Real-time computed tomography-based augmented reality for natural orifice transluminal endoscopic surgery navigation.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) is technically challenging owing to endoscopic short-sighted visualization, excessive scope flexibility and lack of adequate instrumentation. Augmented reality may overcome these difficulties. This study tested whether an image registration system for NOTES procedures (IR-NOTES) can facilitate navigation. METHODS: In three human cadavers 15 intra-abdominal organs were targeted endoscopically with and without IR-NOTES via both transgastric and transcolonic routes, by three endoscopists with different levels of expertise. Ease of navigation was evaluated objectively by kinematic analysis, and navigation complexity was determined by creating an organ access complexity score based on the same data. RESULTS: Without IR-NOTES, 21 (11·7 per cent) of 180 targets were not reached (expert endoscopist 3, advanced 7, intermediate 11), compared with one (1 per cent) of 90 with IR-NOTES (intermediate endoscopist) (P = 0·002). Endoscope movements were significantly less complex in eight of the 15 listed organs when using IR-NOTES. The most complex areas to access were the pelvis and left upper quadrant, independently of the access route. The most difficult organs to access were the spleen (5 failed attempts; 3 of 7 kinematic variables significantly improved) and rectum (4 failed attempts; 5 of 7 kinematic variables significantly improved). The time needed to access the rectum through a transgastric approach was 206·3 s without and 54·9 s with IR-NOTES (P = 0·027). CONCLUSION: The IR-NOTES system enhanced both navigation efficacy and ease of intra-abdominal NOTES exploration for operators of all levels. The system rendered some organs accessible to non-expert operators, thereby reducing one impediment to NOTES procedures.

Augmented environments for minimally invasive therapy: implementation barriers from technology to practice.

Augmented environments for medical applications have been explored and developed in an effort to enhance the clinician's view of anatomy and facilitate the performance of minimally invasive procedures. These environments must faithfully represent the real surgical field and require seamless integration of pre- and intra-operative imaging, surgical instrument tracking and display technology into a common framework centered around the patient. However, few image guidance environments have been successfully translated into clinical use. Several challenges that contribute to the slow progress of integrating such environments into clinical practice are discussed here in terms of both technical and clinical limitations.

Image Registered Gastroscopic Ultrasound (IRGUS) in human subjects: a pilot study to assess feasibility.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound (EUS) is a complex procedure due to the subtleties of ultrasound interpretation, the small field of observation, and the uncertainty of probe position and orientation. Animal studies demonstrated that Image Registered Gastroscopic Ultrasound (IRGUS) is feasible and may be superior to conventional EUS in efficiency and image interpretation. This study explores whether these attributes of IRGUS will be evident in human subjects, with the aim of assessing the feasibility, effectiveness, and efficiency of IRGUS in patients with suspected pancreatic lesions. PATIENTS AND METHODS: This was a prospective feasibility study at a tertiary care academic medical center in human patients with pancreatic lesions on computed tomography (CT) scan. Patients who were scheduled to undergo conventional EUS were randomly chosen to undergo their procedure with IRGUS. Main outcome measures included feasibility, ease of use, system function, validated task load (TLX) assessment instrument, and IRGUS experience questionnaire. RESULTS: Five patients underwent IRGUS without complication. Localization of pancreatic lesions was accomplished efficiently and accurately (TLX temporal demand 3.7 %; TLX effort 8.6 %). Image synchronization and registration was accomplished in real time without procedure delay. The mean assessment score for endoscopist experience with IRGUS was positive (66.6 ± 29.4). Real-time display of CT images in the EUS plane and echoendoscope orientation were the most beneficial characteristics. CONCLUSIONS: IRGUS appears feasible and safe in human subjects, and efficient and accurate at identification of probe position and image interpretation. IRGUS has the potential to broaden the adoption of EUS techniques and shorten EUS learning curves. Clinical studies comparing IRGUS with conventional EUS are ongoing.

The role of a computed tomography-based image registered navigation system for natural orifice transluminal endoscopic surgery: a comparative study in a porcine model.

BACKGROUND AND STUDY AIMS: Most natural orifice transluminal endoscopic surgery (NOTES) procedures have been performed in animal models through the anterior stomach wall, but this approach does not provide efficient access to all anatomic areas of interest. Moreover, injury of the adjacent structures has been reported when using a blind access. The aim of the current study was to assess the utility of a CT-based (CT: computed tomography) image registered navigation system in identifying safe gastrointestinal access sites for NOTES and identifying intraperitoneal structures. METHODS: A total of 30 access procedures were performed in 30 pigs: anterior gastric wall (n = 10), posterior gastric wall (n = 10), and anterior rectal wall (n = 10). Of these, 15 procedures used image registered guidance (IR-NOTES) and 15 procedures used a blind access (NOTES only). Timed abdominal exploration was performed with identification of 11 organs. The location of the endoscopic tip was tracked using an electromagnetic tracking system and was recorded for each case. Necropsy was performed immediately after the procedure. The primary outcome was the rate of complications; secondary outcome variables were number of organs identified and kinematic measurements. RESULTS: A total of 30 animals weighting a mean (± SD) of 30.2 ± 6.8 kg were included in the study. The incision point was correctly placed in 11 out of 15 animals in each group (73.3 %). The mean peritoneoscopy time and the number of properly identified organs were equivalent in the two groups. There were eight minor complications (26.7 %), two (13.3 %) in the IR-NOTES group and six (40.0 %) in the NOTES only group ( P = n. s.). Characteristics of the endoscope tip path showed a statistically significant improvement in trajectory smoothness of motion for all organs in the IR-NOTES group. CONCLUSION: The image registered system appears to be feasible in NOTES procedures and results from this study suggest that image registered guidance might be useful for supporting navigation with an increased smoothness of motion.

Prediction of the spatial distribution of cell survival in heavy ion beams.

The possible use of heavy ion beams for biomedical applications was examined through calculations of the physical beam properties and the spatial distribution of cell survival. Range straggling, creation of secondary particles, electron pickup, and the effects of inhomogeneous absorbers were analyzed in terms of cell survival. Depth-survival plots for typical irradiations provide substantial encouragement for the investigation of these beams for biomedical applications in which localized tissue destruction is desired.

Interaction of 3.9-gev nitrogen ions with matter.

The interaction with matter of nitrogen ions in the 3.9-billion-electron-volt (Gev) beam of the Princeton Particle Accelerator has been studied. In polyethylene, the range of ions is 12.6 +/- 0.2 grams per square centimeter and the mean free path for nuclear collisions is 15.4 +/- 3.8 centimeters; the loss of energy by the ions passing through polyethylene agrees with that predicted by stopping-power theory. The production of secondary particles has been investigated. These data are useful for experiments and for evaluating the merits of nitrogen ions in biomedical application.

Spatial distribution of biological effect n a 3.9-Gev nitrogen ion beam.

A beam of nitrogen ions obtained with the Princeton Particle Accelerator was used for the irradiation of Chinese hamster (M3-1) cells in monolayer culture. The 3.9-billion-electron-volt (Gev) beam passed along the monolayer, so that ions were stopped in the culture. A sharply defined zone of extensive cell destruction occurred in the last centimeter of the beam path.

Visual sensations induced by relativistic nitrogen nuclei.

The ability of the human eye to detect nitrogen nuclei that enter the retina at speeds just above the Cerenkov threshold has been confirmed in an experiment at the Princeton Particle Accelerator. A system for beam transport and subject alignment delivered individual nitrogen nuclei onto a spot 3 millimeters in diameter on the retina at a visual angle of 7 degrees on the temporal side of the fovea. The beam particles entered the retina within 25 degrees of normal and induced visual sensations that had the appearance of streaks for three out of four subjects.

Acceleration of argon ions to 1.17x1010 electron volts.

Argon ions were accelerated to 1.17x10(10) electron volts in the Princeton Particle Accelerator. The synchrotron was tuned by use of a neon beam with a charge-to-mass ratio equal to that of the argon ions. The fully accelerated argon ions were detected by the observation of etched tracks in cellulose nitrate sheets and also by the use of scintillation counters. Predictions of the range and of the characteristics of argon tracks in plastics were confirmed.

Image guided surgery and its potential.

The use of higher technology in medicine promises improved outcomes and enhanced productivity. That is, successful techniques will lead to lower cost, higher quality care for a larger population. In surgery, these changes range from the more efficient use of skilled medical practitioners, through improvements to conventional practice (a recent example is the shift to endoscopic surgery in the abdomen), to the creation of new procedures which capitalize on the availability of information in new forms._Image Guided Surgery may be defined as the use of advanced technology to help the surgeon see with 1) Better resolution 2) Orientation and context setting 3) Higher contrast, and 4) Vision inside "solid objects", including the elimination of occlusion by the surgeon's tools or other external items. We describe here the current imaging processes and their limitations with regard to direct guidance of therapy. The physical properties of real time image acquisition systems are described along with the mechanisms for inherent and enhanced contrast. Examples of the use with surgical instruments or other interventional devices for image-monitored and guided procedures are then discussed, and future prospects elucidated.

Experience with MR-guided therapy.

The use of magnetic resonance imaging (MRI) for the real time guidance of surgical procedures is now undergoing clinical trials. Among the many procedures explored, open craniotomy neurosurgery appears to be among the most promising. Over 50 such cases have been done at the Brigham and Women's Hospital (BWH) in Boston. We review the technical approach used in these and related procedures. We consider the way in which imaging is used to augment and improve the procedures. As well, the implications of these protocols for remote diagnosis and telesurgery are explored. Finally, the implications of this experience for the insertion of new technology into medicine are discussed.

Automatic Segmentation of Breast Carcinomas from DCE-MRI using a Statistical Learning Algorithm.

Segmenting regions of high angiogenic activity corresponding to malignant tumors from DCE-MRI is a time-consuming task requiring processing of data in 4 dimensions. Quantitative analyses developed thus far are highly sensitive to external factors and are valid only under certain operating assumptions, which need not be valid for breast carcinomas. In this paper, we have developed a novel Statistical Learning Algorithm for Tumor Segmentation (SLATS) for automatically segmenting cancer from a region selected by the user on DCE-MRI. In this preliminary study, SLATS appears to demonstrate high accuracy (78%) and sensitivity (100%) in segmenting cancers from DCE-MRI when compared to segmentations performed by an expert radiologist. This may be a useful tool for delineating tumors for image-guided interventions.

Storage and retrieval of radiographic images.

Storage and retrieval of radiographic images was studied to quantify existing procedures and determine the applicability of new technology. Storage practices were found to be consistent among different types of hospitals. About one third of American hospitals have serious problems, particularly lack of space. Most hospitals save radiographs 4-7 years after the latest examination, but one third fall outside this range. It does not appear that there is near-term technological solution for radiographic storage problems.

Cellular effects of heavy charged particles.

The human cell is rendered reproductively inactive by the passage of a single heavy ion through its nucleus when the heavy ion deposits energy at a rate greater than about 3500 MeV cm-1. This is demonstrated by the correlation of inactivation probability with nuclear area when cells having nuclei of different sizes are compared. This single-hit inactivation is irreversible and unmodifiable. The ion path length over which cells will be inactivated in this way is calculable from stopping power theory. Laboratory experiments in which three-dimensional human cell cultures were irradiated with high-energy nitrogen ions (3.9 GeV) at the Princeton Particle Accelerator confirm that cells are inactivated with maximum probability over the last 0.5 cm of the ion trajectory. This means that groups of adjacent cells in the ion path will be inactivated by a single ion with high probability. Organized systems of multiplying cells would be expected to amplify this spatially correlated effect of heavy ion irradiation. Abnormalities induced in Zea seedlings by heavy ion irradiation of seeds are consistent with the inactivation of embryonic cells in groups.