Metamaterial MRI-based sensor for the post-operative monitoring of colorectal anastomosis

Anastomotic leakage (AL) is the leading cause of morbidity and mortality after bowel anastomosis, a surgical procedure used to restore luminal continuity after bowel tumour resection. Even after years of research, its occurrence has not decreased, and new methods of monitoring the wound and predicting anastomotic failure are therefore urgently required. Here we propose the use of an internal coil to increase the signal-to-noise ratio (SNR) during Magnetic Resonance Imaging (MRI ) and/or Spectroscopy (MRS). Both methods may be used to identify ischemia and oedema, considered to be clinical indications of AL. The annular nature of the anastomotic surgical wound suggests the use of a coil with an annular field-of view, mounted on a Biodegradable Anastomosis Ring (BAR), a surgical device commonly used as a temporary mechanical support that is fragmented and excreted from the body after wound healing. The proposed solution is a Magneto-Inductive (MI) ring resonator, based on a set of magnetically coupled L-C resonators. Its advantages are that its separate elements fit comfortably inside the BAR, are not mechanically connected, and consequently may be fragmented and excreted with the BAR itself. A coupled pair of 8-element MI ring resonators is proposed, operating on an anti-symmetric spatial mode to avoid coupling to the B1 field during the excitation phase of MRI. However, the electrical response of an early prototype shows that insufficient rejection of uniform fields is achieved using the most obvious arrangement. Therefore, a search of the effect of design parameters on the spectra of resonant modes supported by the electrical system is carried out to identify an arrangement offering improved decoupling. A suitable design is developed, based on physical overlap between adjacent elements in the same ring, which alters the sign and magnitude of a key magnetic coupling coefficient. MRI fields-of-view are theoretically estimated for several different arrangements for signal extraction, including devices that are mutually coupled to an external read coil and directly coupled devices. Difficulties with combining mutual coupling and B1 field rejection are identified, and wired connections are proposed as a solution. It is found that a device with a single such connection gives a sensitivity pattern with partial symmetry, whereas a quadrature tap restores full symmetry. In vitro 1H MRI is then carried out at 1.5 T and 3.0 T using agar gel immersion phantoms, both for mutually coupled systems and for directly coupled systems. As expected, mutual coupling is found to be an unsuitable readout method for a device operating on its anti-symmetric mode, but does allow analysis of the effectiveness of B1 field decoupling. Directly coupled devices operate essentially as expected, providing up to 15-fold local enhancement in SNR, compared to the system body coil.Open Acces

Study of the Behavior of a Bell-Shaped Colonic Self-Expandable NiTi Stent under Peristaltic Movements

Managing bowel obstruction produced by colon cancer requires an emergency intervention to patients usually in poor conditions, and it requires creating an intestinal stoma in most cases. Regardless of that the tumor may be resectable, a two-stage surgery is mandatory. To avoid these disadvantages, endoscopic placement of self-expanding stents has been introduced more than 10 years ago, as an alternative to relieve colonic obstruction. It can be used as a bridge to elective single-stage surgery avoiding a stoma or as a definitive palliative solution in patients with irresectable tumor or poor estimated survival. Stents must be capable of exerting an adequate radial pressure on the stenosed wall, keeping in mind that stent must not move or be crushed, guaranteeing an adequate lumen when affected by peristaltic waves. A finite element simulation of bell-shaped nitinol stent functionality has been done. Catheter introduction, releasing at position, and the effect of peristaltic wave were simulated. To check the reliability of the simulation, a clinical experimentation with porcine specimens was carried out. The stent presented a good deployment and flexibility. Stent behavior was excellent, expanding from the very narrow lumen corresponding to the maximum peristaltic pressure to the complete recovery of operative lumen when the pressure disappears

Ex vivo experimental investigations and modelling of the layer-dependent, anisotropic, visco-hyperelastic behaviour of the human oesophagus

As a mechanical organ, the material properties of the oesophagus are integral to its function. The quantification of these properties is necessary to investigate the organ’s pathophysiology and is required for a range of applications including medical device design, surgical simula-tions and tissue engineering. However, according to a systematic review of mechanical exper-imentation conducted on the gastrointestinal organs, the discrete layer-dependent properties of the oesophagus have not been investigated using human tissue, especially regarding its vis-coelastic and stress-softening behaviour. Therefore, extensive experimentation was conducted to determine the time, layer and direction-dependent material response of the oesophagus us-ing cadaveric human tissue. The residual strains of the organ were also considered via opening angle experiments. Overall, the results showed distinct properties in each layer, highlighting the importance of treating the oesophagus as a multi-layered composite material. Furthermore, a strong anisotropy was exhibited across both layers, where the longitudinal directions were much stiffer than the circumferential directions. Due to the COVID-19 pandemic, fresh human cadavers were not available from the anatomy laboratory for a considerable amount of time. Therefore, mechanical testing was first completed on embalmed human tissue and then, once available, on fresh human tissue. This unforeseen circumstance, through comparison of the two preservation states, allowed for an interesting discussion on the role of the tissue’s con-stituents on its complex material behaviour. In addition, histological analysis was carried out to determine the density of the oesophagus’ most mechanically relevant fibres: collagen and elastin. This knowledge was then used to inform constitutive modelling of the soft tissue’s behaviour, the outcome of which was able to capture the anisotropy, visco-hyperelasticity and stress-softening observed in the experimental data

Virgin Passive Colon Biomechanics and a Literature Review of Active Contraction Constitutive Models

The objective of this paper is to present our findings on the biomechanical aspects of the virgin passive anisotropic hyperelasticity of the porcine colon based on equibiaxial tensile experiments. Firstly, the characterization of the intestine tissues is discussed for a nearly incompressible hyperelastic fiber-reinforced Holzapfel–Gasser–Ogden constitutive model in virgin passive loading conditions. The stability of the evaluated material parameters is checked for the polyconvexity of the adopted strain energy function using positive eigenvalue constraints of the Hessian matrix with MATLAB. The constitutive material description of the intestine with two collagen fibers in the submucosal and muscular layer each has been implemented in the FORTRAN platform of the commercial finite element software LS-DYNA, and two equibiaxial tensile simulations are presented to validate the results with the optical strain images obtained from the experiments. Furthermore, this paper also reviews the existing models of the active smooth muscle cells, but these models have not been computationally studied here. The review part shows that the constitutive models originally developed for the active contraction of skeletal muscle based on Hill’s three-element model, Murphy’s four-state cross-bridge chemical kinetic model and Huxley’s sliding-filament hypothesis, which are mainly used for arteries, are appropriate for numerical contraction numerical analysis of the large intestine

A comparative study of hyperelastic constitutive models for colonic tissue fitted to multiaxial experimental testing

For colonic stents design, the interaction with colonic tissue is essential in order to characterize the appropriate radial stiffness which provides a minimum lumen for intestinal transit to be maintained. It is therefore important to develop suitable constitutive models allowing the mechanical behavior of the colon tissue to be characterized. The present work investigates the biomechanical behavior of colonic tissue by means of biaxial tests carried out on different parts of the colonic tract taken from several porcine specimens. Samples from the colonic tract were quasi-statically tensioned using a load-controlled protocol with different tension ratios between the circumferential and the axial directions. Fitting techniques were then used to adjust specific hyperelastic models accounting for the multilayered conformation of the colonic wall and the fiber-reinforced configuration of the corresponding tissues. It was found that the porcine colon changed from a more isotropic to a more anisotropic tissue and became progressively more flexible and compliant in circumferential direction depending on the position along the duct as it approaches the rectum. The best predictive capability of mechanical behavior corresponds to the Four Fiber Family model showing mean values of coefficient of determination R2 ¼ 0:97, and a normalized root mean square error of eNRMS ¼ 0:0814 for proximal spiral samples, and R2 ¼ 0:89 ; eNRMS ¼ 0:1600 and R2 ¼ 0:94 ; eNRMS ¼ 0:1227 for distal spiral and descending colon samples, respectively. The other analyzed models provide good results for proximal spiral colon specimens, which have a lower degree of anisotropy. The analyzed models with the fitted elastic parameters can be used for more realistic and reliable FE simulations, providing the appropriate framework for the design of optimal devices for the treatment of colonic diseases

Medical Robotics

The first generation of surgical robots are already being installed in a number of operating rooms around the world. Robotics is being introduced to medicine because it allows for unprecedented control and precision of surgical instruments in minimally invasive procedures. So far, robots have been used to position an endoscope, perform gallbladder surgery and correct gastroesophogeal reflux and heartburn. The ultimate goal of the robotic surgery field is to design a robot that can be used to perform closed-chest, beating-heart surgery. The use of robotics in surgery will expand over the next decades without any doubt. Minimally Invasive Surgery (MIS) is a revolutionary approach in surgery. In MIS, the operation is performed with instruments and viewing equipment inserted into the body through small incisions created by the surgeon, in contrast to open surgery with large incisions. This minimizes surgical trauma and damage to healthy tissue, resulting in shorter patient recovery time. The aim of this book is to provide an overview of the state-of-art, to present new ideas, original results and practical experiences in this expanding area. Nevertheless, many chapters in the book concern advanced research on this growing area. The book provides critical analysis of clinical trials, assessment of the benefits and risks of the application of these technologies. This book is certainly a small sample of the research activity on Medical Robotics going on around the globe as you read it, but it surely covers a good deal of what has been done in the field recently, and as such it works as a valuable source for researchers interested in the involved subjects, whether they are currently “medical roboticists” or not

Nonlinear effects in finite elements analysis of colorectal surgical clamping

Minimal Invasive Surgery (MIS) is a procedure that has increased its applications in past few years in different types of surgeries. As number of application fields are increasing day by day, new issues have been arising. In particular, instruments must be inserted through a trocar to access the abdominal cavity without capability of direct manipulation of tissues, so a loss of sensitivity occurs. Generally speaking, the student of medicine or junior surgeons need a lot of practice hours before starting any surgical procedure, since they have to difficulty in acquiring specific skills (hand–eye coordination among others) for this type of surgery. Here is what the surgical simulator present a promising training method using an approach based on Finite Element Method (FEM). The use of continuum mechanics, especially Finite Element Analysis (FEA) has gained an extensive application in medical field in order to simulate soft tissues. In particular, colorectal simulations can be used to understand the interaction between colon and the surrounding tissues and also between colon and instruments. Although several works have been introduced considering small displacements, FEA applied to colorectal surgical procedures with large displacements is a topic that asks for more investigations. This work aims to investigate how FEA can describe non-linear effects induced by material properties and different approximating geometries, focusing as test-case application colorectal surgery. More in detail, it shows a comparison between simulations that are performed using both linear and hyperelastic models. These different mechanical behaviours are applied on different geometrical models (planar, cylindrical, 3D-SS and a real model from digital acquisitions 3D-S) with the aim of evaluating the effects of geometric non-linearity. Final aim of the research is to provide a preliminary contribution to the simulation of the interaction between surgical instrument and colon tissues with multi-purpose FEA in order to help the preliminary set-up of different bioengineering tasks like force-contact evaluation or approximated modelling for virtual reality (surgical simulations). In particular, the contribution of this work is focused on the sensitivity analysis of the nonlinearities by FEA in the tissue-tool interaction through an explicit FEA solver. By doing in this way, we aim to demonstrate that the set-up of FEA computational surgical tools may be simplified in order to provide assistance to non-expert FEA engineers or medicians in more precise way of using FEA tools

A prospective evaluation to define optimal surgical strategies in the management of complex pancreatic injuries based on the analysis of patients treated at a major South African academic institution

In order to address crucial existing limitations in the assessment and analysis of pancreatic injuries due to the lack of robust data and deficient surgical strategies, this thesis focused on priority topics to resolve existing unanswered and under-researched questions in the management of complex pancreatic injuries. Each of the twelve clinical studies in this thesis evaluated a specific aspect of pancreatic trauma based on the detailed analysis of prospective granular data from a large cohort of patients treated in an academic surgery and trauma centre with substantial experience in civilian operative trauma care in which standard and uniform protocols were applied

The use of knowledge discovery databases in the identification of patients with colorectal cancer

Colorectal cancer is one of the most common forms of malignancy with 35,000 new patients diagnosed annually within the UK. Survival figures show that outcomes are less favourable within the UK when compared with the USA and Europe with 1 in 4 patients having incurable disease at presentation as of data from 2000.Epidemiologists have demonstrated that the incidence of colorectal cancer is highest on the industrialised western world with numerous contributory factors. These range from a genetic component to concurrent medical conditions and personal lifestyle. In addition, data also demonstrates that environmental changes play a significant role with immigrants rapidly reaching the incidence rates of the host country.Detection of colorectal cancer remains an important and evolving aspect of healthcare with the aim of improving outcomes by earlier diagnosis. This process was initially revolutionised within the UK in 2002 with the ACPGBI 2 week wait guidelines to facilitate referrals form primary care and has subsequently seen other schemes such as bowel cancer screening introduced to augment earlier detection rates. Whereas the national screening programme is dependent on FOBT the standard referral practice is dependent upon a number of trigger symptoms that qualify for an urgent referral to a specialist for further investigations. This process only identifies 25-30% of those with colorectal cancer and remains a labour intensive process with only 10% of those seen in the 2 week wait clinics having colorectal cancer.This thesis hypothesises whether using a patient symptom questionnaire in conjunction with knowledge discovery techniques such as data mining and artificial neural networks could identify patients at risk of colorectal cancer and therefore warrant urgent further assessment. Artificial neural networks and data mining methods are used widely in industry to detect consumer patterns by an inbuilt ability to learn from previous examples within a dataset and model often complex, non-linear patterns. Within medicine these methods have been utilised in a host of diagnostic techniques from myocardial infarcts to its use in the Papnet cervical smear programme for cervical cancer detection.A linkert based questionnaire of those attending the 2 week wait fast track colorectal clinic was used to produce a ‘symptoms’ database. This was then correlated with individual patient diagnoses upon completion of their clinical assessment. A total of 777 patients were included in the study and their diagnosis categorised into a dichotomous variable to create a selection of datasets for analysis. These data sets were then taken by the author and used to create a total of four primary databases based on all questions, 2 week wait trigger symptoms, Best knowledge questions and symptoms identified in Univariate analysis as significant. Each of these databases were entered into an artificial neural network programme, altering the number of hidden units and layers to obtain a selection of outcome models that could be further tested based on a selection of set dichotomous outcomes. Outcome models were compared for sensitivity, specificity and risk. Further experiments were carried out with data mining techniques and the WEKA package to identify the most accurate model. Both would then be compared with the accuracy of a colorectal specialist and GP.Analysis of the data identified that 24% of those referred on the 2 week wait referral pathway failed to meet referral criteria as set out by the ACPGBI. The incidence of those with colorectal cancer was 9.5% (74) which is in keeping with other studies and the main symptoms were rectal bleeding, change in bowel habit and abdominal pain. The optimal knowledge discovery database model was a back propagation ANN using all variables for outcomes cancer/not cancer with sensitivity of 0.9, specificity of 0.97 and LR 35.8. Artificial neural networks remained the more accurate modelling method for all the dichotomous outcomes.The comparison of GP’s and colorectal specialists at predicting outcome demonstrated that the colorectal specialists were the more accurate predictors of cancer/not cancer with sensitivity 0.27 and specificity 0.97, (95% CI 0.6-0.97, PPV 0.75, NPV 0.83) and LR 10.6. When compared to the KDD models for predicting the same outcome, once again the ANN models were more accurate with the optimal model having sensitivity 0.63, specificity 0.98 (95% CI 0.58-1, PPV 0.71, NPV 0.96) and LR 28.7.The results demonstrate that diagnosis colorectal cancer remains a challenging process, both for clinicians and also for computation models. KDD models have been shown to be consistently more accurate in the prediction of those with colorectal cancer than clinicians alone when used solely in conjunction with a questionnaire. It would be ill conceived to suggest that KDD models could be used as a replacement to clinician- patient interaction but they may aid in the acceleration of some patients for further investigations or ‘straight to test’ if used on those referred as routine patients