Interventional Bronchoscopy:State-of-the-Art Review

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases

Navigational bronchoscopy for early lung cancer: a road to therapy

Peripheral lung nodules remain challenging for accurate localization and diagnosis. Once identified, there are many strategies for diagnosis with heterogeneous risk benefit analysis. Traditional strategies such as conventional bronchoscopy have poor performance in locating and acquiring the required tissue. Similarly, while computerized-assisted transthoracic needle biopsy is currently the favored diagnostic procedure, it is associated with complications such as pneumothorax and hemorrhage. Video-assisted thoracoscopic and open surgical biopsies are invasive, require general anesthesia and are therefore not a first-line approach. New techniques such as ultrathin bronchoscopy and image-based guidance technologies are evolving to improve the diagnosis of peripheral lung lesions. Virtual bronchoscopy and electromagnetic navigation systems are novel technologies based on assisted-computerized tomography images that guide the bronchoscopist toward the target peripheral lesion. This article provides a comprehensive review of these emerging technologies

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

Exploring novel, minimally invasive, multi-modal bronchoscopic biopsy tools and techniques using radial endobronchial ultrasound and the guide sheath to improve the diagnostic yield of peripheral pulmonary lesions suspected of lung cancer

Peripheral pulmonary lesions (PPL) suspected of lung cancer require a safe, high-yield diagnostic biopsy with concurrent mediastinal staging to reduce treatment delays. Emerging lung cancer screening programmes amplify this need. Radial EBUS is a safe bronchoscopy biopsy method for PPL, but the diagnostic yield is low. This thesis hypothesised that it was possible to improve the yield with novel biopsy tools and techniques. Four multi-centre interventional studies were performed. The novel biopsy tools (cryobiopsy and GenCut tool) were examined, and existing biopsy tools (guide sheath and aspiration needle) were optimised and combined as a multi-modal biopsy. This thesis consists of the first published head-to-head comparison of multi-modal Cryo-Radial biopsy against percutaneous CT-guided biopsy (CT-TTB) for PPL: a study compromised by slow recruitment that resulted in its early termination. Available data showed a modestly lower diagnostic yield than CT-TTB, but significantly fewer critical adverse events, pneumothorax, or haemorrhage. Bronchoscopic cryobiopsy was introduced to tertiary hospitals in New Zealand, for the first time, through this study in 2015 with relevant safety precautions. To cater for centres where cryobiopsy was not widely available but a core tissue sample was required, a novel GenCut tool was explored as an alternative suitable for sedation bronchoscopy. A multi-modal biopsy approach, rather than reliance on forceps alone, improved the diagnostic yield with adequate tissue obtained for critical molecular testing. This concept of multi-modal biopsy was not reported in Radial EBUS literature at the time of these studies in 2015. The addition of these safe diagnostic techniques will allow rapid, personalised diagnostic pathways for patients with suspected lung cancer

Open-source virtual bronchoscopy for image guided navigation

This thesis describes the development of an open-source system for virtual bronchoscopy used in combination with electromagnetic instrument tracking. The end application is virtual navigation of the lung for biopsy of early stage cancer nodules. The open-source platform 3D Slicer was used for creating freely available algorithms for virtual bronchscopy. Firstly, the development of an open-source semi-automatic algorithm for prediction of solitary pulmonary nodule malignancy is presented. This approach may help the physician decide whether to proceed with biopsy of the nodule. The user-selected nodule is segmented in order to extract radiological characteristics (i.e., size, location, edge smoothness, calcification presence, cavity wall thickness) which are combined with patient information to calculate likelihood of malignancy. The overall accuracy of the algorithm is shown to be high compared to independent experts' assessment of malignancy. The algorithm is also compared with two different predictors, and our approach is shown to provide the best overall prediction accuracy. The development of an airway segmentation algorithm which extracts the airway tree from surrounding structures on chest Computed Tomography (CT) images is then described. This represents the first fundamental step toward the creation of a virtual bronchoscopy system. Clinical and ex-vivo images are used to evaluate performance of the algorithm. Different CT scan parameters are investigated and parameters for successful airway segmentation are optimized. Slice thickness is the most affecting parameter, while variation of reconstruction kernel and radiation dose is shown to be less critical. Airway segmentation is used to create a 3D rendered model of the airway tree for virtual navigation. Finally, the first open-source virtual bronchoscopy system was combined with electromagnetic tracking of the bronchoscope for the development of a GPS-like system for navigating within the lungs. Tools for pre-procedural planning and for helping with navigation are provided. Registration between the lungs of the patient and the virtually reconstructed airway tree is achieved using a landmark-based approach. In an attempt to reduce difficulties with registration errors, we also implemented a landmark-free registration method based on a balanced airway survey. In-vitro and in-vivo testing showed good accuracy for this registration approach. The centreline of the 3D airway model is extracted and used to compensate for possible registration errors. Tools are provided to select a target for biopsy on the patient CT image, and pathways from the trachea towards the selected targets are automatically created. The pathways guide the physician during navigation, while distance to target information is updated in real-time and presented to the user. During navigation, video from the bronchoscope is streamed and presented to the physician next to the 3D rendered image. The electromagnetic tracking is implemented with 5 DOF sensing that does not provide roll rotation information. An intensity-based image registration approach is implemented to rotate the virtual image according to the bronchoscope's rotations. The virtual bronchoscopy system is shown to be easy to use and accurate in replicating the clinical setting, as demonstrated in the pre-clinical environment of a breathing lung method. Animal studies were performed to evaluate the overall system performance

Seeing the Big Picture: System Architecture Trends in Endoscopy and LED-Based hyperspectral Subsystem Intergration

Early-stage colorectal lesions remain difficult to detect. Early development of neoplasia tends to be small (less than 10 mm) and flat and difficult to distinguish from surrounding mucosa. Additionally, optical diagnosis of neoplasia as benign or malignant is problematic. Low rates of detection of these lesions allow for continued growth in the colorectum and increased risk of cancer formation. Therefore, it is crucial to detect neoplasia and other non-neoplastic lesions to determine risk and guide future treatment. Technology for detection needs to enhance contrast of subtle tissue differences in the colorectum and track multiple biomarkers simultaneously. This work implements one such technology with the potential to achieve the desired multi-contrast outcome for endoscopic screenings: hyperspectral imaging. Traditional endoscopic imaging uses a white light source and a RGB detector to visualize the colorectum using reflected light. Hyperspectral imaging (HSI) acquires an image over a range of individual wavelength bands to create an image hypercube with a wavelength dimension much deeper and more sensitive than that of an RGB image. A hypercube can consist of reflectance or fluorescence (or both) spectra depending on the filtering optics involved. Prior studies using HSI in endoscopy have normally involved ex vivo tissues or xiv optics that created a trade-off between spatial resolution, spectral discrimination and temporal sampling. This dissertation describes the systems design of an alternative HSI endoscopic imaging technology that can provide high spatial resolution, high spectral distinction and video-rate acquisition in vivo. The hyperspectral endoscopic system consists of a novel spectral illumination source for image acquisition dependent on the fluorescence excitation (instead of emission). Therefore, this work represents a novel contribution to the field of endoscopy in combining excitation-scanning hyperspectral imaging and endoscopy. This dissertation describes: 1) systems architecture of the endoscopic system in review of previous iterations and theoretical next-generation options, 2) feasibility testing of a LED-based hyperspectral endoscope system and 3) another LED-based spectral illuminator on a microscope platform to test multi-spectral contrast imaging. The results of the architecture point towards an endoscopic system with more complex imaging and increased computational capabilities. The hyperspectral endoscope platform proved feasibility of a LED-based spectral light source with a multi-furcated solid light guide. Another LED-based design was tested successfully on a microscope platform with a dual mirror array similar to telescope designs. Both feasibility tests emphasized optimization of coupling optics and combining multiple diffuse light sources to a common output. These results should lead to enhanced imagery for endoscopic tissue discrimination and future optical diagnosis for routine colonoscopy