Upper Gastrointestinal and Hepato-Pancreato-Biliary Section, Department of Surgery, Odense University Hospital, Odense, Denmark.
Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark.
BJS Open. 2021 Mar 5;5(2). doi: 10.1093/bjsopen/zraa008.
In congenital hyperinsulinism (CHI), preoperative prediction of the histological subtype (focal, diffuse, or atypical) relies on genetics and 6-[18F]fluoro-l-3,4-dihydroxyphenylalanine (18F-DOPA) PET-CT. The scan also guides the localization of a potential focal lesion along with perioperative frozen sections. Intraoperative decision-making is still challenging. This study aimed to describe the characteristics and potential clinical impact of intraoperative ultrasound imaging (IOUS) during CHI surgery.
This was a prospective, observational study undertaken at an expert centre over a 2-year interval. IOUS was performed blinded to preoperative diagnostic test results (genetics and 18F-DOPA PET-CT), followed by unblinding and continued IOUS during pancreatic resection. Characteristics and clinical impact were assessed using predefined criteria.
Eighteen consecutive, surgically treated patients with CHI, with a median age of 5.5 months, were included (focal 12, diffuse 3, atypical 3). Focal lesions presented as predominantly hypoechoic, oval lesions with demarcated or blurred margins. Patients with diffuse and atypical disease had varying echogenicity featuring stranding and non-shadowing hyperechoic foci in three of six, whereas these characteristics were absent from those with focal lesions. The blinded IOUS-based subclassification was correct in 17 of 18 patients; one diffuse lesion was misclassified as focal. IOUS had an impact on the surgical approach in most patients with focal lesions (9 of 12), and in those with diffuse (2 of 3) and atypical (2 of 3) disease when the resection site was close to the bile or pancreatic duct.
Uniform IOUS characteristics made all focal lesions identifiable. IOUS had a clinical impact in 13 of 18 patients by being a useful real-time supplementary modality in terms of localizing focal lesions, reducing the need for frozen sections, and preserving healthy tissue and delicate structures.
在先天性高胰岛素血症（CHI）中，术前预测组织学亚型（局灶性、弥漫性或非典型性）依赖于遗传学和 6-[18F]氟-L-3,4-二羟基苯丙氨酸（18F-DOPA）PET-CT。该扫描还可指导潜在局灶性病变的定位以及围手术期冷冻切片。术中决策仍然具有挑战性。本研究旨在描述 CHI 手术中术中超声成像（IOUS）的特点和潜在临床影响。
这是一项在专家中心进行的前瞻性观察性研究，时间跨度为 2 年。IOUS 是在盲法进行的，不参考术前诊断测试结果（遗传学和 18F-DOPA PET-CT），随后在胰腺切除术中进行解盲并继续进行 IOUS。使用预设标准评估特征和临床影响。
18 例连续接受手术治疗的 CHI 患者纳入本研究，中位年龄为 5.5 个月（范围 2-13 个月）（局灶性 12 例，弥漫性 3 例，非典型性 3 例）。局灶性病变表现为主要为低回声、椭圆形病变，边界清晰或模糊。弥漫性和非典型性疾病患者的回声强度不同，其中 6 例中有 3 例存在伴有非阴影状高回声灶的纤维状变，而局灶性病变中不存在这些特征。18 例患者中，有 17 例基于盲法 IOUS 的亚分类是正确的；1 例弥漫性病变被错误分类为局灶性病变。IOUS 对大多数局灶性病变患者（12 例中的 9 例）的手术方法有影响，对弥漫性病变（3 例中的 2 例）和非典型性病变（3 例中的 2 例）也有影响，当切除部位靠近胆管或胰管时。
所有局灶性病变均具有均匀的 IOUS 特征，因此均可识别。IOUS 在 18 例患者中有 13 例具有临床意义，作为一种有用的实时补充方式，可以定位局灶性病变，减少对冷冻切片的需求，并保留健康组织和精细结构。
