CholecTriplet2021: A benchmark challenge for surgical action triplet recognition

Context-aware decision support in the operating room can foster surgical safety and efficiency by leveraging real-time feedback from surgical workflow analysis. Most existing works recognize surgical activities at a coarse-grained level, such as phases, steps or events, leaving out fine-grained interaction details about the surgical activity; yet those are needed for more helpful AI assistance in the operating room. Recognizing surgical actions as triplets of <instrument, verb, target> combination delivers comprehensive details about the activities taking place in surgical videos. This paper presents CholecTriplet2021: an endoscopic vision challenge organized at MICCAI 2021 for the recognition of surgical action triplets in laparoscopic videos. The challenge granted private access to the large-scale CholecT50 dataset, which is annotated with action triplet information. In this paper, we present the challenge setup and assessment of the state-of-the-art deep learning methods proposed by the participants during the challenge. A total of 4 baseline methods from the challenge organizers and 19 new deep learning algorithms by competing teams are presented to recognize surgical action triplets directly from surgical videos, achieving mean average precision (mAP) ranging from 4.2% to 38.1%. This study also analyzes the significance of the results obtained by the presented approaches, performs a thorough methodological comparison between them, in-depth result analysis, and proposes a novel ensemble method for enhanced recognition. Our analysis shows that surgical workflow analysis is not yet solved, and also highlights interesting directions for future research on fine-grained surgical activity recognition which is of utmost importance for the development of AI in surgery.

Conquering Data Variations in Resolution: A Slice-Aware Multi-Branch Decoder Network

Fully convolutional neural networks have made promising progress in joint liver and liver tumor segmentation. Instead of following the debates over 2D versus 3D networks (for example, pursuing the balance between large-scale 2D pretraining and 3D context), in this paper, we novelly identify the wide variation in the ratio between intra- and inter-slice resolutions as a crucial obstacle to the performance. To tackle the mismatch between the intra- and inter-slice information, we propose a slice-aware 2.5D network that emphasizes extracting discriminative features utilizing not only in-plane semantics but also out-of-plane coherence for each separate slice. Specifically, we present a slice-wise multi-input multi-output architecture to instantiate such a design paradigm, which contains a Multi-Branch Decoder (MD) with a Slice-centric Attention Block (SAB) for learning slice-specific features and a Densely Connected Dice (DCD) loss to regularize the inter-slice predictions to be coherent and continuous. Based on the aforementioned innovations, we achieve state-of-the-art results on the MICCAI 2017 Liver Tumor Segmentation (LiTS) dataset. Besides, we also test our model on the ISBI 2019 Segmentation of THoracic Organs at Risk (SegTHOR) dataset, and the result proves the robustness and generalizability of the proposed method in other segmentation tasks.

Simultaneous Alignment and Surface Regression Using Hybrid 2D-3D Networks for 3D Coherent Layer Segmentation of Retina OCT Images

Automated surface segmentation of retinal layer is important and challenging in analyzing optical coherence tomography (OCT). Recently, many deep learning based methods have been developed for this task and yield remarkable performance. However, due to large spatial gap and potential mismatch between the B-scans of OCT data, all of them are based on 2D segmentation of individual B-scans, which may loss the continuity information across the B-scans. In addition, 3D surface of the retina layers can provide more diagnostic information, which is crucial in quantitative image analysis. In this study, a novel framework based on hybrid 2D-3D convolutional neural networks (CNNs) is proposed to obtain continuous 3D retinal layer surfaces from OCT. The 2D features of individual B-scans are extracted by an encoder consisting of 2D convolutions. These 2D features are then used to produce the alignment displacement field and layer segmentation by two 3D decoders, which are coupled via a spatial transformer module. The entire framework is trained end-to-end. To the best of our knowledge, this is the first study that attempts 3D retinal layer segmentation in volumetric OCT images based on CNNs. Experiments on a publicly available dataset show that our framework achieves superior results to state-of-the-art 2D methods in terms of both layer segmentation accuracy and cross-B-scan 3D continuity, thus offering more clinical values than previous works.

Separated Contrastive Learning for Organ-at-Risk and Gross-Tumor-Volume Segmentation with Limited Annotation

Automatic delineation of organ-at-risk (OAR) and gross-tumor-volume (GTV) is of great significance for radiotherapy planning. However, it is a challenging task to learn powerful representations for accurate delineation under limited pixel (voxel)-wise annotations. Contrastive learning at pixel-level can alleviate the dependency on annotations by learning dense representations from unlabeled data. Recent studies in this direction design various contrastive losses on the feature maps, to yield discriminative features for each pixel in the map. However, pixels in the same map inevitably share semantics to be closer than they actually are, which may affect the discrimination of pixels in the same map and lead to the unfair comparison to pixels in other maps. To address these issues, we propose a separated region-level contrastive learning scheme, namely SepaReg, the core of which is to separate each image into regions and encode each region separately. Specifically, SepaReg comprises two components: a structure-aware image separation (SIS) module and an intra- and inter-organ distillation (IID) module. The SIS is proposed to operate on the image set to rebuild a region set under the guidance of structural information. The inter-organ representation will be learned from this set via typical contrastive losses cross regions. On the other hand, the IID is proposed to tackle the quantity imbalance in the region set as tiny organs may produce fewer regions, by exploiting intra-organ representations. We conducted extensive experiments to evaluate the proposed model on a public dataset and two private datasets. The experimental results demonstrate the effectiveness of the proposed model, consistently achieving better performance than state-of-the-art approaches. Code is available at https://github.com/jcwang123/Separate_CL.

Real-time landmark detection for precise endoscopic submucosal dissection via shape-aware relation network

We propose a novel shape-aware relation network for accurate and real-time landmark detection in endoscopic submucosal dissection (ESD) surgery. This task is of great clinical significance but extremely challenging due to bleeding, lighting reflection, and motion blur in the complicated surgical environment. Compared with existing solutions, which either neglect geometric relationships among targeting objects or capture the relationships by using complicated aggregation schemes, the proposed network is capable of achieving satisfactory accuracy while maintaining real-time performance by taking full advantage of the spatial relations among landmarks. We first devise an algorithm to automatically generate relation keypoint heatmaps, which are able to intuitively represent the prior knowledge of spatial relations among landmarks without using any extra manual annotation efforts. We then develop two complementary regularization schemes to progressively incorporate the prior knowledge into the training process. While one scheme introduces pixel-level regularization by multi-task learning, the other integrates global-level regularization by harnessing a newly designed grouped consistency evaluator, which adds relation constraints to the proposed network in an adversarial manner. Both schemes are beneficial to the model in training, and can be readily unloaded in inference to achieve real-time detection. We establish a large in-house dataset of ESD surgery for esophageal cancer to validate the effectiveness of our proposed method. Extensive experimental results demonstrate that our approach outperforms state-of-the-art methods in terms of accuracy and efficiency, achieving better detection results faster. Promising results on two downstream applications further corroborate the great potential of our method in ESD clinical practice.

Generalized Radiograph Representation Learning via Cross-supervision between Images and Free-text Radiology Reports

Pre-training lays the foundation for recent successes in radiograph analysis supported by deep learning. It learns transferable image representations by conducting large-scale fully-supervised or self-supervised learning on a source domain. However, supervised pre-training requires a complex and labor intensive two-stage human-assisted annotation process while self-supervised learning cannot compete with the supervised paradigm. To tackle these issues, we propose a cross-supervised methodology named REviewing FreE-text Reports for Supervision (REFERS), which acquires free supervision signals from original radiology reports accompanying the radiographs. The proposed approach employs a vision transformer and is designed to learn joint representations from multiple views within every patient study. REFERS outperforms its transfer learning and self-supervised learning counterparts on 4 well-known X-ray datasets under extremely limited supervision. Moreover, REFERS even surpasses methods based on a source domain of radiographs with human-assisted structured labels. Thus REFERS has the potential to replace canonical pre-training methodologies.

Unsupervised Representation Learning Meets Pseudo-Label Supervised Self-Distillation: A New Approach to Rare Disease Classification

Rare diseases are characterized by low prevalence and are often chronically debilitating or life-threatening. Imaging-based classification of rare diseases is challenging due to the severe shortage in training examples. Few-shot learning (FSL) methods tackle this challenge by extracting generalizable prior knowledge from a large base dataset of common diseases and normal controls, and transferring the knowledge to rare diseases. Yet, most existing methods require the base dataset to be labeled and do not make full use of the precious examples of the rare diseases. To this end, we propose in this work a novel hybrid approach to rare disease classification, featuring two key novelties targeted at the above drawbacks. First, we adopt the unsupervised representation learning (URL) based on self-supervising contrastive loss, whereby to eliminate the overhead in labeling the base dataset. Second, we integrate the URL with pseudo-label supervised classification for effective self-distillation of the knowledge about the rare diseases, composing a hybrid approach taking advantages of both unsupervised and (pseudo-) supervised learning on the base dataset. Experimental results on classification of rare skin lesions show that our hybrid approach substantially outperforms existing FSL methods (including those using fully supervised base dataset) for rare disease classification via effective integration of the URL and pseudo-label driven self-distillation, thus establishing a new state of the art.

Boundary-aware Transformers for Skin Lesion Segmentation

Skin lesion segmentation from dermoscopy images is of great importance for improving the quantitative analysis of skin cancer. However, the automatic segmentation of melanoma is a very challenging task owing to the large variation of melanoma and ambiguous boundaries of lesion areas. While convolutional neutral networks (CNNs) have achieved remarkable progress in this task, most of existing solutions are still incapable of effectively capturing global dependencies to counteract the inductive bias caused by limited receptive fields. Recently, transformers have been proposed as a promising tool for global context modeling by employing a powerful global attention mechanism, but one of their main shortcomings when applied to segmentation tasks is that they cannot effectively extract sufficient local details to tackle ambiguous boundaries. We propose a novel boundary-aware transformer (BAT) to comprehensively address the challenges of automatic skin lesion segmentation. Specifically, we integrate a new boundary-wise attention gate (BAG) into transformers to enable the whole network to not only effectively model global long-range dependencies via transformers but also, simultaneously, capture more local details by making full use of boundary-wise prior knowledge. Particularly, the auxiliary supervision of BAG is capable of assisting transformers to learn position embedding as it provides much spatial information. We conducted extensive experiments to evaluate the proposed BAT and experiments corroborate its effectiveness, consistently outperforming state-of-the-art methods in two famous datasets.

nnFormer: Interleaved Transformer for Volumetric Segmentation

Transformers, the default model of choices in natural language processing, have drawn scant attention from the medical imaging community. Given the ability to exploit long-term dependencies, transformers are promising to help atypical convolutional neural networks (convnets) to overcome its inherent shortcomings of spatial inductive bias. However, most of recently proposed transformer-based segmentation approaches simply treated transformers as assisted modules to help encode global context into convolutional representations without investigating how to optimally combine self-attention (i.e., the core of transformers) with convolution. To address this issue, in this paper, we introduce nnFormer (i.e., Not-aNother transFormer), a powerful segmentation model with an interleaved architecture based on empirical combination of self-attention and convolution. In practice, nnFormer learns volumetric representations from 3D local volumes. Compared to the naive voxel-level self-attention implementation, such volume-based operations help to reduce the computational complexity by approximate 98% and 99.5% on Synapse and ACDC datasets, respectively. In comparison to prior-art network configurations, nnFormer achieves tremendous improvements over previous transformer-based methods on two commonly used datasets Synapse and ACDC. For instance, nnFormer outperforms Swin-UNet by over 7 percents on Synapse. Even when compared to nnUNet, currently the best performing fully-convolutional medical segmentation network, nnFormer still provides slightly better performance on Synapse and ACDC.

Efficient Global-Local Memory for Real-time Instrument Segmentation of Robotic Surgical Video

Performing a real-time and accurate instrument segmentation from videos is of great significance for improving the performance of robotic-assisted surgery. We identify two important clues for surgical instrument perception, including local temporal dependency from adjacent frames and global semantic correlation in long-range duration. However, most existing works perform segmentation purely using visual cues in a single frame. Optical flow is just used to model the motion between only two frames and brings heavy computational cost. We propose a novel dual-memory network (DMNet) to wisely relate both global and local spatio-temporal knowledge to augment the current features, boosting the segmentation performance and retaining the real-time prediction capability. We propose, on the one hand, an efficient local memory by taking the complementary advantages of convolutional LSTM and non-local mechanisms towards the relating reception field. On the other hand, we develop an active global memory to gather the global semantic correlation in long temporal range to current one, in which we gather the most informative frames derived from model uncertainty and frame similarity. We have extensively validated our method on two public benchmark surgical video datasets. Experimental results demonstrate that our method largely outperforms the state-of-the-art works on segmentation accuracy while maintaining a real-time speed.