Role of glioma stem cells in promoting tumor chemo- and radioresistance: A systematic review of potential targeted treatments

BACKGROUND

Gliomas pose a significant challenge to effective treatment despite advancements in chemotherapy and radiotherapy. Glioma stem cells (GSCs), a subset within tumors, contribute to resistance, tumor heterogeneity, and plasticity. Recent studies reveal GSCs’ role in therapeutic resistance, driven by DNA repair mechanisms and dynamic transitions between cellular states. Resistance mechanisms can involve different cellular pathways, most of which have been recently reported in the literature. Despite progress, targeted therapeutic approaches lack consensus due to GSCs’ high plasticity.

AIM

To analyze targeted therapies against GSC-mediated resistance to radio- and chemotherapy in gliomas, focusing on underlying mechanisms.

METHODS

A systematic search was conducted across major medical databases (PubMed, Embase, and Cochrane Library) up to September 30, 2023. The search strategy utilized relevant Medical Subject Heading terms and keywords related to including “glioma stem cells”, “radiotherapy”, “chemotherapy”, “resistance”, and “targeted therapies”. Studies included in this review were publications focusing on targeted therapies against the molecular mechanism of GSC-mediated resistance to radiotherapy resistance (RTR).

RESULTS

In a comprehensive review of 66 studies on stem cell therapies for SCI, 452 papers were initially identified, with 203 chosen for full-text analysis. Among them, 201 were deemed eligible after excluding 168 for various reasons. The temporal breakdown of studies illustrates this trend: 2005-2010 (33.3%), 2011-2015 (36.4%), and 2016-2022 (30.3%). Key GSC models, particularly U87 (33.3%), U251 (15.2%), and T98G (15.2%), emerge as significant in research, reflecting their representativeness of glioma characteristics. Pathway analysis indicates a focus on phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin (mTOR) (27.3%) and Notch (12.1%) pathways, suggesting their crucial roles in resistance development. Targeted molecules with mTOR (18.2%), CHK1/2 (15.2%), and ATP binding cassette G2 (12.1%) as frequent targets underscore their importance in overcoming GSC-mediated resistance. Various therapeutic agents, notably RNA inhibitor/short hairpin RNA (27.3%), inhibitors (e.g., LY294002, NVP-BEZ235) (24.2%), and monoclonal antibodies (e.g., cetuximab) (9.1%), demonstrate versatility in targeted therapies. among 20 studies (60.6%), the most common effect on the chemotherapy resistance response is a reduction in temozolomide resistance (51.5%), followed by reductions in carmustine resistance (9.1%) and doxorubicin resistance (3.0%), while resistance to RTR is reduced in 42.4% of studies.

CONCLUSION

GSCs play a complex role in mediating radioresistance and chemoresistance, emphasizing the necessity for precision therapies that consider the heterogeneity within the GSC population and the dynamic tumor microenvironment to enhance outcomes for glioblastoma patients.

Chordoma Genetic Aberrations and Targeted Therapies Panorama: A Systematic Literature Review

Background: Chordomas pose a challenge in treatment due to their local invasiveness, high recurrence, and potential lethality. Despite being slow-growing and rarely metastasizing, these tumors often resist conventional chemotherapies (CTs) and radiotherapies (RTs), making surgical resection a crucial intervention. However, achieving radical resection for chordomas is seldom possible, presenting therapeutic challenges. The accurate diagnosis of these tumors is vital for their distinct prognoses, yet differentiation is hindered by overlapping radiological and histopathological features. Fortunately, recent molecular and genetic studies, including extracranial location analysis, offer valuable insights for precise diagnosis. This literature review delves into the genetic aberrations and molecular biology of chordomas, aiming to provide an overview of more successful therapeutic strategies. Methods: A systematic search was conducted across major medical databases (PubMed, Embase, and Cochrane Library) up to 28 January 2023. The search strategy utilized relevant Medical Subject Heading (MeSH) terms and keywords related to "chordomas", "molecular biology", "gene aberrations", and "target therapies". The studies included in this review consist of preclinical cell studies, case reports, case series, randomized controlled trials, non-randomized controlled trials, and cohort studies reporting on genetic and biological aberrations in chordomas. Results: Of the initial 297 articles identified, 40 articles were included in the article. Two tables highlighted clinical studies and ongoing clinical trials, encompassing 18 and 22 studies, respectively. The clinical studies involved 185 patients diagnosed with chordomas. The tumor sites were predominantly sacral (n = 8, 44.4%), followed by clivus (n = 7, 38.9%) and lumbar spine (n = 3, 16.7%). Primary treatments preceding targeted therapies included surgery (n = 10, 55.6%), RT (n = 9, 50.0%), and systemic treatments (n = 7, 38.9%). Various agents targeting specific molecular pathways were analyzed in the studies, such as imatinib (a tyrosine kinase inhibitor), erlotinib, and bevacizumab, which target EGFR/VEGFR. Common adverse events included fatigue (47.1%), skin reactions (32.4%), hypertension (23.5%), diarrhea (17.6%), and thyroid abnormalities (5.9%). Clinical outcomes were systematically assessed based on progression-free survival (PFS), overall survival (OS), and tumor response evaluated using RECIST or CHOI criteria. Notably, stable disease (SD) occurred in 58.1% of cases, and partial responses (PRs) were observed in 28.2% of patients, while 13.7% experienced disease progression (PD) despite targeted therapy. Among the 22 clinical trials included in the analysis, Phase II trials were the most prevalent (40.9%), followed by I-II trials (31.8%) and Phase I trials (27.3%). PD-1 inhibitors were the most frequently utilized, appearing in 50% of the trials, followed by PD-L1 inhibitors (36.4%), CTLA-4 inhibitors (22.7%), and mTOR inhibitors (13.6%). Conclusions: This systematic review provides an extensive overview of the state of targeted therapy for chordomas, highlighting their potential to stabilize the illness and enhance clinical outcomes.

Validation of the Quality Analysis of Medical Artificial Intelligence (QAMAI) tool: a new tool to assess the quality of health information provided by AI platforms

BACKGROUND

The widespread diffusion of Artificial Intelligence (AI) platforms is revolutionizing how health-related information is disseminated, thereby highlighting the need for tools to evaluate the quality of such information. This study aimed to propose and validate the Quality Assessment of Medical Artificial Intelligence (QAMAI), a tool specifically designed to assess the quality of health information provided by AI platforms.

METHODS

The QAMAI tool has been developed by a panel of experts following guidelines for the development of new questionnaires. A total of 30 responses from ChatGPT4, addressing patient queries, theoretical questions, and clinical head and neck surgery scenarios were assessed by 27 reviewers from 25 academic centers worldwide. Construct validity, internal consistency, inter-rater and test-retest reliability were assessed to validate the tool.

RESULTS

The validation was conducted on the basis of 792 assessments for the 30 responses given by ChatGPT4. The results of the exploratory factor analysis revealed a unidimensional structure of the QAMAI with a single factor comprising all the items that explained 51.1% of the variance with factor loadings ranging from 0.449 to 0.856. Overall internal consistency was high (Cronbach's alpha = 0.837). The Interclass Correlation Coefficient was 0.983 (95% CI 0.973-0.991; F (29,542) = 68.3; p < 0.001), indicating excellent reliability. Test-retest reliability analysis revealed a moderate-to-strong correlation with a Pearson's coefficient of 0.876 (95% CI 0.859-0.891; p < 0.001).

CONCLUSIONS

The QAMAI tool demonstrated significant reliability and validity in assessing the quality of health information provided by AI platforms. Such a tool might become particularly important/useful for physicians as patients increasingly seek medical information on AI platforms.

Decoding the puzzle: A multidisciplinary systematic review of adult brainstem glioma

Adult brainstem gliomas (BSGs) are a group of rare central nervous system tumors with varying prognoses and controversial standard treatment strategies. To provide an overview of current trends, a systematic review using the PRISMA guidelines, Class of evidence (CE) and strength of recommendation (SR), was conducted. The review identified 27 studies. Surgery was found to have a positive impact on survival, particularly for focal lesions with CE II SR C. Stereotactic image-guided biopsy was recommended when resective surgery was not feasible with CE II and SR B. The role of systemic treatments remains unclear. Eight studies provided molecular biology data. This review gathers crucial literature on diagnosis and management of adult BSGs. It provides evidence-based guidance with updated recommendations for diagnosing and treating, taking into account recent molecular and genetic advancements. The importance of brain biopsy is emphasized to optimize treatment using emerging genetic-molecular findings and explore potential targeted therapies.

Impact of Sarcopenia on Survival of Patients With Malignant Salivary Glands Tumors

OBJECTIVE

Malignant salivary glands tumors (MSGTs) are a quite rare and heterogeneous group of tumors. Management of these lesions remains controversial and challenging. Thus, finding new prognostic factors that can help to guide the decision-making process, appears to be paramount. The aim of this study was to evaluate the prognostic performance of preoperative sarcopenia to stratify MSGTs patients at high risk of disease progression.

STUDY DESIGN

Retrospective study.

SETTING

A single-institution analysis (Maxillo-facial Surgery Unit, University of Naples Federico II).

METHODS

The study consists of a retrospective analysis of 74 patients surgically treated for MSGTs. For all patients, the skeletal muscle index (SMI) was calculated and sarcopenia was defined as SMI < 41 in females and <43 in males. The correlation between sarcopenia and tumor variables was analyzed. The prognostic performance of sarcopenia was evaluated through survival Kaplan-Meier curves.

RESULTS

Sarcopenia resulted statistically related to age (P < .001), tumor size (P < .001), lymph node metastases (P < .001), and American Joint Committee on Cancer tumor, node, metastasis stage (P < .001). Kaplan-Meier survival curves show that 47.3% of sarcopenic patients died before their final follow-up.

CONCLUSION

Data obtained from our study seem to confirm the correlation between sarcopenia and other high-risk features. The early detection of sarcopenia in patients with negative prognostic factors could be used to implement the support therapeutic strategies aimed at restore the clinical conditions of the patients. Sarcopenia may be routinely investigated before surgery to suggest the implementation of precautionary therapeutic strategies to improve the standard treatment response, reducing possible complications.

The Use of Artificial Intelligence Algorithms in the Prognosis and Detection of Lymph Node Involvement in Head and Neck Cancer and Possible Impact in the Development of Personalized Therapeutic Strategy: A Systematic Review

Given the increasingly important role that the use of artificial intelligence algorithms is taking on in the medical field today (especially in oncology), the purpose of this systematic review is to analyze the main reports on such algorithms applied for the prognostic evaluation of patients with head and neck malignancies. The objective of this paper is to examine the currently available literature in the field of artificial intelligence applied to head and neck oncology, particularly in the prognostic evaluation of the patient with this kind of tumor, by means of a systematic review. The paper exposes an overview of the applications of artificial intelligence in deriving prognostic information related to the prediction of survival and recurrence and how these data may have a potential impact on the choice of therapeutic strategy, making it increasingly personalized. This systematic review was written following the PRISMA 2020 guidelines.

Exploring Deep Cervical Compartments in Head and Neck Surgical Oncology through Augmented Reality Vision: A Proof of Concept

BACKGROUND

Virtual surgical planning allows surgeons to meticulously define surgical procedures by creating a digital replica of patients' anatomy. This enables precise preoperative assessment, facilitating the selection of optimal surgical approaches and the customization of treatment plans. In neck surgery, virtual planning has been significantly underreported compared to craniofacial surgery, due to a multitude of factors, including the predominance of soft tissues, the unavailability of intraoperative navigation and the complexity of segmenting such areas. Augmented reality represents the most innovative approach to translate virtual planning for real patients, as it merges the digital world with the surgical field in real time. Surgeons can access patient-specific data directly within their field of view, through dedicated visors. In head and neck surgical oncology, augmented reality systems overlay critical anatomical information onto the surgeon's visual field. This aids in locating and preserving vital structures, such as nerves and blood vessels, during complex procedures. In this paper, the authors examine a series of patients undergoing complex neck surgical oncology procedures with prior virtual surgical planning analysis. For each patient, the surgical plan was imported in Hololens headset to allow for intraoperative augmented reality visualization. The authors discuss the results of this preliminary investigation, tracing the conceptual framework for an increasing AR implementation in complex head and neck surgical oncology procedures.

Surgical Treatment of Spheno-Orbital Meningiomas: A Systematic Review and Meta-Analysis of Surgical Techniques and Outcomes

BACKGROUND

Spheno-orbital meningiomas (SOMs) are rare tumors arising from the meninges surrounding the sphenoid bone and orbital structures. Surgical resection is the primary treatment approach for SOMs. Several surgical approaches have been described during the decades, including microsurgical transcranial (MTAs), endoscopic endonasal (EEAs), endoscopic transorbital (ETOAs), and combined approaches, and the choice of surgical approach remains a topic of debate.

PURPOSE

This systematic review and meta-analysis aim to compare the clinical and surgical outcomes of different surgical approaches used for the treatment of SOMs, discussing surgical techniques, outcomes, and factors influencing surgical decision making.

METHODS

A comprehensive literature review of the databases PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted for articles published on the role of surgery for the treatment of SOMs until 2023. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Meta-analysis was performed to estimate pooled event rates and assess heterogeneity. Fixed- and random-effects were used to assess 95% confidential intervals (CIs) of presenting symptoms, outcomes, and complications.

RESULTS

A total of 59 studies comprising 1903 patients were included in the systematic review and meta-analysis. Gross total resection (GTR) rates ranged from 23.5% for ETOAs to 59.8% for MTAs. Overall recurrence rate after surgery was 20.7%. Progression-free survival (PFS) rates at 5 and 10 years were 75.5% and 49.1%, respectively. Visual acuity and proptosis improvement rates were 57.5% and 79.3%, respectively. Postoperative cranial nerve (CN) focal deficits were observed in 20.6% of cases. The overall cerebro-spinal fluid (CSF) leak rate was 3.9%, and other complications occurred in 13.9% of cases. MTAs showed the highest GTR rates (59.8%, 95%CI = 49.5-70.2%; p = 0.001) but were associated with increased CN deficits (21.0%, 95%CI = 14.5-27.6%). ETOAs had the lowest GTR rates (23.5%, 95%CI = 0.0-52.5%; p = 0.001), while combined ETOA and EEA had the highest CSF leak rates (20.3%, 95%CI = 0.0-46.7%; p = 0.551). ETOAs were associated with better proptosis improvement (79.4%, 95%CI = 57.3-100%; p = 0.002), while anatomical class I lesions were associated with better visual acuity (71.5%, 95%CI = 63.7-79.4; p = 0.003) and proptosis (60.1%, 95%CI = 38.0-82.2; p = 0.001) recovery. No significant differences were found in PFS rates between surgical approaches.

CONCLUSION

Surgical treatment of SOMs aims to preserve visual function and improve proptosis. Different surgical approaches offer varying rates of GTR, complications, and functional outcomes. A multidisciplinary approach involving a skull base team is crucial for optimizing patient outcomes.

The Role of Temporomandibular Joint Arthroscopy for Diagnosis and Surgical Management of Synovial Chondromatosis

OBJECTIVE

We report the experience of our maxillo-facial surgery unit into the diagnostic and the therapeutic role of arthroscopy of temporomandibular joint (TMJ) synovial chondromatosis (SC).

MATERIALS AND METHODS

A series of sixteen patients with an imaging, arthroscopical, and histological diagnosis of SC treated with arthroscopy was selected. The surgeries were conducted in the Department of Maxillo-facial surgery, Academic hospital of Udine, from January 2016 to December 2022. Medical history, clinical examination, imaging, arthroscopical, and histological characteristics were recorded and then reviewed and discussed.

RESULTS

Clinical improvement, both in pain and in maximum incisal opening (MIO), were noticed in whole patients. Histologically, according to Milgram's classification, the sample was fairly homogeneous. Arthroscopic treatment was successful in 87.5% of the patients. Only two cases of SC relapse were registered and were then submitted to open surgery to perform a total sinovectomy. The data collected were used to develop an SC classification proposal based on clinical, radiological (magnetic resonance imaging), arthroscopical, and histopathological characteristics.

CONCLUSIONS

TMJ arthroscopy must be considered the first line of treatment for SC, leaving open surgery to relapses cases and those cases with extraarticular extension. A univocal classification is essential to best stage and prognostically characterise this pathology.

Accuracy of ChatGPT-Generated Information on Head and Neck and Oromaxillofacial Surgery: A Multicenter Collaborative Analysis

OBJECTIVE

To investigate the accuracy of Chat-Based Generative Pre-trained Transformer (ChatGPT) in answering questions and solving clinical scenarios of head and neck surgery.

STUDY DESIGN

Observational and valuative study.

SETTING

Eighteen surgeons from 14 Italian head and neck surgery units.

METHODS

A total of 144 clinical questions encompassing different subspecialities of head and neck surgery and 15 comprehensive clinical scenarios were developed. Questions and scenarios were inputted into ChatGPT4, and the resulting answers were evaluated by the researchers using accuracy (range 1-6), completeness (range 1-3), and references' quality Likert scales.

RESULTS

The overall median score of open-ended questions was 6 (interquartile range[IQR]: 5-6) for accuracy and 3 (IQR: 2-3) for completeness. Overall, the reviewers rated the answer as entirely or nearly entirely correct in 87.2% of cases and as comprehensive and covering all aspects of the question in 73% of cases. The artificial intelligence (AI) model achieved a correct response in 84.7% of the closed-ended questions (11 wrong answers). As for the clinical scenarios, ChatGPT provided a fully or nearly fully correct diagnosis in 81.7% of cases. The proposed diagnostic or therapeutic procedure was judged to be complete in 56.7% of cases. The overall quality of the bibliographic references was poor, and sources were nonexistent in 46.4% of the cases.

CONCLUSION

The results generally demonstrate a good level of accuracy in the AI's answers. The AI's ability to resolve complex clinical scenarios is promising, but it still falls short of being considered a reliable support for the decision-making process of specialists in head-neck surgery.

Reply to Mattei et al. Jacob Disease, Osteochondroma of the Coronoid Process, Coronoid Process Hyperplasia or Langenbeck Disease: The Big Jumble. Comment on "Raccampo et al. Jacob's Disease: Case Series, Extensive Literature Review and Classification Proposal. J. Clin. Med. 2023, 12, 938"

As authors of the text, we can only thank Mattei et al. [...].

Optimizing efficiency in the creation of patient-specific plates through field-driven generative design in maxillofacial surgery

Field driven design is a novel approach that allows to define through equations geometrical entities known as implicit bodies. This technology does not rely upon conventional geometry subunits, such as polygons or edges, rather it represents spatial shapes through mathematical functions within a geometrical field. The advantages in terms of computational speed and automation are conspicuous, and well acknowledged in engineering, especially for lattice structures. Moreover, field-driven design amplifies the possibilities for generative design, facilitating the creation of shapes generated by the software on the basis of user-defined constraints. Given such potential, this paper suggests the possibility to use the software nTopology, which is currently the only software for field-driven generative design, in the context of patient-specific implant creation for maxillofacial surgery. Clinical scenarios of applicability, including trauma and orthognathic surgery, are discussed, as well as the integration of this new technology with current workflows of virtual surgical planning. This paper represents the first application of field-driven design in maxillofacial surgery and, although its results are very preliminary as it is limited in considering only the distance field elaborated from specific points of reconstructed anatomy, it introduces the importance of this new technology for the future of personalized implant design in surgery.

Extended Complex Temporomandibular Joint Reconstructions Exploiting Virtual Surgical Planning, Navigation Assistance, and Custom-Made Prosthesis: A Comprehensive Protocol and Workflow

BACKGROUND

Alloplastic temporomandibular joint (TMJ) replacement is a well-established procedure in maxillo-facial surgery. However, the surgical management of large excision in this area requires complex reconstruction beyond the standard TMJ prosthesis.

OBJECTIVE

This study aims to describe the design and the consequential application of a protocol which involves the use of computer-assisted surgery tools to best face complex TMJ reconstruction (TMJR). Preoperative accurate study of every single case and intraoperative check of the surgical act are nowadays essential to perform such delicate surgical procedures.

MATERIALS AND METHODS

The study is a retrospective and single institution case series. The various processes of the management and planning of extended TMJ reconstruction (eTMJR) are extensively described, from the preoperative clinical evaluation, imaging acquisition protocols and virtual surgical planning (VSP), focusing also on the intraoperative transfer of VSP using navigation and surgical guides.

RESULTS

We included nine patients with different pathologies which were candidates for eTMJR. Overall, the application of our protocol and workflow permitted the reduction of complications and pain, and the improvement of the maximum interincisal opening (MIO) of the patients, restoring patients' masticatory function and esthetics.

CONCLUSIONS

The eTMJR should be considered as a safe and reliable surgical management modality in selected patients with large temporomandibular joint and skull base (TMJ-SB) lesions. An accurate preoperative protocol and workflow is essential to perform such insidious and complex reconstruction. However, more extensive studies on this type of device have to be conducted in order to validate its real usefulness and indications.

Tumor Microenvironment and Glioblastoma Cell Interplay as Promoters of Therapeutic Resistance

The invasive nature of glioblastoma is problematic in a radical surgery approach and can be responsible for tumor recurrence. In order to create new therapeutic strategies, it is imperative to have a better understanding of the mechanisms behind tumor growth and invasion. The continuous cross-talk between glioma stem cells (GSCs) and the tumor microenvironment (TME) contributes to disease progression, which renders research in this field difficult and challenging. The main aim of the review was to assess the different possible mechanisms that could explain resistance to treatment promoted by TME and GSCs in glioblastoma, including the role of M2 macrophages, micro RNAs (miRNAs), and long non-coding RNAs (lncRNAs) from exosomes from the TME. A systematic review of the literature on the role of the TME in developing and promoting radioresistance and chemoresistance of GBM was performed according to PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. A dedicated literature review search was also performed on the immunotherapeutic agents against the immune TME. We identified 367 papers using the reported keywords. The final qualitative analysis was conducted on 25 studies. A growing amount of evidence in the current literature supports the role of M2 macrophages and non-coding RNAs in promoting the mechanisms of chemo and radioresistance. A better insight into how GBM cells interact with TME is an essential step towards comprehending the mechanisms that give rise to resistance to standard treatment, which can help to pave the way for the development of novel therapeutic strategies for GBM patients.

Perspectives on medical 3D printing at the point-of-care from the new European 3D Printing Special Interest Group

This editorial presents the vision for the newly formed (2022) European 3D Special Interest Group (EU3DSIG) in the landscape of medical 3D printing. There are four areas of work identified by the EU3DSIG in the current landscape, namely: 1) creating and fostering communication channels among researches, clinicians and industry, 2) generating awareness of hospitals point-of-care 3D technologies; 3) knowledge sharing and education; 4) regulation, registry and reimbursement models.

The shark flap: a modified internal mammary artery perforator flap for composite defects in head and neck reconstruction

This report describes a multi-vector variant of IMAP flap which allows to reconstruct composite head and neck defects. It was named the 'shark flap' because of its shape: a main body (the regular IMAP) and a superior 'fin' based on a randomic vascular pathway.

Double osseous flaps for simultaneous midfacial and mandible reconstruction: Automation in surgical complexity within an entirely computerized workflow

Introduction

Broad maxillofacial surgical resections involving both the midface and the mandible represent a challenge in terms of reconstruction. Although several papers have explored the possibility of simultaneously using two microsurgical flaps, reports on the implementation of a dual osseous flap strategy are limited, and mainly addressed to static anatomical reconstruction, regardless of functional implications. In particular, there is a lack in the literature of a unifying protocol which illustrates how technology including virtual planning, statistical shape modeling, virtual occlusion, 3D-printing and patient-specific implants can address the functional and accuracy needs required for an optimal reconstruction.

Materials and methods

In this paper, the Authors present their preliminary experience in a two-center study, showing how broad maxillofacial defects, requiring a simultaneous reconstruction in both the mandible and the midface, can be successfully reconstructed using the combination of two osseous flaps in an automated sequence in which all steps are anticipately defined in a virtual plan, accounting for the optimal alignment of temporomandibular joint, predicting the final occlusion and defining a mandibular shape according to a statistical shape model.

Results

Average RMSE for the iliac bone crest flap was of 3.2 ± 0.36 mm; for the fibula flap, RMSE value was of 2.3 ± 0.65 mm, for patient-specific implants, for mandibular prostheses the average RMSE was 2.46 mm with 0.76 mm standard deviation. Temporomandibular joint function increased when a TMJ prosthesis was placed.

Conclusions

Double bone free flap is a valuable resource to reconstruct wide defects that simultaneously involve two thirds of the cranio-maxillo-facial skeleton, but a careful virtual planning study should be always performed before approaching this surgical option.

Computerized Three-Dimensional Analysis: A Novel Method to Assess the Effect of Open-Door Laminoplasty

INTRODUCTION

The three-dimensional elaboration of morphological data derived from computed tomography (CT) and magnetic resonance imaging (MRI) scans generates virtual anatomical reconstructions. Here, we propose a novel protocol to analyze the postoperative results of open-door laminoplasty to evaluate differences in the volume of the spinal canal. The protocol uses geometric models in patients with cervical degenerative myelopathy before versus after cervical laminoplasty.

MATERIALS AND METHODS

Mimics and 3-Matic software (Materialise, Leuven, BE) programs were used to segment anatomical structures and create polygon meshes of spines. Patients with cervical spondylotic myelopathy were enrolled. The models obtained before and after laminoplasty were superimposed by using a global registration function. The magnitude of divergence was quantified by using the root-mean-square error (RMSE).

RESULTS

Using this novel protocol, we were able to map the differences in the volume of the spinal canal before laminoplasty and after laminoplasty and to quantify its magnitude and calculate the volumes.

DISCUSSION AND CONCLUSIONS

The development of a procedure to measure the space within the cervical bone walls using geometric parameters represents a new, powerful method to verify the results obtained by cervical laminoplasty. Further research horizons may include the routine use of virtual models in surgical planning for this procedure.

Anatomical Computerized Exploration to Excise Malignancies in Deep Facial Compartments: An Advanced Virtual Reality Protocol for a Tailored Surgical Approach

Objective/Hypothesis

This study describes the design and application of a novel advanced protocol for virtual three-dimensional anatomical reconstruction of the deep facial compartments, aiming to improve the preoperative understanding and the intraoperative assistance in complex resective surgeries performed for malignant diseases which extend in complex spaces, including the pterygomaxillopalatine fossa, the masticator space, and the infratemporal fossa.

Methods

This study is a non-profit, retrospective, and single-institution case series. The authors clearly describe in detail imaging acquisition protocols which are suitable to segment each target, and a multilayer reconstruction technique is presented to simulate anatomical structures, with particular focus on vascular networks. Virtual surgical planning techniques are individually designed for each case to provide the most effective access to the deep facial compartments. Intraoperative guidance systems, including navigation and virtual endoscopy, are presented, and their role is analyzed.

Results

The study included seven patients with malignant disease located in the deep facial compartments requiring radical resection, and all patients underwent successful application of the protocol. All lesions, except one, were subject to macroscopically radical resection. Vascular structures were identified with overall reconstruction rates superior to 90% for major caliber vessels. Prominent landmarks for virtual endoscopy were identified for each case.

Conclusions

Virtual surgical planning and multilayer anatomical reconstruction are valuable methods to implement for surgeries in deep facial compartments, providing the surgeon with improved understanding of the preoperative condition and intraoperative guidance in critical phases for both open and endoscopic phases. Such techniques allow to tailor each surgical access, limiting morbidity to strictly necessary approaches to reach the disease target.

Pneumomediastinum, pneumothorax and subcutaneous emphysema after tracheostomy closure. When less is more

Pneumomediastinum is a threatening complication that might occur after tight surgical closure of tracheostomy is performed. Physiopathology of this condition is based on several factors, including direct trauma to the tracheal wall caused by surgical maneuvers or insufficient closure of soft tissue layers which do not seal air leakage. In this paper we explore this phenomenon by reporting the case of one patient undergoing surgical closure of tracheostomy after two weeks, who later developed subcutaneous emphysema followed by pneumomediastinum. Physiopatology is analyzed and management strategies for this condition are suggested based on our experience.

How to resume safe access to a medical simulation center at the time of COVID-19 pandemic: The proposal of a protocol from a university institution in North-Eastern Italy

INTRODUCTION

The Covid-19 global pandemic has suspended thousands of clinical education programs around the world. Also in Italy, as in the rest of the world, frontal teaching activities and internships in the medical field have been suspended. At the university hospital of Udine (North-Eastern Italy) it was decided to strengthen the use of simulation in all training stages to get over the block of training activities.

METHODS

A protocol has been drawn up with the aim of providing training in safety for every student of the degree courses in medicine and health area and for doctors in residency training. In this way it was possible to carry out training sessions with a maximum of 6 students engaged in the simulation activities offered by the Center (3D) virtual cadaver, laparoscopic pelvic trainer stations, ultrasound laboratory, microsurgery, etc.). The key points of the protocol were represented by i) internet booking of the training activity; ii) respect of safety measures (hand hygiene, safe distance, restricted total number of presences, constant use of the surgical mask) and iii) reorganization of the material and cleaning of the rooms.

RESULTS

Our educational strategy allowed to resume training activity maintaining adequate levels of safety for students and teachers. Applying our protocol, it was possible to guarantee safe access to our Medical Simulation Center (MSC) to a total of about 1400 students from different course of study during the period between June 2020 and February 2021.

CONCLUSIONS

Our protocol could represent a practical tool in the management of resuming the activity at a MSC.

The Transantral Endoscopic Approach: A Portal for Masses of the Inferior Orbit-Improving Surgeons' Experience Through Virtual Endoscopy and Augmented Reality

In the past years, endoscopic techniques have raised an increasing interest to perform minimally invasive accesses to the orbit, resulting in excellent clinical outcomes with inferior morbidities and complication rates. Among endoscopic approaches, the transantral endoscopic approach allows us to create a portal to the orbital floor, representing the most straightforward access to lesions located in the inferior orbital space. However, if endoscopic surgery provides enhanced magnified vision of the anatomy in a bloodless field, then it has several impairments compared with classic open surgery, owing to restricted operative spaces. Virtual surgical planning and anatomical computer-generated models have proved to be of great importance to plan endoscopic surgical approaches, and their role can be widened with the integration of surgical navigation, virtual endoscopy simulation, and augmented reality (AR). This study focuses on the strict conjugation between the technologies that allow the virtualization of surgery in an entirely digital environment, which can be transferred to the patient using intraoperative navigation or to a printed model using AR for pre-surgical analysis. Therefore, the interaction between different software packages and platforms offers a highly predictive preview of the surgical scenario, contributing to increasing orientation, awareness, and effectiveness of maneuvers performed under endoscopic guidance, which can be checked at any time using surgical navigation. In this paper, the authors explore the transantral approach for the excision of masses of the inferior orbital compartment through modern technology. The authors apply this technique for masses located in the inferior orbit and share their clinical results, describing why technological innovation, and, in particular, computer planning, virtual endoscopy, navigation, and AR can contribute to empowering minimally invasive orbital surgery, at the same time offering a valuable and indispensable tool for pre-surgical analysis and training.

Virtual planning and navigation for targeted excision of intraorbital space-occupying lesions: proposal of a computer-guided protocol

The purpose of this study was to present an innovative approach for the preoperative assessment and intraoperative targeted excision of masses occupying the intraorbital space based on multimodal image fusion, segmentation, virtual models, digital planning, and navigation. Nineteen patients were studied and underwent surgery using the presented workflow, in both open and endoscopic procedures. Three main scenarios were standardized for the application of computer-guided surgery: single masses of the superior-lateral compartment, single masses of the inferior-medial compartment, and multifocal masses. An operative protocol was devised, and the accuracy of the osteotomies was analysed. All patients were managed successfully by applying the same protocol. No intraoperative complications were reported. The accuracy of the osteotomies was evaluated as a surrogate endpoint for the overall precision of surgery, showing average discrepancies of <1 mm for lateral marginotomies and <0.5 mm for endoscopic osteotomies. This study outlines an operative workflow for the implementation of virtual models to excise orbital masses, enhancing in-depth preoperative understanding of the anatomical relationships within the orbital space and increasing precision in both open and endoscopic approaches.

Cubik system: maximizing possibilities of in-house computer-guided surgery for complex craniofacial reconstruction

Craniofacial reconstruction represents a major challenge due to the complex anatomical morphology. Although implant production has often been outsourced to external companies, in-house planning and manufacturing has developed in many centres. This note introduces a conceptualized modular mould system to perform any desired craniofacial reconstruction, named 'Cubik', inspired by the famous Rubik's cube. A sophisticated virtual process is described that simulates realistic cranio-orbital resections, and the workflow to create multi-component moulds in order to achieve intraoperatively moulded implants is presented. The description focuses on the appropriate definition of interfaces between the subdivision surfaces of the planned implant, which is the key element to successful design and function of the moulds during surgery and is the peculiarity of the Cubik system. The use of Cubik does not prolong the overall duration of surgery, and it appears to be a very versatile tool, allowing personalized implants with different morphology to be created, which are suitable to cover every potential defect of the skull and the orbital region. This study extends the potential of in-house production, allowing highly accurate implantable craniofacial implants to be fabricated, and in the future this might represent a solution to achieve in-house replacement of other segments of the facial skeleton.

Ultrasound-guided core needle biopsy compared with open biopsy: a new diagnostic approach to salivary gland enlargement in Sjögren's syndrome?

OBJECTIVE

Persistent (≥2 months) major salivary gland enlargement in primary SS (pSS) patients is a well-known sign of possible involvement by B cell lymphoma. The study aimed to evaluate the diagnostic accuracy and safety of US-guided core needle biopsy (CNB) of major salivary glands compared with open surgical biopsy.

METHODS

Prospective pSS patients (cases) with clinically persistent salivary gland enlargement underwent US-guided CNB and were compared with retrospective pSS patients (controls) submitted to open surgical biopsy. The features analysed were pre-biopsy clinical and laboratory findings, adequacy of the material for histology and diagnostic-rendered and biopsy-related complications (reported by the patient with a questionnaire and clinically verified).

RESULTS

Thirteen cases underwent US-guided CNB: in nine, biopsy was performed on the parotid gland and in four it was performed on the submandibular gland. Sufficient material was obtained for pathological diagnosis in all samples. The final diagnoses were 5 (38.5%) B cell lymphoma, 1 (7.7%) lymphoepithelial sialadenitis, 4 (30.7%) other sialadenitis (granulomatous consistent with sarcoidosis, IgG4-related disease, chronic sclerosing, diffuse chronic) and 3/13 (23.1%) miscellaneous lesions. Thirteen controls underwent open surgical biopsy of the parotid. In one, inadequate material was obtained, while in 12 (92.3%) the pathologic diagnoses were 4 (33.3%) B cell lymphoma, 2 (16.7%) lymphoepithelial sialadenitis, 4 (33.3%) uncertain lymphoproliferative lesions and 2 (16.7%) miscellaneous lesions. Six cases (46.1%) reported six transient complications and 12/13 (92.3%) controls had 2 persistent and 14 transient complications.

CONCLUSION

US-guided CNB represents a novel, clinically relevant and safe approach for the management of pSS patients with parotid or submandibular persistent enlargement.

POS0735 ULTRASOUND-GUIDED CORE NEEDLE BIOPSY FOR SALIVARY GLAND ENLARGEMENT IN SJÖGREN’S SYNDROME: PROCEDURE SAFETY AND PATIENT TOLERANCE

Background:

Persistent enlargement of major salivary glands (SGs) is one of the main risk factors for B-cell lymphoma in primary Sjögren’s syndrome (pSS). The Ultrasound-guided Core Needle Biopsy (US-guided CNB) could be a novel technique for the management of SGs enlargement in pSS (1).

Objectives:

To evaluate the procedure safety and the patient tolerance of US-guided CNB in pSS patients with major SGs enlargement.

Methods:

Consecutive patients, with either definite or clinically suspected pSS, and with clinical indication for SGs biopsy due to persistent glandular enlargement were screened for US-guided CNB from September 2019 to December 2020. All patients were evaluated clinically between 1 and 2 weeks and 12 weeks following US-guided CNB. All patients were asked to complete a questionnaire to report post-procedural complications (Figure 1, English version) and intra- and post-procedural pain Visual Analogue Scale (VAS). The complications were classified as transient (<12 weeks) or persistent (≥12 weeks).

Results:

US-guided CNB was performed in 21 glands (12 parotid and 9 submandibular glands) in 20 pSS patients. 16/20 (80%) patients fulfilled the ACR-EULAR classification criteria for pSS (2). The mean age at the time of biopsy was 62.1 (±11.7) years. US-guided CNB was well tolerated, no long-term complications were reported in the follow-up period (mean 9.5 ±5.7 months). Only transient complications were noticed in 11 patients (55%). In particular, two cases of local swelling at the biopsy site lasting no more than 6 days, one case of local bleeding and subsequently hematoma of the submandibular area, one case of transient facial paresis (lasting less than one hour), seven cases of post-procedural mild local pain, that resolved within 10 days without the need of analgesics (Table 1). The procedure was well tolerated, with a very low reported intra-operative pain (mean VAS 1.74 ±2.49) and a mean post-operative pain VAS of 1.39 (±2.33). The biopsy sampling was diagnostic in 19/20 patients (95%).

Conclusion:

US-guided CNB represents a novel approach for the management of pSS patients with SGs enlargement. This procedure shows a remarkable patient safety and tolerance, allowing an adequate glandular sampling and definite diagnosis in almost all the studied patients.

References:

[1]Zabotti A, Zandonella Callegher S, Lorenzon M, Pegolo E, Scott CA, Tel A, et al. Ultrasound-guided core needle biopsy compared with open biopsy: a new diagnostic approach to salivary gland enlargement in Sjögren’s syndrome? Rheumatology (Oxford) 2020.

[2]Shiboski CH, Shiboski SC, Seror R, Criswell LA, Labetoulle M, Lietman TM, Rasmussen A, Scofield H, Vitali C, Bowman SJ, Mariette X; International Sjögren’s Syndrome Criteria Working Group. 2016 American College of Rheumatology/European League Against Rheumatism Classification Criteria for Primary Sjögren’s Syndrome: A Consensus and Data-Driven Methodology Involving Three International Patient Cohorts. Arthritis Rheumatol. 2017 Jan;69(1):35-45. doi: 10.1002/art.39859. Epub 2016 Oct 26. PMID: 27785888; PMCID: PMC5650478.

Table 1.

Description of complications

Complications of US-guided CNBPatients presenting complications, n/N (%)11/20 (55%)Description of transient complicationsSwelling at biopsy site, n2Bleeding, n1Hematoma, n1Local Pain, n7Local infection, n0Sialocele or fistula, n0Anaesthesia/paraesthesia, n0Transient facial palsy (< 1 hour), n1No persistent complications reported

All the above specified complications were transient (< 12 weeks). No persistent complications were reported in the follow up.

Figure 1.

Post-biopsy complication Questionnaire

Disclosure of Interests:

Alen Zabotti Speakers bureau: UCB, Novartis, Janssen, Paid instructor for: Amgen, Consultant of: Janssen, Ivan Giovannini: None declared, Sara Zandonella Callegher: None declared, Valeria Manfrè: None declared, Michele Lorenzon Consultant of: not relevant for this study, Enrico Pegolo: None declared, Cathryn Ann Scott: None declared, Alessandro Tel: None declared, Massimo Robiony Consultant of: not relevant for this study, Grant/research support from: not relevant for this study, Chiara Zuiani Consultant of: not relevant for this study, Grant/research support from: not relevant for this study, Salvatore De Vita Consultant of: GSK, Roche, Grant/research support from: not relevant for this study

Advances in Multidisciplinary Management of Skull Base Meningiomas

The surgical management of Skull Base Meningiomas (SBMs) has radically changed over the last two decades. Extensive surgery for patients with SBMs represents the mainstream treatment; however, it is often challenging due to narrow surgical corridors and proximity to critical neurovascular structures. Novel surgical technologies, including three-dimensional (3D) preoperative imaging, neuromonitoring, and surgical instruments, have gradually facilitated the surgical resectability of SBMs, reducing postoperative morbidity. Total removal is not always feasible considering a risky tumor location and invasion of surrounding structures and brain parenchyma. In recent years, the use of primary or adjuvant stereotactic radiosurgery (SRS) has progressively increased due to its safety and efficacy in the control of grade I and II meningiomas, especially for small to moderate size lesions. Patients with WHO grade SBMs receiving subtotal surgery can be monitored over time with surveillance imaging. Postoperative management remains highly controversial for grade II meningiomas, and depends on the presence of residual disease, with optional upfront adjuvant radiation therapy or close surveillance imaging in cases with total resection. Adjuvant radiation is strongly recommended in patients with grade III tumors. Although the currently available chemotherapy or targeted therapies available have a low efficacy, the molecular profiling of SBMs has shown genetic alterations that could be potentially targeted with novel tailored treatments. This multidisciplinary review provides an update on the advances in surgical technology, postoperative management and molecular profile of SBMs.

Ultrasound and Bioptic Investigation of Patients with Primary Sjögren's Syndrome

Primary Sjögren's syndrome (pSS) is a chronic and heterogeneous disorder characterized by a wide spectrum of glandular and extra-glandular features. The hallmark of pSS is considered to be the immune-mediated involvement of the exocrine glands and B-cell hyperactivation. This leads pSS patients to an increased risk of developing lymphoproliferative diseases, and persistent (>2 months) major salivary gland enlargement is a well-known clinical sign of possible involvement by B cell lymphoma. Better stratification of the patients may improve understanding of the mechanism underlying the risk of lymphoproliferative disorder. Here, we summarize the role of different imaging techniques and a bioptic approach in pSS patients, focusing mainly on the role of salivary gland ultrasonography (SGUS) and a US-guided core needle biopsy (Us-guided CNB) as diagnostic and prognostic tools in pSS patients with persistent parotid swelling.

Scoping Zygomaticomaxillary Complex Fractures With the Eyes of Virtual Reality: Operative Protocol and Proposal of a Modernized Classification

INTRODUCTION

Fractures of the zygomaticomaxillary complex (ZMC) represent an extremely heterogeneous group of injuries to the midfacial skeleton. Traditionally, the diagnosis of such fractures was based on 2-dimensional radiograms and, more recently, on volumetric computed tomography (CT) scans, while the treatment was exclusively based on the surgeon's experience. Many classification attempts have been made in the past, but no paper has taken into account the importance of virtual surgical planning (VSP) in proving a modernized classification. The authors propose a classification based on the use of VSP which can guide the surgeon to identify the optimal reduction method and reproduce it in the operating room through the use of navigation.

METHODS

Patients with ZMC fractures were collected to create a study model. The VSP was used to generate 3-dimensional models of fractures. Fractured segments were duplicated and digitally put in the optimal reduction position. Repositioned fragments were overlapped to their original preoperative counterparts and exported to the surgical navigator to be navigated. Planned virtual reduction was overlaid to postoperative CT scan to assess the accuracy of reduction, explored using color maps and the calculation of root mean square error.

RESULTS

For all patients, the application of VSP was successfully accomplished. High accuracy was confirmed between the planned virtual reduction and the postoperative CT scan. A 5-item classification based on VSP is proposed. All patients were included in the presented subclasses.

CONCLUSIONS

The adoption of virtual planning in ZMC fractures allows for an improved study of the displacement of the fracture and might indicate to the surgeons the required maneuvers to achieve optimal reduction. The presented proposal of classification might be an aid to simplify the choice of the most appropriate reduction method and might provide a deeper insight into the morphologic characteristics of fractures.

Temporomandibular Joint Arthrocentesis and Microfragmented Adipose Tissue Injection for the Treatment of Internal Derangement and Osteoarthritis: A Randomized Clinical Trial

PURPOSE

Internal derangement and osteoarthritis are the most common degenerative temporomandibular joint diseases and initial treatment for such conditions relies on arthrocentesis. Microfragmentation of adipose tissue has been proven in orthopedic literature to represent a more effective method to preserve stem cells, but no application has ever been reported in the temporomandibular joint. The purpose of this randomized clinical trial is to compare standard treatment conducted by injecting hyaluronic acid after the procedure to the new treatment relying upon microfragmented adipose tissue injection using the Lipogems technology.

MATERIALS AND METHODS

A randomized clinical trial was designed enrolling 20 patients in the control group receiving the standard treatment and 20 patients in the experimental group receiving microfragmented adipose tissue obtained through the Lipogems technology after arthrocentesis. Two main outcomes were defined, pain (visual analogic scale) and function (maximum interincisal opening). Both were measured in the immediate preoperative time, and 10 days, 1 month, and 6 months after the procedure.

RESULTS

In both groups, pain reduction and mouth opening significantly improved compared with the preoperative situation (P = .001). At 6-month follow-up, there was an almost statistically significant reduction of pain compared with preoperative visual analogic scale (P = .0546) and a statistically significant improvement of mouth opening (P = .0327). Overall, statistical analyses showed that the experimental group had a statistically significant superiority in the success rate of the procedure compared with the control group (P = .018).

CONCLUSIONS

Preliminary results of this clinical trial show that the injection of microfragmented adipose tissue can significantly improve outcomes of pain and function compared with the standard treatment and encourage to pursue research on this topic. Further studies with a longer follow-up time are needed to evaluate the clinical stability of the achieved improvement in pain and function.

Working in the era of COVID-19: An organization model for maxillofacial surgery based on telemedicine and video consultation

The worldwide pandemic caused by the COVID-19 outbreak has led to an unprecedented burden on hospital structures, posing new challenges in terms of reshaping healthcare services. At the same time, the so-called 'lockdown' restrictions have decreased overall mobility, thereby challenging the traditional concept of clinical examination. Moreover, the need for security for both patients and healthcare personnel has posed a further limitation to face-to-face meeting. Telemedicine has provided a valuable solution for such issues, allowing the evaluation of oral and maxillofacial surgery patients through technological interfaces, restricting physical consultations to cases with high clinical priority, intercepting suspects, and maintaining contact with discharged patients. Thanks to the experience gained during the previous wave of infections, the purpose of this study was to present a reorganization of clinical services for oral and maxillofacial surgery in order to help cope with the latest COVID-19 resurgence. Using commonly available software for telecommunications and online meetings, the Oral and Maxillofacial Surgery Department of the University Hospital of Udine has reshaped the organization of healthcare services, with telemedicine central to the continuity of assistance, while at the same time minimizing the risk of exposure for both patients and operators. Additionally, the high number of patients evaluated through telemedicine improved our ability to define signs and symptoms of diseases using informatic tools, thus allowing the introduction of the concept of 'telesemiology'. During our previous lockdown experience, between March and April 2020, 78 patients were evaluated using teleconsultation. All outpatient examinations were rescheduled and translated into a virtual platform, allowing each patient to undergo evaluation in the most appropriate setting. Special attention was paid to the follow-up of oncological patients. The rehabilitation team represented a crucial element in maintaining contact with more complex patients in this crucial time. This study was based on our previous lockdown experience - a situation that many will be facing again over the coming months. Our hope is that the organizational structure that our department applied during the previous wave of infections may offer other colleagues a solution to facing the current COVID-19 recrudescence.

The use of cutting/positioning devices for custom-fitted temporomandibular joint alloplastic reconstruction: current knowledge and development of a new system

Alloplastic replacement of the temporomandibular joint (TMJ) is the treatment of choice in cases of TMJ end-stage disease. Improvements in computer-aided design/computer-aided manufacturing (CAD/CAM) translated into the possibility ongf designi very precise TMJ prostheses based on the anatomy of each single patient. Custom-made TMJ prostheses are described in the most recent literature and provide facilitations in terms of ease of placement and accuracy. Although before the era of custom-made surgical guides, they did not play a prominent role in the field of TMJ surgery, their use has become mandatory when custom-made prostheses are used. Surgical guides, generally known also as cutting guides, allow the subcondylar bone cut to be performed according to the exact shape and size of the planned prostheses. Additionally, they allow the predrilling of fixation holes in the mandible to minimize errors in prostheses positioning. However, the design of surgical guides did not evolve over time as much as prostheses did. In this paper the authors critically analysed literature on this topic and described the improvements of surgical guides over time. Moreover, based on the findings of literature research, a new cutting guide system was developed and is proposed in this article.

General surgery and COVID-19: review of practical recommendations in the first pandemic phase

BACKGROUND

In March, 2020, the World Health Organization declared COVID-19 a pandemic. The absence of previous knowledge of COVID-19 has made decision-making difficult for all in health care, including surgical departments. We reviewed the management recommendations for surgical activity and changes to surgical practice, identifying concordances and discrepancies, based on the literature published in the early phase of the pandemic.

METHOD

We searched the electronic datasets, PubMed Database, Google, and Google Scholar, using the keywords "SARS-CoV-2", "COVID-19", "surgery", "recommendations", "guideline", and "triage". The search was limited to the first 2 months after the pandemic began and was closed on May 6, 2020.

RESULTS

Twenty papers were included in the analysis and their recommendations are divided into the following categories: 1. general aspects, such as maintaining the safety of health personnel and indications for surgery. 2. The preoperative phase, with recommendations about activating different care pathways for COVID-19 positive patients. 3. The operative phase, with recommendations about activating safety measures for aerosol-generating procedures. 4. The postoperative phase, with recommendations for managing operating theatres and patient transfers.

CONCLUSION

The recommendations proposed in the revised documents are considered good practices aimed at keeping patients and healthcare professionals safe. However, these recommendations must be contextualized in each individual hospital.

Redesigning the Paradigms of Clinical Practice for Oral and Maxillofacial Surgery in the Era of Lockdown for COVID-19: From Tradition to Telesemeiology

The rise of the COVID-19 pandemic has posed new challenges for health care institutions. Restrictions imposed by local governments worldwide have compromised the mobility of patients and decreased the number of physicians in hospitals. Additional requirements in terms of medical staff security further limited the physical contact of doctors with their patients, thereby questioning the traditional methods of clinical examination. Our institution has developed an organization model to translate the essential clinical services into virtual consultation rooms using a telemedicine interface which is commonly available to patients. We provide examples of clinical activity for a maxillofacial surgery department based on teleconsultation. Our experience is summarized and an organization model is drafted in which outpatient consultation offices are translated into virtual room environments. Clinical examples are provided, demonstrating how each subspecialty of oral and maxillofacial surgery can benefit from virtual examinations. The concept of "telesemeiology" is introduced and a checklist is presented to guide clinicians to perform teleconsultations. This paper is intended to provide an organization model based on telemedicine for maxillofacial surgeons and aims to represent an aid for colleagues who are facing the pandemic in areas where lockdown limits the possibility of a physical examination.

The Impact of COVID-19 on Plastic Surgery Residency Training

Abstract

Nowadays didactic and surgical activities for residents in the surgery field are less and less due to an increasing burden of documentation and “non-educational work.” Considering the current lockdown due to the COVID-19 pandemic, it has never been so important to find different ways to allow residents to improve their knowledge. We asked all plastic and esthetic surgery residents in our country to fill out a questionnaire to investigate changes in their didactical activity and analyze problems about their professional growth in the last few months. From the results of such questionnaires, we found that most of the residents feel the decrease in surgical activities during this time is a detrimental factor for their training and that even if all the schools have changed their didactical activities no school has introduced the use of virtual simulators to compensate for the decrease in surgical practice. Actually, the majority of residents use webinars to keep updated, stating that such technologies are useful but not sufficient to analyze plastic surgery topics in depth during COVID-19 lockdown. Virtual interactive tools are well known in different clinical and surgical specialties, and they are considered as a valid support, but it seems that in plastic surgery they are not so used. According to the most recent studies about residents’ didactical program, we have investigated the potential of Anatomage Table in combination with Touch Surgery application as physical and mental aids to bypass the decreased number and kind of surgical interventions performed in this particular time. Anatomage is an academic user-friendly touch screen table; it is used by both medical students and residents to learn human anatomy and to master surgical anatomy. Touch Surgery is an application available on smartphones and tablets that gives the possibility to watch real and virtually designed surgical videos, accompanied by explanatory comments on the surgical phases; they are interactive and give the possibility to check what you have learned through tests administered after virtual classes. In our opinion, these tools represent reliable solutions to improve plastic residents’ training, mostly during the COVID-19 pandemic.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Protocol for fully digital and customized management of concomitant temporomandibular joint replacement and orthognathic surgery

End-stage temporomandibular joint (TMJ) disease is caused by a multitude of pathological processes that impair TMJ anatomy and function. In many cases, end-stage TMJ disease and dentofacial skeletal deformities coexist. The optimal treatment for such conditions is total alloplastic joint replacement and orthognathic surgery. Such procedures have historically been conducted in two separate stages. Furthermore, while technological improvements resulting from the widespread adoption of virtual reality initially led to significant improvements in the field of orthognathic planning, the adoption of virtual design techniques to optimize TMJ reconstruction was a later achievement. Therefore, planning for TMJ replacement and orthognathic surgery did not develop in parallel, leading to various combinations of planning for orthognathic surgery and TMJ replacement with the aim of performing both procedures simultaneously in one stage. Nowadays, improvements in virtual planning and three-dimensional printing have allowed these procedures to be conducted in the same surgical step based on fully digital planning and entirely customized surgery. This paper introduces a fully digital protocol for the treatment of end-stage TMJ disease and associated acquired dentofacial deformities, in which all surgical steps are customized and the whole surgery is performed in succession using automated procedures, thanks to the combined use of virtual surgical planning, surgical guides, custom-designed TMJ prostheses, and patient-fitted osteosynthesis devices.

One-Stage Computer-Guided Customized Management of Skeletal Asymmetry by Concomitant Proportional Condylectomy and Orthognathic Surgery in Patients With Unilateral Condylar Hyperplasia

PURPOSE

Facial asymmetry associated with unilateral condylar hyperplasia can benefit from condylectomy, which aims to arrest the pathologic condylar growth and restore an appropriate posterior height. However, there are several cases in which condylar hyperplasia is combined with various dentofacial deformities, for which joint surgery has to be accompanied by concomitant orthognathic surgery. The literature is relatively poor of examples in which virtual planning for orthognathic surgery includes the evaluation of condylectomy, which is often manually performed. The aim of this study was to present and discuss a workflow for 1-stage computer-guided customized management of skeletal asymmetry by simultaneous condylectomy and orthognathic surgery.

MATERIALS AND METHODS

Five patients were enrolled in this study from 2018 to 2019. All patients underwent combined virtual planning of orthognathic surgery and condylectomy. Virtual surgery was translated into real surgical coordinates using patient-specific surgical guides and custom-designed osteosynthesis plates.

RESULTS

All surgical procedures were uneventful, and in all patients, virtual planning was successfully brought into the operating room with high accuracy, as confirmed by superimposition analyses. Symmetrization of the face and achievement of correct occlusion were observed in all cases.

CONCLUSIONS

The presented protocol is a reliable solution for the combined planning of orthognathic surgery and condylectomy. Virtual planning, surgical guides, and custom-designed plates allow computerized simulations to be replicated in the real patient.

Fungus ball of the maxillary sinus: Retrospective study of 48 patients and review of the literature

BACKGROUND

Maxillary fungus ball (FB) is the most frequent paranasal localization.

OBJECTIVE

To review clinical presentation, surgery and results of treatment in our series of patients with maxillary FB. To review the literature concerning treatment of maxillary FB.

PATIENTS AND METHODS

48 patients with a diagnosis of maxillary FB were treated with endoscopic sinus surgery (ESS) alone or in association with external approaches. Before surgery all patients received computed tomography (CT), nasal endoscopy and dental examination. All the patients were followed for 1 year after surgery. Studies concerning surgical treatment of maxillary FB from 2006 were reviewed.

RESULTS

The mean age of patients was 53.6 ± 11.9 years. 20 patients (41.6%) did not present any symptom, 19 patients (39.7%) had nasal symptoms, 3 patients (6.2%) had facial pain, 6 patients (12.5%) had a combination of both. Endoscopic examination was positive in 31 patients (64.6%), 17 patients (35.4%) showed negative findings. Logit regression model demonstrated that clinical symptoms contribute to the prediction of a positive endoscopic examination. 25 patients (52.1%) presented odontogenic factors. Complete clinical and radiological resolution of FB was observed in 46 patients (95.8%).

CONCLUSIONS

Comparing our sample to the studies reviewed we may concluded that odontogenic factors were frequently reported and should be treated at the same time of maxillary FB. ESS alone or in association with external approaches is an effective treatment for patients with maxillary FB.