Interventional Radiology
The Future of Surgery in
Microgravity
David J. Lerner MD
• Diagnostic and Interventional Radiology
• University of Missouri – Kansas City
• PGY-4
Fellowship in Abdominal Imaging with
focus on Ultrasound Guided
Percutaneous Procedures at MIR
Fellowship in Abdominal Imaging with
focus on Ultrasound Guided
Percutaneous Procedures at MIR
Fellowship in Abdominal Imaging with
focus on Ultrasound Guided
Percutaneous Procedures at MIR
Fellowship in Abdominal Imaging with
focus on Ultrasound Guided
Percutaneous Procedures at MIR
Special Thanks
• Allen J. Parmet MD
• Brandt C. Wible MD, Kenneth Cho MD, John J.
Borsa MD, Nathan Saucier MD, Michael Royce
MD, Douglas C. Rivard DO, William Holloway
MD
• Kelli Andresen MD, Melissa L. Rosado de
Christensen MD, Jeff Kunin MD, Lisa H. Lowe
MD
• Nima Kasraie PhD Radiologic Physics
What is Interventional Radiology?
What is Interventional Radiology?
• Minimally-invasive image-guided procedures
to diagnose and treat diseases in nearly every
organ system.
“I’m Sick! Help!”
“I’m Sick! Help!”
“I’m Sick! Help!”
• Stabilize, Rescue craft within 24 hours, Return
to Earth, Receive proper medical attention.
“I’m Sick! Help!”
“I’m Sick! Help!”
… Sorry?
“I’m Sick! Help!”
… Sorry?
We don’t accept Earth
Health Insurance.
• Stabilization is not good enough
What we worry about
(Most Common)
Cholecystitis
Appendicitis
Hydronephrosis/Pyonephrosis
Choledocholithiasis
Abscess
Pneumothorax/Hydrothorax/Empyema
Pancreatic Pseudocyst
Peritoneal Fluid
Central Venous/Arterial Access
Septic Joint
Laparoscopic vs. Interventional
Radiology
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•
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•
•
Perioperative Planning and Care
Recovery Time
Results
Volume and Mass Supply Limitations
Expertise
Sedation/Anesthesia
Sterile Field
Training Constraints
Hypothetical Astronaut
6 Months Out
•
•
•
•
Fever: 102 F
Chills/Nausea/Vomiting
Right Sided Back Pain
WBC: 17
Differential?
What Next?
What Next?
What Next?
Diagnosis?
Diagnosis?
• Right Pyonephrosis
• Surgical Emergency
• Sepsis, quick decompensation and death if
untreated
Treatment?
Treatment?
• Prior to 1980 on Earth: Laparoscopic/Open Nephrectomy/Partial Nephrectomy
/Nephrostomy (Still general ideology for
Explorer Class Missions)
• Now on Earth: IR Percutaneous Nephrostomy
(and Urologic Stenting less often)
Perioperative Planning and Care
• Lap/Open Partial
Nephrectomy/Nephrostomy
• Significant Planning
•
•
•
•
•
•
•
Surgical ICU
ICU Nurses
Continuous Monitoring
Fluid Management
Foley Catheter
Central Venous Access
Daily Blood Draws
Perioperative Planning and Care
• Lap/Open Partial
Nephrectomy/Nephrostomy
• Percutaneous Nephrostomy
• Significant Planning
• Great for Microgravity
•
•
•
•
•
•
•
• IV Access
• No ICU (Extremely short
recovery time)
• No Nurses or PACU Care
• No Fluid Management (Can
start drinking and eating in
hours)
• No Foley
Surgical ICU
ICU Nurses
Continuous Monitoring
Fluid Management
Foley Catheter
Central Venous Access
Daily Blood Draws
Complications
• Lap/Open Partial
Nephrectomy/Nephrostomy
• Many Possible Complications
• Adverse Reaction to General
Anesthetic
• Laceration of Ureter, Renal Artery,
Renal Vein
• Extravesation
• Convert to Open
• Infection
• Stroke (Inadequate
Hemodynamics During
Anesthesia)
• Many More
Complications
• Lap/Open Partial
Nephrectomy/Nephrostomy
• Percutaneous Nephrostomy
• Many Possible Complications
• Adverse Reaction to General
Anesthetic
• Laceration of Ureter, Renal Artery,
Renal Vein
• Extravesation
• Convert to Open
• Infection
• Stroke (Inadequate
Hemodynamics During
Anesthesia)
• Many More
• Significantly decreased/Nonexistent
• Performed Under Real Time
Sonographic Graphic Guidance
• Avoidance of
Artery/Vein/Ureter
• Needle Size for Access (21g,
.018 wire)
• Minimal Hemodynamic
Concern
Recovery Time/Results
• Lap/Open Partial
Nephrectomy/Nephrostomy
• Significant
• Days to Weeks
• ICU
Recovery Time/Results
• Lap/Open Partial
Nephrectomy/Nephrostomy
• Significant
• Days to Weeks
• ICU
• Percutaneous Nephrostomy
• Recovery Immediate
• 24-48 Hours Full Recovery
with PCN and Antibiotics
• Can be Done as Outpatient
Procedure (General U/S
Percutaneous Procedures)
• Performed Hundreds/
Thousands of Times a Day
Across the Country
• Standard of Care Currently in
US
Volume and Mass Supply
Limitations
• Lap/Open Partial Nephrectomy/Nephrostomy
•
•
•
•
HEAVY
MASS
VOLUME
ONE USE
LESS THAN 0.3
KG!!!
• Four/Five Orders of Magnitude Difference
Expertise
Surgery and Interventional Radiology
Both Require Significant Training
General Residency and Year of Fellowship (6 years)
Plus Astronaut Training Program (2 years)
Expertise
Surgery and Interventional Radiology
Both Require Significant Training
General Residency and Year of Fellowship (6 years)
Plus Astronaut Training Program (2 years)
Luckily…
Specifically Doing Only Ultrasound Guided
Percutaneous Drainage Procedures is More Amenable
to Be Learned in Short Time Frame
Expertise
Solution
1.
Find Radiologist with Abdominal Imaging Fellowship and Percutaneous
U/S Guided Focus Willing to Join Astronaut Program
2.
Find Radiologist with Interventional Radiology Fellowship Willing to Join
Astronaut Program
3.
Have Physician Already in Astronaut Program do 3 Month Intensive
Training in U/S Guided Procedures at Academic Institution
4.
Have Any Astronaut do 3 Month Intensive Training in U/S Guided
Procedures at Academic Institution
Sedation/Anesthesia/Analgesia
• Lap/Open Partial
Nephrectomy/Nephrostomy
• Requires General
Anesthetic/Intubation
• Not Going to Have MDs
With Anesthesia Expertise
• Hemodynamics
• Extubation
• Drug Reaction
• Fluid Stability
Sedation/Anesthesia/Analgesia
• Lap/Open Partial
Nephrectomy/Nephrostomy
• Percutaneous Nephrostomy
• Requires General
Anesthetic/Intubation
• Not Going to Have MDs
With Anesthesia Expertise
• Hemodynamics
• Extubation
• Drug Reaction
• Fluid Stability
• Can be done Awake with only
Lidocaine (Applies to all
procedures in table)
• No Intubation
• No Hemodynamic
• No Fluid Stability
• No Drug Reaction
• No Additional MD Expertise
Sterility
• Lap/Open Partial
Nephrectomy/Nephrostomy
•
•
•
•
•
Brought up in Many Texts
Lots of Research/Cost
Not Perfected
Converting to Open
Microgravity (Things
Float… Including Organs)
Sterility
• Lap/Open Partial
Nephrectomy/Nephrostomy
•
•
•
•
•
Brought up in Many Texts
Lots of Research/Cost
Not Perfected
Converting to Open
Microgravity (Things
Float… Including Organs)
• Percutaneous Nephrostomy
• Significantly Decreased
• Only 1-2 mm Skin Incision
• Transfer of Wires/Fluid Always
Controlled I.E. Stopcocks, Caps
• Blood Loss Less than 2ml
Sterility
Sterility
Future “Earth based” Research
• These have been thoroughly researched, proven, and
performed every single day by hundreds of IR
physicians across the United States.
• Few studies on KC-135, indicated that anatomy and
physiology remains the same as far as percutaneous
procedures go.
• Further researched utilizing the KC-135 and newer
“zero g” research aircraft with anesthetized pigs
• Remote “bases” such as a submarine, aircraft-carrier
and hospital-ships
• Isolated bases such as the Antarctic research stations
Ways to Train
Ways to Train
Ways to Train
Ways to Train
Ways to Train
Goal
• To recreate training environment for NBL to
assess proof of concept for Interventional
Radiology training
Supplies
• Ballistics Gel Phantom with fluid pocket
simulating abscess. (Waterproofed)
• Percutaneous Drainage Devices (Catheters,
Access needles, Guidewire, Syringe)
• Video Recording Devices (Waterproofed)
• And Portable Ultrasound… Waterproofed… *
Portable Ultrasound
• Just how small can we go???
Portable Ultrasound
• Just how small can we go???
Portable Ultrasound
• Just how small can we go???
Portable Ultrasound
• Just how small can we go???
New Age of Technology
New Age of Technology
Waterproofing Technology
• Latest and most technological scientific
breakthroughs of waterproofing…
Waterproofing Technology
EXPERIMENT
Video
Additional Modalities
• FLUOROSCOPY
Additional Modalities
• Fluoroscopy combined with Ultrasound is the
workhorse of Interventional Radiology
• Enables even better localization
• Makes possible innumerable more procedures
to treat medical and surgical emergencies
Fluoroscopy
TOO HEAVY!!
Once again…
New Age of Technology
Portable DR Radiography
• Approximately 5-15 pounds
Intervention and Diagnostic
Intervention
• Provides single shot image for localization of
needles and wires
• Can inject contrast and perform multiple
single shots for fluoroscopic approximation
(Not fast enough for vascular intervention: IE
arteriograms)
Diagnostic
• Innumerable diagnoses can be obtained from
xray imaging.
Ultrasound + X Ray/Radiography
Ultrasound + X Ray/Radiography
• Powerful Combination
What we worry about
(Most Common)
Cholecystitis
Appendicitis*
Hydronephrosis/Pyonephrosis
Choledocholithiasis
Abscess
Pneumothorax/Hydrothorax/Empyema
Pancreatic Pseudocyst
Peritoneal Fluid
Central Venous/Arterial Access
Septic Joint
Appendix *
Appendix * (And Gallbladder)
• Vestigial organ: Not needed
• Can wreak havoc on Explorer Class Mission
• How do we deal with it?
Appendix *
Explorer Class Mission
• Treatment options:
• Medical: Antibiotics etc. Hope it does not perf.
•
Research on non-operative treatment has been performed with variable outcomes
• Laparoscopic appendectomy in microgravity
•
(Complications previously discussed)
Appendix *
Explorer Class Mission
• IR:
• Drain abscess after perforation.
•
(Not ideal, peritonitis, sepsis, etc)
• Percutaneous access, use catheter/balloon to
push out appendicolith
•
(No research on Earth, however this is occasionally done for nephrolithiasis,
cholelithiasis/cystitis, and choledocolithiasis)
Appendix *
Appendix *
Explorer Class Missions
• PRE MISSION ELECTIVE APPENDECTOMY
Conclusions
• Many surgical problems may arise during an Explorer Class spaceflight
mission.
• Necessary equipment to surgically solve these problems would not be
readily available or ideal.
• This lecture is to suggest a possible paradigm shift in the approach to
surgical treatment in microgravity.
• Sonographically guided percutaneous procedures can treat many medical
and surgical events while having many advantages.
• These are performed every day by radiologists throughout the country,
and generally carry risk and complication rates comparable or better than
to surgery.
• Although further research is required, interventional radiology is ideally
suited to handle the predicted medical and surgical problems of Explorer
Class spaceflight missions with percutaneous treatment, resolving
symptomatology and clinical disease during the mission, and which could
then be definitively treated upon return to Earth.
THANK YOU!
Questions?
References
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1. Campbell MR, Billica RD . Surgical Care in Spacefl ight. In: Barratt MR, Pool SL, eds. Principles of clinical medicine
for space fl ight. New York: Springer; 2008 .
2. Camúñez F, Echenagusia A, Prieto ML, Salom P, Herranz F,Hernandez C . Percutaneous nephrostomy in
pyonephrosis .Urol Radiol 1989 ; 11 : 77 – 81 .
3. Chew BH, Denstedt JD . Access, stents and urinary drainage. In: Nakada SY, Pearle MS, eds. Advanced
endourology: the complete clinical guide. New York: Springer; 2006.
4. Ferral H, Lorenz JM . Interventional radiology (Rad Cases). New York: Thieme; 2010 .
5. Jimenez JF, Lopez Pacios MA, Llamazares G, Conejero J, Sole-Balcells F . Treatment of pyonephrosis: a
comparative study. J Urol 1978; 120:287 – 9.
6. Jones JA, Kirkpatrick A, Hamilton DR, Sargsyan AE, Campbell M, et al. Percutaneous bladder catheterization in
microgravity . Can J Urol 2007 ; 14 : 3493 – 8 .
7. Kirkpatrick AW, Nicolaou S, Campbell MR, Sargsyan AE, Dulchavsky SA, et al. Percutaneous aspiration of fl uid for
management of peritonitis in space . Aviat Space Environ Med 2002 ; 73 : 925 – 30 .
8. Kaufman JA, Lee MJ . Vascular and interventional radiology: the requisites. Philadelphia: Saunders; 2003 .
9. Mauro MA, Kieran Murphy K, Thomson K, Venbrux AC, Zollikofer CL . Image-Guided Interventions: Expert
Radiology Series, 1 st ed. Philadelphia: Saunders; 2008 .
10. Lerner DJ, Parmet AJ. Interventional Radiology: The Future of Surgery in Microgravity. Aviat Space Environ
Med 2013; 84:1 – 3.
11. Campbell MR, Johnston III SL, Marshburn T, Kane J, Lugg D, MD, FAFOM Nonoperative Treatment of Suspected
Appendicitis in Remote Medical Care Environments: Implications for Future Spaceflight Medical Care. J Am Coll
Surg, Vol. 198, No. 5, May 2004
12. Stock Photos, Public Domain, Google