Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_857_Библиотеки_им_академика_М_И_Перельмана
.pdf
20 How toUse Surgical Ultrasound inResource-Limited Settings
https://t.me/medicina_free
215
ab
cd
Fig. 20.10 Probe positions for FAST exam. (a) Subxiphoid cardiac view. (b) Right upper quadrant view. (c) Left upper
quadrant view. (d) Suprapubic view [39]
pleted in any particular order. Approximately
200 cc of uid is the minimum detectable volume. The “E-FAST” exam consists of additional
views to assess the pleural spaces for free uid.
First, starting in the right upper quadrant, we
are looking for uid in Morrison’s pouch. In a
non-fasting patient where bowel gas may interfere with transmission of acoustic energy more
anteriorly, an excellent approach is to place the
probe at the right anterior axillary line, between
the 10th and 11th ribs. This allows the acoustic
energy to transmit through the liver directly to the
right kidney. If there is an intact interface between
these two structures, as indicated by a white line,
there is no free uid (Fig.20.11). In contrast, a
hypoechoic area seen between the liver and the
kidney is diagnostic of free uid in Morrison’s
pouch (Fig.20.12). The right inferior pleural can
also be evaluated by directing the probe cephalad, looking for the hyperechoic right hemidiaphragm. A hypoechoic density signifying uid
present on the thoracic side of the diaphragm is a
pleural effusion. Moving the probe slightly will
allow one to discern the pitfall of the mirror
image artifact, where reverberation echoes from
Fig. 20.11 B-mode image of a normal hepatorenal space
the liver may appear as if they are coming from
the other (thoracic) side of the diaphragm.
The second view of the FAST exam is obtained
in the left upper quadrant, to examine the splenorenal space. Similarly to the previously described
view, the probe is placed on the left side at the
mid-axillary line, between the tenth and 11th ribs
(or even one interspace above). The goal is an
image with the spleen-left kidney interface.
Similar to Morrison’s pouch, a thin hyperechoic
interface between the kidney and spleen signies
a negative exam (Fig. 20.13), while a wider
hypoechoic area between the kidney and spleen
is diagnostic of free uid (Fig.20.14). The left
216
https://t.me/medicina_free
B. A. Schrope et al.
Fig. 20.12 B-mode image of positive FAST exam in the
right upper quadrant. The hypoechoic signal between the
liver and kidney (*) represents free intraabdominal uid [41]
Fig. 20.13 B-mode image of normal left upper quadrant
view of FAST exam
pleural space can also be evaluated by angling the
Fig. 20.14 B-mode image of left upper quadrant view
showing free uid in splenorenal space
Fig. 20.15 Normal B-mode image of FAST exam, pelvic
view
Fig. 20.16 Positive FAST exam, pelvic view
probe cephalad, directing the ultrasound through
the spleen and left hemi-diaphragm.
Third is the evaluation of the pelvis. This is
aided by a full bladder, so if a catheter is present,
sterile saline may be instilled in the bladder
(roughly 200cc) and the catheter clamped for the
duration of the exam. This avoids mirror image
artifacts in the pelvis, resulting from strong
echoes from the sacrum. The probe is placed in
the suprapubic position and oriented posteriorly
to inferiorly. With a relatively full bladder, that
should be the only uid-lled structure seen
(Fig.20.15). A positive FAST in the pelvis is the
appearance of two uid-lled structures in the
pelvis, the bladder, and a pelvic uid collection
(Fig.20.16).
20 How toUse Surgical Ultrasound inResource-Limited Settings
https://t.me/medicina_free
217
Finally, the pericardial space is assessed.
Placing the ultrasound probe in the subxiphoid
position, orient it toward the left shoulder. A
comprehensive cross-sectional view of the ventricles and atria is not required here; one simply
needs to view a section of the ventricular myocardium. Normally, the myocardium is a soft
tissue density surrounded by a subtle hyperechoic pericardium (Fig.20.17). A pericardial
effusion appears as a hypoechoic area between
the myocardium and the pericardium
(Fig.20.18).
The Acute Abdomen
Central to evaluation for acute abdominal pain
is of course physical examination, and holding
an ultrasound probe in the hand can certainly be
considered an extension of the physical exam.
With some practice, numerous areas and pathologies can be evaluated with ultrasound. Imaging
transhepatically to avoid interference from
bowel gas, the gallbladder is easily evaluated
for shadowing gallstones, pericholecystic uid,
and a thickened gallbladder wall, signs pathognomic for acute cholecystitis (Fig. 20.19).
Moving to the right lower quadrant, placing the
probe at McBurney’s point, one can assess for a
thickened appendix (Fig.20.20), diagnostic of
acute appendicitis. Accepted criteria for diagnosing acute appendicitis by ultrasound is the
identication of an enlarged and noncompressible appendix, with its outer anteroposterior
diameter under compression, measured in the
transverse plane, of >6mm.
Fig. 20.17 Normal pericardial view of FAST exam
Fig. 20.19 B-mode
image of acute
cholecystitis. Note
pericholecystic uid and
wall thickening
indicative of edema and
inammation, as well as
a gallstone impacted in
the neck of the
gallbladder [42]
Fig. 20.18 Pericardial effusion detected with FAST
exam. The asterisk (*) denotes uid in the pericardial sac
218
https://t.me/medicina_free
B. A. Schrope et al.
Fig. 20.20 B-mode
image of acute
appendicitis. Under
compression with the
probe, the maximal
diameter of the appendix
was measured to be
11mm, meeting criteria
for acute appendicitis.
(a) transverse view; (b)
longitudinal view [43]
ab
Although the assessment of a normal aorta can
be difcult in the non-fasting patient due to overlying bowel gas from an anterior approach, an
abdominal aortic aneurysm can be quite apparent, particularly in a thin person. Lateral views
are also worth attempting, as an enlarged aorta
will push surrounding structures out of the way.
The goal of the ultrasound exam is to identify the
location of maximal aortic dilatation in the longitudinal plane and then to measure the diameter in
the transverse plane. Diameters greater than 3cm
are considered aneurysmal (Fig. 20.21).
Additionally, it is also useful to assess for evidence of leaking blood by the presence of free
uid around the aneurysm with the aid of the
duplex setting.
Ultrasound-Guided Procedures
Fig. 20.21 Transverse view of abdominal aorta measur-
ing 8.95 cm in anterior-posterior diameter at its largest
point. The aneurysm had an anechoic center with echogenic material in the posterior lumen, representing cholesterol deposit. Free uid was seen anterior to the aneurysm
suggestive of rupture [44]
Ultrasound can greatly facilitate many different
types of procedures, including vascular access
or drainage procedures. The target, whether it
be a vein, an abscess, or an acutely inamed
and distended gallbladder, for example, can be
visualized as the intervention is being performed. If at all possible, the instrument (needle, guidewire, catheter) can be imaged
“in-plane,” where the probe is held such that the
needle, as it travels through the tissue, is visualized along its entire path (Fig.20.22). If anatomy doesn’t permit (structures such as ribs
interfering), the target is imaged, and the needle
is seen entering it only. To facilitate the early
learner, needle guides for attachment to the
probe are available, though as one gains experience, they tend to become more of a nuisance
than helpful.
20 How toUse Surgical Ultrasound inResource-Limited Settings
https://t.me/medicina_free
219
Fig. 20.22 In-plane versus out-of-plane imaging for
ultrasound-guided procedures. Note the reverberation
artifact of the entire needle in the in-plane approach, versus visualization of only a small cross-section of needle
with the out of plane technique (This work is licensed
Abdominal Surgical Ultrasound
Ultrasound in the surgeon’s hands can be invaluable for more precise and safe operations. Beyond
diagnostic imaging, adding ultrasound to the surgeon’s armamentarium guides interventions both
in the operating room and at the bedside. This
enables efcient and economical care, which is
particularly imperative in resource-limited
settings.
Liver Resection
Direct application of the transducer to the liver
surface intraoperatively affords high-resolution
images to be attained without signal attenuation
from intervening tissue such as abdominal wall
and/or air. When available, the surgeon may use
intraoperative ultrasound to identify tumors deep
in liver parenchyma that are not palpable.
under the Creative Commons Attribution 4.0 International
License. To view a copy of this license, visit http://cre-
ativecommons.org/licenses/by/4.0/ or send a letter to
Creative Commons, PO Box 1866, Mountain View, CA
94042, USA)
Typically, the surgeon will identify tumor margins and use this information to mark a parenchymal transection line, ensuring microscopic
margin clearance (R0 resection). Often, sterile
covers for the ultrasound probes are not available
in low-resource centers. In these cases, we will
still be able to utilize intraoperative ultrasound by
placing the probes, along with acoustic gel, in a
sterile surgical glove (Fig.20.23).
Ablative Therapies
Ablation has become accepted as an alternative
to resection for hepatic and renal tumors in
appropriate cases. In the liver, ablative therapies
have found application for hepatocellular carcinomas and colorectal liver metastases. The two
most commonly utilized energy sources are
microwave ablation and radiofrequency ablation.
Although both techniques utilize differing energy
220
https://t.me/medicina_free
B. A. Schrope et al.
sources, the ultimate aim is thermal destruction
of all tissues in contact with the ablation antenna.
Therefore, the antenna must be accurately placed
within the center of the target lesion. This is often
done by image guidance, either with CT guidance by our radiology colleagues or via intraoperative ultrasound (Fig.20.24) in the operating
room with a surgeon. Dedicated interventional
suites may not be readily available in resourcelimited regions, so the option for surgeonperformed procedures is an attractive one in these
settings.
Targeted Biopsy
Fig. 20.23 Practice in resource-limited settings some-
times requires exibility and ingenuity. In this case, a sterile surgical glove substitutes for a sterile probe cover for
intraoperative ultrasound
Ultrasound can be used to guide intraoperative
biopsies for tumors that are difcult to target
solely by palpation. As discussed in another part
of this chapter, ultrasound-guided breast biopsy
Fig. 20.24 Combined use of ultrasound and CT targeting during microwave ablation of colorectal liver metastases to
the left hemi-liver. Inset: pre-ablation (yellow arrow) and post-ablation (red arrow) CT images are seen
20 How toUse Surgical Ultrasound inResource-Limited Settings
https://t.me/medicina_free
221
has been shown to be superior to palpationguided breast biopsy in terms of sensitivity, false
negative rates, and repeat biopsy rates [45].
Targeted biopsies of the liver, kidneys, lymph
nodes, prostate, and other miscellaneous lesions
can be done under local anesthesia and with same
day discharge.
Laparoscopic Ultrasound
Ultrasound can also be used at laparoscopic surgery with dedicated laparoscopic probes. These
are usually specially congured linear array
probes with ≤10 mm diameter that can pass
through 12mm laparoscopic ports, with a working shaft length of 35–40cm to allow access to
the viscera. The tip of the probe typically has
multiple degrees of freedom to allow optimal
scanning angles (Fig. 20.25). These modied
laparoscopic probes usually operate at frequencies of 5–7.5MHz with depth penetration from 4
to 10cm [46]. In these cases, the ultrasound is
usually operated by surgeons as radiologists may
nd it difcult to organize dedicated time in the
operating room. Surgeons may have less exposure to the principles of ultrasound use during
their surgical postgraduate training, and this
exposure/training would normally be attained
Fig. 20.25 Intraoperative use of a laparoscopic ultrasound probe (US) during liver resection. The instrument is
exed to maintain contact with the liver surface (L) and
produce optimal scanning angles. Electrocautery is being
used simultaneously to score the liver capsule (arrow),
while intraoperative ultrasound ensures adequate resection margins
during fellowship training or post-training
mentorship.
When available, laparoscopic ultrasound can
be used as an adjunct to staging laparoscopy for a
variety of malignancies, with only a few minutes
of additional operating time and no increase in
perioperative complications [47]. Diagnostic laparoscopy with laparoscopic ultrasound has been
shown to upstage esophageal/gastric cancer
patients in up to 40% of cases and prevent nontherapeutic laparotomy in 25% of cases [48, 49].
Laparoscopic ultrasound has been shown to
increase the accuracy of staging in patients with
hepatocellular carcinomas and colorectal liver
metastases, with up to 20% of patients having
additional lesions detected when compared to
their preoperative CT scans [50, 51] and with
management changes in up to 40% of cases [52].
Existing data suggests that laparoscopic ultrasound has 75–90% specicity and 80–100% sensitivity for staging in patients diagnosed with
colorectal liver metastases and hepatocellular
carcinomas [53, 54]. There is also value in
patients with pancreatic adenocarcinomas, where
vascular invasion and/or liver metastases may be
detected, preventing non-therapeutic laparotomies in up to 30% of patients [55–58].
Laparoscopic ultrasound to evaluate periampullary carcinomas has been reported to have
85–100% diagnostic accuracy [56, 57, 59] and
better sensitivity than CT scans to identify liver
metastases, vascular encasement, and nodal
involvement [59].
Laparoscopic ultrasound has also found application in patients without malignancies. It has
been used as an adjunct to guide liver biopsies,
resect giant hepatic cysts, identify bile duct anatomy, and detect common duct stones. The advantage is that it avoids the need for catheterization
of the biliary system, prevents radiation exposure, reduces cost, and requires less time than
intraoperative cholangiography [60, 61]. Current
reports suggest that laparoscopic ultrasound has
90–96% sensitivity, 100% specicity, 98% positive predictive value, and 92% negative predictive value to detect choledocholithiasis [60–62].
A drawback is that the diagnostic yield is heavily
user-dependent and has a steep learning curve.
222
https://t.me/medicina_free
B. A. Schrope et al.
While there is useful application in laparoscopic surgery, its use remains limited in the
resource-poor nations for numerous possible reasons: (1) Dedicated laparoscopic probes (even
entire ultrasound units reserved for the operating
room) may not be universally available. (2)
Operating room and biomedical engineering staff
may be unfamiliar with the ultrasound machine
for cleaning, sterilization, and maintenance.
Surgeons would require additional training in
imaging techniques, scanning parameters, and
recognition of anatomic landmarks or subtle
pathologic abnormalities.
Training andCertication
Often in severely resource-limited areas or lowincome countries, training in new technologies is
dependent on the movement of surgeons, either
an experienced surgeon coming to mentor
trainees or a local surgeon travelling for a minifellowship or training session elsewhere.
Certainly, these expensive and time-consuming
movements can be somewhat mitigated by online
educational programs, which may be viewed
prior to travel and hands-on training. Strategies
for training and attainment of competency are
addressed forthwith.
Skills andEquipment Acquisition
inResource-Limited Settings
It is readily apparent that ultrasound is a highly
appropriate choice for surgeons and others in
resource-limited settings. Lack of availability of
even rudimentary equipment and training, as well
as ongoing technical support, has made adoption
difcult [63, 64]. There are success stories, however, to learn from [65–67]. Although most
reported literature focusses on emergency ultrasound, surgeons may fall under a similar rubric
and indeed are arguably more accustomed to
adopting new skills than their medical
counterparts.
Training
In 2016, Salmon et al. [65] suggested a framework for initiating and maintaining ultrasound
curricula and practices on the African continent.
Foremost is the integration of an ultrasound curriculum into residency programs. As with any
new skill or technology, it is often the academic
centers that pave the way forward for widespread
adoption. “Champions,” those who undertake
dedicated training and integrate new skills into
their practice, are the backbone of integrating
new skills into residency programs. Once a program has been initiated, attention to continuing
medical education and longitudinal training is
paramount. Shared resources for training as well
as durable equipment across a region is an important consideration, to ensure equitable access for
all. Finally, regional standards for resourcelimited locales can be based on accepted standards adopted from high-income countries.
For non-residency associated training, a
review of the available literature [68] suggests
that a short but intensive training period is sufcient for preparing clinical ofcers, nurses, and
physicians alike to perform basic ultrasound
exams. The more successful training program
includes both lecture and practical experience
and provides opportunity for continued upkeep
of skills through review sessions and ongoing
quality assurance after the training period ends.
Particularly for ongoing support, SonoWorld
is a group of medical professionals launched in
1999 to provide free educational materials to
ultrasound practitioners in developing countries
around the world (https://www.sonoworld.com).
With more than 170,000 registered members and
over 150,000 monthly visits, SonoWorld reaches
more ultrasound professionals worldwide than
any other communication channel. The site has
also become the world’s largest single repository
of ultrasound-related educational materials. With
over 450 streaming video lectures by the most
widely recognized authorities in the world, clinical cases, textbook chapters, and a wide range of
other educational and informational materials, all
20 How toUse Surgical Ultrasound inResource-Limited Settings
https://t.me/medicina_free
223
free and readily accessible from anywhere in the
world, SonoWorld is an excellent resource for
basic and continuing education in ultrasound.
The explosion of telehealth options in the
developed world is relevant to at least the issues
of training and credentialing, as well as ongoing
skills assessment. It has been suggested that
images captured by non-physicians can theoretically be remotely transmitted to physicians anywhere in the world and successfully utilized to
expand care [69] and assure quality control.
Although randomized control studies are scarce
for this scenario, one might argue that rapid
adoption in parallel to data acquisition and analysis is reasonable given the extreme lack of
resources in certain parts of the world.
Equipment Acquisition
In addition to access to operator training, equipment acquisition and maintenance can be a barrier to adoption of ultrasound in
resource-challenged settings. This is due in part
to nancial constraints and in part to general lack
of infrastructure and support. Fortunately, a
growing movement among ultrasound equipment
manufacturers is the development of lower-cost,
“pared-down” equipment targeted to the developing world [70].
The Buttery Network, a Connecticut-based
company, launched its portable ultrasound prototype known as the Buttery iQ in 2017 (https://
www.butterynetwork.com). The device costs
approximately $2400 and is around the same size
as a cell phone. The company’s founder, Jonathan
Rothberg, has donated scanners to multiple lowincome countries as part of its Global Health
Program, partnering with organizations such as
Access Afya, Bridge to Health, MedGlobal,
NYAGI, and others. The organization also has
backing from external supporters such as USAID
(United States Agency for International
Development) and the Bill and Melinda Gates
Foundation to help further its reach.
Installed in over 100 countries, GE
Healthcare’s Vscan also offers an affordable and
portable solution for remote and resource-limited
areas (https://handheldultrasound.gehealthcare.
com). Starting at around $4500, the basic unit
comprises of a wireless, two-sided probe coupled
with a display the size of a smartphone.
California-based SonoQue offers a range of
solutions in the form of iPhone/iPad-compatible
transducers ranging from $1350 to $4400 (https://
www.sonoque.com). Each wireless transducer
relies on built-in WiFi, so no access to the Internet
is necessary. Multiple probes are available to
choose from, including a premium dual-head
probe for maximum exibility.
Clarius has developed a similar wireless probe
technology compatible with both Apple and
Android devices (https://www.clarius.com). This
unit has been cleared for sale in many countries
throughout the world, including developing
nations. The units start at around $3000 and
include a unique “endocavity” option. Purchase
includes 60 min of 1:1 instruction; buying the
membership option includes in-app video tutorials and availability of second opinion via
telemedicine.
Similarly, Philips, a leader in hospital-based
systems, offers its own portable ultrasound platform in Lumify (https://www.usa.philips.com/
healthcare/sites/lumify/tele- ultrasound- solution).
Here they partnered with (and recently acquired)
Innovative Imaging Technologies Inc. (IIT),
which developed a real-time collaborative teleultrasound solution (Reacts). The user of the
Lumify system can interact with other Reacts
users to share imaging data and seek advice as
they are scanning the patient. Multiple different
probes are available that connect to a range of
compatible tablets including iPads and iPhones.
Summary
Although potentially daunting to the initiate, the
adoption of ultrasound in various practices of
surgery is an invaluable investment. In combination with online learning and through cooperation with clinical colleagues in other departments,
regions, and countries, training, competency, and
certication are possible. Equipment that is at a
reasonable price point is readily available and
224
https://t.me/medicina_free
B. A. Schrope et al.
often comes with online training and support.
Surgeons of various specialties should strongly
consider acquiring ultrasound skills and integrating it into their practice, no matter the setting
they practice, for pre-, intra-, and postoperative
care of their patients.
References
1. McQueen AS, Bhatia KS.Head and neck ultrasound:
technical advances, novel applications and the role of
elastography. Clin Radiol. 2018;73(1):81–93.
2. Haugen B, Alexander E, Bible K, etal. 2015 American
Thyroid Association management guidelines for adult
patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1–133.
3. Papini E, Guglielmi R, Bianchini A, etal. 2002 Risk
of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab. 2002;87:1941–6.
4. Kwak JY, Han KH, Yoon JH, et al. Thyroid imaging
reporting and data system for US features of nodules:
a step in establishing better stratication of cancer
risk. Radiology. 2011;260:892–9.
5. Moon WJ, Jung SL, Lee JH, etal. Benign and malignant thyroid nodules: US differentiation—multicenter
retrospective study. Radiology. 2008;247:762–70.
6. Horvath E, Majlis S, Rossi R, Franco C, Niedmann JP,
Castro A.An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. J Clin Endocrinol Metab. 2009;94:1748–51.
7. Tae HJ, Lim DJ, Baek KH, etal. Diagnostic value of
ultrasonography to distinguish between benign and
malignant lesions in the management of thyroid nodules. Thyroid. 2007;17:461–6.
8. Shimura H, Haraguchi K, Hiejima Y, et al. Distinct
diagnostic criteria for ultrasonographic examination
of papillary thyroid carcinoma: a multicenter study.
Thyroid. 2005;15:251–8.
9. Tessler FN, Middleton WD, Grant EG, etal. ACR thyroid imaging, reporting and data system (TI-RADS):
white paper of the ACR TI-RADS committee. J Am
Coll Radiol. 2017;14:587–95.
10. Nam-Goong IS, Kim HY, Gong G, et al.
Ultrasonography-guided ne- needle aspiration of
thyroid incidentaloma: correlation with pathological
ndings. Clin Endocrinol. 2004;60:21–8.
11. Huang BL, Ebner SA, Makkar JS, Bentley-Hibbert S,
McConnell RJ, Lee JA, Hecht EM, Kuo JH.A multidisciplinary head-to-head comparison of American
College of Radiology Thyroid Imaging and Reporting
Data System and American Thyroid Association
ultrasound risk stratication systems. Oncologist.
2020;25:398–403.
12. Hamming JF, Goslings BM, van Steenis GJ, van
Ravenswaay CH, Hermans J, Van de Velde CJ. The
value of ne-needle aspiration biopsy in patients with
nodular thyroid disease divided into groups of suspicion of malignant neoplasms on clinical grounds.
Arch Intern Med. 1990;150:113–6.
13. Seim NB, Wood CB, Yancey KL, Mannion K,
Netterville JL. Head and neck ultrasound in otolaryngology surgical missions. Ear Nose Throat J.
2019;98:535–6.
14. Brito JP, Gionfriddo MR, Al NA, et al. The accuracy of thyroid nodule ultrasound to predict thyroid
cancer: systematic review and meta-analysis. J Clin
Endocrinol Metab. 2014;99:1253–63.
15. Sung JY. Parathyroid ultrasonography: the evolving role of the radiologist. Ultrasonography.
2015;34:268–74.
16. Lubitz CC, Stephen AE, Hodin RA, Pandharipande
P. Preoperative localization strategies for primary
hyperparathyroidism: an economic analysis. Ann
Surg Oncol. 2012;19:4202–9.
17. Solorzano CC, Carneiro-Pla DM, Irvin GL 3rd.
Surgeon-performed ultrasonography as the initial and
only localizing study in sporadic primary hyperparathyroidism. J Am Coll Surg. 2006;202:18–24.
18. Stack B, Moreno M.Neck dissection. 1st ed. 2018.
19. Frasoldati A, Valcavi R.Challenges in neck ultrasonography: lymphadenopathy and parathyroid glands.
Endocr Pract. 2004;10:261–8.
20. Kuna SK, Bracic I, Tesic V, Kuna K, Herceg GH,
Dodig D.Ultrasonographic differentiation of benign
from malignant neck lymphadenopathy in thyroid
cancer. J Ultrasound Med. 2006;25:1531–7.
21. Leboulleux S, Girard E, Rose M, et al. Ultrasound
criteria of malignancy for cervical lymph nodes in
patients followed up for differentiated thyroid cancer.
J Clin Endocrinol Metab. 2007;92:3590–4.
22. Kuo JH, McManus C, Graves CE, Madani A, Khokhar
MT, Huang B, Lee JA.Updates in the management of
thyroid nodules. Curr Probl Surg. 2019;56:103–27.
23. Becker D, Tafoya C, Becker S, Kruger G, Tafoya
M, Becker T.The use of portable ultrasound devices
in low- and middle- income countries: a systematic review of the literature. Trop Med Int Health.
2016;21:294–311.
24. Beal E, Sigmond B, Sage-Silski L, Lahey S, Nguyen
V, Bahner D. Point-of-care ultrasound in general surgery residency training. J Ultrasound Med.
2017;36:2577–84.
25. American Institute of Ultrasound in Medicine
Training Guidelines for Physicians who evaluate and
interpret diagnostic thyroid, parathyroid, and neck
ultrasound examinations. Ofcial Statement; 2019.
www.aium.org
26. Broach RB, Geha R, Englander BS, DeLaCruz L,
Thrash H, Brooks AD. A cost-effective handheld
breast scanner for use in low-resource environments: a validation study. World J Surg Oncol. 2016;
14(1):277.
27. Sood R, Rositch AF, Shakoor D, etal. Ultrasound for
breast cancer detection globally: a systematic review
and meta-analysis. J Glob Oncol. 2019;5:1–17.
Соседние файлы в папке Библиотека им академика М.И. Перельмана