram&#237;rez J&#44; Calvo Arrojo G&#44; Vidal Came&#225;n C&#44; Crespo Teijeiro JM&#46; Valor de la ecograf&#237;a intraoperatoria realizada con sondas convencionales y su utilidad en el manejo quir&#250;rgico y terap&#233;utico de los pacientes&#46; Radiolog&#237;a&#46; 2017&#59;59&#58;516&#8211;522&#46;</p>"
      ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Placing of sterile covers on the conventional ultrasound unit used&#46; Unit and probe with the sterile covers ready to go&#46; Radiologist performing an intraoperative ultrasound scan in the operating room&#46;</p>"
        ]
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Typical behavior of hypovasular hepatic metastasis&#46; Basal intraoperative ultrasound scan and after the administration of a contrast enhancement agent&#46; Hepatic focal lesion in the transition of segments IVa and VIII that happens to be a hypoechoic and hypo-uptake lesion with respect to the remaining hepatic parenchyma after the administration of contrast&#46;</p>"
        ]
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        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Bar graph showing the matches between the intraoperative ultrasound scan and the histological findings&#44; and pie chart showing the matches between the intraoperative ultrasound scan and the preoperative imaging modalities&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient with sigma tumor &#40;left upper computed tomography &#8211; CT scan&#44; arrowhead&#41; who received neoadjuvant treatment with chemotherapy&#44; and whose preoperative study confirms presence of hepatic steatosis &#40;right upper CT scan&#41; without any evidence of focal lesions suggestive of metastasis&#46; The patient is candidate to surgery with curative intent &#40;sigmoidectomy procedure&#41;&#44; and during surgery the surgeon performs hepatic palpation finding suspicious nodularities&#46; One intraoperative ultrasound scan &#40;below&#41; is urgently ordered that confirms the presence of one hepatic&#44; focal lesion that is later biopsized and confirm the presence of adenocarcinoma metastasis&#46;</p>"
        ]
      ]
      4 => array:8 [
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        "etiqueta" => "Table 1"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Underlying conditions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Tumors &#40;92 per cent&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Colorectal cancer</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hepatobiliary carcinomas</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Hepatocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Vesicle cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cholangiocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neuroendocrine cancer</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pancreatic cancer</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Breast cancer</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Other</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Infections &#40;5 per cent&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Abscesses</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Hepatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Occipital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hydatid cysts</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Complicated hepatic cyst</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Chronic inflammation &#40;3 per cent&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chronic hepatopathy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chronic cholecystitis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chronic pancreatitis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The subcategory &#8220;Other Neoplasms&#8221; includes thyroid cancer&#59; parotid gland cancer&#59; uterine cancer&#59; ovary cancer&#59; renal cancer&#59; melanomas&#59; and sarcomas&#44; because there was one &#40;1&#41; case of each only&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Underlying conditions of patients who underwent intraoperative scans grouped into three &#40;3&#41; different categories&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 2"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reason for ordering IOUS scans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of hepatic metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Assessment of the response to therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of malignant lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of benign lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of relapse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of abscess&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of infiltration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">All those orders made less frequently to guide radiofrequency ablation procedures&#59; assess complications and suspicions of metastasis in other locations and confirm the absence of lesions were placed under the subcategory &#8220;Other&#8221;&#46;</p>"
            ]
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2017.10.002

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2018 January	2	0	2

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