Stories about: surgery

Monitoring mitochondria: Laser device tells whether oxygen is sufficient

Shining a laser-based device on a tissue or organ may someday allow doctors to assess whether it’s getting enough oxygen, a team reports today in the journal Science Translational Medicine.

Placed near the heart, the device can potentially predict life-threatening cardiac arrest in critically ill heart patients, according to tests in animal models. The technology was developed through a collaboration between Boston Children’s Hospital and device maker Pendar Technologies (Cambridge, Mass.).

“With current technologies, we cannot predict when a patient’s heart will stop,” says John Kheir, MD, of Boston Children’s Heart Center, who co-led the study. “We can examine heart function on the echocardiogram and measure blood pressure, but until the last second, the heart can compensate quite well for low oxygen conditions. Once cardiac arrest occurs, its consequences can be life-long, even when patients recover.”

In critically ill patients with compromised circulation or breathing, oxygen delivery is often impaired. The new device measures, in real time, whether enough oxygen is reaching the mitochondria, the organelles that provide cells with energy.

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Training neurosurgeons in a rare hydrocephalus procedure, with a little help from Hollywood

ETV trainer

A 4-year-old has a progressively enlarging head and loss of developmental milestones: a clear case of hydrocephalus. He undergoes a minimally invasive endoscopic third ventriculostomy (ETV) to drain off the trapped cerebrospinal fluid.

This requires puncturing the floor of the brain’s third ventricle (fluid-filled cavity) with an endoscope — while avoiding a lethal tear in the basilar artery, which lies perilously close.

There are no good neurosurgical training models for this rare and scary operation.

“We semi-blindly poke a hole through the ventricle floor,” says Benjamin Warf, MD, director of Neonatal and Congenital Anomaly Neurosurgery at Boston Children’s Hospital. “To make the technique safer and to be able to train more people, it would be very helpful to make that hole in a way that’s less anxiety-provoking.”

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Helping tissue grafts build a blood supply: Less is more

blood vessels in vivo

For a tissue graft to survive in the body — whether it’s a surgical graft or bioengineered tissue — it needs to be nourished by blood vessels, and these vessels must connect with the recipient’s circulation. While scientists know how to generate blood vessels for engineered tissue, efforts to get them to connect with the recipient’s vessels have mostly failed.

“Surgeons will tell you that when putting tissue in a new location in the body, the small blood vessels don’t connect at the new site,” says Juan Melero-Martin, PhD, a researcher in Cardiac Surgery in Boston Children’s Hospital. “If you want to engineer a tissue replacement, you’d better understand how the vessels get connected, because if the vessels go, the graft goes.”

Melero-Martin and colleagues have uncovered several strategies to help these connections form, as they describe online today in Nature Biomedical Engineering. The strategies could help improve the success of such procedures as heart patching, bone grafting, fat transplants and islet transplantation.

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3D-printed models assist complex brain surgery for encephalocele

Encephalocele 3D printing

At five months’ gestation, Bentley Yoder was given little chance to live. A routine 20-week “gender reveal” ultrasound showed that a large portion of his brain was growing outside of his skull, a malformation known as an encephalocele. But he was moving and kicking and had a strong heartbeat, so his parents, Sierra and Dustin, carried on with the pregnancy.

Born through a normal vaginal delivery (the doctors felt that a C-section would interfere with Sierra’s grieving process), Bentley surprised everyone by thriving and meeting most of his baby milestones.

But the large protuberance on his head was holding him back. It steadily got larger, filling with cerebrospinal fluid. Bentley couldn’t hold his head up for more than a few seconds.

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The evolution of pediatric surgery

Flashback3

Nearly 100 years ago, William Ladd, MD, of Boston Children’s Hospital, helped establish pediatric surgery as a medical subspecialty. The recognition that children require unique surgical management hasn’t changed, but the instruments and procedures we use to operate on children have evolved dramatically. Here’s a glimpse of the surgical state of the art then and now.

Then

The 1920s marked the earliest use of scrub attire. White gowns, white masks and white linens emphasized the importance of cleanliness — and perhaps compensated for the dim lighting. Chloroform and ether, dating back before the Civil War, were the anesthetics of the day. Though penicillin was discovered in 1928, antibiotics were still two decades away from actual use. Imaging was limited to X-rays. It was in this setting that pediatric surgery began to evolve.

Now

Today’s operations are increasingly more precise and less invasive. Surgeons can practice on custom 3-D models of patients’ anatomy, take an MRI scan mid-operation to ensure accuracy and (at least in animals) repair a still-beating heart with a patch delivered through a vein. “GPS” systems are guiding surgeons to deep lesions through the smallest possible incisions, lasers are replacing scalpels and robots are handling complex moves. Above, surgeons operate on a child with spasticity, opening a small window in his spine and carefully stimulating each nerve before deciding which to cut.

Learn more about what’s next in pediatric innovation. Register today for the Global Pediatric Innovation Summit + Awards.

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Hold me, turn me: 3D printed models help doctors rehearse tricky cerebrovascular procedures

Vein of Galen-3D-20140418_Orbach-croppedFour children with life-threatening malformations of blood vessels in the brain appear to be the first to benefit from 3D printing of their anatomy before undergoing high-risk corrective procedures.

The children, ranging from 2 months to 16 years old, all posed particular treatment challenges: cerebrovascular disease often entails complex tangles of vessels in sensitive brain areas.

“These children had unique anatomy with deep vessels that were very tricky to operate on,” says Boston Children’s neurosurgeon Edward Smith, MD, senior author of the paper and co-director of the hospital’s Cerebrovascular Surgery and Interventions Center. “The 3D-printed models allowed us to rehearse the cases beforehand and reduce operative risk as much as we could. You can physically hold the 3D models, view them from different angles, practice the operation with real instruments and get tactile feedback.”

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Inside the Lancet Commission on Global Surgery: A conversation with John G. Meara

meara-global-surgery
John G. Meara, MD, plastic surgeon-in-chief at Boston Children’s Hospital, co-chaired the Lancet Commission on Global Surgery, which released its findings today.

Although global health has come a long way over the past 25 years, access to surgical care remains very uneven across the world. Five billion people lack access to basic surgical care; this translates into unnecessary death and disability. More than one-third of all global deaths are from conditions requiring surgical care—more than the number of deaths from HIV/AIDs, tuberculosis and malaria combined. In addition, one-quarter of the world’s disability has been attributed to surgically treatable conditions.

In January 2014, an international team of 25 surgeons and public health experts launched The Lancet Commission on Global Surgery to address the widespread need for surgical care around the world. After 14 months of global consultation and four international meetings, the commission published a 32,000- word report today in The Lancet that provides a strategy for governments, policy makers, non-profits, funding agencies, academic institutions, professional associations, health care providers and local communities to engage in concrete action in low- and middle-income countries.

On May 6, the commission hosts its North American launch in Boston to present its key findings and priority action items. John G. Meara, MD, DMD, MBA, Plastic Surgeon-in Chief at Boston Children’s Hospital and the Kletjian Professor of Global Surgery at Harvard Medical School, is one of three chairs of the commission. We sat down with Meara to learn more about the commission’s work, which he describes as one of the “most impactful things he has done in his career to date.”

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Magnetic needle tackles suturing in challenging surgical fields

magnetic suturing needle
A magnetic needle and thread lets surgeons maneuver in tight spots.
The current method of suturing used in surgery—stitching with a needle and thread—has been around for thousands of years. Kaifeng Liu, MD, a research fellow at Boston Children’s Hospital, hopes to reimagine this fundamental operating room practice. His workbench is filled with various prototypes of a magnetic needle, a device he hopes will make suturing simpler, faster and more efficient for researchers and clinicians alike.

“Sometimes it is the simplest things in medicine that stay the same over time,” says Liu, whose invention will be featured later this week at Boston Children’s Hospital’s Global Pediatric Innovation Summit + Awards 2014 (October 30-31).

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Could a simple injection fix spina bifida before birth?

spina bifida myelomeningocele
Prenatal cell therapy could avoid the need for invasive myelomeningocele surgery.

The neural tube, which becomes the spinal cord and brain, is supposed to close during the first month of prenatal development. In children with spina bifida, it doesn’t close completely, leaving the nerves of the spinal cord exposed and subject to damage. The most common and serious form of spina bifida, myelomeningocele, sets a child up for lifelong disability, causing complications such as hydrocephalus, leg paralysis, and loss of bladder and bowel control.

New research from Boston Children’s Hospital, though still in animal models, suggests that standard amniocentesis, followed by one or more injections of cells into the womb, could be enough to at least partially repair spina bifida prenatally.

Currently, the standard procedure is to operate on infants soon after delivery.

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Skin-like material can ‘sense’ if surgeons get off track

Experimental setup for calibrating the sensing skin. Each sensor pad is lowered onto the indentation surface placed on a weight-measuring scale. Changes in the channel resistance are processed through analog signal conditioning and a DAC board, and recorded on a computer. (J Neurosurgery: Pediatrics)
Experimental setup for calibrating the sensing skin. Each sensor pad is lowered onto the indentation surface placed on a weight-measuring scale. Changes in the channel resistance are processed through analog signal conditioning and a DAC board, and recorded on a computer. (Images: J Neurosurgery: Pediatrics)
When surgeons perform image-guided minimally invasive procedures using an endoscope, some aspects of visualization and image quality are typically compromised as compared with open surgeries in which the physician can peer into the body. However, a new pressure-sensing material, placed over an endoscope, may someday provide surgeons with additional guidance and protect healthy tissue during these procedures.

“Neurosurgeons, especially pediatric neurosurgeons, are increasingly using neuroendoscopy to perform minimally invasive brain and spine surgery,” notes Patrick Codd, MD, from the Department of Neurosurgery at Boston Children’s Hospital, who was the lead author on a study evaluating this new material.

“Whenever you move to image-guided minimally invasive surgery, there is typically a tradeoff between the resolution of the image and the field of view,” where you have one but not the other, says Pierre Dupont, PhD, chief of Pediatric Cardiac Bioengineering at Boston Children’s and senior author on the study.

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