Surgeons produce better outcomes using image-guided technologies

By Andy Shaw

Dr. Lloyd Smith is keen to show visitors his two, state-of-the-art operating rooms for minimally invasive surgery. A general surgeon at the Toronto Western Hospital campus of the University Health Network (UHN), Dr. Smith points with pride to each OR’s feature attraction, a voice-activated Hermes laparoscopic surgical system from Computer Motion.

The new ORs, which opened for business in September, were a year in research and development followed by five months of renovation and construction. They came with a $800,000 price tag. Recently Dr. Smith, who heads up UHN’s minimally invasive program, led an in vivo tour of one suite during a gall bladder operation conducted by a colleague. In the OR were a journalist and the architect who designed the rooms, accompanied by the latter’s two school-aged children.

“You know, as modern as all this is, by the time your kids are grown up you may see me flipping burgers at McDonald’s,” said Smith with a smile.

Yet to come, say some futurists, will be surgical systems using injected “surgi-bots”. They’ll zoom about the inside of the body under remote control and attack targeted trauma and lesions with nothing more invasive than a needle prick. Shades of the Hollywood sci/fi flick, Fantastic Voyage. And that will soon put surgeons like Smith out of work.

Well, maybe not quite so soon.

Author Mario Apicella, a senior test analyst for InfoWorld.com, predicts that such minute medical robots will need another 10 to 20 years of development.

In the meantime, Smith and his laparoscopic ORs are the future – and a model for how they were designed.

“Generally, we now do almost any surgery a general surgeon would do, but we do it using laparoscopy,” said Smith. “And I think that’s the way all surgery will eventually go despite higher original costs for suites like these.”

Smith and architect Dominic Meffe, the UHN’s Director of Facilities Renewal, agreed that a laparoscopic suite costs about $150,000 more than a regular OR – but the benefit in terms of costs savings, patient comfort, and recovery time make them compelling.

“With regular surgery, the average stay in hospital for a gall bladder patient was 6.9 days. But this patient, came in here this morning and will be home this afternoon,” said Smith.

Four small holes in the patient’s CO2 inflated abdomen – one for a camera cum light probe, and the other three for a cauterizing L-hook scalpel, specialized clamps, and other instruments – are all that are needed in a laparoscopic gall bladder removal that normally incurs no more than 5cc’s of blood loss. (A special “mother-in-law” clamp that just won’t let go, finally drags the gall bladder out through one of the holes.)

But though bloodless, the creation of the new ORs was not sweat-less.

“We looked at what others had developed, then we did a lot of work with what turned out to be a large but extremely helpful team of about 20 people in first selecting the equipment and then designing the rooms,” said Smith.

Consulted were electrical, mechanical, and structural engineers, the hospital’s own medical engineers, medical gases specialists, vendors of the system’s startlingly clear flat screen monitors and their supporting arms, and naturally the doctors and nurses whose workplace the new ORs have become.

“At first glance it might look like an unwieldy team but we found that virtually everyone made a contribution that proved to be important,” said Meffe, whose architectural design pulled all the inputs together.

One surprising aspect of the new laparoscopic ORs – they’re bigger.

“Even though the equipment itself is more compact, we made the rooms bigger so we could include more technology,” said Smith. “We know we’ll be adding things such as ultrasound scopes but we don’t know what all the new technology is going to be exactly. For sure, though, there’s going to be more and more technology in surgery. That’s why we left room for it.”

So in future surgery, it seems, both smaller and bigger is better. The question is: Will the surgeons be any better as a result?

Authors of a definitive report on medical imaging technology for Industry Canada (http://strategis.ic.gc.ca/SSG/hm01516e.html) conclude there’s lots of encouraging surgery-related technology around now including robotics, high speed volume rendering, virtual reality displays, and haptic feedback to name a few – but we humans still haven’t grasped how to fully interact with these new tools.

A contributor to that report, however, said we’re making strides. Bruce Davey of Cedara Software Corp. in Mississauga, Ont., sat on the report’s analysis and visualization work group. He is a PhD engineer in charge of advanced technology and market development for Cedara, a pioneer of image-guided surgery software.

“We’re starting to see customization of image-guided software and systems for different parts of the body, but they are all in different stages of development,” said Davey. “In neurosurgery, for example, image guidance has become the standard of care and the technology is quite mature. Its use in spinal surgery is not yet as pervasive. And now, systems designed specifically for orthopaedics are coming on the market. Then there is the potential for the soft tissue areas.”

The problem for soft tissues is that they tend to slop around. As a result, organs don’t look the same to an operating surgeon as they did in the image captured before the patient was wheeled in. So Cedara and others are developing systems that make images in the OR itself, using fluoroscopic technology, which provides a much more immediate and accurate picture.

“We move in on the patient with a scanner very briefly then back away again,” explains Davey. “So the images are only a few seconds or a minute old.”

Not quite real time, but close.

For close to four years now, Dr. Walter Kucharczyk, a radiologist at the Toronto Hospital campus of the UHN, has been developing and using a real-time imaging system for neurosurgery. It’s an open-style, two-panel MRI that scans continuously. Since its launch in February of 1998, the system has guided over 100 neurosurgeries, mostly for brain tumours. But surgeons early on paid a price.

“At first, everything had to be compatible with a magnetic environment, so they couldn’t use a lot of the tools they were used to,” said Dr. Kucharczyk, who also chairs the department of medical imaging at the University of Toronto. “But we have developed a lot of new tools for the magnetic environment. And we’ve also realized that for many procedures you don’t need continuous imaging. So we’ve developed techniques that switch off the magnet and allow surgeons to now bring in their surgical microscopes or neural navigation systems like Stealth, BrainLab, or ISG (now Cedara). Before they would back-off from using MRI if they had to give up their familiar tools.”

Having accommodated today’s image-guided systems, Kucharczyk is planning for tomorrow.

“We’re striving to make sure, first of all, that no matter what system comes along, surgeons will be able to use them close to the magnet,” said Kucharczyk. “We’re developing our own neural navigational system that will work with any other system. So the surgeon can go into the operating room and know that he can use any tool he wants. That will broaden the spectrum of procedures that can be done using open MRI.”

The challenge for the next version of the open MRI that Dr. Kucharczyk and others elsewhere are working on involves a wrestling match with MRI physics.

“There’s always a struggle between image quality and accessibility. You get the best, most uniformly strong field and hence the best images in an enclosed MRI system,” said Kucharczyk. The more you open up the traditional cylindrical system to allow the surgeon better access to the patient the more you lose field strength and uniformity. So those are the competing influences and it’s not quite clear on the world level yet in what direction MRI development is headed.”

A tool that solves the accessibility issue and is new to Canada is now at the disposal of surgeons at the Jewish General Hospital in Montreal. FluoroTrak from Visualization Technology Inc. (VTI) in Lawrence, Massachusetts, is the world’s first fluoroscopy-based navigation system to employ electromagnetic tracking technology. Used for cranial, spinal, and sinus surgery, the FluoroTrak system at the Jewish General is the latest version.

“It’s a third-generation no-block tracking system,” explains Natacha Treskin, VTI’s Canadian territory manager. “And what that means is that there are no line of sight restrictions for surgeons or nurses. They can walk around the patient without fear of blocking the imaging. So neurosurgeons can stand at the head of a patient where they normally do and not have to pull away for the imaging.”

Originally developed at the renowned Massachusetts Institute of Technology, the FluoroTrak system dominates the U.S. market for sinus surgery – where precision is paramount.

“When you’re working in the sinuses, you’re working in an area where the skull is the thickness of an egg shell,” said Treskin. “One wrong move can lead to a puncture and consequent meningitis infection or even death. So our system is very accurate. It is a kind of GPS for the human body.”

As a Canadian Centre of Excellence, the Jewish General will be using its new system for research as well, linking it with ultrasound technology aimed at developing real time imaging.

At another Centre of Excellence in Windsor, Ontario, the Hôtel-Dieu Grace Hospital, neurosurgeons are working with the first Ontario installation of a $500,000 German-made BrainLab platform, mostly to root out brain and spinal tumours.

“BrainLab is purely a software company. It doesn’t sell other things so the software is very accurate and high quality,” said Dr. Susan Brien, Hôtel-Dieu’s chief of neurosurgery. “With BrainLab we can combine just about every kind of two-dimensional image such as CT scans and MRI with functional images from PET and nuclear medicine scanning and then fuse all those images. So we can plan the surgery on a workstation then put the images on a zip drive and take them into navigation station in the OR. There we use a special laser pointer called a Z-Touch to outline the patient’s face and the computer morphs the facial features on to the patient’s images.”

Having such capabilities in a regular hospital, said Dr. Brien, is breaking traditional boundaries of surgical system use and development.

“We used to think that a centre of excellence for surgery had to be on a university campus. But those days are gone now,” said Brien who gained her early experience in image-guided surgery as an assistant professor at McGill University. “With the first systems, you had to have a PhD student along to run them. They weren’t very user friendly.”

But now BrainLab is making much easier work not just of complex brain procedures but also of the routine tasks of lumber fusions and placement of spinal instrumentation, added Brien.

At a centre of excellence in Norway, researchers there are striving to give surgical systems even greater ease of use.

In 1995, the Norwegian health ministry established the Center of Excellence in 3D Ultrasound in Trondheim, recognizing that the ultimate ease technology can give surgeons is to let them see in real time what they are working on – not just images of it. Ultrasound holds that potential.

Since the 1970s, Trondheim has been recognized as a hotbed of ultrasound development. No less than five local institutions now contribute to ultrasound innovation including the Norwegian University of Science and Technology, the University Hospital of Trondheim, and the research and development organization, SINTEF Unimed Ultrasound (www.us.unimed.sintef.no).

Toril N. Hernes, with doctorates in biophysics and medical technology behind him, is SINTEF’s research director. Dr. Hernes and his staff spearheaded the development of an ultrasound-guided neurosurgery system that was due for launch in September by Mison AS, a spin-off company.

“It’s the first system in the world that integrates high quality 3D ultrasound with navigation technology,” said Hernes.

According to Hernes, the system addresses the main challenge of neuronavigation: changes in patient anatomy that occur during surgery. Computer based systems do a fine job of imaging the patients before surgery so that it can be mapped out in great detail. However, they are of less value during the operation then they might be, because the moment any part of the brain shifts, “the map then no longer corresponds to the road”.

The current Mison model, like the opened-up MRI of Dr Kucharczyk in Toronto, provides tracking of any anatomy shifts that occur during surgery in near real time. But ultrasound devices will be much cheaper than their MRI counterparts, said Hernes, and newer versions to come from Mison will track changes in real time.

Nonetheless, Hernes sees a future for surgical systems that combines MRI, ultrasound, fluoroscopy and other image guidance technology.

And no doubt larger ORs, like UHN’s laparoscopic suites in Toronto, in order to hold all that gear.

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Incubators will develop ‘wireless’ healthcare solutions

By Jerry Zeidenberg

MISSISSAUGA, ONT. – It’s a disaster that happens all too frequently. A proud, elderly woman living on her own suddenly collapses, the victim of a stroke or myocardial infarction. Ordinarily, it might take hours for her to be discovered and rushed to hospital.

But in another scenario, the woman could be wearing a high-tech wristwatch capable of monitoring her vital signs. The watch transmits a stream of signals, via low-power Bluetooth technology, to a receiving station in the house or apartment. From there, the signals could be wired through the telephone to a nurse-run monitoring centre.

When the alarms are triggered at the call centre, an ambulance is immediately dispatched and paramedics are treating the woman within minutes. They can even obtain a quick readout of vital signs from the computerized wristwatch, again by wireless Bluetooth technology. In the end, the elderly woman’s hopeless situation has been transformed by a low-key technology that operates in the background.

In fact, it’s just one of the technological solutions currently in development by Hewlett-Packard Co. and its partners, through a number of Mobile E-Services Bazaar centres located around the world.

Earlier this year, HP opened one of six international Mobile E-Services Bazaar facilities at its Canadian headquarters in Mississauga, Ont. E-Bazaar partners collaborate at these centres, which are essentially high-tech incubators, to develop and integrate new and sophisticated solutions using wireless technologies.

“We’re bringing together technologies in new ways, driven by the needs of our customers,” said Bob Miller, business development manager for HP Canada. “And wireless systems are capable of solving many problems encountered by the healthcare system.”

The Mobile E-Services Bazaar centres are coordinating this and other wireless research in ambitious ways. HP hopes to have 20 E-Solutions Bazaar facilities running at sites around the world by the end of 2002, and it is forging alliances with an increasing number of wireless technology companies. There are currently more than 400 partners working together on wireless solutions – including everything from medical applications to chain-store retailing and auto manufacturing – and the numbers are growing.

“Hewlett-Packard is playing a role as an aggregator and facilitator in this,” said Miller. He added that the company is bringing its own research to the mix, such as its own work on “wearable appliances.”

“The solutions are customer-driven,” he added. “Meaning that the research and development are answers to real-world problems that plague enterprises.” For its part, Hewlett-Packard intends to learn what the most intractable problems are for hospitals, physicians, and community health organizations, and will attempt to solve some of them through innovative wireless technologies.

Through the Mobile E-Services Bazaar, a wireless partner in Boston has produced technology capable of accessing various computer systems in a hospital on a wireless device, such as a handheld computer or cell phone. The user can access these systems with a single log-on, and obtain the information – for example, from an ADT system or lab system – through a single interface.

Other partners have created a mobile locating system that helps an organ transplant organization in Minnesota. Using the solution, the organization can find the closest of its representatives to pick up organs across the mid-western United States.

These representatives are constantly moving throughout the country, so it is often difficult to find out where they are at any given time. Using the cellular technology, however, signals from their phones or computers are picked up and charted. Since organ transplants must often be performed within hours, it’s important to find the nearest person to pick up a liver or heart, and deliver the organ to the proper hospital.

There are many potential solutions using wireless technology that could assist hospitals, nursing homes and home-care organizations. Bedside or wearable wireless devices in the hospital can alert doctors and nurses more quickly when the vital signs of a patient have changed and the person needs fast medical attention. Conversely, various types of wireless monitoring devices could keep tabs on long-term care patients, monitoring the person remotely, and reducing the need for visits by nurses and doctors.

And some care could be transferred outside of institutions, assisted by wireless devices. Some births, for example, could be conducted in a patient’s home – if that is the parents’ choice. “A caregiver could deliver the baby in the mother’s home, with wireless links to a hospital for advice and backup,” Miller noted. “This could provide a socially responsible solution that saves money for the healthcare system, and offers people more choice for healthcare procedures.”

Miller explained that these technological solutions often involve several companies or organizations working together, as they bring a variety of skills. What’s more, they’re often complex applications, consisting of hardware, software and ‘middleware’ – the systems that glue everything together.” Said Miller: “Hewlett-Packard is creating the ecosystem, where all of this can come together.”

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Innovative new tool created for care planning, analysis and benchmarking

By Ron Brown

A strategic alliance consisting of GE Medical Systems Canada, the Kingston General Hospital and Queen’s University has created an innovative database/mapping tool that will allow care providers and managers to analyze and compare their current performance against local, regional, provincial, national and international best practices.

What’s more, the computerized system will enable hospitals to place their experience within the context of regional socio-demographic profiles and trends.

The tool will be ready for pilot projects in early 2002, and the partners believe the system will be ready for production and wider release in April 2002.

The new system is a solution to a growing problem in Canadian hospitals – the mismatch between revenue and expenditure. For most hospitals, demand for healthcare services is soaring. This will only intensify during the next 10 to 25 years as the oldest baby boomers have now hit 55 and will demand a higher level of service from hospitals.

With these pressures on hospitals, the need for efficient use of resources, the development of methods to identify and disseminate best practices and the prediction of required resources to meet the needs of the population has never been greater.

The partners believe that efficient use of resources requires a collective regional vision, which is difficult to achieve if the focus is the individual hospital. Hence, they argue the tool must be web-based to encourage wide participation and enable hospitals to understand the dynamics of their operation in a regional, national and even international context.

The group’s experience, coupled with recent database software and Internet mapping developments, makes the vision practical and immediately achievable.

The Tool: At present, the tool will be based on three core data sources:

• Canadian Institute for Health Information (CIHI) hospital abstracts;

• hospital financial reporting (Ontario Hospital Reporting System (OHRS)) in Ontario;

• Statistics Canada population measurements and projections.

Other data sources can be added as they are developed and become available on a system-wide basis.

At the heart of the tool are two integrated software components. The first, a dynamic database analysis package, allows multi-level and scalable analysis of individual hospital performance by both internal hospital comparisons and benchmarking between hospitals.

Performance benchmarks and best practices can be chosen from regional, provincial, national and international databases.

The second component, an Internet mapping software package, provides an alternative window on the data to assist hospitals in understanding demographic pressures, and predicting and planning to meet needs resulting from demographic and other changes in their regions. Both packages will be linked to available socio-demographic databases.

The tool is designed to assist physician managers, hospital managers and system managers in maximizing quality and efficiency of service delivery, in ways that follow clinical and management logic.

The Background: Over the past eight years, Kingston General Hospital (KGH) has developed, through its Strategic Information Development (SID) group, a regional database of the CIHI data for the 14 counties of eastern Ontario that make up Region 2 of the Ontario Hospital Association.

SID has developed an intense understanding of the data and its potential for in-hospital dynamic analysis. As well, in collaboration with Queen’s University Geographic Information Systems (GIS) Laboratory and Autodesk Canada, they have developed tools to allow on-line mapping of a population’s utilization of specific hospital services and individual hospital provision of the same services to populations.

Kingston General Hospital, Queen’s University and General Electric Medical Systems Canada (GEMS) entered into a Strategic Alliance in May of 1999. Among other issues covered under this alliance was the potential for KGH to act as a demonstration site for GEMS Healthcare Solutions consulting services.

As a result of the alliance GEMS became aware of the work done by the SID group and the GIS Lab and KGH became aware of the DYNAMO (Dynamic Analysis of Measured Outcomes) product widely distributed in the United States by GEMS.

Components of the Prototype: There are three functional components to be integrated into the proposed prototype.

The CIHI and OHRS data sets contain more then 350 reportable data elements. The proposed link with financial data will enable cost profiling, trending, comparisons and certain types of benchmarking.

The tool, to be known as cDYNAMO, will be on display at the GE Medical Systems booth during the OHA Convention, Toronto, November 5 and 6, 2001.

Ron Brown is Marketing Manager for GE Medical Systems Information Technologies, in Mississauga, Ont.  John Lott, the Director of Information Management for the Kingston General Hospital, leads the hospital’s participation in the alliance.

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DR system for general radiography scores high on productivity and quality

By Jerry Zeidenberg

TORONTO – Mount Sinai Hospital’s test of a general-purpose digital radiography (DR) system – said to be one of the first units installed worldwide – has shown the technology to be so useful that the hospital may acquire two more of the systems during the next year.

This will enable the medical centre to run three general radiography rooms instead of the current five rooms. Because of the high efficiency of DR, the hospital will still be able to process the same number of patients for skeletal exams.

“In our experience, there are significant advantages to digital radiography,” said Dr. Lawrence White, head, division of musculoskeletal imaging at the University of Toronto. “Image acquisition and quality review is faster than conventional film and computed radiography, so patient throughput is higher and the efficiency of the room is much greater.

“The quality of the image is also very high,” he said. “It’s better than CR, and in my experience, equivalent to film. With DR, there’s information available, that may be limited with conventional film-screen radiography, acquisitions”

As an example, on a computer screen he displayed an X-ray image of a patient’s foot that had been taken using the DR system. Dr. White could zoom in, focus and brighten all parts of the image, showing details on all bones of the foot.

He explained that with a traditional, film-based image, that level of flexibility afforded by the ability to alter image display would not be available. In a conventional film-based radiograph of the foot, the phalanges might be optimally imaged, but the hindfoot and base of the fibula and tibia might be underexposed and thus not seen.

Mount Sinai Hospital, a major acute care and teaching facility, runs its diagnostic imaging department in conjunction with the University Health Network – the Toronto Hospital, the Toronto Western Hospital and the Princess Margaret Hospital.

A few years ago, the hospitals decided to move to a ‘filmless’ model of radiology, so that images could be more easily shared by physicians through the use of computer networks.

In October 2000, Mount Sinai installed a Revolution XR/d digital radiographic imaging system from GE Medical Systems.

The University Health Network hospitals already had installed systems for DR chest X-rays and DR mammography, but this was the first implementation of a table-based system for general radiography.

“It was good timing,” said Dr. White. “We wanted to learn more about DR in this area and push forward, and GE had just come out with the technology.”

Dr. White pointed out that on the road to going filmless, CR was also an option. Indeed, the joint department of medical imaging at Mount Sinai Hospital and the UHN has quite a few installations of CR systems for a variety of purposes. However, CR can be slow and cumbersome compared to DR, as technologists must carry large cassettes containing plates back and forth from camera and patient to the image reader.

What’s more, there are quality issues with the images produced by CR systems. In a nutshell there are several technological steps involved in the collection of a CR image and some information is lost along the way.

DR does have some drawbacks, too. First, it’s expensive – much more so than a conventional film-based room or CR. While the cost of typical X-ray room – with cameras and equipment for upright and table shots – runs about $130,000, the cost of similar DR room would be in the order of $550,000 for a table-top system and $750,000 if you added an upright system for imaging the chest.

What’s more, there’s less flexibility with current DR systems. For example, they’re unable to take side views of patients on a table (cross table radiographs) and some oblique image acquisitions, and are instead restricted to shooting from above the patient.

That may change in the future, as manufacturers enhance the flexibility of systems.

Nevertheless, the benefits of DR – namely the throughput, image quality and ability to integrate images with the PACS and hospital information system – have made the technology attractive and valuable to Mount Sinai Hospital and the University Health Network.

The productivity issue has become extremely important. At Mount Sinai, the DR room currently handles about 45 non-ambulatory patients a day (patients who need assistance getting on and off the table.) Technologists estimate they’d only be able to image 30 such patients each day using a standard film-based system or CR.

Dr. White noted that a complete skeletal survey could comprise 16 or 17 radiographic views, which could take up to an hour to perform in a conventional or CR-based X-ray room. “With DR, we can perform a similar exam in approximately half that time.”

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