The authors have no acknowledgments.

The protocol was performed in accordance with the ethical guidelines of the University of Malaya Medical Center. Written consent was obtained, and a detailed explanation of the procedure was provided to the patient. Permission was also granted to produce the video of the procedure for educational purposes.
1. Positioning and sedation
<ol>
	<li>Place the patient in a prone position. Provide moderate sedation using intravenous infusion of Propofol. Ensure the infusion is titrated by the anesthetist.</li>
</ol>
2. Identifying the suitable target dilated left intrahepatic ducts
<ol>
	<li>Advance the linear echoendoscope making sure it passes the gastro-esophageal junction.</li>
	<li>Place the tip of the echoendoscope at the lesser curvature of the gastric cavity and proceed to identify the dilated left intrahepatic duct (IHD).</li>
	<li>Perform fluoroscopic imaging to ascertain the position of the echoendoscope. The tip of the echoendoscope must be placed at the lesser curvature of the gastric cavity, as stated previously. Always maintain the echoendoscope position and stabilize with periodic checks using fluoroscopic imaging throughout the procedure.</li>
	<li>Identify the dilated segment 3 IHD. Slightly tilt the angle of the tip of the echoendoscope upward to facilitate the next step in needle puncture. 
	&#8203;NOTE: Subsequent steps of the procedure involve inserting and exchanging of accessories via the working channel of the echoendoscope throughout the procedure.</li>
</ol>
3. Needle access into the targeted dilated left intrahepatic duct
<ol>
	<li>Perform Doppler ultrasound to ensure that there are no intervening blood vessels around the targeted IHD.</li>
	<li>Using a 19 G needle, puncture the segment 3 IHD (Figure 2A). Using a 10 mL syringe preloaded with 7 mL of the contrast solution, gently aspirate the bile solution, this was to confirm the success of biliary access.</li>
	<li>Following that, perform contrast injection to opacify the left IHD and the rest of the biliary system.</li>
</ol>
4. Guidewire manipulation
<ol>
	<li>Use a 0.025-inch guidewire to navigate into the left IHD under the fluoroscopic guidance.</li>
	<li>Cannulate the guidewire across into the right intrahepatic duct (Figure 2B). 
	&#8203;NOTE: Ideally, the guidewire should be manipulated deep into the common bile duct; however, it was not possible in this case due to the obstructing hilar tumor.</li>
</ol>
5. Fistula tract dilation
<ol>
	<li>Dilate the fistula tract using a 6 Fr electrocautery dilator in addition to using a 4 mm biliary balloon dilator (Figure 2C). 
	NOTE: Fistula tract dilation is required to facilitate insertion of the biliary stent later.</li>
	<li>Perform balloon inflation for approximately 5 s. 
	NOTE: While doing these, monitor the position of the accessories monitored using both the sonographic and fluoroscopic image, ensuring that the wire is visible and the echoendoscope position is maintained. This is done to ensure a smooth transition during the exchange of accessories which is very important.</li>
</ol>
6. Stent insertion and deployment
<ol>
	<li>Deploy a 10 mm sized partially covered biliary stent (length of 10 cm) under fluoroscopic guidance (Figure 3A). 
	NOTE: The stent has a 3 cm uncovered distal portion and a 7 cm covered proximal portion. The uncovered part must be within the intrahepatic duct (Figure 3C). Approximately 3 cm of the covered part of the stent is left in the gastric cavity to prevent inward migration of the stent (Figure 3B).</li>
	<li>Ensure that the distal end of the stent opens in the IHD. Deploy the proximal end within the working channel of the echoendoscope and subsequently release into the stomach with bile seen flowing within the stent.</li>
</ol>

The authors have nothing to disclose.

The above case description illustrates the possibility of using EUS-HGS as an alternative biliary drainage method in the management of biliary tract malignancies compared to existing methods such as ERCP and PTBD. Among the steps described above, identifying, and accessing the correct intrahepatic duct, guidewire manipulation, and stent deployment are the three main crucial steps in ensuring that the procedure can be performed successfully and safely.
In choosing the ideal liver segment for bi...

Patients with malignant biliary obstruction are often unresectable and advanced at presentation1,2. As a result, palliative endoscopic biliary decompression is often needed in managing these cases3,4,5. According to current recommendations, Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary method of biliary drainage, whenever possible, and if this fails or is contraindicated, Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method6,7,8. However, there are certain complications associated with PTBD, which include septicemia, cholangitis, bleeding, electrolyte lost, leakage, wound infection, local discomfort; these complications are reported to be as high as 53.2%9. The emergence of Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method to address this gap. The principal technique of EUS-BD involves the use of endosonographic imaging to guide access to the biliary system via the gastrointestinal tract to provide therapeutic decompression of an obstructed biliary system.
EUS-BD was first performed in 2001, and since then, this method of biliary drainage has evolved over the years10. Methods of EUS-BD commonly are EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided Anterograde stenting (EUS-AS), and EUS-guided Rendezvous (EUS-RV)11,12. To date, the indications for EUS-BD include patients who have failed ERCP, patients having an inaccessible papilla by duodenal obstruction, and patients with altered surgical anatomy13,14,15.
EUS-HGS involves transmural drainage of the left intrahepatic duct into the stomach. The main advantage is that it provides internal drainage, which is more physiological and, most of all, offers better patients&#39; comfort compared to PTBD12,16. This method is feasible for both hilar and distal malignant biliary obstruction. Here, we describe the technique of EUS-HGS as one of the methods of EUS-BD in a case of unresectable malignant hilar tumor.
A 71-year-old female was presented with painless jaundice and had a weight loss of 4 kg in 2 weeks duration. On examination, she was found to have scleral jaundice. Abdominal examination was unremarkable. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor involving the bifurcation of the right hepatic duct, the confluence of hepatic ducts and extrahepatic ducts, causing marked intrahepatic duct dilatation with lymphadenopathy and liver metastasis (Figure 1A). EUS fine needle biopsy (FNB) of the lesion was performed and it showed adenocarcinoma with positive CK7 and CA19-9 which was consistent with the diagnosis of hilar cholangiocarcinoma (Figure 1B). Her bilirubin levels were 212 &#181;mol/L (&#60;15) at presentation and CA19-9 levels were 305 U/mL. EUS-HGS was performed to provide relief in the biliary obstruction.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>10mm in size, 10cm in length Partially Covered Metallic Stent</td>
			<td>M.I Tech</td>
			<td>BPD10100-E180</td>
			<td></td>
		</tr>
		<tr>
			<td>Curved Linear Echoendoscopy</td>
			<td>Fujifilm</td>
			<td>EG-580UT</td>
			<td></td>
		</tr>
		<tr>
			<td>Electrocautary Dilator, 6Fr</td>
			<td>G-Flex</td>
			<td>CYSTO06U</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoscopic Ultrasound System Processor</td>
			<td>Fujifilm</td>
			<td>SU-1</td>
			<td></td>
		</tr>
		<tr>
			<td>Expect 19-guage FNA Needle</td>
			<td>Boston Scientific</td>
			<td>M00555500</td>
			<td></td>
		</tr>
		<tr>
			<td>Hurricane Biliary Balloon Dilator, 4mm</td>
			<td>Boston Scientific</td>
			<td>M00545900</td>
			<td></td>
		</tr>
		<tr>
			<td>Visiglide 0.025-inch Guidewire, 4500mm in length</td>
			<td>Olympus</td>
			<td>G-240-2545S</td>
			<td></td>
		</tr>
	</tbody>
</table>

endoscopic ultrasound-guided biliary drainage: endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage.
Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 &#181;mol/L (&lt;15) during presentation.
A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 &#181;mol/L and 14 &#181;mol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

The procedure was completed in approximately 30 min. There were no complications after the procedure and the patient was able to resume oral intake the next day. The bilirubin levels fell to 92 &#181;mol/L and she was discharged three days after the procedure. A repeated CT imaging was done which showed the stent in position with a resolution of biliary obstruction. The bilirubin level on the follow-up was 30 &#181;mol/L after 2 weeks post procedure and 14 &#181;mol/L at 4 weeks post procedure (Table 1)....

Watch this Scientific Journal Video about Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction at JoVE.com

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) is an alternative method of biliary decompression in malignant biliary obstruction. Here we describe the technique of EUS guided-Hepaticogastrostomy (EUS-HGS) in a case of unresectable malignant hilar biliary obstruction.

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde ...

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5.5K Views.  University of Malaya. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) is an alternative method of biliary decompression in malignant biliary obstruction. Here we describe the technique of EUS guided-Hepaticogastrostomy (EUS-HGS) in a case of unresectable malignant hilar biliary obstruction.

Video: Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

Ultrasound-guided Transthoracic Intramyocardial Injection in Mice

Murine models of cardiovascular disease are important for investigating pathophysiological mechanisms and exploring potential regenerative therapies. Experiments involving myocardial injection are currently performed by direct surgical access through a thoracotomy. While convenient when performed at the time of another experimental manipulation such as coronary artery ligation, the need for an invasive procedure for intramyocardial delivery limits potential experimental designs. With ever improving ultrasound resolution and advanced noninvasive imaging modalities, it is now feasible to routinely perform ultrasound-guided, percutaneous intramyocardial injection. This modality efficiently and reliably delivers agents to a targeted region of myocardium. Advantages of this technique include the avoidance of surgical morbidity, the facility to target regions of myocardium selectively under ultrasound guidance, and the opportunity to deliver injectate to the myocardium at multiple, predetermined time intervals. With practiced technique, complications from intramyocardial injection are rare, and mice quickly return to normal activity on recovery from anesthetic. Following the steps outlined in this protocol, the operator with basic echocardiography experience can quickly become competent in this versatile, minimally invasive technique.

Echocardiography-guided percutaneous intramyocardial injection represents an efficient, reliable, and targetable modality for the delivery of gene transfer agents or cells into the murine heart. Following the steps outlined in this protocol, the operator can quickly become competent in this versatile, minimally invasive technique.

Murine models of cardiovascular disease are important for investigating pathophysiological mechanisms and exploring potential regenerative therapies. ...

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the lack of a standardized definition for STG. Biopsy is often required to differentiate benign from malignant lesions. Unlike cervical thyroid, the overlying sternum precludes ultrasound-guided percutaneous fine needle aspiration of STG. Consequently, surgical mediastinoscopy is performed in the majority of cases, causing significant procedure related morbidity and cost to healthcare. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a frequently used procedure for diagnosis and staging of non-small cell lung cancer (NSCLC). Minimally invasive needle biopsy for lesions adjacent to the airways can be performed under real-time ultrasound guidance using EBUS. Its safety and efficacy is well established with over 90% sensitivity and specificity. The ability to perform EBUS as an outpatient procedure with same-day discharges offers distinct morbidity and financial advantages over surgery. As physicians performing EBUS gained procedural expertise, they have attempted to diversify its role in the diagnosis of non-lymph node thoracic pathologies. We propose here a role for EBUS-TBNA in the diagnosis of substernal thyroid lesions, along with a step-by-step protocol for the procedure.

Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea

Neurological diseases can be complicated by sialorrhea, an excessive flow of saliva. Patients suffering from moderate to severe sialorrhea have an impaired quality of life, often worsened by correlated complications such as aspiration pneumonia, oral infections, dental caries, and maceration of the skin. Diverse therapeutic approaches have been proposed for the treatment of sialorrhea, including surgery and the use of anticholinergic agents, with limited results and the possible occurrence of serious adverse events. Recently, botulinum toxin (BoNT) injection within the major salivary glands has been proposed in patients refractory to anticholinergic therapy, with the aim of inhibiting local acetylcholine release and gland activity. 
In order to obtain a better outcome in terms of reduction of saliva production, efficacy, duration, and avoidance of major adverse events, we developed an ultrasound-guided BoNT-type A injection technique accurately described in the text. Here we present a method of treating sialorrhea with bilateral parotid and submandibular gland BoNT-type A injections under ultrasound guidance. Four quadrants of the parotid gland and two quadrants of the submandibular gland are visualized and injected using two accesses and one access, respectively. 
The ultrasound-guided procedure provides a simple, non-invasive, real-time visualization of the muscular and glandular tissues and their surrounding structures, optimizing treatment efficacy and safety.

Botulinum toxin is injected into the salivary glands for the treatment of sialorrhea. The ultrasound-guided botulinum toxin injection in both the parotid and submandibular glands demonstrates a sustained efficacy and the absence of serious side effects.

Neurological diseases can be complicated by sialorrhea, an excessive flow of saliva. Patients suffering from moderate to severe sialorrhea have an ...

Ultrasound-guided Intracardiac Injection of Human Mesenchymal Stem Cells to Increase Homing to the Intestine for Use in Murine Models of Experimental Inflammatory Bowel Diseases

Crohn&#39;s disease (CD) is a common chronic inflammatory disease of the small and large intestines. Murine and human mesenchymal stem cells (MSCs) have immunosuppressive potential and have been shown to suppress inflammation in mouse models of intestinal inflammation, even though the route of administration can limit their homing and effectiveness 1,3,4,5. Local application of MSCs to colonic injury models has shown greater efficacy at ameliorating inflammation in the colon. However, there is paucity of data on techniques to enhance the localization of human bone marrow-derived MSCs (hMSCs) to the small intestine, the site of inflammation in the SAMP-1/YitFc (SAMP) model of experimental Crohn&#39;s disease. This work describes a novel technique for the ultrasound-guided intracardiac injection of hMSCs in SAMP mice, a well-characterized spontaneous model of chronic intestinal inflammation. Sex- and age-matched, inflammation-free AKR/J (AKR) mice were used as controls. To analyze the biodistribution and the localization, hMSCs were transduced with a lentivirus containing a triple reporter. The triple reporter consisted of firefly luciferase (fl), for bioluminescent imaging; monomeric red fluorescent protein (mrfp), for cell sorting; and truncated herpes simplex virus thymidine kinase (ttk), for positron emission tomography (PET) imaging. The results of this study show that 24 h after the intracardiac administration, hMSCs localize in the small intestine of SAMP mice as opposed to inflammation-free AKR mice. This novel, ultrasound-guided injection of hMSCs in the left ventricle of SAMP mice ensures a high success rate of cell delivery, allowing for the rapid recovery of mice with minimal morbidity and mortality. This technique could be a useful method for the enhanced localization of MSCs in other models of small-intestinal inflammation, such as TNF&#916;RE6. Future studies will determine if the increased localization of hMSCs by intra-arterial delivery can lead to increased therapeutic efficacy.

Murine studies in models of colonic inflammation have demonstrated that a small percentage (1 - 5%) of mesenchymal stem cells (MSC) injected intravenously or intraperitoneally home to the inflamed colon1,2. This study shows that ultrasound-guided intracardiac injections of MSCs result in increased localization to the intestine.

Crohn&#39;s disease (CD) is a common chronic inflammatory disease of the small and large intestines. Murine and human mesenchymal stem cells (MSCs) have ...

International Expert Consensus and Recommendations for Neonatal Pneumothorax Ultrasound Diagnosis and Ultrasound-guided Thoracentesis Procedure

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic compromise, a life-threatening disorder. Traditionally, neonatal pneumothorax diagnosis has been based on clinical images, auscultation, transillumination, and chest X-ray findings. This approach may potentially lead to a delay in both diagnosis and treatment. The use of lung US in diagnosis of PTX together with US-guided thoracentesis results in earlier and more precise management. The recommendations presented in this publication are aimed at improving the application of lung US in guiding neonatal PTX diagnosis and management.

Pneumothorax is a common emergency and critical disease in newborn infants that needs rapid, clear diagnosis and timely treatment. Diagnosis and treatment based on chest X-rays are associated with delayed management and radiation damage. Lung ultrasound (US) provides useful guidance for rapid, accurate diagnosis and the precise thoracentesis of pneumothorax.

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic ...

Endoscopic Cholesteatoma Surgery

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.

The present protocol describes a step-by-step guide for the complete endoscopic removal of epitympanic cholesteatoma with different techniques for cholesteatoma dissection and bone removal for epitympanectomy.

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. ...

Ultrasound-Guided Induced Pluripotent Stem Cell-Derived Cardiomyocyte Implantation in Myocardial Infarcted Mice

The key objective of cell therapy after myocardial infarction (MI) is to effectively enhance the cell grafted rate, and human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) are a promising cell source for cardiac repair after ischemic damage. However, a low grafted rate is a significant obstacle for effective cardiac tissue regeneration after transplantation. This protocol shows that multiple hiPSC-CM ultrasound-guided percutaneous injections into an MI area effectively increase cell transplantation rates. The study also describes the entire hiPSC-CM culture process, pretreatment, and ultrasound-guided percutaneous delivery methods. In addition, the use of human mitochondrial DNA help detect the absence of hiPSC-CMs in other mouse organs. Lastly, this paper describes the changes in cardiac function, angiogenesis, cell size, and apoptosis at the infarcted border zone in mice 4 weeks after cell delivery. It can be concluded that echocardiography-guided percutaneous injection of the left ventricular myocardium is a feasible, relatively invasive, satisfactory, repeatable, and effective cellular therapy.

Ultrasound-guided cell delivery around the site of myocardial infarction in mice is a safe, effective, and convenient way of cell transplantation.

The key objective of cell therapy after myocardial infarction (MI) is to effectively enhance the cell grafted rate, and human induced pluripotent stem ...

A Comprehensive Step-By-Step Guide for Exclusive Endoscopic Ossiculoplasty

Techniques of Endoscopic Ossiculoplasty

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This technique offers a panoramic view of the middle ear and provides an optimal magnification of the oval window region, the stapes' suprastructure, and the footplate, allowing great precision in prosthesis positioning during ossiculoplasty (OPL). Various techniques for ossicular chain reconstruction have been described in the literature. Either autologous or synthetic materials can be used for reconstruction. The use of a patient's own tissue minimizes the risk of implant rejection or extrusion of the prosthesis through the tympanic membrane. On the other hand, synthetic materials like titanium are light and rigid and do not require time-consuming prosthesis remodeling. The main objective of this article is to present a comprehensive step-by-step guide that serves as a surgical manual for exclusive endoscopic OPL. This guide will explain various forms of OPL using synthetic and autologous materials. The goal is to provide a comprehensive understanding of the various surgical techniques and support the integration into clinical practice.

Author Spotlight: Advancing Endoscopic Ossiculoplasty &#8211; Techniques, Innovations, and Practical Guidance for Clinical Integration

Exclusive Endoscopic ossiculoplasty (EEO) is a promising and minimally invasive approach for the treatment of conductive hearing loss due to ossicular chain disruptions and associated middle ear pathologies. Herein, step-by-step instructions and a discussion of various endoscopic ossiculoplasty techniques are presented.

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This ...

Building Custom Ballistic Gel Ultrasound Phantoms for Nerve Block Simulations

Building Affordable, Durable, Medium-Fidelity Ballistic Gel Phantoms for Ultrasound-Guided Nerve Block Training

Ultrasound phantoms - alternatives to live human tissue - give learners the opportunity to practice ultrasound-guided regional anesthesia without introducing undue risk to patients. Gelatin-based phantoms provide educators with durable and reusable task trainers; however, commercially available gel-based phantoms are expensive. Here, we investigate the production of durable, low-cost, ballistic gel-based ultrasound phantoms for median, femoral, suprainguinal fascia iliaca plane, and serratus anterior plane nerve blocks, as well as a methodology for producing a phantom for any ultrasound-guided nerve block procedure.
Computer-aided design (CAD) software was utilized to design four phantoms replicating the anatomy of median, femoral, suprainguinal fascia iliaca plane, and serratus anterior plane nerve blocks, including relevant landmarks and tissue planes. Plastic models of the desired tissue planes were 3D printed and used to create silicone molds. Ballistic gel was melted and mixed with flour and dye to create a liquid, echogenic ballistic gel, which was poured into the silicone molds. Vessels were simulated by creating negative space in the ballistic gel using metal rods. Nerves were simulated using yarn submerged in ultrasound gel. Simulated bones were designed using CAD and 3D printed.
Ballistic gel is a versatile, durable medium that can be used to simulate a variety of tissues and can be melted and molded into any shape. Under ultrasound, these phantoms provide realistic tissue planes that represent the borders between different layers of skin, muscle, and fascia. The echogenicity of the muscle tissue layers, nerves, vessels, and bones is realistic, and bones have significant posterior shadowing as would be observed in a human subject. These phantoms cost $200 each for the first phantom and $60 for each subsequent phantom. These phantoms require some technical skill to design, but they can be built for just 4% of the cost of their commercial counterparts.

Author Spotlight: Developing Cost-Effective and Durable Ultrasound-Guided 3D-Printed Nerve Block Trainers

Here, we demonstrate the design and creation of four custom ballistic gelatin ultrasound phantoms for ultrasound-guided regional anesthesia training. We designed the phantoms using computer-aided design software, used 3D-printed models to create silicone molds, and then poured melted ballistic gel into the molds to create custom tissue layers.

Ultrasound phantoms - alternatives to live human tissue - give learners the opportunity to practice ultrasound-guided regional anesthesia without ...

Managing Knee Osteoarthritis Using Ultrasound-Guided Acupotomy

Clinical Effects of Ultrasound-Guided Acupotomy in Knee Osteoarthritis Treatment

The protocol presented here demonstrates the operation method of ultrasound-guided acupotomy for knee osteoarthritis (KOA), including patient recruitment, preoperative preparation, manual operation, and postoperative care. The purpose of this protocol is to relieve pain and improve knee function in patients with KOA. A total of 60 patients with KOA admitted between June 2022 and June 2023 were treated with ultrasound-guided acupotomy. Pathological changes and knee function scores were compared before and after the treatment. After 1 week of treatment, the synovial thickness of the suprapatellar bursae was significantly lesser than before treatment (p &lt; 0.05), the Hospital for Special Surgery Knee Score (HSS) was significantly higher than before treatment (p &lt; 0.05), the Visual analogue scale (VAS) was significantly lower than those of the control group (p &lt; 0.05) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were significantly lower than those of the control group (p &lt; 0.05). Therefore, ultrasound-guided acupotomy for the treatment of KOA can reduce synovial thickness, relieve pain, improve knee joint function, and have a remarkable curative effect.

Author Spotlight: Minimally Invasive Ultrasound-Guided Acupotomy in Knee Osteoarthritis Treatment

This paper introduces the operation method of ultrasound-guided acupotomy for knee osteoarthritis, which can reduce synovial thickness and improve knee joint function. It has the advantages of precise target, low treatment risk, few complications, and high safety.

The protocol presented here demonstrates the operation method of ultrasound-guided acupotomy for knee osteoarthritis (KOA), including patient recruitment, ...