Recent advances in visualization, imaging, and navigation in hepatobiliary and pancreatic sciences

Background/purpose

Recent introduction of multi-detector CT (MDCT) and high-speed magnetic resonance (MR) imaging have dramatically advanced visualization and imaging technology in diagnostic and therapeutic strategy in hepatobiliary pancreatic disease. However, image diagnostics have progressed with a background of the essence of anatomy, pathology, and physiology. It is important to object the reflection of the patient’s condition and pathology of each disease and remove pattern recognition in what they were depicted as an image. Visualization plays another important role in various medical diagnostics. Trends in scientific visualization will depend on advancements in molecular technology and computer hardware as well as trends in engineering disciplines.

Methods

In this special issue, the recent advances in visualization and imaging in the field of hepatobiliary and pancreatic sciences are featured including application of advanced visualization techniques, data management, data compression, feature extraction.

Results

We discuss the potential benefits of new technologies and procedures in hepatobiliary and pancreatic areas, that are circulating tumor cells, MR imaging for hepatocellular carcinoma, indocyanine green using fluorescence under infrared light observation, carbon dioxide enhanced MDCT virtual cholangiopancreatography, endoscopic ultrasonography-guided biliary drainage, natural orifice translumenal endoscopic surgery, MR-laparoscopy, and image overlay navigation surgery by OsiriX.

Conclusion

Some of the recent trends are discussed in terms of visualization and imaging in hapatobiliary and pancreatic sciences. The goal in using visualization is to assist existing scientific procedures by providing new insight through visual representation.     

动脉瘤夹闭手术中近红外光吲哚菁绿造影的评价

目的 通过观察脑动脉瘤夹闭,载瘤动脉及主要分支动脉闭锁或狭窄,对比研究手术显微镜下吲哚菁绿血管造影(ICGA)与术后脑血管造影(DSA),评价ICGA在动脉瘤夹闭手术中的应用价值.方法 对101例颅内动脉瘤患者的113枚动脉瘤常规手术夹闭,在手术中应用整合近红外光(NIR)吲哚菁绿(ICG)血管造影的手术显微镜新技术,将ICG染料经静脉单次注射到达NIR照射术野,观察诱发出的ICG荧光影像.将ICG造影证实载瘤动脉通畅度、穿通支和动脉瘤夹闭状态与术后复查DSA对比.结果 101例患者动脉瘤夹闭前后行荧光造影219次,除3例外,ICGA图像质量和分辨率良好,可以实时显示脑循环.ICGA可以提供脑动脉,毛细血管和静脉与手术后DSA对比.3例术中ICGA提供有意义的手术信息,调整了动脉瘤夹.101例动脉瘤手术中ICGA与手术后DSA符合,无动脉瘤瘤蒂残留,载瘤动脉畅通.结论 手术显微镜结合ICGA在手术中可以提供动脉瘤夹闭和载瘤动脉情况,实时简便,重复性好,可以作为术中多普勒超声和术中DSA补充,可能成为动脉瘤术中血管造影的常规技术.     

Development and applications of photo-triggered theranostic agents

Theranostics, the fusion of therapy and diagnostics for optimizing efficacy and safety of therapeutic regimes, is a growing field that is paving the way towards the goal of personalized medicine for the benefit of patients. The use of light as a remote-activation mechanism for drug delivery has received increased attention due to its advantages in highly specific spatial and temporal control of compound release. Photo-triggered theranostic constructs could facilitate an entirely new category of clinical solutions which permit early recognition of the disease by enhancing contrast in various imaging modalities followed by the tailored guidance of therapy. Finally, such theranostic agents could aid imaging modalities in monitoring response to therapy. This article reviews recent developments in the use of light-triggered theranostic agents for simultaneous imaging and photoactivation of therapeutic agents. Specifically, we discuss recent developments in the use of theranostic agents for photodynamic-, photothermal- or photo-triggered chemotherapy for several diseases.     

吲哚菁绿荧光血管造影在前循环动脉瘤手术中的应用

目的探讨吲哚菁绿（ICG）脑血管造影在颅内前循环动脉瘤手术中的作用。方法回顾性研究2007年1月至2008年4月开颅手术治疗的前循环动脉瘤患者42例,荧光显微镜下观察术野中血管,指导手术操作。术后行3DCTA或DSA检查,评估术中ICG荧光造影对开颅手术治疗颅内动脉瘤的作用。结果术中确认动脉瘤颈残留2例,载瘤动脉分支血管闭塞1例,穿通血管误夹2例,重新调整动脉瘤夹位置后,再次荧光血管造影,证实动脉瘤颈夹闭满意,术后DSA（或MRA、CTA）均证实术中ICG造影结果。结论ICG血管造影是一种术中监测颅内动脉瘤颈是否残留、载瘤动脉是否狭窄及穿通支血管是否闭塞的重要检查手段。     

Complicated grief and impaired sleep in patients with bipolar disorder

OBJECTIVES: To examine the relationship of sleep disturbance with complicated grief (CG) in patients with bipolar disorder (BD). METHODS: Adults with DSM-IV BD were asked if they ever experienced significant loss and, if so, completed the Inventory of Complicated Grief. Subjective sleep disturbance was assessed with the Pittsburgh Sleep Quality Index (PSQI). The association of CG with sleep disturbance was assessed in univariate t-tests, and in multivariate analyses controlling for the presence of anxiety disorder comorbidity and current bipolar recovery status. RESULTS: Individuals with CG had significantly higher mean PSQI scores (10.9 versus 7.9, p = 0.003) than those without CG. Further, within the group of BD participants who had experienced a significant loss, those with CG had significantly poorer sleep (p = 0.01). CG remained significantly associated with greater sleep impairment after adjustment for comorbid anxiety disorder and bipolar mood state. This additive impairment in sleep with CG comorbidity was evident for four of the PSQI component scales: sleep quality, sleep duration, sleep efficiency and sleep disturbance. CONCLUSIONS: Our data indicate a significant association of CG with poor sleep in individuals with BD. Disturbed sleep may be a mechanism by which CG increases the burden of illness in BD.     

Successful laparoscopic resection of gastric lymphangioma under the intraoperative guidance of indocyanine green fluorescence imaging: A case report

Gastric lymphangioma (GLA) is an extremely rare tumor without an established therapeutic strategy. Surgical resection is considered the mainstay of treatment, although there is a high risk of local recurrence if negative margins are not achieved. A 51-year-old man underwent routine abdominal ultrasonography, which incidentally detected a 20-mm tumor adjacent to the lesser curvature of the stomach. GLA was suspected based on its polycystic appearance. After a 16-month monitoring period, laparoscopic resection was performed because of tumor growth and involvement of the left gastric artery. Intraoperative indocyanine green (ICG) navigation system revealed lymphatic drainage from the tumor, which we used to help determine the optimal excision line and minimize the loss of gastric volume. Pathological examination confirmed complete resection with negative margins and supported a diagnosis of lymphangioma. We performed laparoscopic radical resection of GLA under guidance from intraoperative ICG fluorescence imaging, which allowed us to maximize residual gastric volume.     

Guía de uso e indicaciones de la fluorescencia con verde de indocianina (ICG) en cirugía general: recomendaciones basadas en la revisión descriptiva de la literatura y el análisis de la experiencia

Indocyanine Green is a fluorescent substance visible in near-infrared light. It is useful for the identification of anatomical structures (biliary tract, ureters, parathyroid, thoracic duct), the tissues vascularization (anastomosis in colorectal, esophageal, gastric, bariatric surgery, for plasties and flaps in abdominal wall surgery, liver resection, in strangulated hernias and in intestinal ischemia), for tumor identification (liver, pancreas, adrenal glands, implants of peritoneal carcinomatosis, retroperitoneal tumors and lymphomas) and sentinel node identification and lymphatic mapping in malignant tumors (stomach, breast, colon, rectum, esophagus and skin cancer). The evidence is very encouraging, although standardization of its use and randomized studies with higher number of patients are required to obtain definitive conclusions on its use in general surgery.The aim of this literature review is to provide a guide for the use of ICG fluorescence in general surgery procedures.     

高容量血液滤过对MODS患者血流动力学的影响

目的初步探讨高容量血液滤过(HVHF)对多器官功能障碍综合征(MODS)患者血流动力学的影响.方法选择多器官功能障碍综合征(MODS)患者11例,行HVHF治疗,11例患者均在开始HVHF前及HVHF治疗后1h、4h、8h、12h分别测量心率(HR)、平均动脉压(MAP)、中心静脉压(CVP),通过美国Wan-tangh公司的IQ智能无创连续血流动力学监护仪在治疗前、后测出患者心排出量等各项血流动力学参数.结果患者行HVHF治疗后心率(HR)显著下降(P＜0.05),平均动脉压(MAP)明显升高(P＜0.05),中心静脉压(CVP)显著下降(P＜0.05).心排出量(CO),射血分数(EF)、心指数(CI)、左心搏出功指数(LCWI),体循环血管阻力指数(SVRI)显著升高(P＜0.05).结论 HVHF可以改善MODS患者的血流动力学.     

Intrahepatic flow disturbance by clomipramine in the isolated perfused rat liver

Intrahepatic flow disturbance may have important pharmacological and toxicological significance. However, apart from pathological conditions, flow disturbance by drugs has received little attention. In the isolated perfused rat liver (IPRL), we found that infusion of tricyclic antidepressants increased portal perfusion pressure (PP) with a coincidental decrease in oxygen uptake at concentrations of 3-30 microM; the order of potency was clomipramine > amitriptyline > imipramine approximately nortriptyline > desipramine. The characteristics of clomipramine action were as follows: (1) The extrahepatic portal vein was much less sensitive to clomipramine than the IPRL. (2) Changes in PP and oxygen uptake required Ca(2+) in the perfusate and were inhibited by papaverine, staurosporine, sodium nitroprusside and indomethacin. (3) Compared with endothelin-1, clomipramine produced a greater decrease in the ratio of oxygen uptake/PP together with a greater overflow of loaded indocyanine green for an increase in PP by about 2 cm H(2)O. (4) Vital staining with trypan blue and rhodamine 6G and histological examinations revealed that 3-10 microM clomipramine produced marked flow redistribution due to the constriction of portal vein branches. Portal flow was short-circuited to the hepatic vein at a deeper and hilar portion of the liver, with minimal perfusion of the periphery. These results demonstrate an example of drug-induced intrahepatic flow disturbance in vitro. Its contribution to the development of toxicity in vivo remains to be studied.     

An impedance cardiography system: A new design

An IBM compatible impedance cardiac output monitoring prototype system has been developed for use at the bedside on patients in the ICU, CCU, ER, Cath. Lab, and OR, etc. This impedance cardiography (ICG) system, whose operation is completely technician-free, provides a continuous display with digital results and four channel color waveforms on an Enhanced Graphics Display screen. The software is written in C language with several special segments in assembly code where speed is essential. In this prototype system, a real-time algorithm was introduced to modify the ensemble averaging technique so that it averages nonperiodic signals such as: ECG, dZ/dT, ΔZ, etc. Also, a real-time algorithm was developed to adaptively detect R spikes from conventional ECG signals. A signal preprocessor was developed to process signals digitally before any further work is done. This procedure reduces muscle noise, 60 Hz interference, and ventilatory movement. A special digital filter was designed to cope with the cases in which pacemakers are used. A special algorithm was also developed to further reduce the ventilation artifacts so that a period of apnea is unnecessary during the performance of the measurements. An anatomically specified electrode configuration has been defined enabling precise and reproducible positioning of the electrodes—hopefully leading to electrode standardization. At the present time, this prototype system has been compared with standard hand calculation and correlated with the clinical “gold standard,” the Swan-Ganz thermodilution cardiac output. Using 144 sets of data from 10 healthy volunteers, 4 critically ill patients, and 8 healthy exercising volunteers, calculations of cardiac output were made using our system and the standard hand calculation of stroke volume, based upon Kubicek's equation; there was a relatively high and stable correlation: r=0.93, p<0.005 (healthy); r=0.94, p<0.002 (ill); r=0.95, p<0.002 (exercise). From 20 patients at two different hospitals all with Swan-Ganz catheters in their hearts 65 correlation studies between our system and the standard thermodilution technique were performed; the results were encouraging in terms of accuracy and consistency (r₁=0.84, p<0.01, n=10 CCU patients), and (r₂=0.93, p<0.01, n=ICU, patients). These results along with a growing body of data from other investigators indicate that this noninvasive and technician-free system for measuring cardiac output could have a significant role in patient care.