Patient Education for Endoscopic Sinus Surgery: Preliminary Experience Using 3D-Printed Clinical Imaging Data

Clinical Practice Guideline: Surgical Management of Chronic Rhinosinusitis

OBJECTIVE

The purpose of this specialty-specific clinical practice guideline is to identify quality improvement opportunities and provide clinicians with trustworthy, evidence-based recommendations for the surgical management of chronic rhinosinusitis in adults. The target audience includes otolaryngologist-head and neck surgeons who manage adults with chronic rhinosinusitis, including candidacy and performance of endoscopic sinus surgery.

METHODS

This guideline was developed using the 55-page protocol published as the American Academy of Otolaryngology-Head and Neck Surgery Foundation's Clinical Practice Guideline Development Manual (3rd edition), which summarizes the methodology for assessments of current data, topic prioritization, development of key action statements (KASs), application of value judgments, and related procedures. The guideline group represented otolaryngologists, rhinologists, advanced practice nursing and physician assistants, and consumers who represented participating national professional organizations.

ACTION STATEMENTS

The Guideline Development Group made strong recommendations for the following KASs: Before considering surgery, the surgeon should verify an existing diagnosis of chronic rhinosinusitis to ensure established diagnostic criteria (signs and symptoms) from clinical practice guidelines are met, and the surgeon should assess candidacy for sinus surgery based on symptoms, disease characteristics, quality of life, and prior medical or surgical therapy (KASs 1A and 1B). The surgeon or their designee should not prescribe antibacterial therapy to an adult with chronic rhinosinusitis if significant or persistent purulent nasal discharge (anterior, posterior, or both) is absent on examination (KAS 3). The Guideline Development Group made recommendations for the following KASs: The surgeon should not endorse or require a predefined, one-size-fits-all regimen or duration of medical therapy (eg, antibiotics, steroids, antihistamines) as a prerequisite to sinus surgery for an adult with chronic rhinosinusitis (KAS 2). The surgeon should identify patients with chronic rhinosinusitis that would benefit most from surgery and are least likely to benefit from continued medical therapy alone, such as those with chronic rhinosinusitis subtypes that include, but are not limited to, chronic rhinosinusitis with polyps, polyps with bony erosion, eosinophilic mucin, or fungal balls (KAS 4). The surgeon or their designee should counsel patients before sinus surgery to establish realistic expectations, including the potential for chronicity or relapse, and the likelihood of long-term medical management, taking into account their chronic rhinosinusitis subtype (KAS 5). The surgeon should offer sinus surgery to an adult with chronic rhinosinusitis when the anticipated benefits exceed that of nonsurgical management alone, there is clarity regarding the anticipated outcomes, and the patient understands the expectation for long-term disease management following surgery (KAS 6). For an adult who is a candidate for sinus surgery, the surgeon or their designee should obtain a computed tomography (CT) scan with a fine-cut protocol, if not already available, to examine the paranasal sinuses for surgical planning (KAS 7). The surgeon should not plan the extent of sinus surgery (eg, which specific sinuses to operate on) solely based on arbitrary criteria regarding a minimal level of mucosal thickening, sinus opacification, or outflow obstruction on a CT scan (KAS 8). The surgeon or their designee should educate an adult with chronic rhinosinusitis who is scheduled for sinus surgery regarding anticipated postoperative care, specifically pain control, debridement, medical management, activity restrictions, return to work, duration and frequency of follow-up visits, and the potential for recurrent disease or revision surgery (KAS 9). When the sinus involves polyps, osteitis, bony erosion, or fungal disease in an adult with chronic rhinosinusitis who is scheduled for sinus surgery, the surgeon should perform sinus surgery that includes full exposure of the sinus cavity (lumen) and removal of diseased tissue, not just balloon or manual ostial dilation, or refer the patient to a surgeon who can perform this extent of surgery (KAS 10). The surgeon or their designee should routinely follow up to assess and document outcomes of sinus surgery for chronic rhinosinusitis, between 3 and 12 months after the procedure, through history (symptom relief, quality of life, complications, adherence to therapy, need for rescue medications, and ongoing care) and nasal endoscopy (KAS 11). There were no recommendations that were considered options from the Guideline Development Group.

Exploring Mixed Reality for Patient Education in Cerebral Angiograms: A Pilot Study

Cerebral aneurysms (CAs) affect 3 to 5% of the general population, with saccular aneurysms being the most common type. Despite advances in treatment, patient understanding of CAs and associated procedures remains limited, impacting informed consent and treatment outcomes.This pilot study aims to evaluate the effectiveness of mixed reality (MR) technology in enhancing patient education and understanding of cerebral angiograms and aneurysm treatment, thereby improving the patient-surgeon communication process.A nonrandomized single-center prospective study was conducted with 16 patients diagnosed with intracranial aneurysms. Participants used a Microsoft HoloLens to view an interactive 3D presentation about cerebral angiograms and aneurysm treatments. Pre- and post-intervention surveys assessed their knowledge and anxiety levels using a 5-point Likert scale. The Wilcoxon's signed-rank test was used for statistical analysis.Post-intervention, the total survey scores improved significantly (average increase of 6.7 points, p < 0.05). Seven out of eight survey questions showed significant knowledge improvement. The mean perceived ability to explain aneurysm treatment improved by 1.38 points and understanding of access points for procedures increased by 1.31 points (both p < 0.05). The question regarding understanding of treatment risks did not show significant change (p > 0.05). Anxiety levels decreased, with 75% of participants reporting reduced anxiety post-intervention.MR technology significantly enhances patient understanding and reduces anxiety regarding cerebral angiogram procedures and aneurysm treatments. These findings support the integration of MR in patient education to improve clinical outcomes and patient satisfaction. This approach offers a promising direction for future health care communication strategies, especially in complex procedures requiring detailed patient comprehension.

Enhanced recovery after endoscopic sinus surgery: Establishing comprehensive protocols for improvement of perioperative patient care

Objectives

Enhanced recovery after surgery (ERAS) protocols for endoscopic sinus surgery (ESS) have not been widely implemented, and a critical review of ERAS recommendations and a comprehensive analysis of the supporting literature has not been undertaken. We describe an ESS ERAS protocol including key perioperative interventions for patients undergoing ESS and assess the available evidence.

Data Sources

A search was conducted of all relevant ERAS literature in otorhinolaryngology, anesthesia, and surgery using Medline (via PubMed), and Scopus. Keywords included "endoscopic sinus surgery," "sinus surgery," "FESS," and "ESS" for each area of intervention. Where applicable, the authors considered high-level evidence for recommendations devised for patient cohorts in otorhinolaryngology not undergoing ESS, as well as cohorts undergoing surgical procedures for which ERAS protocols have been extensively evaluated.

Methods

Studies received grades of "low," "moderate," or "high" quality evidence based on the Oxford Centre for Evidence-Based Medicine criteria. Each intervention was subsequently assigned a grade of "strong," "weak," or "conditional" based on the available evidence.

Results

Strong recommendations include comprehensive patient education and counseling, minimization of preoperative fasting, application of topical/local anesthetics and vasoconstrictors, use of total intravenous anesthesia, avoidance of pharyngeal packing, and use of postoperative nasal irrigation and multimodal analgesia. Conditional recommendations include antibiotic prophylaxis. Weak recommendations include perioperative venous thromboembolism prophylaxis, controlled hypotension, and use of postoperative nasal packing/dressing.

Conclusion

A comprehensive ERAS protocol for ESS can include a variety of high yield, evidence-based interventions that would likely improve surgical outcomes and patient satisfaction.

Clinical validation of 3D virtual modelling for laparoscopic complete mesocolic excision with central vascular ligation for proximal colon cancer

INTRODUCTION

Laparoscopic Complete Mesocolic Excision (CME) with Central Vascular Ligation (CVL) in colon cancer surgery has not been broadly adopted in part because of safety concerns. Pre-operative 3-D virtual modelling (3DVM) may help but needs validation.

METHODS

3DVM were routinely constructed from CT mesenteric angiograms (CTMA) using a commercial service (Visible Patient, Strasbourg, France) for consecutive patients during our CMECVL learning curve over three years. 3DVMs were independently checked versus CTMA and operative findings. CMECVL outcomes were compared versus other patients undergoing standard mesocolic excision (SME) surgery laparoscopically in the same hospital as control. Stakeholders were studied regarding 3DVM use and usefulness (including detail retention) versus CTMA and a physical 3D-printed model.

RESULTS

26 patients underwent 3DVM with intraoperative display during laparoscopic CMECVL within existing workflows. 3DVM accuracy was 96 % re arteriovenous variations at patient level versus CTMA/intraoperative findings including accessory middle colic artery identification in three patients. Twenty-two laparoscopic CMECVL with 3DVM cases were compared with 49 SME controls (age 69 ± 10 vs 70.9 ± 11 years, 55 % vs 53 % males). There were no intraoperative complications with CMECVL and similar 30-day postoperative morbidity (30 % vs 29 %), hospital stay (9 ± 3 vs 12 ± 13 days), 30-day readmission (6 % vs 4 %) and reoperation (0 % vs 4 %) rates. Intraoperative times were longer (215.7 ± 43.9 vs 156.9 ± 52.9 min, p=<0.01) but decreased significantly over time. 3DVM surveys (n = 98, 20 surgeons, 48 medical students, 30 patients/patient relatives) and comparative study revealed majority endorsement (90 %) and favour (87 %).

CONCLUSION

3DVM use was positively validated for laparoscopic CMECVL and valued by clinicians, students, and patients alike.

Enhancing Patient Comprehension in Skull-Base Meningioma Surgery through 3D Volumetric Reconstructions: A Cost-Effective Approach

BACKGROUND

Understanding complex neurosurgical procedures and diseases, such as skull-base meningiomas, is challenging for patients due to the intricate anatomy and the involvement of critical neurovascular structures. Enhanced patient comprehension is crucial for satisfaction and improved clinical outcomes. Patient-specific 3D models have demonstrated benefits in patient education, though they are costly and time-intensive to produce. This study investigates whether the use of 3D volumetric reconstructions with anatomical segmentation, widely available via neuronavigation software, can improve patients' understanding of skull-base meningiomas, surgical procedures, and potential complications.

MATERIALS AND METHODS

This study included twenty patients with skull-base meningiomas. Three-dimensional volume reconstructions and anatomical segmentations were created using preoperative MRI sequences with neuronavigation software. These reconstructions were used during patient consultations where a surgeon explained key aspects of the disease, the surgical intervention, and potential complications. A questionnaire assessed the patients' perceptions of the utility of these 3D reconstructions.

RESULTS

The majority of patients (75%) found the 3D volumetric reconstructions and anatomical segmentations to be more beneficial than MRI images for understanding their disease. Similarly, 75% reported improved comprehension of the surgical approach, and 85% felt that the reconstructions enhanced their understanding of potential surgical complications. Overall, 65% of patients considered the 3D reconstructions valuable in medical consultations.

CONCLUSIONS

Our study indicates that using accessible, cost-effective, and non-time-consuming 3D volumetric reconstructions with anatomical segmentation enhances patient understanding of skull-base meningiomas. Further research is necessary to confirm these findings, compare these reconstructions with physical 3D models and virtual reality models, and evaluate their impact on patient anxiety regarding the surgical procedure.

Exploring methods of improving patient understanding and communication in a complex anal fistula clinic: results from a randomized controlled feasibility study

AIM

Patient understanding of disease can guide decision-making in the management of anal fistula. This prospective feasibility study aimed to assess the acceptability and methods of assessing the impact of viewing realistic models on patients with anal fistula.

METHODS

New referrals to a tertiary clinic participated in this single-centre, parallel-group randomized controlled study. Baseline characteristics, Decisional Conflict Scale and understanding of disease were assessed pre-consultation. Participants were randomized to a standard consultation, where disease and treatment options were explained using magnetic resonance images and drawn diagrams, or a similar consultation supplemented with an appropriate generic three-dimensional (3D) printed model. Understanding of disease and proposed surgery, Decisional Conflict Scale and ratings of visual aids were assessed post-consultation, along with 3D model feedback.

RESULTS

All 52 patients who were approached agreed to be randomized (25 standard, 27 3D consultation). Understanding of disease increased post-consultation in both groups. Post-consultation decisional conflict (0, no; 100, high decisional conflict) was low (median 27 post-standard vs. 24 post-3D consultation). Patients scored highly on measures assessing understanding of proposed surgery. 3D models were rated highly, with 96% of patients wanting to see them again in future consultations.

CONCLUSIONS

Three-dimensional printed fistula models are a welcome addition to outpatient consultations with results suggesting that understanding of surgery is improved. A future trial should be powered to detect whether 3D models result in a significant improvement in understanding beyond traditional methods of explanation and explore the conditions in which models have their maximal utility.

CLINICALTRIALS

GOV REGISTRATION ID

This study was registered on ClinicalTrials.gov (ID: NCT04069728). Registered on 23 August 2019.

Successful use of a patient specific 3D-printed biomodel as surgical guide for excision of juvenile nasopharyngeal angiofibroma extending to skull base: A case report

Background

3-Dimensional (3D) printing has proven its role in various fields. Recently, 3D printing has also been introduced in the otolaryngology domain. The nasopharynx, paranasal sinuses, and the anterior skull base have a complex anatomy. Critical structures must be delicately protected and preserved during a surgical procedure. It is, therefore, very important for the surgeon to have an excellent spatial understanding of the complex surgical field that is being traversed.

Case Description

Our case is of a 19-year-old male with a 2-month history of recurrent epistaxis, nasal blockage, and headache. Based on the computed tomography scan and the clinical presentation, the patient was diagnosed with juvenile nasopharyngeal angiofibroma. The patient underwent angioembolization of the tumor followed by endoscopic surgical resection. The patient remained stable postoperatively and demonstrated a good recovery in the follow-up visit with no signs of cranial deficits. This case report highlights the use of a patient-specific 3D-printed biomodel to visualize this rare tumor of the nasopharynx. The benefits of using the model in surgical planning, patient education, and resident training are reported. We found that the ability to visualize the tumor on a tangible model, viewing its actual size in relation to the adjacent anatomy and all the structures associated with it, greatly enhances the surgeon's capacity to tackle such a difficult tumor endoscopically.

Conclusion

Incorporating 3D-printed biomodels in surgical practice should result in improved outcomes for the patients.

3D-Printed Head Model in Patient's Education for Micro-Neurosurgical Aneurysm Clipping Procedures

BACKGROUND

Computed tomography (CT), Magnetic resonance imaging (MRI), and 3D reconstruction from Digital Subtraction Angiography (DSA) are currently used in clinical consultations for patients diagnosed with intracranial aneurysms; however, they have limitations in helping patients understand the disease and possible treatments. This study investigates the use of a 3D-printed model of the patients' neurosurgical anatomy and vascular pathology as an educational tool in outpatient clinics.

METHODS

A 3D-printed model of a middle cerebral artery aneurysm was created for use during patient consultations to discuss microsurgical treatment of unruptured cerebral aneurysms. In total, 38 patients and 5 neurosurgeons were included in the study. After the consultation, the patients and neurosurgeons received a questionnaire to assess the effectiveness of the 3D-printed model as an educational tool.

RESULTS

The 3D model improved the patients' understanding of the diagnosis, the aneurysm's relationship to the parent artery; the treatment process as well as the risks if left untreated. The patients found the 3D model to be an interesting tool (97%). The neurosurgeons were satisfied with the 3D-printed model as a patient encounter tool, they found the model effective during consultation (87%) and better than the conventional education tools used during consultations (97%).

CONCLUSIONS

Using a 3D model improves communication, enhances the patient's understanding of the pathology and its treatment and potentially facilitates the informed consent process in patients undergoing intracranial aneurysm surgery.

Development of a Survey Tool: Understanding the Patient Experience With Personalized 3D Models in Surgical Patient Education

BACKGROUND

Three-dimensional (3D) printing has been increasingly utilized in the healthcare sector for many applications including guiding surgical procedures, creating medical devices, and producing custom prosthetics. As personalized medicine becomes more accessible and desired, 3D printed models emerge as a potential tool in providing patient-specific education. These personalized 3D models are at the intersection of technological innovation and medical education. Our study group utilized a modified Delphi process to create a comprehensive survey tool assessing patient experience with personalized 3D models in preoperative education.

METHODS

A rigorous literature review was conducted of prior patient education survey tools in surgical cases across specialties involving personalized 3D printed models. Through categorization and mapping, a core study team reviewed individual questions, removed duplicates, and edited them into generalizable form. A modified Delphi process was then used to solicit feedback on question clarity and relevance from both 3D printing healthcare experts and patients to create a final survey.  Results: 173 survey questions from the literature were evaluated by the core study team, yielding 31 unique questions for further review. After multiple rounds of feedback, a final survey containing 18 questions was developed.  Conclusion: 3D printed models have the potential to be helpful tools in surgical patient education, and there exists a need to standardize the assessment of patient experience with these models. This survey provides a standardized, generalizable way to investigate the patient experience with personalized 3D-printed models.

Alternative lung cell model systems for toxicology testing strategies: Current knowledge and future outlook

Due to the current relevance of pulmonary toxicology (with focus upon air pollution and the inhalation of hazardous materials), it is important to further develop and implement physiologically relevant models of the entire respiratory tract. Lung model development has the aim to create human relevant systems that may replace animal use whilst balancing cost, laborious nature and regulatory ambition. There is an imperative need to move away from rodent models and implement models that mimic the holistic characteristics important in lung function. The purpose of this review is therefore, to describe and identify the various alternative models that are being applied towards assessing the pulmonary toxicology of inhaled substances, as well as the current and potential developments of various advanced models and how they may be applied towards toxicology testing strategies. These models aim to mimic various regions of the lung, as well as implementing different exposure methods with the addition of various physiologically relevent conditions (such as fluid-flow and dynamic movement). There is further progress in the type of models used with focus on the development of lung-on-a-chip technologies and bioprinting, as well as and the optimization of such models to fill current knowledge gaps within toxicology.

A High-Fidelity Artificial Urological System for the Quantitative Assessment of Endoscopic Skills

Minimally-invasive surgery is rapidly growing and has become a standard approach for many operations. However, it requires intensive practice to achieve competency. The current training often relies on animal organ models or physical organ phantoms, which do not offer realistic surgical scenes or useful real-time feedback for surgeons to improve their skills. Furthermore, the objective quantitative assessment of endoscopic skills is also lacking. Here, we report a high-fidelity artificial urological system that allows realistic simulation of endourological procedures and offers a quantitative assessment of the surgical performance. The physical organ model was fabricated by 3D printing and two-step polymer molding with the use of human CT data. The system resembles the human upper urinary tract with a high-resolution anatomical shape and vascular patterns. During surgical simulation, endoscopic videos are acquired and analyzed to quantitatively evaluate performance skills by a customized computer algorithm. Experimental results show significant differences in the performance between professional surgeons and trainees. The surgical simulator offers a unique chance to train endourological procedures in a realistic and safe environment, and it may also lead to a quantitative standard to evaluate endoscopic skills.

Utility of 3-dimensionally printed models for parent education in pediatric plagiocephaly

Objectives

Demonstrate the benefits of using 3D printed skull models when counseling families regarding disorders of the cranial vault (namely plagiocephaly and craniosynostosis), as traditional imaging review and discussion is often insufficient.

Methods

3D printed skull models of a patient with plagiocephaly were used during clinic appointments to aid in the counseling of parents. Surveys were distributed following the appointment to evaluate the utility of these models during the discussion.

Results

Fifty surveys were distributed (with a 98% response rate). 3D models were both empirically and anecdotally helpful for parents in understanding their child's diagnosis.

Conclusion

Advances in 3D printing technology and software have made producing models more accessible. Incorporating physical, disorder-specific models into our discussions has led to improvements in our ability to communicate with our patients and their families.

Innovation

Disorders of the cranial can be challenging to describe to the parents and guardians of affected children; using 3D printed models is a useful adjunct in patient-centered discussions. The subject response to the use of these emerging technologies in this setting suggests a major role for 3D models in patient education and counseling for cranial vault disorders.

Application of three-dimensional visualization technology in laparoscopic pyeloplasty for ureteropelvic junction obstruction caused by crossing vessels: a retrospective comparative cohort study

Background

Ureteropelvic junction obstruction (UPJO) caused by crossing vessels is a common upper urinary tract abnormal development in which the vessels compress the upper segment of the ureter leading to different grades of hydronephrosis. Compared with routine computed tomography (CT) examination, three-dimensional visualization technology (3DVT) can help surgeons better understand the anatomical structure of the target surgical area. The aim of this study was to investigate the clinical value of 3DVT for the diagnosis, preoperative surgical planning, perioperative outcomes, and patient education of UPJO caused by crossing vessels.

Methods

In this study, we retrospectively analyzed the clinical data of 28 patients who were admitted to the Department of Urology in Xiangya Hospital between January 2016 and December 2021 presenting with UPJO caused by crossing vessel compression. Among the 28 patients included, 13 patients underwent preoperative 3DVT and 15 patients underwent routine computed tomography (CT) scans. After the initial evaluation, all patients received standardized dismembered LP. The 2 groups of patients were compared in terms of demographic parameters, intraoperative data, and perioperative results. After surgery, all patients were asked to complete a Likert scale questionnaire to gain insight into their understanding of the disease and surgery, as well as their satisfaction with the use of different imaging techniques.

Results

There were no statistically significant differences in age, gender, body mass index (BMI), side of obstruction, blood vessel compressing the ureteropelvic junction (UPJ), mean duration of hospitalization, and surgical efficacy between the 2 groups. However, the 3DVT group experienced a significant reduction in operation duration (120.8±7.0 versus 144.0±7.9 min, P=0.039), time required for dismemberment of the UPJ (14.8±1.7 versus 24.0±2.2 min, P=0.004), and the amount of intraoperative blood loss (60.8±10.5 versus 95.3±11.9 mL, P=0.041). The 3DVT group was also notably superior to the conventional CT group in terms of the overall levels of patient satisfaction and understanding of the disease and surgery.

Conclusions

3DVT is a helpful preoperative examination tool which can clearly show the anatomical relationship between crossing vessels and the UPJ. In addition, 3DVT can also help patients better understand their conditions and surgical plans, thereby improving patient satisfaction.

Assessment of a novel patient-specific 3D printed multi-material simulator for endoscopic sinus surgery

Background: Three-dimensional (3D) printing is an emerging tool in the creation of anatomical models for surgical training. Its use in endoscopic sinus surgery (ESS) has been limited because of the difficulty in replicating the anatomical details. Aim: To describe the development of a patient-specific 3D printed multi-material simulator for use in ESS, and to validate it as a training tool among a group of residents and experts in ear-nose-throat (ENT) surgery. Methods: Advanced material jetting 3D printing technology was used to produce both soft tissues and bony structures of the simulator to increase anatomical realism and tactile feedback of the model. A total of 3 ENT residents and 9 ENT specialists were recruited to perform both non-destructive tasks and ESS steps on the model. The anatomical fidelity and the usefulness of the simulator in ESS training were evaluated through specific questionnaires. Results: The tasks were accomplished by 100% of participants and the survey showed overall high scores both for anatomy fidelity and usefulness in training. Dacryocystorhinostomy, medial antrostomy, and turbinectomy were rated as accurately replicable on the simulator by 75% of participants. Positive scores were obtained also for ethmoidectomy and DRAF procedures, while the replication of sphenoidotomy received neutral ratings by half of the participants. Conclusion: This study demonstrates that a 3D printed multi-material model of the sino-nasal anatomy can be generated with a high level of anatomical accuracy and haptic response. This technology has the potential to be useful in surgical training as an alternative or complementary tool to cadaveric dissection.

The current and possible future role of 3D modelling within oesophagogastric surgery: a scoping review

BACKGROUND

3D reconstruction technology could revolutionise medicine. Within surgery, 3D reconstruction has a growing role in operative planning and procedures, surgical education and training as well as patient engagement. Whilst virtual and 3D printed models are already used in many surgical specialities, oesophagogastric surgery has been slow in their adoption. Therefore, the authors undertook a scoping review to clarify the current and future roles of 3D modelling in oesophagogastric surgery, highlighting gaps in the literature and implications for future research.

METHODS

A scoping review protocol was developed using a comprehensive search strategy based on internationally accepted guidelines and tailored for key databases (MEDLINE, Embase, Elsevier Scopus and ISI Web of Science). This is available through the Open Science Framework (osf.io/ta789) and was published in a peer-reviewed journal. Included studies underwent screening and full text review before inclusion. A thematic analysis was performed using pre-determined overarching themes: (i) surgical training and education, (ii) patient education and engagement, and (iii) operative planning and surgical practice. Where applicable, subthemes were generated.

RESULTS

A total of 56 papers were included. Most research was low-grade with 88% (n = 49) of publications at or below level III evidence. No randomised control trials or systematic reviews were found. Most literature (86%, n = 48) explored 3D reconstruction within operative planning. These were divided into subthemes of pre-operative (77%, n = 43) and intra-operative guidance (9%, n = 5). Few papers reported on surgical training and education (14%, n = 8), and were evenly subcategorised into virtual reality simulation (7%, n = 4) and anatomical teaching (7%, n = 4). No studies utilising 3D modelling for patient engagement and education were found.

CONCLUSION

The use of 3D reconstruction is in its infancy in oesophagogastric surgery. The quality of evidence is low and key themes, such as patient engagement and education, remain unexplored. Without high quality research evaluating the application and benefits of 3D modelling, oesophagogastric surgery may be left behind.

Caregiver Preferences for Three-Dimensional Printed or Augmented Reality Craniosynostosis Skull Models: A Cross-Sectional Survey

BACKGROUND

Recent advances in three-dimensional (3D) printing and augmented reality (AR) have expanded anatomical modeling possibilities for caregiver craniosynostosis education. The purpose of this study is to characterize caregiver preferences regarding these visual models and determine the impact of these models on caregiver understanding of craniosynostosis.

METHODS

The authors constructed 3D-printed and AR craniosynostosis models, which were randomly presented in a cross-sectional survey. Caregivers rated each model's utility in learning about craniosynostosis, learning about skull anatomy, viewing an abnormal head shape, easing anxiety, and increasing trust in the surgeon in comparison to a two-dimensional (2D) diagram. Furthermore, caregivers were asked to identify the fused suture on each model and indicate their preference for generic versus patient-specific models.

RESULTS

A total of 412 craniosynostosis caregivers completed the survey (mean age 33 years, 56% Caucasian, 51% male). Caregivers preferred interactive, patient-specific 3D-printed or AR models over 2D diagrams (mean score difference 3D-printed to 2D: 0.16, P < 0.05; mean score difference AR to 2D: 0.17, P < 0.01) for learning about craniosynostosis, with no significant difference in preference between 3D-printed and AR models. Caregiver detection accuracy of the fused suture on the sagittal model was 19% higher with the 3D-printed model than with the AR model (P < 0.05) and 17% higher with the 3D-printed model than with the 2D diagram (P < 0.05).

CONCLUSIONS

Our findings indicate that craniosynostosis caregivers prefer 3D-printed or AR models over 2D diagrams in learning about craniosynostosis. Future craniosynostosis skull models with increased user interactivity and patient-specific components can better suit caregiver preferences.

Additive manufacturing technology of polymeric materials for customized products: recent developments and future prospective

The worldwide demand for additive manufacturing (AM) is increasing due to its ability to produce more challenging customized objects based on the process parameters for engineering applications. The processing of conventional materials by AM processes is a critically demanded research stream, which has generated a path-breaking scenario in the rapid manufacturing and upcycling of plastics. The exponential growth of AM in the worldwide polymer market is expected to exceed 20 billion US dollars by 2021 in areas of automotive, medical, aerospace, energy and customized consumer products. The development of functional polymers and composites by 3D printing-based technologies has been explored significantly due to its cost-effective, easier integration into customized geometries, higher efficacy, higher precision, freedom of material utilization as compared to traditional injection molding, and thermoforming techniques. Since polymers are the most explored class of materials in AM to overcome the limitations, this review describes the latest research conducted on petroleum-based polymers and their composites using various AM techniques such as fused filament fabrication (FFF), selective laser sintering (SLS), and stereolithography (SLA) related to 3D printing in engineering applications such as biomedical, automotive, aerospace and electronics.

Precision Postoperative Radiotherapy in Sinonasal Carcinomas after Endonasal Endoscopic Surgery

Simple Summary

Sinonasal cancers are rare and heterogeneous tumors, mainly carcinomas, with essentially local evolution and a severe vital and functional prognosis. These tumors are more and more being treated in first intent by a mini-morbid endoscopic approach rather than open surgery as the cornerstone of curative treatment. Adjuvant radiotherapy remains necessary owing to non-optimal local control. This article describes the requirements of radiotherapy to ensure adequate delays, the potential of postoperative radiotherapy to increase local and distant disease control and to decrease morbidity further after mini morbid surgery and dose painting techniques, and reviews the criteria that lead to the choice of one technique over another.

Abstract

Radiotherapy plays an important role in the treatment of sinonasal cancer, mainly in the adjuvant setting after surgical resection. Many technological approaches have been described, including intensity-modulated radiotherapy, concomitant chemoradiotherapy, charged particle therapy or combined approaches. The choice is based on general criteria related to the oncological results and morbidity of each technique and their availability, as well as specific criteria related to the tumor (tumor extensions, pathology and quality of margins). The aims of this review are: (i) to provide an overview of the radiotherapy techniques available for the management of sinonasal malignant tumors and (ii) to describe the constraints and opportunities of radiotherapy owing to the recent developments of endonasal endoscopic surgery. The indication and morbidity of the different techniques will be discussed based on a critical literature review.

The State of the Art of Material Jetting-A Critical Review

Material jetting (MJ) technology is an additive manufacturing method that selectively cures liquid photopolymer to build functional parts. The use of MJ technology has increased in popularity and been adapted by different industries, ranging from biomedicine and dentistry to manufacturing and aviation, thanks to its advantages in printing parts with high dimensional accuracy and low surface roughness. To better understand the MJ technology, it is essential to address the capabilities, applications and the usage areas of MJ. Additionally, the comparison of MJ with alternative methods and its limitations need to be explained. Moreover, the parameters influencing the dimensional accuracy and mechanical properties of MJ printed parts should be stated. This paper aims to review these critical aspects of MJ manufacturing altogether to provide an overall insight into the state of the art of MJ.

3D printing technology in healthcare: applications, regulatory understanding, IP repository and clinical trial status

Mass consumerization of three-dimensional (3D) printing innovation has revolutionised admittance of 3D-printing in an expansive scope of ventures. When utilised predominantly for industrial manufacturing, 3D-printing strategies have rapidly attained acquaintance in different parts of health care industry. 3D-printing is a moderately new technology that has discovered promising applications in the medication conveyance and clinical areas. This review intends to explore different parts of 3D- printing innovation concerning pharmaceutical and clinical applications. Review on pharmaceutical products like tablets, caplets, films, polypills, microdots, biodegradable patches, medical devices (uterine and subcutaneous), patient specific implants, cardiovascular stents, etc. and prosthetics/anatomical structures, surgical models, organs and tissues created utilising 3D-printing is being presented. In addition, the regulatory understanding and current IP and clinical trial status pertaining to 3D fabricated products/medical applications have also been funnelled, garnering information from different web portals of regulatory agencies and databases. It is additionally certain that for such new innovations, there would be difficulties and questions before these are acknowledged as protected and viable. The circumstance demands purposeful and wary endeavours to acquire regulations which would at last prompt the accomplishment of this progressive innovation, thus various regulatory challenges faced have been conscientiously discussed.

Additive manufacturing pertaining to bone: Hopes, reality and future challenges for clinical applications

For the past 20 years, the democratization of additive manufacturing (AM) technologies has made many of us dream of: low cost, waste-free, and on-demand production of functional parts; fully customized tools; designs limited by imagination only, etc. As every patient is unique, the potential of AM for the medical field is thought to be considerable: AM would allow the division of dedicated patient-specific healthcare solutions entirely adapted to the patients' clinical needs. Pertinently, this review offers an extensive overview of bone-related clinical applications of AM and ongoing research trends, from 3D anatomical models for patient and student education to ephemeral structures supporting and promoting bone regeneration. Today, AM has undoubtably improved patient care and should facilitate many more improvements in the near future. However, despite extensive research, AM-based strategies for bone regeneration remain the only bone-related field without compelling clinical proof of concept to date. This may be due to a lack of understanding of the biological mechanisms guiding and promoting bone formation and due to the traditional top-down strategies devised to solve clinical issues. Indeed, the integrated holistic approach recommended for the design of regenerative systems (i.e., fixation systems and scaffolds) has remained at the conceptual state. Challenged by these issues, a slower but incremental research dynamic has occurred for the last few years, and recent progress suggests notable improvement in the years to come, with in view the development of safe, robust and standardized patient-specific clinical solutions for the regeneration of large bone defects.

Information Recall in Pre-Operative Consultation for Glioma Surgery Using Actual Size Three-Dimensional Models

Three-dimensional (3D) technologies are being used for patient education. For glioma, a personalized 3D model can show the patient specific tumor and eloquent areas. We aim to compare the amount of information that is understood and can be recalled after a pre-operative consult using a 3D model (physically printed or in Augmented Reality (AR)) versus two-dimensional (2D) MR images. In this explorative study, healthy individuals were eligible to participate. Sixty-one participants were enrolled and assigned to either the 2D (MRI/fMRI), 3D (physical 3D model) or AR groups. After undergoing a mock pre-operative consultation for low-grade glioma surgery, participants completed two assessments (one week apart) testing information recall using a standardized questionnaire. The 3D group obtained the highest recall scores on both assessments (Cohen’s d = 1.76 and Cohen’s d = 0.94, respectively, compared to 2D), followed by AR and 2D, respectively. Thus, real-size 3D models appear to improve information recall as compared to MR images in a pre-operative consultation for glioma cases. Future clinical studies should measure the efficacy of using real-size 3D models in actual neurosurgery patients.

Three-Dimensional Printing of Prenatal Ultrasonographic Diagnosis of Cleft Lip and Palate: Presenting the Needed "Know-How" and Discussing Its Use in Parental Education

Parental prenatal counseling is of paramount significance since parents often experience an emotional crisis with feelings of disappointment and helplessness. Three-dimensional (3D) printed model of the unborn child's face presenting with cleft lip and palate, based on ultrasonographic information, could be used to provide visual 3D information, further enhancing the prospective parent's comprehension of their unborn child's pathology and morphology, helping them to be psychologically prepared and improving the communication with the caretaking team. Prospective parents appreciate if prenatal counseling is available with the most detailed information as well as additional resources. The technique necessary to create 3D models after ultrasonographic information is explained, and the related costs are evaluated. The use of such models in parental education is then discussed.

What would you like to print? Students' opinions on the use of 3D printing technology in medicine

Background

Recent advances in 3D printing technology, and biomaterials are revolutionizing medicine. The beneficiaries of this technology are primarily patients, but also students of medical faculties. Taking into account that not all students have full, direct access to the latest advances in additive technologies, we surveyed their opinion on 3D printing and education in this area. The research aimed to determine what knowledge about the use of 3D printing technology in medicine, do students of medical faculties have.

Methods

The research was carried out in the form of a questionnaire among 430 students of the Medical University of Silesia in Katowice (Poland) representing various fields of medicine and health sciences. The questions included in the survey analyzed the knowledge of the respondents for 3D printing technology and the opportunities it creates in medicine.

Results

The results indicate that students do have knowledge about 3D printing obtained mainly from the internet. They would be happy to deepen their knowledge at specialized courses in this field. Students appreciated the value of 3D printing in order to obtain accurate anatomical models, helpful in learning. However, they do not consider the possibility of complete abandonment of human cadavers in the anatomy classes. Their knowledge includes basic information about current applications of 3D printing in medicine, but not in all areas. However, they have no ethical doubts regarding the use of 3D printing in any form. The vast majority of students deemed it necessary to incorporate information regarding 3D printing technology into the curriculum of different medical majors.

Conclusion

This research is the first of its kind, which allows for probing students' knowledge about the additive technologies in medicine. Medical education should be extended to include issues related to the use of 3D printing for medical applications.

Color Enhancement Strategies for 3D Printing of X-ray Computed Tomography Bone Data for Advanced Anatomy Teaching Models

Three-dimensional (3D) printed anatomical models are valuable visual aids that are widely used in clinical and academic settings to teach complex anatomy. Procedures for converting human biomedical image datasets, like X-ray computed tomography (CT), to prinTable 3D files were explored, allowing easy reproduction of highly accurate models; however, these largely remain monochrome. While multi-color 3D printing is available in two accessible modalities (binder-jetting and poly-jet/multi-jet systems), studies embracing the viability of these technologies in the production of anatomical teaching models are relatively sparse, especially for sub-structures within a segmentation of homogeneous tissue density. Here, we outline a strategy to manually highlight anatomical subregions of a given structure and multi-color 3D print the resultant models in a cost-effective manner. Readily available high-resolution 3D reconstructed models are accessible to the public in online libraries. From these databases, four representative files (of a femur, lumbar vertebra, scapula, and innominate bone) were selected and digitally color enhanced with one of two strategies (painting or splitting) guided by Feneis and Dauber’s Pocket Atlas of Human Anatomy. Resulting models were created via 3D printing with binder-jet and/or poly-jet machines with important features, such as muscle origin and insertion points, highlighted using multiple colors. The resulting multi-color, physical models are promising teaching tools that will enhance the anatomical learning experience.

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.

Three-Dimensional Printing: Current Use in Rhinology and Endoscopic Skull Base Surgery

Background

In the discipline of rhinology and endoscopic skull base surgery (ESBS), 3-dimensional (3D) printing has found meaningful application in areas including preoperative surgical planning as well as in surgical education. However, its scope of use may be limited due to the perception among surgeons that there exists a prohibitively high initial investment in resources and time to acquire the requisite technical expertise. Nevertheless, given the ever decreasing cost of advancing technology coupled with the need to understand the complex spatial relationships of the paranasal sinuses and skull base, the use of 3D printing in rhinology and ESBS is poised to blossom.

Objective

Help the reader identify current or potential future uses of 3D printing technology relevant to their rhinologic clinical or educational practice.

Methods

A review of published literature relating to 3D printing in rhinology and ESBS was performed.

Results

Results were reviewed and organized into 5 overarching categories including an overview of the 3D printing process as well as applications of 3D printing including (1) surgical planning, (2) custom prosthetics and implants, (3) patient education, and (4) surgical teaching and assessment.

Conclusion

In the discipline of rhinology and ESBS, 3D printing finds use in the areas of presurgical planning, patient education, prosthesis creation, and trainee education. As this technology moves forward, these products will be more broadly available to providers in the clinical and educational setting. The possible applications are vast and have great potential to positively impact surgical training, patient satisfaction, and most importantly, patient outcomes.

Beyond the Learning Curve: Comparison of Microscopic and Endoscopic Incidences of Internal Carotid Injury in a Series of Highly Experienced Operators

BACKGROUND

As the endoscopic endonasal approach (EEA) has gained popularity as an alternative to microsurgery (MS) for transsphenoidal resection (TSR), numerous studies have attempted to assess the differential risk of internal carotid artery (ICA) injury between the techniques, yet results have been equivocal and contradictory. The aim of this study was to evaluate ICA injury in MS versus EEA among highly experienced neurosurgeons.

METHODS

We performed a systematic literature review of publications from 2002-2017 reporting ICA injury outcomes in ≥250 cases using MS or EEA.

RESULTS

Seventeen series reporting 11,149 patients were included: 3 MS series, 13 EEA series, and 1 series with adequate samples for each. ICA injury incidences were 0.0%-1.6% in cohorts of 275-3000. MS series documented 5 ICA injuries in 2672 operations, for an overall incidence of 0.2% (range, 0.0%-0.4%), and EEA series reported 30 ICA injuries in 8477 operations, for a 0.4% injury rate (range, 0.0%-1.6%); the difference was nonsignificant (P = 0.25). Increased operative experience was associated with decreased incidence of ICA injury, a finding preserved in the overall study cohort and within discretely examined MS and EEA subgroups (overall r² = 0.08, MS r² = 0.23, EEA r² = 0.07).

CONCLUSIONS

ICA injury is the most serious complication of TSR of pituitary neoplasms. Operator inexperience may be a more important risk factor than choice of surgical technique, given the comparably low rates of injury obtained by highly experienced surgeons independent of technique. This emphasizes the need for consolidated care in pituitary centers of excellence, improvement of high-fidelity simulators, and skull base mentorship between senior and junior staff.

Knowledge, awareness, and perception of oral and maxillofacial surgery among the public and professionals in Saudi Arabia: a cross-sectional study

Although oral and maxillofacial surgery (OMS) is expanding rapidly in Saudi Arabia, accurate knowledge of the specialty appears to be lacking. The aim of this study was to assess the knowledge, awareness, and perception of OMS among the public and professionals in Saudi Arabia. A cross-sectional design was adopted, incorporating five groups: dental interns, dental practitioners, medical interns, medical practitioners, and the public. A sample size of 130 was determined for each group, assuming a significance level of 5% and test power of 90%. Surveys were distributed randomly to participants from March to June 2018. For each of 15 specific clinical problems, respondents were asked to choose the most appropriate of three overlapping specialties for treatment, including OMS. A total of 1051 responses were collected. Participants correctly recognized OMS as appropriate for some problems, such as mandibular reconstruction, but for others recognition was poor. Surprisingly, medical professionals were the only group to strongly consider plastic surgery appropriate for treating orthognathic correction. Dental professionals were the most informed. This study highlights the need for greater awareness and education regarding OMS, promoting its development, contribution, and impact among the public and healthcare professionals in Saudi Arabia.

Implementing Virtual and Augmented Reality Tools for Radiology Education and Training, Communication, and Clinical Care

Advances in virtual immersive and augmented reality technology, commercially available for the entertainment and gaming industry, hold potential for education and clinical use in medicine and the field of medical imaging. Radiology departments have begun exploring the use of these technologies to help with radiology education and clinical care. The purpose of this review article is to summarize how three institutions have explored using virtual and augmented reality for radiology.

3D Models in the Diagnosis of Subglottic Airway Stenosis

PURPOSE

Preoperative assessment of benign subglottic stenosis is usually performed by endoscopy and a computed tomography scan. Both diagnostic modalities have relevant limitations and sometimes an accurate assessment of the extent of disease is challenging.

DESCRIPTION

Based on computed tomography scans of benign glotto-subglottic stenosis and a control airway, color-coded three-dimensional (3D) models were produced using a commercially available 3D printer. The diagnostic relevance of 3D models was tested by means of a quiz.

EVALUATION

52 thoracic surgeons from 4 North American and 1 European institution with different levels of experience in airway surgery were invited to test the diagnostic accuracy of 3D models against endoscopy films and computed tomography scans. 3D models were found to be superior to the other two diagnostic tools in terms of grading the extent of the stenosis and selecting the correct surgical strategy. The group of residents benefited the most from the 3D models.

CONCLUSIONS

3D models of complex glotto-subglottic airway stenosis are a useful supplement of the preoperative assessment. In addition, they can serve as a teaching tool for residents and fellows.

Patient-specific 3D printed and augmented reality kidney and prostate cancer models: impact on patient education

Background

Patient-specific 3D models are being used increasingly in medicine for many applications including surgical planning, procedure rehearsal, trainee education, and patient education. To date, experiences on the use of 3D models to facilitate patient understanding of their disease and surgical plan are limited. The purpose of this study was to investigate in the context of renal and prostate cancer the impact of using 3D printed and augmented reality models for patient education.

Methods

Patients with MRI-visible prostate cancer undergoing either robotic assisted radical prostatectomy or focal ablative therapy or patients with renal masses undergoing partial nephrectomy were prospectively enrolled in this IRB approved study (n = 200). Patients underwent routine clinical imaging protocols and were randomized to receive pre-operative planning with imaging alone or imaging plus a patient-specific 3D model which was either 3D printed, visualized in AR, or viewed in 3D on a 2D computer monitor. 3D uro-oncologic models were created from the medical imaging data. A 5-point Likert scale survey was administered to patients prior to the surgical procedure to determine understanding of the cancer and treatment plan. If randomized to receive a pre-operative 3D model, the survey was completed twice, before and after viewing the 3D model. In addition, the cohort that received 3D models completed additional questions to compare usefulness of the different forms of visualization of the 3D models. Survey responses for each of the 3D model groups were compared using the Mann-Whitney and Wilcoxan rank-sum tests.

Results

All 200 patients completed the survey after reviewing their cases with their surgeons using imaging only. 127 patients completed the 5-point Likert scale survey regarding understanding of disease and surgical procedure twice, once with imaging and again after reviewing imaging plus a 3D model. Patients had a greater understanding using 3D printed models versus imaging for all measures including comprehension of disease, cancer size, cancer location, treatment plan, and the comfort level regarding the treatment plan (range 4.60–4.78/5 vs. 4.06–4.49/5, p < 0.05).

Conclusions

All types of patient-specific 3D models were reported to be valuable for patient education. Out of the three advanced imaging methods, the 3D printed models helped patients to have the greatest understanding of their anatomy, disease, tumor characteristics, and surgical procedure.

Novel Biomaterials Used in Medical 3D Printing Techniques

The success of an implant depends on the type of biomaterial used for its fabrication. An ideal implant material should be biocompatible, inert, mechanically durable, and easily moldable. The ability to build patient specific implants incorporated with bioactive drugs, cells, and proteins has made 3D printing technology revolutionary in medical and pharmaceutical fields. A vast variety of biomaterials are currently being used in medical 3D printing, including metals, ceramics, polymers, and composites. With continuous research and progress in biomaterials used in 3D printing, there has been a rapid growth in applications of 3D printing in manufacturing customized implants, prostheses, drug delivery devices, and 3D scaffolds for tissue engineering and regenerative medicine. The current review focuses on the novel biomaterials used in variety of 3D printing technologies for clinical applications. Most common types of medical 3D printing technologies, including fused deposition modeling, extrusion based bioprinting, inkjet, and polyjet printing techniques, their clinical applications, different types of biomaterials currently used by researchers, and key limitations are discussed in detail.

Image once, print thrice? Three-dimensional printing of replacement parts

OBJECTIVE

The last 20 years has seen an exponential increase in 3D printing as it pertains to the medical industry and more specifically surgery. Previous reviews in this domain have chosen to focus on applications within a specific field. To our knowledge, none have evaluated the broad applications of patient-specific or digital imaging and communications in medicine (DICOM) derived applications of this technology.

METHODS

We searched PUBMED and CINAHL from April 2012 to April 2017.

RESULTS

261 studies fulfilled the inclusion criteria. Proportions of articles reviewed: DICOM (5%), CT (38%), MRI (20%), Ultrasonography (28%), and Bio-printing (9%).

CONCLUSION

There is level IV evidence to support the use of 3D printing for education, pre-operative planning, simulation and implantation. In order to make this technology widely applicable, it will require automation of DICOM to standard tessellation language to implant. Advances in knowledge: Recent lapses in intellectual property and greater familiarity with rapid prototyping in medicine has set the stage for the next generation of custom implants, simulators and autografts. Radiologists may be able to help establish reimbursable procedural terminology.