Virtual surgical planning and three-dimensional printing in multidisciplinary oncologic chest wall resection and reconstruction: A case report

The role of 3D printing in chest wall reconstruction

Technology is advancing fast, and chest wall surgery finds particular benefit in the broader availability of three-dimensional (3D) reconstruction and printing. An increasing number of reports are being published on the use of these resources in virtual 3D reconstructions of chest walls in computed tomography (CT) scans, virtual surgeries, 3D printing of real-size models for surgical planning, practice, and education, and of note, the manufacture of customized 3D printed implants, changing the fundamental conception from a surgery that fits all, to a surgery for each patient. In this review, we explore the evidence published on simple chest wall reconstruction, including the use of 3D technology to assist in the improvement of the repair of the most frequent chest wall deformities: pectus excavatum and carinatum. Current studies are oriented to the automatization and customization of transthoracic implants, as well as education on real-size models. Next, we investigate the implementation of 3D printing in the repair of complex chest wall reconstruction, comprised of infrequent chest wall deformities such as pectus arcuatum and Poland syndrome. These malformations are very heterogeneous resulting in a high degree of improvisation during the surgical repair. In this setting, 3D technology plays a role in the standardization of a process that contemplates customization, concepts that may seem contradictory. Finally, 3D printing with biocompatible materials is rapidly becoming the first choice for the reconstruction of wide chest wall oncological resections. In this work, we review the first and most important current publications on the subject.

Collaborative Virtual Reality Real-Time 3D Image Editing for Chest Wall Resections and Reconstruction Planning

The integration of extended reality (XR) technologies into health care procedures presents transformative opportunities, particularly in surgical processes. This study delves into the utilization of virtual reality (VR) for preoperative planning related to chest wall resections in thoracic surgery. Leveraging the capabilities of 3-dimensional (3D) imaging, real-time visualization, and collaborative VR environments, surgeons gain enhanced anatomical insights and can develop predictive surgical strategies. Two clinical cases highlighted the effectiveness of this approach, showcasing the potential for personalized and intricate surgical planning. The setup provides an immersive, dynamic representation of real patient data, enabling collaboration among teams from separate locations. While VR offers enhanced interactive and visualization capabilities, preliminary evidence suggests it may support more refined preoperative strategies, potentially influence postoperative outcomes, and optimize resource management. However, its comparative advantage over traditional methods needs further empirical validation. Emphasizing the potential of XR, this exploration suggests its broad implications in thoracic surgery, especially when dealing with complex cases requiring multidisciplinary collaboration in the immersive virtual space, often referred to as the metaverse. This innovative approach necessitates further examination, marking a shift toward future surgical preparations. In this article, we sought to demonstrate the technique of an immersive real-time volume-rendered collaborative VR-planning tool using exemplary case studies in chest wall surgery.

Three-Dimensional Volume Rendering of Pelvic Floor Anatomy with Focus on Fibroids in Relation to the Lower Urogenital Tract Based on Cross-Sectional MRI Images

We aimed to assess the feasibility of developing three-dimensional (3D) models of pelvic organs using cross-sectional MRI images of patients with uterine fibroids and urinary symptoms and of obtaining anatomical information unavailable in 2D imaging modalities. We also aimed to compare two image processing applications. We performed a feasibility study analysing MRI scans from three women, aged 30 to 58 years old, with fibroids and urinary symptoms. Cross-sectional images were used to render 3D models of pelvic anatomy, including bladder, uterus and fibroids, using 3D Slicer and OsiriX. Dimensions, volumes and anatomical relationships of the pelvic organs were evaluated. Comparisons between anatomical landmarks and measurements obtained from the two image processing applications were undertaken. Rendered 3D pelvic models yielded detailed anatomical information and data on spatial relationships that were unobtainable from cross-sectional images. Models were rendered in sufficient resolution to aid understanding of spatial relationships between urinary bladder, uterus and fibroid(s). Measurements of fibroid volumes ranged from 5,336 to 418,012 mm3 and distances between the fibroid and urinary bladder ranged from 0.10 to 83.60 mm. Statistical analysis of measurements showed no significant differences in measurements between the two image processing applications. To date, limited data exist on the use of 3D volume reconstructions of routine MRI scans, to investigate pelvic pathologies such as fibroids in women with urinary symptoms. This study suggests that post-MRI image processing can provide additional information over standard MRI. Further studies are required to assess the role of these data in clinical practice, surgical planning and training. Three-dimensional reconstruction of routine two-dimensional magnetic resonance imaging provides additional anatomical information and may improve our understanding of anatomical relationships, their role in clinical presentations and possibly guide clinical and surgical management.

Three-dimensional technologies in chest wall resection and reconstruction

Resection and reconstruction of the chest wall can pose unique challenges given its vital role in the protection of the thoracic viscera and the dynamic part it plays in respiration. A number of new three-dimensional (3D) technologies may be invaluable in tackling these challenges. Herein we review the use of 3D technologies in preoperative imaging with virtual 3D models, printing of 3D models for preoperative planning, and printing of 3D prostheses when approaching complex chest wall reconstruction.

Oncological Outcome of Surgically Resected Sternal Tumors, 16 Years’ Experience

BACKGROUND: Tumors of the sternum are rare and can develop from primary bone pathology or through metastatic spread. Sternal resection with immediate reconstruction of the anterior chest wall defect was recommended for both primary and secondary sternal tumors as curative treatment. AIM: The purpose of our study was to examine the perioperative outcomes, recurrence rate, and OS in patients undergoing partial, subtotal, and total sternectomy. METHODS: We retrospectively reviewed our experience with sternal resections in 29 patients during a 16-year period. The purpose of our study was to examine the perioperative outcomes, recurrence rate, and overall survival (OS) in patients undergoing partial, subtotal, and total sternectomy. RESULTS: We found that 5-year OS was 26.0%, Univariate analysis of predictors of survival revealed that, there was a trend toward prolonged 5-year survival at R0 resection (35.5% vs. 0%, p = 0.058). Post resection defect size associated with prolonged 5-year OS (42.1% vs. 0%, p < 0.001). The absence of post-operative complications associated with prolonged 5-year OS (40.4% vs. 0%, p = 0.012), with special attention to absence of post-operative flail chest which was associated with prolonged 5-year OS (36.2% vs. 0%, p < 0.001). On multivariable analysis, R0 resection (HR, 3.692 [95% CI, 1.190–11.456], p = 0.024) and absence of post-operative flail chest (HR, 52.204 [95% CI, 5.908–461.289], p < 0.001) were associated with improved OS. CONCLUSIONS: We have shown that sternal resection of benign and primary malignant tumors can yield long-term survival. The completeness of resection and absence of postoperative flail chest are the strongest predictors of survival.

The Application of Three-Dimensional Technology Combined With Image Navigation in Nasal Skull Base Surgery

Three-dimensional (3D) technology including 3D reconstruction and 3D printing technology, has been widely used in clinical treatment, especially in surgical planning, and image navigation technology, which can make surgical procedures more accurate, now is also increasingly favored by surgeons. But the combination of those 2 technologies was rarely reported. Thus, this study will preliminarily investigate the feasibility and the effect of the combination of 2 technologies in endonasal skull base surgery. Eight patients were involved in this study (from October 2016 to July 2017 at The Affiliated Hospital of Qingdao University), 5 cases of nasal skull base tumors and 3 cases of foreign body perforation. All operations were done under the assistance of 3D technology and image guidance system. Surgical discussion with patient, preoperative planning and clinical teaching were investigated between 2D images and 3D models by voting. For all cases, 3D reconstruction model and 3D printed model were deemed to be more helpful than CT/MRI images in surgical discussion with the patient; surgical simulation on 3D model in preoperative planning was largely deemed to be helpful and very helpful; and in clinical teaching, 3D models combined with image guidance system were deemed to be more helpful in understanding the disease than using 2D images. Besides, all patients recovered well after surgery, no recurrence and complications were found in the follow-up. The combination of 3D technology and electromagnetic image guidance system could improve surgical efficiency and the quality of clinical teaching.

Reconstruction of massive chest wall defects: A 20-year experience

BACKGROUND

Large chest wall resections can result in paradoxical chest wall movement leading to prolonged ventilator dependence and major respiratory impairment. The purpose of this study was to determine as to which factors are predictive or protective of complications in massive oncologic chest wall defect reconstructions.

METHODS

A retrospective review of a prospectively maintained database of consecutive patients who underwent immediate reconstruction of massive thoracic oncologic defects (≥5 ribs) was performed. Univariate and multivariate logistic regression analyses identified risk factors.

RESULTS

We identified 59 patients (median age, 53 years) with a mean follow-up of 36 months. Rib resections ranged from 5 to 10 ribs (defect area, 80-690 cm²). Sixty-two percent of the patients developed at least one postoperative complication. Superior/middle resections were associated with increased risk of general and pulmonary complications (71.4% vs. 35.3%; OR 4.54; p = 0.013). The 90-day mortality rate following massive chest wall resection and reconstruction was 8.5%. Two factors that were significantly associated with shorter overall survival time were preoperative XRT and preoperative chemotherapy (p = 0.021 and p < 0.001, respectively).

CONCLUSIONS

Patients with massive oncological thoracic defects have a high rate of reconstructive complications, particularly pulmonary, leading to prolonged ventilator dependence. Superior resections were more likely to be associated with increased pulmonary and overall complications. The length of postoperative recovery was significantly associated with the size of the defect, and larger defects had prolonged hospital stays. Because of the large dimensions of chest wall defects, almost half of the cases required flap coverage to allow for appropriate defect closure. Understanding the unique demands of these rare but challenging cases is critically important in predicting patient outcomes.

Reconstruction of Oncologic Sternectomy Defects: Lessons Learned from 60 Cases at a Single Institution

Oncologic sternectomy results in complex defects where preoperative planning is paramount to achieve best reconstructive outcomes. Although pectoralis major muscle flap (PMF) is the workhorse for sternal soft tissue coverage, additional flaps can be required. Our purpose is to evaluate defects in which other flaps beside PMF were required to achieve optimal reconstruction.

Hybrid nanocomposite as a chest wall graft with improved integration by adipose-derived stem cells

Surgery of the chest wall is potentially required to cover large defects after  removal of malignant tumours. Usually, inert and non-degradable Gore-Tex serves to replace the missing tissue. However, novel biodegradable materials combined with stem cells are available that stimulate the healing. Based on poly-lactic-co-glycolic acid and amorphous calcium phosphate nanoparticles (PLGA/aCaP) and pure PLGA, a dual layer biodegradable hybrid nanocomposite was generated. Mouse adipose-derived stem cells were cultered on electrospun disks (ASCs of C57BL/6), and biomechanical tests were performed. The cell-seeded scaffolds were engrafted in C57BL/LY5.1 mice to serve as a chest wall substitute. Cell invasion into the bi-layered material, extent of CD45⁺ cells, inflammatory response, neo-vascularization and ECM composition were determined at 1 and 2 months post-surgery, respectively. The bi-layered hybrid nanocomposite was stable after a 2-week in vitro culture, in contrast to PLGA/aCaP without a PLGA layer. There was a complete biointegration and good vascularization in vivo. The presence of ASCs attracted more CD45⁺ cells (hematopoietic origin) compared to cell-free scaffolds. Inflammatory reaction was similar for both groups (±ASCs) at 8 weeks. A bi-layered hybrid nanocomposite fabricated of electrospun PLGA/aCaP and a reinforcing layer of pristine PLGA is an ideal scaffold for chest wall reconstruction. It is stable and allows a proper host tissue integration. If ASCs are seeded, they attract more CD45⁺ cells, supporting the regeneration process.

The Use of 3D Printed Vasculature for Simulation-based Medical Education Within Interventional Radiology

Three-dimensional (3D) printing has become a useful tool within the field of medicine as a way to produce custom anatomical models for teaching, surgical planning, and patient education. This technology is quickly becoming a key component in simulation-based medical education (SBME) to teach hands-on spatial perception and tactile feedback. Within fields such as interventional radiology (IR), this approach to SBME is also thought to be an ideal instructional method, providing an accurate and economical means to study human anatomy and vasculature. Such anatomical details can be extracted from patient-specific and anonymized CT or MRI scans for the purpose of teaching or analyzing patient-specific anatomy. There is evidence that 3D printing in IR can also optimize procedural training, so learners can rehearse procedures under fluoroscopy while receiving immediate supervisory feedback. Such training advancements in IR hold the potential to reduce procedural operating time, thus reducing the amount of time a patient is exposed to radiation and anaesthetia. Using a program evaluation approach, the purpose of this technical report is to describe the development and application of 3D-printed vasculature models within a radiology interest group to determine their efficacy as supplementary learning tools to traditional, lecture-based teaching. The study involved 30 medical students of varying years in their education, involved in the interest group at Memorial University of Newfoundland (MUN). The session was one hour in length and began with a Powerpoint presentation demonstrating the insertion of guide wires and stents using 3D-printed vasculature models. Participants had the opportunity to use the models to attempt several procedures demonstrated during the lecture. These attempts were supervised by an educational expert/facilitator. A survey was completed by all 30 undergraduate medical students and returned to the facilitators, who compiled the quantitative data to evaluate the efficacy of the 3D-printed models as an adjunct to the traditional didactic teaching within IR. The majority of feedback was positive, supporting the use of 3D=printed vasculature as an additional tactile training method for medical students within an IR academic setting. The hands-on experience provides a valuable training approach, with more opportunities for the rehearsal of high-acuity, low-occurrence (HALO) procedures performed in IR.