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collage of hyperspectral imaging (sHSI) camera and brain surgery

Novel camera + machine learning = hope for more precise neurosurgery

collage of hyperspectral imaging (sHSI) camera and brain surgery

Researchers at Children’s National Hospital developed a compact imaging camera capable of seeing beyond the human visual spectrum to help segment healthy brain tissue from tumors during surgery. The groundbreaking technology will allow neurosurgeons to make more precise, real-time decisions in the operating room, rather than sending samples to pathology labs for biopsies.

In a manuscript published in Bioengineering, the team of engineers and neurosurgeons details how its snapshot hyperspectral imaging (sHSI) camera can be used to capture and process images of brain tissue, using the wide spectrum of light between visible and infrared wavelengths. That additional information — beyond the human eye — has the potential to allow for more accurate and complete tumor removal.

“In the hands of a neurosurgeon, this camera, when combined with machine learning, could dramatically improve outcomes for some of our most vulnerable brain tumor patients,” said Richard Jaepyeong Cha, Ph.D., an optical engineer and principal investigator at the Sheikh Zayed Institute of Pediatric Surgical Innovation. “We are able to attach the camera to a surgical microscope and process a significant amount of information from the patient while in the operating room. Not only could this lead to more complete tumor resection, it will also allow the surgeon to save as much healthy brain tissue as possible and reduce lifelong neurological complications.”

Why we’re excited

Brain tumors are the most common solid tumors in children, accounting for the highest number of pediatric cancer deaths globally each year. To develop a treatment plan, neurosurgeons need to understand the tumor’s features, including its type, grade of malignancy, location and its categorization as a primary or metastatic cancer. This information leads to decisions about how to remove or biopsy a tumor.

Under the current protocols, surgeons evaluate tumor margins in the operating room by examining the appearance of the brain tissue and sending out small samples to the pathology department for biopsies. This can lead to longer surgeries and difficult real-time surgical decisions. For instance, some low-grade tumors are visually indistinguishable from healthy brain tissue.

In four investigational cases approved by the hospital’s institutional research board, the sHSI camera was used in the operating room to help segment healthy pediatric brain tissue from tumors. Unlike the conventional red-green-blue (RGB) imaging cameras, which use only those three colors, HSI captures spectral data at each pixel of the image — a task too complex for the human eye — and sends it instantly for processing by an algorithm designed to assist in tumor segmentation.

What’s ahead

Despite the small dataset, the researchers were able to successfully segment healthy brain tissue from lesions with a high specificity during pediatric brain tumor resection procedures. Significant work remains to refine the technology and the machine learning behind it. Researchers also plan to integrate the sHSI camera into a laparoscope to visualize tumors that are not on the brain’s surface and collect data from more angles.

“As we develop these groundbreaking tools, we plan to continue to expand the dataset and refine the algorithm to make pediatric neurosurgery continually more precise,” said Naomi Kifle, M.S., research and development engineer at Children’s National and first author on the paper. “As our dataset grows, we hope to create a model that can distinguish healthy brain tissue, tumor and skull. This groundbreaking surgical tool shows significant promise.”

doctors doing heart surgery

Novel dye may improve outcomes for liver surgery

Researchers at Children’s National Hospital and the National Cancer Institute (NCI) have developed a novel, near‐infrared dye that can help surgeons identify structures and detect leakage during liver surgery, offering a promising tool that may someday improve outcomes for patients undergoing gastroenterology procedures.

The problem has vexed the medical community for some time: Despite advances in bile leak detection, only a third of bile duct injuries are found at the time of surgery, extending hospital stays and increasing the risk of liver failure, sepsis and even death.

Why we’re excited

The new dye – known as Bile Label Dye 760 (BL-760) – provided several promising advantages over existing surgical tools during non-clinical testing. When administered into the liver, BL‐760 was excreted and visible in bile ducts within minutes, without significant or prolonged impact on organ tissue. Its fluorescence against the surgical field also provided a superior view of leaks, offering an opportunity to treat the patient while still in the operating room. Details were published recently in Lasers in Surgery and Medicine.

“BL-760 is a promising option for monitoring the health of the liver during surgery, and we are excited to continue our testing and hopefully see first-in-human trials in the future,” said Richard Cha, Ph.D., principal investigator at the Sheikh Zayed Institute of Pediatric Surgical Innovation, part of the NIH-funded team that developed the dye.

doctors doing heart surgery

The new dye – known as Bile Label Dye 760 (BL-760) – provided several promising advantages over existing surgical tools during non-clinical testing.

The big picture

The dye could significantly advance hepatobiliary and pancreatic (HPB) procedures in years to come. More than 40,000 new cases of liver cancer are diagnosed each year, causing more than 30,000 deaths in the U.S. alone. Gallbladder disease is also one of the most common conditions in the U.S., with more than 20 million people affected annually. In pediatrics, gall bladder removal, or cholecystectomy, is on the rise.

Procedures to treat these diseases have many challenges. During minimally invasive surgery, including laparoscopic cholecystectomy or robot-assisted hepatectomy, surgeons can struggle to precisely identify the bile ducts because of a narrow field of view or because they are embedded in fat or other tissues. Existing FDA-approved contrast agents that can enhance the biliary anatomy such as indocyanine green (ICG) aren’t well tailored for HPB surgeries because of the timing of their administration and their inferior ability to highlight biliary structures. In addition, while pre-operative imaging has improved outcomes, it cannot be used to predict leaks from the surgery itself.

What’s ahead

BL-760 was created at Children’s National and NCI by a team of experts in surgery and engineering, led by Anthony Sandler, M.D., senior vice president and surgeon-in-chief. They hope to continue their testing on the dye in the months ahead. The team was encouraged when Michele Saruwatari, M.D., a Joseph E. Robert Fellow in the Sheik Zayed Institute, recently won first place in the resident and fellow abstract presentation competition at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“Having this tool in the operating room will change outcomes for our pediatric patients,” Sandler said.  “This dye has the potential to become an essential step in liver cancer surgery, cholecystectomy and treating other pediatric diseases like biliary atresia. I look forward to the day when we can get it in the hands of surgical teams.”

parathyroid close-up

A new imaging device with AI may reduce complications during thyroid surgery

parathyroid close-upSurgeons perform approximately 150,000 thyroidectomies in the United States. Post-surgical complications from this procedure frequently occur due to the misidentification or accidental removal of healthy parathyroid glands. On average, 27% of these patients suffer from transient or permanent hypocalcemia, a condition in which the blood has too little calcium, leading to lifelong complications and socioeconomic burden.

To improve parathyroid detection during surgery, Children’s National Hospital experts developed a prototype equipped with a dual-sensor imaging device and a deep learning algorithm that accurately detects parathyroids, according to a new study published in the Journal of Biophotonics.

“What excited us in this study was that even deep-seated tissues were able to be imaged without light loss, and high resolution imaging was possible due to the unique optical design,” said Richard Jaepyeong Cha, Ph.D., council member of the International Society of Innovative Technologies for Endocrine Surgery and principal investigator for the Sheikh Zayed Institute for Pediatric Surgical Innovation at Children’s National Hospital. “Moreover, in several cases, parathyroid autofluorescence was detected even before the surgeon dissected the parathyroid gland, and while it was covered by fat and/or fascia.”

What’s unique

This is the first study that uses color RGB/NIR paired imaging-based parathyroid detection by incorporating multi-modal (both RGB light and near-infrared autofluorescence, or NIRAF, ground truth imaging) data into parathyroid identification using a deep learning algorithm.

The patient benefit

“We envision that our technology will open a new door for the digital imaging paradigm of dye-free, temporally unlimited, and precise parathyroid detection and preservation,” said Richard. “Successful translation of this technology will potentially reduce the risk of hypoparathyroidism after common thyroid surgery and improve the clinical outcomes.”

The results support the effectiveness of their novel approach despite the small sample size, which can potentially improve specificity in the identification of parathyroid glands during parathyroid and thyroid surgeries.

The hold-up in the field

It is often difficult for surgeons with naked eyes to identify parathyroid glands from thyroid tissue because of the small size, the variable position, and similar appearance to the surrounding tissues.

Since 2011, surgeons have benefited from using NIRAF, a non-invasive optical method for intraoperative real-time localization of parathyroids.

While the NIRAF technology has gained traction among endocrine surgery community, false negatives can occur with current devices that use the NIRAF technology in secondary hyperparathyroidism cases. According to Kim et al., the technology is still suboptimal, and a significant percentage of parathyroid is being missed.

Children’s National Hospital leads the way

Engineers in Children’s National are leading this field through several innovations:

  • Non-dye injected, label-free use in real-time in comparison to temporally limited ICG angiography. This technology was featured as the cover article in the journal Lasers in Surgery and Medicine 54(3), 2022.).
  • Simultaneous perfusion assessment from four glands at any time during operation.
  • Arterial flow detection from pulsatile information in well-perfused PG vasculature.
  • Quantified parathyroid detection and classification with prediction values using deep learning technique.

You can read the full study “A co-axial excitation, dual-RGB/NIR paired imaging system toward computer-aided detection (CAD) of parathyroid glands in situ and ex vivo” in the Journal of Biophotonics.

overview of parathyroid surgery procedure

multimodal imaging images

Real-time surgical guidance system enables multimodal tissue monitoring

For the first time, researchers at Children’s National Hospital successfully demonstrated a label-free tissue perfusion imaging in a pre-clinical model, according to a study published in IEEE Transactions on Biomedical Engineering.

Richard Jaepyeong Cha, Ph.D., research faculty associate professor at Children’s National, and colleagues combined visible, near-infrared laser speckle contrast imaging (LSCI) and snapshot hyperspectral (HSI) cameras into a single clinical multimodal imaging device suitable for real-time intraoperative visualization and demonstrated such a device in a surgical model for the first time, to the best knowledge of the authors. This system provides instant microcirculation information about the ischemic regions, normal tissue and transitional ischemic zones with quantitative values that are reproducible.

“Our pre-clinical work demonstrated a novel, dye-free imaging platform for quantitatively assessing bowel perfusion. The ability to identify optimal surgical resection margins can improve surgical performance and patient outcome in terms of more targeted bowel resection and bowel preservation without anastomotic leakage,” Cha said. “This new optical imaging and quantitative assessment technology holds great promise to solving the long-standing issue of suboptimal assessment of intestinal viability.”

Intraoperative imaging techniques for the precise monitoring of blood flow, hemorrhage and oxygen saturation are needed to minimize errors caused by blood vessel ligation to reduce surgical blood loss and successfully isolate and resect ischemic regions.

When the blood flow, hemorrhage and oxygen are not monitored properly, anastomotic leak (AL) is a serious complication of intestinal surgery that can occur due to a technical error, and most frequently because of poorly vascularized intestine.

This complication of intestinal surgery carries with it a reported mortality ranging from 6 to 39%. The best time to prevent a possible AL is during its creation in the operating room.

Creating a healthy and safe intestinal anastomosis requires a good blood supply to the two ends of bowel to be joined. The tools for diagnosing well-perfused bowel intraoperatively are limited and often rely on the subjective evaluation of the surgeon.

“We are hoping that the use and application of multimodal LSCI/HSI imaging, capable of both non-invasive and quantitative gross tissue perfusion assessment, will provide colorectal/general surgeons with a convenient and objective method for assessment of bowel perfusion characteristics and facilitate surgical transection in tissues requiring colorectal anastomosis,” Cha said.

Recently, indocyanine green fluorescence angiography (ICG-FA) was introduced for intraoperative assessment of anastomotic perfusion. Preliminary evidence suggests that ICG-FA may reduce the rate of anastomotic leakage in gastrointestinal surgery.

Perfusion assessment at the site of anastomosis may alter surgical strategy and possibly reduce anastomotic leakage rates. However, ICG-FA evaluation requires an exogenous fluorophore and the surgeon must subjectively assess the quality of perfusion. For an ideal intestinal viability test, it is essential that the technique is easily performed by the surgeon, minimally invasive, objective and reproducible—which is what Lee et al. demonstrate with their new approach.

multimodal imaging system

schematic of Mueller polarimetric imaging

Novel technique improved nerve visualization in head and neck surgery

In a pre-clinical model, researchers from Children’s National Hospital found that the Mueller polarimetric imaging, a novel technique that improves image contrast, may help identify nerves from other surrounding tissues during neck and head surgical procedures, avoiding accidental nerve damage.

“This technology holds great promise for the possibility of a truly noninvasive imaging approach and may help improve surgical outcomes by potentially reducing inadvertent, ill effects of nerve injuries in head and neck surgery,” said Bo Ning, Ph.D., R&D engineer at Children’s National and lead author of the study.

This pre-clinical study presents the first application of a full-field polarimetric imaging technique in vivo during head and neck surgery to highlight the vagus nerve (VN) and a branch that supplies all the intrinsic muscles to the larynx, known as recurrent laryngeal nerve (RLN).

“Unlike conventional nerve identification devices, this technique is noninvasive and less interruptive to intact tissues without disrupting surgical workflows,” said Ning et al. “Since the technique has an easy mechanism and promising performance in our study, this novel method holds great potential for real-time, noninvasive, and convenient nerve visualization.”

While some promising methods use polarimetric imaging for tissue characterizations, the current literature is still limited to ex vivo conditions due to the system complications and prolonged acquisition speeds.

“Recently, the industry released a new polarimetric camera, which is compact and allows fast and high-definition polarimetric imaging through simple snapshots. Enlightened by this technical advance, we have developed a practical polarimetric imaging method,” said Ning, who also develops compact and practical imaging systems for surgical innovation, including 3D, fluorescent, laser speckle and hyperspectral techniques. “It allows fast polarimetric analysis and can acquire birefringence maps over the whole field of view within 100 milliseconds, which provides an appropriate speed for directly surgical use.”

The new approach proofs that the concept is feasible to set up in live subjects during head and neck surgery, which can also be easily adapted for other surgeries. Among the seven subjects, the VNs and RLNs were successfully differentiated from arteries and other surrounding tissues.

Additional co-authors from Children’s National include Itai Katz, Ph.D., M.S., R&D staff engineer III; Anthony D. Sandler, M.D., Senior Vice President and Surgeon-in-Chief; Richard Jaepyeong Cha, Ph.D., research faculty assistant professor.

schematic of Mueller polarimetric imaging

Researchers at Children’s National used a novel technique that improves image contrast, which may help improve surgical outcomes.

Zeroing in on Zero Harm

Zeroing in on zero harm: Innovative quality and safety initiatives from Children’s National experts

Zeroing in on Zero Harm

Leaders at Children’s National Health System recently showcased innovative quality and safety initiatives on a national stage at the Children’s Hospital Association’s 2018 Quality and Safety in Children’s Health Conference.

Leaders at Children’s National Health System recently showcased innovative quality and safety initiatives on a national stage at the Children’s Hospital Association’s 2018 Quality and Safety in Children’s Health Conference. While collaborating with other medical professionals in the field, the team made an impact by sharing key projects implemented at Children’s National to enhance patient care and reduce harm, including:

    • Safety in Numbers: Driving 10,000 Good Catches – Presented by Rahul Shah, M.D., vice president, chief quality and safety officer, and Rebecca Cady, Esq, BSN, vice president, chief risk officer: Recognizing barriers to reporting safety events, Children’s National embarked upon a three-year corporate goal to double the number of safety event reports, ultimately leading to reduction of preventable harm. By promoting staff accountability and using incentives to drive reporting, incident reports more than doubled in a three-year time frame.
    • Moving from Disjointed Spreadsheets to a Real-Time Data Management System – Presented by Evan Hochberg, R.N., patient safety consultant, and Neil Bhattarai, C.S.T., process improvement consultant: Tracking hospital-acquired conditions (HACs) requires robust data capabilities, which is why Children’s National sought to improve its HAC data system with increased efficiencies and reduced delays in how staff presented data to the hospital. The team recognized opportunities to improve the management of HAC data, leading to the finding that increased real-time awareness of harm events while utilizing existing infrastructure can accelerate harm reduction.
    • Improving the Surgical Experience for Children with Autism – Presented by Terry Spearman, C.C.L.S., manager of child life services: Staff at Children’s National found that many patients with autism entering the operating room needed special support to make it through pre-op, complicating their path toward surgery and causing frustration for patients, families and the care team. The team solved this challenge by creating a system to identify patients before they arrived for surgery, which allowed staff to create a safe passage plan for each patient and to achieve better care coordination with all care team members. Titled “Help Me Keep Calm,” the hospital’s program provides a more peaceful and individualized experience for both the patient and his or her family.
    • IMPACT Session: Enhancing Psychological Safety to Improve the Safety Climate – Presented by Rahul Shah, M.D., vice president, chief quality and safety officer; Evan Hochberg, R.N., patient safety consultant; and Kathryn Jacobsen, R.N., director of patient safety: Psychological safety around event reporting is a crucial element of safety culture and the ability to voice concerns without reprisal leads to the ideal safe environment.