Advanced Endoscopic Navigation:Surgical Big Data,Methodology,and Applications

随着科学技术的飞速发展，健康与环境问题日益成为人类面临的最重大问题之一。信息科学、计算机技术、电子工程与生物医学工程等学科的综合应用交叉前沿课题，研究现代工程技术方法，探索肿瘤癌症等疾病早期诊断、治疗和康复手段。本论文综述了计算机辅助微创外科手术导航、多模态医疗大数据、方法论及其临床应用：从引入微创外科手术导航概念出发，介绍了医疗大数据的术前与术中多模态医学成像方法、阐述了先进微创外科手术导航的核心流程包括计算解剖模型、术中实时导航方案、三维可视化方法及交互式软件技术，归纳了各类微创外科手术方法的临床应用。同时，重点讨论了全球各种手术导航技术在临床应用中的优缺点，分析了目前手术导航领域内的最新技术方法。在此基础上，提出了微创外科手术方法正向数字化、个性化、精准化、诊疗一体化、机器人化以及高度智能化的发展趋势。【Abstract】Interventional endoscopy (e.g., bronchoscopy, colonoscopy, laparoscopy, cystoscopy) is a widely performed procedure that involves either diagnosis of suspicious lesions or guidance for minimally invasive surgery in a variety of organs within the body cavity. Endoscopy may also be used to guide the introduction of certain items (e.g., stents) into the body. Endoscopic navigation systems seek to integrate big data with multimodal information (e.g., computed tomography, magnetic resonance images, endoscopic video sequences, ultrasound images, external trackers) relative to the patient's anatomy, control the movement of medical endoscopes and surgical tools, and guide the surgeon's actions during endoscopic interventions. Nevertheless, it remains challenging to realize the next generation of context-aware navigated endoscopy. This review presents a broad survey of various aspects of endoscopic navigation, particularly with respect to the development of endoscopic navigation techniques. First, we investigate big data with multimodal information involved in endoscopic navigation. Next, we focus on numerous methodologies used for endoscopic navigation. We then review different endoscopic procedures in clinical applications. Finally, we discuss novel techniques and promising directions for the development of endoscopic navigation.X.L. acknowledges funding from the Fundamental Research Funds for the Central Universities. T.M.P. acknowledges funding from the Canadian Foundation for Innovation, the Canadian Institutes for Health Research, the National Sciences and Engineering Research Council of Canada, and a grant from Intuitive Surgical Inc

New technologies for the further advancement of ERCP

Background: The capabilities of conventional endoscopic retrograde cholangiopancreatography (ERCP) are hampered by several limitations. Newly developed adjunct technologies such as single operator peroral cholangiopancreatoscopy (SOPCP) and new imaging techniques could overcome some of these limitations, but their role in common clinical practice have not yet been established. Aims: To assess the diagnostic and therapeutic yield of SOPCP in the diagnosis and treatment of biliopancreatic disease. To investigate patient-related risk factors for post procedural pancreatitis (PPP) following single-operator peroral pancreatoscopy. To determine the feasibility and potential clinical yield of bimodal ERCP. To assess radiation dose in cone beam ERCP. Methods: In paper I, All SOPCP procedures performed at Karolinska University Hospital between March 2007 and December 2014 were included in this study and each procedure’s diagnostic yield and therapeutic value was evaluated using a predefined 4 grade assessment scale. In paper II, all consecutive patients that underwent single operator pancreatoscopy (SOPP) at Karolinska University Hospital between April 2015 and Nov 2020 were included. The Swedish Registry for Gallstone Surgery and ERCP (GallRiks) was used to retrieve patient data and preprocedural imaging was reviewed in consensus by two senior radiologists. Pancreatic gland morphology and main pancreatic duct (MPD) diameter were evaluated as risk factors for PPP using uni- and multivariate logistic regression. In paper III, patients undergoing conventional ERCP had a previous T2-weighted magnetic resonance cholangiopancreatography (MRCP) sequence aligned and fused with the two-dimensional image generated from the fluoroscopy c-arm unit in real time and data regarding feasibility and clinical yield was retrieved. In paper IV, radiation exposure data from conventional ERCP procedures and cone beam ERCP (CB-ERCP) procedures performed between February 2016 and June 2017 at a tertiary high volume endoscopy unit was analyzed. CBERCP cases used either the standard exposure protocol ‘DR’ or the modified low dose exposure protocol‘DR Care’. Results: During the study period in paper I, 365 SOPCP procedures were performed. SOPCP was found to be of pivotal importance (grade 4) in 19% of cases, and of great clinical significance (grade 3) in 44% of cases. SOPCP did not affect clinical decision-making or alter clinical course (grade 1 and 2) in 37% of cases. In paper II, Postprocedural pancreatitis occurred in 15 (23%) of patients during the 30-day follow up. Univariate analysis of risk factors for PPP showed a significant association with chronic pancreatitis (OR 0.28 95% CI 0.08-0.92), insertion of a pancreatic stent (OR 0.28; 95% CI 0.08-0.95) and the ratio between MPD and pancreatic gland thickness in the body of pancreas (OR 1.14; 95% CI 1.03-1.28). In a multivariate regression model, the association between an increased body MPD/gland ratio in pancreatic body and PPP remained significant (OR 1.26; 95% CI 1.06-1.57) after adjustments for confounders including chronic pancreatitis. In paper III, 13 patients underwent bimodal ERCP for bile duct stricture, complex cholelithiasis or ductal leakage. Bimodal ERCP was feasible in all 13 cases, and image quality was assessed as “good” in 11 patients (85%). Bimodal ERCP aided in visualizing the lesion of interest (77 %), assisted in understanding the 3D anatomy of the biliopancreatic ductal system (62 %), and aided in finding a favorable position for the c-arm (38%) for subsequent therapeutic intervention. In paper IV, 728 conventional ERCP procedures were performed and 42 cases utilized CBERCP. The median total dose area product (DAP) was 48.9 Gycm2 for CB-ERCP procedures using the DR exposure protocol and 19.7 Gycm2 for CB-ERCP procedures using the DR care exposure protocol. The median total DAP was 6.5 Gycm2 when conventional ERCP was used. Conventional ERCP generated a significantly reduced total DAP compared to both CBERCP using the ‘DR’ exposure protocol (U=908, p < 0.001) and CB-ERCP using the ‘DR care’exposure protocol (U=3823, p < 0.001). Conclusions: SOPCP has a high impact on management of patients with complex cholelithiasis, indeterminate biliary strictures and pancreatic cystic lesions in a tertiary care setting, but the procedure contributes to a considerable risk of adverse events. There is an association between the pancreatic gland thickness and MPD diameter in the pancreatic body with the risk of developing PPP after SOPP. Bimodal ERCP is feasible and can aid in understanding biliary anatomy and visualizing the lesion of interest. Its future area of use may lie in the assessment and treatment of complex intrahepatic biliary disease. Cone beam asssisted ERCP procedures are associated with higher total radiation doses than conventional ERCP procedures, but it is possible to decrease radiation doses to acceptable levels with adjustments of exposure protocols. These adjustments do not compromise the capabilities of cone beam ERCP to provide enhanced intraprocedural guidance

Medical image computing and computer-aided medical interventions applied to soft tissues. Work in progress in urology

Until recently, Computer-Aided Medical Interventions (CAMI) and Medical Robotics have focused on rigid and non deformable anatomical structures. Nowadays, special attention is paid to soft tissues, raising complex issues due to their mobility and deformation. Mini-invasive digestive surgery was probably one of the first fields where soft tissues were handled through the development of simulators, tracking of anatomical structures and specific assistance robots. However, other clinical domains, for instance urology, are concerned. Indeed, laparoscopic surgery, new tumour destruction techniques (e.g. HIFU, radiofrequency, or cryoablation), increasingly early detection of cancer, and use of interventional and diagnostic imaging modalities, recently opened new challenges to the urologist and scientists involved in CAMI. This resulted in the last five years in a very significant increase of research and developments of computer-aided urology systems. In this paper, we propose a description of the main problems related to computer-aided diagnostic and therapy of soft tissues and give a survey of the different types of assistance offered to the urologist: robotization, image fusion, surgical navigation. Both research projects and operational industrial systems are discussed

Computer- and robot-assisted Medical Intervention

Medical robotics includes assistive devices used by the physician in order to make his/her diagnostic or therapeutic practices easier and more efficient. This chapter focuses on such systems. It introduces the general field of Computer-Assisted Medical Interventions, its aims, its different components and describes the place of robots in that context. The evolutions in terms of general design and control paradigms in the development of medical robots are presented and issues specific to that application domain are discussed. A view of existing systems, on-going developments and future trends is given. A case-study is detailed. Other types of robotic help in the medical environment (such as for assisting a handicapped person, for rehabilitation of a patient or for replacement of some damaged/suppressed limbs or organs) are out of the scope of this chapter.Comment: Handbook of Automation, Shimon Nof (Ed.) (2009) 000-00

Hacia el modelado 3d de tumores cerebrales mediante endoneurosonografía y redes neuronales

Las cirugías mínimamente invasivas se han vuelto populares debido a que implican menos riesgos con respecto a las intervenciones tradicionales. En neurocirugía, las tendencias recientes sugieren el uso conjunto de la endoscopia y el ultrasonido, técnica llamada endoneurosonografía (ENS), para la virtualización 3D de las estructuras del cerebro en tiempo real. La información ENS se puede utilizar para generar modelos 3D de los tumores del cerebro durante la cirugía. En este trabajo, presentamos una metodología para el modelado 3D de tumores cerebrales con ENS y redes neuronales. Específicamente, se estudió el uso de mapas auto-organizados (SOM) y de redes neuronales tipo gas (NGN). En comparación con otras técnicas, el modelado 3D usando redes neuronales ofrece ventajas debido a que la morfología del tumor se codifica directamente sobre los pesos sinápticos de la red, no requiere ningún conocimiento a priori y la representación puede ser desarrollada en dos etapas: entrenamiento fuera de línea y adaptación en línea. Se realizan pruebas experimentales con maniquíes médicos de tumores cerebrales. Al final del documento, se presentan los resultados del modelado 3D a partir de una base de datos ENS.Minimally invasive surgeries have become popular because they reduce the typical risks of traditional interventions. In neurosurgery, recent trends suggest the combined use of endoscopy and ultrasound (endoneurosonography or ENS) for 3D virtualization of brain structures in real time. The ENS information can be used to generate 3D models of brain tumors during a surgery. This paper introduces a methodology for 3D modeling of brain tumors using ENS and unsupervised neural networks. The use of self-organizing maps (SOM) and neural gas networks (NGN) is particularly studied. Compared to other techniques, 3D modeling using neural networks offers advantages, since tumor morphology is directly encoded in synaptic weights of the network, no a priori knowledge is required, and the representation can be developed in two stages: off-line training and on-line adaptation. Experimental tests were performed using virtualized phantom brain tumors. At the end of the paper, the results of 3D modeling from an ENS database are presented

Development and evaluation of image-guided neuroendoscopy, with investigation of post-imaging brain distortion and accuracy of frameless stereotaxy

Neuroendoscopy enables a surgeon to operate deep within the brain whilst limiting morbidity through a minimally invasive approach. Technical advances in illumination, instrumentation and camera design, along with evidence for improved clinical outcome, have increased the indications for this technique and have ensured widespread popularity. However, broader application of neuroendoscopy is restricted by the necessity for direct vision of targets and by spatial disorientation. The aim of this investigation was to overcome these limitations by combining neuronavigation with neuroendoscopy to develop Image-Guided Neuroendoscopy (IGN). The strategy adopted for this was firstly to select, assess and validate a neuronavigation system, secondly to develop methods of endoscope tracking and frameless stereotactic implantation. Thirdly, to assess the impact of post-imaging brain distortion upon neuronavigation, fourthly to correct distortion of the endoscope image and finally to assess the use of graphics overlay in IGN. Laboratory phantom accuracy assessments revealed a mean point localisation error for the navigation system pointers of0.8mm (SD 0.4mm) with CT imaging, for the tracked endoscope of 1.5mm (SD 0.8mm) and for frameless stereotaxy of 1.3mm (SD 0.6mm). An in vivo study revealed a mean Euclidean error of 4.8mm (SD 2.0mm) for frame less stereotactic biopsy. The navigation system was evaluated through a clinical series of 100 cases, the frameless stereotactic technique was employed in 21 brain biopsy procedures and IGN evaluated in 5 procedures. The magnitude of post-imaging brain distortion was determined and correlations discovered with pre-operative image characteristics. The conclusions of this thesis are that IGN can be accomplished with acceptable accuracy, including frameless stereotactic implantation, and that the impact of postimaging brain distortion will not negate the value of IGN in most cases. Thus, the method developed for IGN has overcome both major constraints of neuroendoscopy, enabling endoscopic surgery to pass through and beyond the ventricular wall, to be undertaken safely in cases with distorted anatomy and opening the potential for wider application of these minimally invasive techniques

Using CamiTK for rapid prototyping of interactive Computer Assisted Medical Intervention applications

Computer Assisted Medical Intervention (CAMI hereafter) is a complex multi-disciplinary field. CAMI research requires the collaboration of experts in several fields as diverse as medicine, computer science, mathematics, instrumentation, signal processing, mechanics, modeling, automatics, optics, etc

Performance of image guided navigation in laparoscopic liver surgery – A systematic review

Background: Compared to open surgery, minimally invasive liver resection has improved short term outcomes. It is however technically more challenging. Navigated image guidance systems (IGS) are being developed to overcome these challenges. The aim of this systematic review is to provide an overview of their current capabilities and limitations. Methods: Medline, Embase and Cochrane databases were searched using free text terms and corresponding controlled vocabulary. Titles and abstracts of retrieved articles were screened for inclusion criteria. Due to the heterogeneity of the retrieved data it was not possible to conduct a meta-analysis. Therefore results are presented in tabulated and narrative format. Results: Out of 2015 articles, 17 pre-clinical and 33 clinical papers met inclusion criteria. Data from 24 articles that reported on accuracy indicates that in recent years navigation accuracy has been in the range of 8–15 mm. Due to discrepancies in evaluation methods it is difficult to compare accuracy metrics between different systems. Surgeon feedback suggests that current state of the art IGS may be useful as a supplementary navigation tool, especially in small liver lesions that are difficult to locate. They are however not able to reliably localise all relevant anatomical structures. Only one article investigated IGS impact on clinical outcomes. Conclusions: Further improvements in navigation accuracy are needed to enable reliable visualisation of tumour margins with the precision required for oncological resections. To enhance comparability between different IGS it is crucial to find a consensus on the assessment of navigation accuracy as a minimum reporting standard