Current use of intraoperative ultrasound in modern liver surgery

Ultrasound plays an important role not only in preoperative diagnosis but also in intraoperative guidance for liver surgery.Intraoperative ultrasound(IOUS)has become an indispensable tool for modern liver surgeons,especially for minimally invasive surgeries,partially substituting for the surgeon’s hands.In fundamental mode,Doppler mode,contrast enhancement,elastography,and real-time virtual sonography,IOUS can provide additional real-time information regarding the intrahepatic anatomy,tumor site and characteristics,macrovascular invasion,resection margin,transection plane,perfusion and outflow of the remnant liver,and local ablation efficacy for both open and minimally invasive liver resections.Identification and localization of intrahepatic lesions and surrounding structures are crucial for performing liver resection,preserving the adjacent vital vascular and bile ducts,and sparing the functional liver parenchyma.Intraoperative ultrasound can provide critical information for intraoperative decision-making and navigation.Therefore,all liver surgeons must master IOUS techniques,and IOUS should be included in the training of modern liver surgeons.Further investigation of the potential benefits and advances in these techniques will increase the use of IOUS in modern liver surgeries worldwide.This study comprehensively reviews the current use of IOUS in modern liver surgeries.

Resection of Vaginal Septum in Obstructed Hemivagina and Ipsilateral Renal Anomaly: Utility of Three Dimensional Intraoperative Ultrasound

Background: Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare congenital condition of the female urogenital tract, presenting intraoperative challenges. We demonstrate the utility of three dimensional intraoperative ultrasound to better delineate anatomy and aid in optimal resection of the vaginal septum. Case: A 12-year-old female was referred to pediatric and adolescent gynecology for irregular periods and evaluation of her gynecologic organs. Imaging studies confirmed OHVIRA syndrome. She underwent uncomplicated vaginal septum resection, guided by three dimensional intraoperative ultrasound. Summary and Conclusion: Intraoperative ultrasound can better delineate challenging anatomy. We show that three dimensional intraoperative ultrasound offers significant advantages over traditional two dimensional ultrasound and is a supplement to MRI, which may be helpful in complex anatomical cases like OHVIRA syndrome.

Value of contrast-enhanced intraoperative ultrasound for cirrhotic patients with hepatocellular carcinoma:A report of 20 cases

AIM: To assess the clinical value of contrast-enhanced intraoperative ultrasound (CE-IOUS) as a novel tool in partial hepatectomy for cirrhotic patients with hepatocellular carcinoma (HCC). METHODS: From January 2007 to September 2007, a total of 20 consecutive cirrhotic patients with HCC scheduled to undergo partial hepatectomy were studied. Preoperative contrast enhanced computer tomography (CT) and/or magnetic resonance (MR) scans were performed within 1-2 wk before operation. Intraoperative ultrasound (IOUS) and CE-IOUS were carried out after mobilization of the liver. Lesions on precontrast and postcontrast scans were counted and mapped. CE-IOUS was performed with intravenous injection of ultrasound contrast agents SonoVue (Bracco Imaging, Milan, Italy). Arterial, portal and late phases of contrast enhancement were recorded and analyzed. Nodules showing arterial phase hyper-enhancing and/or hypo-enhancing in late parenchymal phase were considered malignant and removed surgically. Ultrasound-guided biopsy and ethanol ablation would be an option if the nodule could not be removed surgically. Newly detected nodules on IOUS showing iso-enhancement in both arterial and late phases were considered benign. These nodules were eitherremoved surgically if they were close to the main lesion or followed by examinations of alpha-fetoprotein (AFP) level and ultrasound and/or CT/MR every 3 mo. RESULTS: IOUS found 41 nodules in total, among which 17 (41.46%) were newly detected compared to preoperative imaging. Thirty-three nodules were diagnosed malignant by CE-IOUS, including one missed by IOUS. The sensitivity and specif icity of CE-IOUS on detecting HCC nodules are 100% (33/33 and 100% (9/9), respectively. Nine nodules were considered benign by CE-IOUS, four was confi rmed at histology and fi ve by follow-up. CE-IOUS changed the surgical strategy in 35% (7/20) of patients and avoid unnecessary intervention in 30% (6/20) of patients. CONCLUSION: CE-IOUS is a useful means to charac-terize the nodules detected by IOUS in cirrhotic liver, to fi nd isoechoic HCC nodules which can not be shown on IOUS and to improve the accuracy of conventional IOUS, thus it can be used as an essential tool in the surgical treatment of cirrhotic patients with HCC.

Intraoperative ultrasound as an educational guide for laparoscopic biliary surgery

AIM: To analyze the efficacy of routine intraoperative ultrasound (IOUS) as a guide for understanding biliary tract anatomy, to avoid bile duct injury (BDI) after laparoscopic cholecystectomy (LC), as well as any burden during the learning period. METHODS: A retrospective analysis was performed using 644 consecutive patients who underwent LC from 1991 to 2006. An educational program with the use of IOUS as an operative guide has been used in 276 cases since 1998. RESULTS: IOUS was highly feasible even in patients with high-grade cholecystitis. No BDI was observed after the introduction of the educational program, despite 72% of operations being performed by inexperienced surgeons. Incidences of other morbidity, mortality, and late complications were comparable before and after the introduction of routine IOUS. However, the operation time was significantly extended after the educational program began (P < 0.001), and the grade of laparoscopic cholecystitis (P = 0.002), use of IOUS (P = 0.01), and the experience of the surgeons (P = 0.05) were significant factors for extending the length of operation. CONCLUSION: IOUS during LC was found to be a highly feasible modality, which provided accurate, real- time information about the biliary structures. Theeducational program using IOUS is expected to minimize the incidence of BDI following LC, especially when performed by less-skilled surgeons.

Role of preoperative endoscopic ultrasound-guided fine-needle tattooing of a pancreatic head insulinoma

Although insulinomas are rare, they are the most com-mon pancreatic neuroendocrine tumor, with an inci-dence of four cases per million population. Insulinomas are generally benign indolent intrapancreatic tumors. Surgical resection remains the main option for treat-ment. However, up to 67% of a pancreatic head insu-linomas are nonpalpable, thus surgical resection of the nonplapable insulinoma in this area could become prob-lematic resulting in prolonged surgical time, increased risk of pancreatic duct injury and need for pancreati-coduodenectomy. Endoscopic ultrasound-guided fine- needle tattooing(EUS-FNT), has been shown to have a crucial role for localization of pancreatic body and tail lesions, facilitating laparoscopic distal pancreatectomyand helping surgeons identify the location of the tumor. EUS-FNT might have a role for preoperative localiza-tion of pancreatic head insulinomas which are likely to be nonpalpable. We report a case of preoperative EUS-FNT for localization of a nonplapable pancreatic head insulinoma. This report demonstrates that EUS-FNT of pancreatic head insulinomas may facilitate surgical resection, reduce operative time and decrease surgical complications.

Endoscopic ultrasound radiofrequency ablation of pancreatic insulinoma in elderly patients:Three case reports

BACKGROUND Endoscopic ultrasound(EUS)-guided radiofrequency ablation(RFA)has recently been proposed as a local treatment for functional pancreatic neuroendocrine neoplasms in patients unfit for surgery,in order to obtain clinical syndrome regression.Data on the safety and long-term effectiveness of this approach are scarce,and EUS-RFA procedures are not standardized.CASE SUMMARY The present case series reports 3 elderly patients with a pancreatic insulinoma and comorbidities,locally treated by EUS-guided RFA with clinical success in terms of hypoglycemic symptoms.RFA procedures were performed during deep sedation,under EUS control with a 19 G needle,an electrode 5-mm in size at a power of 30 W and multiple RFA applications during the same session in order to treat the whole area of the lesions.Immediate relief of symptoms was evident in 2 patients after the first EUS-RFA,while in the third patient a second endoscopic treatment was needed.All 3 patients are symptom-free without need of medications after 24 mo of follow-up with imaging follow-up showing no disease recurrence.A single adverse event of intraprocedural bleeding occurred,which was successfully treated endoscopically.CONCLUSION EUS-RFA represents an effective and safe alternative to surgery for the treatment of insulinomas in elderly patients at high surgical risk.However,larger multicenter studies withlonger follow-up are needed in order to better assess its safety and clinical success.

INTRAOPERATIVE ULTRASOUND FOR HEPATIC NEOPLASM DURING SURGERY

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Survival Analysis of Patients Undergoing Intraoperative Contrast-enhanced Ultrasound in the Surgical Treatment of Malignant Glioma

Objective:Complete resection of malignant gliomas is often challenging.Our previous study indicated that intraoperative contrast-enhanced ultrasound(ICEUS)could aid in the detection of residual tumor remnants and the total removal of brain lesions.This study aimed to investigate the survival rates of patients undergoing resection with or without the use of ICEUS and to assess the impact of ICEUS on the prognosis of patients with malignant glioma.Methods:A total of 64 patients diagnosed with malignant glioma(WHO grade HI and IV)who underwent surgery between 2012 and 2018 were included.Among them,29 patients received ICEUS.The effects of ICEUS on overall survival(OS)and progression-free survival(PFS)of patients were evaluated.A quantitative analysis was performed to compare ICEUS parameters between gliomas and the surrounding tissues.Results:The ICEUS group showed better survival rates both in OS and PFS than the control group.The univariate analysis revealed that age,pathology and ICEUS were significant prognostic factors for PFS,with only age being a significant prognostic factor for OS.In multivariate analysis,age and ICEUS were significant prognostic factors for both OS and PFS.The quantitative analysis showed that the intensity and transit time of microbubbles reaching the tumors were significantly different from those of microbubbles reaching the surrounding tissue.Conclusion:ICEUS facilitates the identification of residual tumors.Age and ICEUS are prognostic factors for malignant glioma surgery,and use of ICEUS offers a better prognosis for patients with malignant glioma.

Contrast-Enhanced Ultrasonographic Detection and Dual-Phase Computed Tomographic Angiography in a 5-Year-Old Boxer with Pancreatic Insulinoma<br/>—Case Report

This case report describes the findings in a canine histopathologically confirmed pancreatic insulinoma using contrast-enhanced ultrasound (CEUS) and dual-phase computed tomographic angiography (CTA). The insulinoma was better demarcated in CEUS and CTA compared with conventional B-mode ultrasound. On the other hand, only one of two nodules visible in CTA was detected in CEUS. In this case, the insulinoma had an atypical non-contrast-enhancing appearance in both CEUS and CTA. Lack of enhancement in CEUS and CTA has previously been reported in human and canine studies, but this was the first report using both CEUS and CTA for detecting canine insulinoma.

Application of Intraoperative Contrast-Enhanced Ultrasound in the Resection of Brain Tumors

Objective:To investigate the value of routine intraoperative ultrasound(IU)and intraoperative contrast-enhanced ultrasound(ICEUS)in the surgical treatment of brain tumors,and to explore the utilization of ICEUS for the removal of the remnants surrounding the resection cavity.Methods:In total,51 patients who underwent operations from 2012 to 2018 due to different tumors in the brain were included in this study.The clinical data were evaluated retrospectively.IU was performed in all patients,among which 28 patients underwent ICEUS.The effects of IU and ICEUS on tumor resection and recurrence were evaluated.

Non-anatomical liver resection for hepatocellular carcinoma:the SegSubTe classification to overcome the problem of heterogeneity

Background:The superiority of anatomical resection(AR)vs.non-anatomical resection(NAR)in the surgical management of hepatocellular carcinoma(HCC)is debated.ARs are well-defined procedures,whereas the lack of NAR standardization results in heterogeneous outcomes.This study aimed to introduce the SegSubTe classification for NAR detailing the appropriateness of the level of surgical section of the Glissonean pedicles feeding the tumor.Methods:A single-center retrospective analysis of pre-and postoperative imaging of consecutive patients treated with NAR for single HCC between 2012 and 2020 was conducted.The quality of surgery was assessed classifying the type of vascular supply and the level of surgical section(segmental,subsegmental or terminal next to the tumor)of vascular pedicles feeding the HCCs;then,the population was divided in“SegSubTe-IN”or“SegSubTe-OUT”groups,and the tumor recurrence and survival were analyzed.Results:Ninety-seven patients who underwent NAR were included;76%were SegSubTe-IN and 24%were SegSubTe-OUT.Total disease recurrence,local recurrence and cut-edge recurrence in the SegSubTe-IN vs.SegSubTe-OUT groups were 50%vs.83%(P=0.006),20%vs.52%(P=0.003)and 16%vs.39%(P=0.020),respectively.SegSubTe-OUT odds ratio for local recurrence was 4.1 at univariate regression analysis.One-,three-,and five-year disease-free survival rates in the SegSubTe-IN vs.SegSubTe-OUT groups were 81%,58%and 35%vs.46%,21%and 11%,respectively(P<0.001).Conclusions:The SegSubTe classification is a useful tool to stratify and standardize NAR for HCC,aiming at improving long-term oncological outcomes and reducing the heterogeneity of quality of NAR for HCC.

术中B超指引颅内压传感器置入移位、变形脑室的应用价值

目的 分析探讨术中B超在重型颅脑外伤脑疝患者去骨瓣减压术中脑室型颅内压监护传感器置入变形、移位脑室的临床应用价值。方法 对34例重型颅脑外伤脑疝需先行去骨瓣减压术的患者,去骨瓣减压后在B超指导下行脑室穿刺,对这些患者脑室型颅内压传感器穿刺到位情况、并发症情况回顾分析。结果 34例患者均成功置入脑室,其中33例首次置入成功,无术后颅内感染及穿刺相关出血病例。结论 术中B超指导去骨瓣减压术后行脑室型颅内压监护传感器置入变形移位脑室安全有效,值得应用推广。

三维可视化、荧光影像联合术中超声在腹腔镜解剖性肝切除术中的应用

目的分析三维可视化、荧光影像联合术中超声在针对原发性肝癌的腹腔镜解剖性肝切除术中的应用效果。方法回顾性分析武汉市中心医院肝胆胰外科2023年1月至2023年12月期间行腹腔镜解剖性肝切除的22例原发性肝癌病人的临床资料。术前通过专业软件建立肝脏三维可视化模型并规划手术路径,术中通过荧光影像技术和术中超声的导航,进行解剖性肝切除。结果22例病人均按术前规划顺利完成手术。21例病人吲哚菁绿染色均成功,有1例因肝硬化严重而导致肿瘤吲哚菁绿染色未成功,但亦通过术中超声顺利完成解剖性肝切除。病理结果:肝细胞癌20例,胆管细胞癌1例,混合型肝癌1例;切缘均为阴性。病人术后恢复良好,顺利出院。随访2~8个月未见肿瘤复发。结论三维可视化、吲哚菁绿荧光影像联合术中超声对进行腹腔镜解剖性肝切除术提供了坚实的基础。

相位对比电影MRI及术中超声在Chiari畸形1型手术方式选择中的临床应用进展

枕大孔减压术是治疗Chiari畸形1型(CM1)患者的通用手术,但减压范围、临床疗效存在争议,没有单一、明确的治疗方法。脑脊液流体动力学的改善可能与临床症状的缓解有关,相位对比电影MRI(PC-MRI)联合术中超声(IOUS)可以准确评估颅颈交界区的脑脊液流体动力学改变,两者结合可以为损害程度评估提供有效信息,指导手术方式的选择,预测临床改善效果,减少再手术的发生。本文对PC-RMI联合IOUS在CM1术式选择中的临床应用进行综述。

超声医学在脑胶质瘤诊治方面的研究进展

脑胶质瘤恶性程度高,患者预后差,胶质瘤的标准化治疗是最大限度地手术切除及放化疗。由于开颅术中“脑漂移”的存在和保护脑功能区的需求,术中超声多种新技术可发挥实时导航定位、协助判断肿瘤边界和识别残留病灶的作用;此外,超声造影和人工智能技术的引入为快速分子病理学诊断展现出广阔的应用前景。同时,超声响应性纳米体系具有临时打开血脑屏障和精确控制药物释放的双重效应,并呈现出优异的生物相容性和针对胶质瘤的高度特异性。本文对上述临床和基础两个方面的研究进展进行述评,旨在为脑胶质瘤的诊疗提供新的参考。

TCD脑血流监测在颈动脉内膜剥脱术中指导血压调控的应用

目的探讨经颅彩色超声多普勒系统(TCD)监测脑血流在颈动脉内膜剥脱术(CEA)中指导血压个体化调控的作用。方法选择2018年12月至2020年12月在邢台市第三医院收治的140例拟行CEA治疗的颈动脉狭窄患者,其中男性74例,女性66例;年龄45~65岁,平均年龄57.41岁;糖尿病10例,高血压12例;美国麻醉师协会(ASA)分级:Ⅱ级30例,Ⅲ级110例。采用随机数字表法分为研究组和对照组,每组分为70例。对照组采用传统手段控制血压,研究组根据TCD脑血流参数指导调节血压。术中连续监测两组患者的有创动脉压力并对大脑中动脉平均血流速度进行监测。记录两组各个时刻点大脑中动脉血流速度(Vm)及外周有创动脉收缩压,比较两组患者围术期相关指标,统计术中心动过速/心动过缓发生次数及术后心脑血管事件发生情况。结果研究组术中硝酸甘油、去甲肾上腺素用量低于对照组[(34.87±10.27)μg vs(48.56±6.92)μg、(15.97±4.54)μg vs(24.15±3.99)μg。P<0.05],心动过缓发生率明显少于对照组(2.86%vs 19.40%。P<0.05)。在T00、T0、T3和T4时,两组间Vm值和收缩压比较,差异无统计学意义(P>0.05)。在T1和T2时,研究组Vm值和收缩压明显低于对照组[T1:(38.87±6.19)cm/s vs(44.42±4.16)cm/s,(119.84±8.12)mmHg vs(150.78±6.51)mmHg;T2:(29.46±4.58)cm/s vs(34.94±3.64)cm/s,(142.04±10.91)mmHg vs(152.23±5.84)mmHg。P<0.05]。其中两组患者在T2时Vm值显著下降[(29.46±4.58)cm/s vs(34.94±3.64)cm/s。P<0.05],收缩压值显著上升[(142.04±10.91)mmHg vs(152.23±5.84)mmHg。P<0.05]。研究组术后并发症发生率低于对照组(7.14%vs 20.90%。P<0.05)。研究组CEA后颈动脉超声心动图改变或术后再狭窄<50%、50%~69%和继发血栓形成的患者数明显少于对照组(2.86%vs 11.94%、2.86%vs 13.43%、1.43%vs 8.96%、0.00%vs 5.97%。P<0.05)。结论TCD监测颈动脉狭窄患者脑血管血流动力学对CEA麻醉中血压的调控具有较好的指导意义,有利于实现血压个体化调控,提高血压调控准确率,减少心脑血管事件的出现。

超声引导下微波消融与开放手术治疗甲状腺良性结节对术中出血量、激素水平及并发症的影响

目的分析超声引导下微波消融与开放手术治疗甲状腺良性结节(BTN)对术中出血量、激素水平及并发症的影响。方法选取150例BTN患者,采用随机数字表法分为微波消融组(超声引导下微波消融术)和开放手术组(开放手术),各75例。比较两组BTN患者手术一般情况、术后结节清除率和术前和术后1周血清游离三碘甲状腺原氨酸(FT_(3))、游离甲状腺素(FT_(4))、促甲状腺激素(TSH)水平及并发症发生率。结果微波消融组手术时间、切口长度、术中出血量、术后引流量和住院时间均低于开放手术组,差异均有统计学意义(t分别=23.30、46.88、49.11、11.79、32.02,P均<0.05);术后1周,微波消融组血清TSH水平低于开放手术组,FT_(3)和FT_(4)水平高于开放手术组(t分别=-3.41、4.78、6.32,P均<0.05);微波消融组术后并发症发生率为9.33%,低于开放手术组的21.33%,差异有统计学意义(χ^(2)=4.16,P<0.05)。结论与开放手术比较,超声引导下微波消融术可减少BTN患者术中出血量,改善术后甲状腺激素水平,降低并发症发生率。

术中超声在神经根型颈椎病颈后路椎板成形术中的应用价值

目的:探讨术中超声在神经根型颈椎病颈后路椎板成形术中的应用价值。方法:回顾性采集2020年1月至2021年1月于医院接受颈后路椎板成形术治疗的30例神经根型颈椎病患者的临床资料,纳入对照组;采集2021年1月至2022年1月于医院接受在术中超声下行颈后路椎板成形术治疗的30例神经根型颈椎病患者的临床资料,纳入观察组。两组均进行颈后路椎板成形术,对照组根据医生观察结果评估减压效果,观察组采用术中超声评估减压效果。对比两组术前、术后半年颈椎功能评分,术后半年恢复率以及术前、术后3 m采用疼痛数字量表评定疼痛程度。结果:术前,两组的颈椎评分对比无显著差异(P>0.05)。术后半年,观察组颈椎评分显著高于对照组(P<0.05)。观察组的术后恢复率显著高于对照组(P<0.05)。术前,两组的疼痛数字评分无显著差异(P>0.05)。术后3 m,观察组的评分显著低于对照组(P<0.05)。结论:术中超声应用于神经根型颈椎病颈后路椎板成形术中,能改善患者的脊椎功能、促进术后恢复,缓解疼痛。

Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy

AIM To assess the role of laparoscopic ultrasound(LUS) as a substitute for intraoperative cholangiography(IOC) during cholecystectomy.METHODS We present a MEDLINE and Pub Med literature search, having used the key-words "laparoscopic intraoperative ultrasound" and "laparoscopic cholecystectomy". All relevant English language publications from 2000 to 2016 were identified, with data extracted for the role of LUS in the anatomical delineation of the biliary tract, detection of common bile duct stones(CBDS), prevention or early detection of biliary duct injury(BDI), and incidental findings during laparoscopic cholecystectomy. Data for the role of LUS vs IOC in complex situations(i.e., inflammatory disease/fibrosis) were specifically analyzed. RESULTS We report data from eighteen reports, 13 prospective non-randomized trials, 5 retrospective trials, and two meta-analyses assessing diagnostic accuracy, with one analysis also assessing costs, duration of the examination, and anatomical mapping. Overall, LUS was shown to provide highly sensitive mapping of the extra-pancreatic biliary anatomy in 92%-100% of patients, with more difficulty encountered in delineation of the intra-pancreatic segment of the biliary tract(73.8%-98%). Identification of vascular and biliary variations has been documented in two studies. Although inflammatory disease hampered accuracy, LUS was still advantageous vs IOC in patients with obscured anatomy. LUS can be performed before any dissection and repeated at will to guide the surgeon especially when hilar mapping is difficult due to fibrosis and inflammation. In two studies LUS prevented conversion in 91% of patients with difficult scenarios. Considering CBDS detection, LUS sensitivity and specificity were 76%-100% and 96.2%-100%, respectively. LUS allowed the diagnosis/treatment of incidental findings of adjacent organs. No valuable data for BDI prevention or detection could be retrieved, even if no BDI was documented in the reports analyzed. Literature analysis proved LUS as a safe, quick, non-irradiating, costeffective technique, which is comparatively well known although largely under-utilized, probably due to the perception of a difficult learning curve. CONCLUSION We highlight the advantages and limitations of laparoscopic ultrasound during cholecystectomy, and underline its value in difficult scenarios when the anatomy is obscured.

Contrast-enhanced ultrasound:Improving the preoperative staging of hepatocellular carcinoma and guiding individual treatment

AIM:To investigate the clinical role of contrast-enhanced ultrasound(CEUS) combined with contrast-enhanced computed tomography(CE-CT) or magnetic resonance imaging to improve the preoperative staging of hepatocellular carcinoma(HCC) and guide surgical decisionmaking.METHODS:Sixty-nine patients who underwent liver resection for HCC in our center were enrolled prospectively in the study.CEUS and CE-CT/MRI were performed before surgery.Intraoperative ultrasound(IOUS)wascarried out after liver mobilization.Lesions depicted by each imaging modality were counted and mapped.To investigate the impact of tumor size on the study,we divided the patients into two groups,the"Smaller group"(S-group,≤5 cm in diameter)and the"Largergroup"(L-group,>5 cm in diameter).The sensitivity,specificity,accuracy,positive predictive value,and negative predictive value of CE-CT/MRI,CEUS,IOUS,CEUS+CE-CT/MRI and the tumor node metastasis staging of tumors were calculated and compared.Changes in the surgical strategy as a result of CEUS and IOUS were analyzed.RESULTS:One hundred and twenty-seven nodules,comprising 94 HCCs confirmed by histopathology and33 benign lesions confirmed by histopathology and follow-up,were identified in 69 patients.The overall diagnostic sensitivity rates of CE-CT/MRI,CEUS,IOUS and CEUS+CE-CT/MRI were 78.7%,89.4%,89.4%and 89.4%,respectively.There was a significant difference between CEUS+CE-CT/MRI and CE-CT/MRI(P=0.046).Combining CEUS with CT or MRI increased,the diagnostic specificity compared with CT/MRI,CEUS and IOUS,and this difference was statistically significant(100%,72.7%,97.0%,and 69.7%,P=0.004,P=0.002,P=0.002,respectively).The diagnostic accuracy was significantly higher for CEUS+CT/MRI compared with CT/MRI(92.1%vs 77.2%,P=0.001).The TNM staging of tumors based on CEUS+CE-CT/MRI approximated to the final pathological TNM staging(P=0.977).There was a significant difference in the accuracy of TNM staging when comparing CEUS+CECT/MRI with CE-CT/MRI(P=0.002).Before surgery,strategies were changed in 15.9%(11/69)of patients as a result of CEUS.Finally,only 5.7%(4/69)of surgical strategies were changed because of IOUS findings.In the S-group,CEUS revealed 12 false positive lesions,including seven false positive lesions that were diagnosedby preoperative imaging examinations and five by IOUS.In contrast,in the L-group,IUOS revealed eight new malignant lesions;six of these lesions were true HCCs that were also identified by preoperative CEUS.CONCLUSION:CEUS combined with CT or MRI improves the accuracy of preoperative staging for hepatocellular carcinoma and may help to guide individualized treatment for patients with HCC.CEUS may better identify non-malignant lesions in patients with small tumors and discover new malignant lesions in patients with large tumors.