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Bannone E, Collins T, Esposito A, Cinelli L, De Pastena M, Pessaux P, Felli E, Andreotti E, Okamoto N, Barberio M, Felli E, Montorsi RM, Ingaglio N, Rodríguez-Luna MR, Nkusi R, Marescaux J, Hostettler A, Salvia R, Diana M. Surgical optomics: hyperspectral imaging and deep learning towards precision intraoperative automatic tissue recognition-results from the EX-MACHYNA trial. Surg Endosc 2024; 38:3758-3772. [PMID: 38789623 DOI: 10.1007/s00464-024-10880-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Hyperspectral imaging (HSI), combined with machine learning, can help to identify characteristic tissue signatures enabling automatic tissue recognition during surgery. This study aims to develop the first HSI-based automatic abdominal tissue recognition with human data in a prospective bi-center setting. METHODS Data were collected from patients undergoing elective open abdominal surgery at two international tertiary referral hospitals from September 2020 to June 2021. HS images were captured at various time points throughout the surgical procedure. Resulting RGB images were annotated with 13 distinct organ labels. Convolutional Neural Networks (CNNs) were employed for the analysis, with both external and internal validation settings utilized. RESULTS A total of 169 patients were included, 73 (43.2%) from Strasbourg and 96 (56.8%) from Verona. The internal validation within centers combined patients from both centers into a single cohort, randomly allocated to the training (127 patients, 75.1%, 585 images) and test sets (42 patients, 24.9%, 181 images). This validation setting showed the best performance. The highest true positive rate was achieved for the skin (100%) and the liver (97%). Misclassifications included tissues with a similar embryological origin (omentum and mesentery: 32%) or with overlaying boundaries (liver and hepatic ligament: 22%). The median DICE score for ten tissue classes exceeded 80%. CONCLUSION To improve automatic surgical scene segmentation and to drive clinical translation, multicenter accurate HSI datasets are essential, but further work is needed to quantify the clinical value of HSI. HSI might be included in a new omics science, namely surgical optomics, which uses light to extract quantifiable tissue features during surgery.
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Affiliation(s)
- Elisa Bannone
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France.
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, P.Le Scuro 10, 37134, Verona, Italy.
| | - Toby Collins
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, P.Le Scuro 10, 37134, Verona, Italy
| | - Lorenzo Cinelli
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
- Department of Gastrointestinal Surgery, San Raffaele Hospital IRCCS, Milan, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, P.Le Scuro 10, 37134, Verona, Italy
| | - Patrick Pessaux
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
- Institut of Viral and Liver Disease, Inserm U1110, University of Strasbourg, Strasbourg, France
| | - Emanuele Felli
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
- Institut of Viral and Liver Disease, Inserm U1110, University of Strasbourg, Strasbourg, France
| | - Elena Andreotti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, P.Le Scuro 10, 37134, Verona, Italy
| | - Nariaki Okamoto
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
- Photonics Instrumentation for Health, iCube Laboratory, University of Strasbourg, Strasbourg, France
| | - Manuel Barberio
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
- General Surgery Department, Ospedale Cardinale G. Panico, Tricase, Italy
| | - Eric Felli
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roberto Maria Montorsi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, P.Le Scuro 10, 37134, Verona, Italy
| | - Naomi Ingaglio
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, P.Le Scuro 10, 37134, Verona, Italy
| | - María Rita Rodríguez-Luna
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
- Photonics Instrumentation for Health, iCube Laboratory, University of Strasbourg, Strasbourg, France
| | - Richard Nkusi
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
| | - Jacque Marescaux
- Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
| | | | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, P.Le Scuro 10, 37134, Verona, Italy
| | - Michele Diana
- Photonics Instrumentation for Health, iCube Laboratory, University of Strasbourg, Strasbourg, France
- Department of Surgery, University Hospital of Geneva, Geneva, Switzerland
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Dalli J, Epperlein JP, Hardy NP, Khan MF, Mac Aonghusa P, Cahill RA. Clinical and computational development of a patient-calibrated ICGFA bowel transection recommender. Surg Endosc 2024; 38:3212-3222. [PMID: 38637339 PMCID: PMC11133155 DOI: 10.1007/s00464-024-10827-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/23/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Intraoperative indocyanine green fluorescence angiography (ICGFA) aims to reduce colorectal anastomotic complications. However, signal interpretation is inconsistent and confounded by patient physiology and system behaviours. Here, we demonstrate a proof of concept of a novel clinical and computational method for patient calibrated quantitative ICGFA (QICGFA) bowel transection recommendation. METHODS Patients undergoing elective colorectal resection had colonic ICGFA both immediately after operative commencement prior to any dissection and again, as usual, just before anastomotic construction. Video recordings of both ICGFA acquisitions were blindly quantified post hoc across selected colonic regions of interest (ROIs) using tracking-quantification software and computationally compared with satisfactory perfusion assumed in second time-point ROIs, demonstrating 85% agreement with baseline ICGFA. ROI quantification outputs detailing projected perfusion sufficiency-insufficiency zones were compared to the actual surgeon-selected transection/anastomotic construction site for left/right-sided resections, respectively. Anastomotic outcomes were recorded, and tissue lactate was also measured in the devascularised colonic segment in a subgroup of patients. The novel perfusion zone projections were developed as full-screen recommendations via overlay heatmaps. RESULTS No patient suffered intra- or early postoperative anastomotic complications. Following computational development (n = 14) the software recommended zone (ROI) contained the expert surgical site of transection in almost all cases (Jaccard similarity index 0.91) of the nine patient validation series. Previously published ICGFA time-series milestone descriptors correlated moderately well, but lactate measurements did not. High resolution augmented reality heatmaps presenting recommendations from all pixels of the bowel ICGFA were generated for all cases. CONCLUSIONS By benchmarking to the patient's own baseline perfusion, this novel QICGFA method could allow the deployment of algorithmic personalised NIR bowel transection point recommendation in a way fitting existing clinical workflow.
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Affiliation(s)
- Jeffrey Dalli
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Niall P Hardy
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mohammad Faraz Khan
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Ronan A Cahill
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland.
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
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Chalopin C, Pfahl A, Köhler H, Knospe L, Maktabi M, Unger M, Jansen-Winkeln B, Thieme R, Moulla Y, Mehdorn M, Sucher R, Neumuth T, Gockel I, Melzer A. Alternative intraoperative optical imaging modalities for fluorescence angiography in gastrointestinal surgery: spectral imaging and imaging photoplethysmography. MINIM INVASIV THER 2023; 32:222-232. [PMID: 36622288 DOI: 10.1080/13645706.2022.2164469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/29/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Intraoperative near-infrared fluorescence angiography with indocyanine green (ICG-FA) is a well-established modality in gastrointestinal surgery. Its main drawback is the application of a fluorescent agent with possible side effects for patients. The goal of this review paper is the presentation of alternative, non-invasive optical imaging methods and their comparison with ICG-FA. MATERIAL AND METHODS The principles of ICG-FA, spectral imaging, imaging photoplethysmography (iPPG), and their applications in gastrointestinal surgery are described based on selected published works. RESULTS The main applications of the three modalities are the evaluation of tissue perfusion, the identification of risk structures, and tissue segmentation or classification. While the ICG-FA images are mainly evaluated visually, leading to subjective interpretations, quantitative physiological parameters and tissue segmentation are provided in spectral imaging and iPPG. The combination of ICG-FA and spectral imaging is a promising method. CONCLUSIONS Non-invasive spectral imaging and iPPG have shown promising results in gastrointestinal surgery. They can overcome the main drawbacks of ICG-FA, i.e. the use of contrast agents, the lack of quantitative analysis, repeatability, and a difficult standardization of the acquisition. Further technical improvements and clinical evaluations are necessary to establish them in daily clinical routine.
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Affiliation(s)
- Claire Chalopin
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Annekatrin Pfahl
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Luise Knospe
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Marianne Maktabi
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
- Department of Electrical, Mechanical and Industrial Engineering, Anhalt University of Applied Science, Köthen (Anhalt), Germany
| | - Michael Unger
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
- Department of General, Visceral and Oncological Surgery, St. Georg Hospital, Leipzig, Germany
| | - René Thieme
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Yusef Moulla
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Robert Sucher
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Thomas Neumuth
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Andreas Melzer
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
- Institute of Medical Science and Technology (IMSAT), University of Dundee, Dundee, UK
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Renna MS, Grzeda MT, Bailey J, Hainsworth A, Ourselin S, Ebner M, Vercauteren T, Schizas A, Shapey J. Intraoperative bowel perfusion assessment methods and their effects on anastomotic leak rates: meta-analysis. Br J Surg 2023; 110:1131-1142. [PMID: 37253021 PMCID: PMC10416696 DOI: 10.1093/bjs/znad154] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/24/2023] [Accepted: 04/29/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Anastomotic leak is one of the most feared complications of colorectal surgery, and probably linked to poor blood supply to the anastomotic site. Several technologies have been described for intraoperative assessment of bowel perfusion. This systematic review and meta-analysis aimed to evaluate the most frequently used bowel perfusion assessment modalities in elective colorectal procedures, and to assess their associated risk of anastomotic leak. Technologies included indocyanine green fluorescence angiography, diffuse reflectance spectroscopy, laser speckle contrast imaging, and hyperspectral imaging. METHODS The review was preregistered with PROSPERO (CRD42021297299). A comprehensive literature search was performed using Embase, MEDLINE, Cochrane Library, Scopus, and Web of Science. The final search was undertaken on 29 July 2022. Data were extracted by two reviewers and the MINORS criteria were applied to assess the risk of bias. RESULTS Some 66 eligible studies involving 11 560 participants were included. Indocyanine green fluorescence angiography was most used with 10 789 participants, followed by diffuse reflectance spectroscopy with 321, hyperspectral imaging with 265, and laser speckle contrast imaging with 185. In the meta-analysis, the total pooled effect of an intervention on anastomotic leak was 0.05 (95 per cent c.i. 0.04 to 0.07) in comparison with 0.10 (0.08 to 0.12) without. Use of indocyanine green fluorescence angiography, hyperspectral imaging, or laser speckle contrast imaging was associated with a significant reduction in anastomotic leak. CONCLUSION Bowel perfusion assessment reduced the incidence of anastomotic leak, with intraoperative indocyanine green fluorescence angiography, hyperspectral imaging, and laser speckle contrast imaging all demonstrating comparable results.
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Affiliation(s)
- Maxwell S Renna
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of General Surgery, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Mariusz T Grzeda
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - James Bailey
- Department of General Surgery, University of Nottingham, Nottingham, UK
| | - Alison Hainsworth
- Department of General Surgery, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Sebastien Ourselin
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Hypervision Surgical Ltd, London, UK
| | | | - Tom Vercauteren
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Hypervision Surgical Ltd, London, UK
| | - Alexis Schizas
- Department of General Surgery, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Jonathan Shapey
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Hypervision Surgical Ltd, London, UK
- Department of Neurosurgery, King’s College Hospital, London, UK
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Sutton PA, van Dam MA, Cahill RA, Mieog S, Polom K, Vahrmeijer AL, van der Vorst J. Fluorescence-guided surgery: comprehensive review. BJS Open 2023; 7:7162090. [PMID: 37183598 PMCID: PMC10183714 DOI: 10.1093/bjsopen/zrad049] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Despite significant improvements in preoperative workup and surgical planning, surgeons often rely on their eyes and hands during surgery. Although this can be sufficient in some patients, intraoperative guidance is highly desirable. Near-infrared fluorescence has been advocated as a potential technique to guide surgeons during surgery. METHODS A literature search was conducted to identify relevant articles for fluorescence-guided surgery. The literature search was performed using Medical Subject Headings on PubMed for articles in English until November 2022 and a narrative review undertaken. RESULTS The use of invisible light, enabling real-time imaging, superior penetration depth, and the possibility to use targeted imaging agents, makes this optical imaging technique increasingly popular. Four main indications are described in this review: tissue perfusion, lymph node assessment, anatomy of vital structures, and tumour tissue imaging. Furthermore, this review provides an overview of future opportunities in the field of fluorescence-guided surgery. CONCLUSION Fluorescence-guided surgery has proven to be a widely innovative technique applicable in many fields of surgery. The potential indications for its use are diverse and can be combined. The big challenge for the future will be in bringing experimental fluorophores and conjugates through trials and into clinical practice, as well as validation of computer visualization with large data sets. This will require collaborative surgical groups focusing on utility, efficacy, and outcomes for these techniques.
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Affiliation(s)
- Paul A Sutton
- The Colorectal and Peritoneal Oncology Centre, Christie Hospital, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Martijn A van Dam
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronan A Cahill
- RAC, UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
- RAC, Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sven Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Karol Polom
- Clinic of Oncological, Transplantation and General Surgery, Gdansk Medical University, Gdansk, Poland
| | | | - Joost van der Vorst
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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