Background: Pancreatic adenocarcinomas are aggressive
and mostly diagnosed at an advanced stage. Precise radiological assessment
remains challenging and small tumors can be difficult to localize during
surgery, necessitating large resections. An innovative approach for the
pre-operative work-up of borderline or small tumors is the three-dimensional
(3D) printed pancreas model.
Objective: We conducted a scoping review of research on
the use of 3D printing in pancreatic tumor surgery to review current status and
future perspectives of this approach and its advantages and disadvantages. We
examined the feasibility of implementing it in our unit with a case study.
Design: Online databases were used to identify all
papers published, including conference abstracts, primary research and expert
consensus. We selected 8 publications that discussed the utility of 3D
modelling and printing in pancreatic tumour surgery.
Results: Two case studies, 2 cases series, 1 expert
consensus, 1 review, and 2 randomized trials reported on advantages and
disadvantages on 3D printing in pancreatic surgery, three of which were
conference abstracts. There was no homogeneity in the reported outcomes.
Our case
study was a 48 years old patient with a neuro-endocrine tumor of the pancreatic
head managed with exploratory laparotomy and subsequent cephalic
duodeno-pancreatectomy.
Retrospective
evaluation of a 3D printed model of his pancreas indicates that the exploratory
laparotomy could have been avoided if such model was available at the time.
Conclusion: The quality of current literature is low,
and further research is required to establish concrete benefits of this technique.
Early reports show benefit in the preoperative diagnosis and evaluation of the
resectability, vascular invasiveness, and relative position of the tumor to
abutting structures. Main disadvantages are time requirements, cost and
availability of expert radiologists.
Implementation
of 3D printing is accessible to our hospital and not considered a major
technical challenge, but a new method of using available resources.
Keywords: Imaging,
Three-Dimensional Printing, Three-Dimensional 3D printing, Pancreas, Pancreatic
Neoplasms, Pancreatic tumors
INTRODUCTION
Current diagnostic
methods for pancreatic tumors
Pancreatic
adenocarcinoma is associated with high mortality and short life expectancy
despite recent advances in our comprehension of its pathophysiology. A
confounding factor is that, due to its central location in the abdomen,
symptoms and clinical signs are discreet and late to be recognised. The main curative treatment
consists of surgical excision followed by adjuvant chemotherapy. To determine
whether the patient is eligible for surgery, it is necessary to establish the
stage of the tumor, the presence or absence of distant metastases and the
extension of the tumor to surrounding structures, in particular the arterial
vessels (celiac artery, common hepatic artery, splenic artery, superior
mesenteric artery) and veins (portal vein, splenic vein, superior mesenteric
vein).
Establishing
the stage and extension of pancreatic tumors can be achieved through various
radiological methods, with relatively similar performances. Abdominal Computer
Tomography (CT) scanning remains the key reference for evaluating pancreatic
tumors and, depending on the location of the tumor, other radiological
examinations such as pancreatic MRI, endoscopic ultrasound or PET-CT can also
be useful. Several staging systems exist today to establish the resectability
of these tumors. The most widely used system on an international basis is the
‘MD Anderson Varadhachary/Katz” staging system for adenocarcinoma of the
pancreatic head and uncinate process [1].
This staging
system is relatively simple and useful for clearly resectable and
non-resectable tumors. However, given the heterogeneity of pancreatic tumors,
establishing the relationship between the tumor and the vascular structures
represents a major challenge, especially as this precise relationship
constitutes the main cornerstone impacting medical decision. Therefore, a less
clear intermediate zone exists for borderline tumor that remains a radiological
challenge to this day. One technique to assist in visualization and
interpretation of pancreatic CT or MRI images is the use of three dimensional
(3D) radiological reconstructions, a common practice in several areas of
medicine, such as angiology, oncology, surgery and anatomy [2].
Although it
allows for a better representation than two dimensional imaging (2D), it still
relies on subjective interpretation due to the radiological heterogeneity of
pathological human tissue. In order to increase the precision of tumor
representation with regard to neighboring structures, the method of
segmentation and 3D printing has been recently tested by a small number of
medical centers, especially in Asia [3].
This technique
proposes a selection of pancreas tissue, tumor and blood vessels based on
CT-scan slices, from which a 3D model is created with specialized software. The
location, sizes and congruity ratios between other anatomical structures and
the tumor are highlighted on the 3D model with different colors and volumes.
The model is saved as a readable file in STL format (stereo lithography) that
can be sent to a 3D printer. The result is a physical 1:1 scale model, which
can be used “hands-on” to evaluate the extent of the parenchymal tumor, its
vascular relationships and location.
Applications of 3D printing in the medical field
Yao et al. [4]
summarized various applications for 3D printing in medicine. They reported that
it already plays a prominent role in some areas of surgery, such as
neurosurgery, plastic surgery, oral and maxillofacial surgery, orthopaedics and
cardio-vascular surgery, including anatomical training for medical students.
Among the benefits of this technique, the authors mention improved
pre-operative planning, reduced surgical time and rates of complications as
surgeons are able to prepare before the surgery, for example to ascertain more
precise tumor location.
A recent
systematic review by Martelli et al. [5] identified various advantages and
disadvantages of the use of 3D printing in surgery. The review included 158
studies dating between 2005 and 2015, the majority from China, Germany, the US
and Japan. The main scope of application was the production of anatomical
models, surgical aids and “hands-on” operative models, with maxillofacial
surgery and orthopedics being predominately featured among the included
studies.
Other
innovative applications included the use of sterilized models placed on the
surgical field allowing for more precise surgical gestures (the surgeon being
able to keep both the model and important anatomical markers in the operative
field in direct sight), and the construction of implants specifically adapted
to the patient’s anatomy.
The authors
highlighted that 3D printing offered a better understanding of anatomical
characteristics, a heightened visualization of potential difficulties to surmount
and the study of the patient’s standard vascular variations. Beyond the
improved standard pre-operative planning, some surgeons were also able to run
through surgical simulations, thus establishing better approaches and improved
surgical procedures. Operative times and patient morbidity-mortality rates were
reduced due to fewer risks and post-operative complications (shorter anesthesia
leading to reduced risk of wound infection, reduced blood loss). In certain
cases, the availability of 3D printed models reduced radiological exposure of
the patients and medical staff.
However, there are certain limitations and
disadvantages in the use of 3D printing. The segmentation time required by the
radiologist and the production time of the 3D model from radiology images is
the most important factor preventing the use of 3D printing in the field of
emergency medicine [4, 5].
The additional
costs resulting from the purchase of effective computer hardware, segmentation
software (although free software can be found) and of 3D printers assuring
accurate and useful rendering for the surgeons, are also a major disadvantage.
This limitation raises the question of reimbursement possibilities of these new
techniques. Finally, the quality of purchased material can impose resolution
limitations which could affect precision of the printed model and, therefore,
its validity.
The potential
benefits of 3D printing in pancreatic surgery are obvious. Aspects of patient
management that can be impacted by this technique include indication for
surgery, surgical preparation and intra-operative anatomical guidance,
resulting in reduction of operative times and better resection margins.
Ideally, this innovative process could allow for improved evaluation of the
operability of tumors with borderline indications, thus reducing the need for
unnecessary surgery, as well as establishing adequate margins during the
surgical removal of these tumors, therefore limiting the progression of the
cancer. However, the extend of the evidence supporting these claims is unclear.
Study Aim
There seems to
be limited literature on the use of 3D printing for pancreatic tumors, even
though rapid evolution is expected over the coming years. The aim of this
scoping review was to ascertain the current application of this technique on
pancreatic tumors, its advantages and disadvantages and to prepare a study
protocol for a prospective clinical pilot study. The objective was to inform
readers on the current techniques of 3D modelling and printing in the field of
pancreatic cancer surgery and demonstrate the potential benefits by presenting
how the availability of a printed model would have affected the management of a
retrospective case at Geneva University Hospitals (HUG).
MATERIALS & METHODS
Scoping review
A protocol for
the scoping review was prepared internally and agreed by the authors in advance
but has not been published or submitted for registration to local or national
databases. The local institutional review board (IRB)
approved the review and the case study. The review was not funded by any specific
organisation. Following the guidelines of our IRB (based at the « Centre
Hospitalier Universitaire Vaudois - CHUV), we neither need an approval for a
single retrospective case analysis, nor for the informed consent of the
patient. Consultants (radiologists, surgeons, 3D printing specialists) are
co-authors of this study and have given their written consent for this
publication.
SEARCH STRATEGY
Both PubMed
and Embase were searched electronically on the 2nd February 2019 with the
following search terms: (3D printing) AND pancreas; (3D printing) AND
(pancreatic tumour); (3D printing) AND (pancreatic surgery). No date or study
type limits were set. The exact search for Pubmed can be found in additional
file 1.
Articles selection and data extraction
After removing
the duplicates, we performed title and abstract screening followed by full text
screening, to identify articles that met the following inclusion criteria:
articles written in French, English or Chinese language (since they could be
translated by staff); all types of studies, including expert opinion; articles
discussing the utility of 3D modelling and printing in pancreatic tumor surgery
in humans. One author (BM) extracted the following data, where available, from
the included studies on an excel sheet:
• Favorable
outcomes: operative time, rate of complications, approach, number of infections,
blood loss, feasibility, length of hospitalization.
• Non-favorable:
cost, model production time.
Case Selection
There are over
60 pancreatic surgeries performed per year in our institution. We chose to
evaluate a recent challenging case of a patient with neuro-endocrine pancreatic
tumor that, ultimately, required cephalic duodeno-pancreatectomy. For the
purposes of the case study, all details were collected retrospectively and with
confidentiality. We selected this case to report that our standard management
for a neuroendocrine tumor lead to the impossibility for its localization
during the first surgery, which finally led to a second laparotomy and a large
duodeno-pancreatic resection. We think that the availability of a 3D printed
model of the pancreatic head might have allowed an enucleation or at least
would have avoided the second laparotomy.
RESULTS
The initial search for each term (3D printing) AND
pancreas; (3D printing) AND (pancreatic tumor); (3D printing) AND (pancreatic
surgery)) resulted in 27, 11 and 26 hits in PubMed, and 63, 25 and 39 hits in
Embase respectively. Title and abstract screening identified 9 articles, 1 of
which was excluded because it was in Japanese. A total of 5 articles and 3
supplements (conference abstracts) were included after full text screening
(Figure 1 and Table 1). The majority of evidence levels were case
reports/series or expert advice. There was great heterogeneity among the
articles, and the variables were rarely quantifiable. Therefore, we were unable
to apply any form of systematic grouping to them or compare results, and a
narrative synthesis was performed. The most pertinent information from each
study is listed in Table 1. We note that 3D visualization and printing are two
closely-related subjects, and various authors often broach both subjects simultaneously.
None of the 3 conference abstracts mention funding information, and one study
and one expert review received public sponsorship. The other three studies were
non-sponsored.
DISCUSSION
Expert consensus on the optimal
use of 3D visualization in pancreatic surgery: An essential prerequisite for 3D
printing
There is
consensus among Asian experts regarding the management of patients with tumors of the pancreas head, that 3D visualization provides benefits in terms of determining the tumor
location, its form and its invasiveness [3].
The vascular
structures (celiac artery, superior mesenteric artery, portal vein and superior mesenteric vein) are represented simultaneously and their invasiveness is better measurable. The same applies
to the location of the Wirsung or Santorini
ducts. 3D visualization and printing offer the added-value of being able to
manipulate structures under different
viewpoints before and during surgery.
The image
resolution required must allow for differentiation between the structures with millimeter precision in order to then obtain three phases of CT-scan images:
native, arterial and venous [3]. Other authors recommend
the use of biphasic injection CT-scan with what is called “pancreatic injection time”
[6]. This “time”
occurs between 40 and 70 seconds
after the injection of the contrast. Another group of Japanese researchers proposes an imaging
method enabling the detection of early-stage pancreas
cancers [7]. Their respective studies conclude that the change in
mitigation between the pancreatic parenchyma and a locally advanced tumor is
more important during the arterial
phase. For early-stage tumors, mitigation is more pronounced during the pancreatic
and venous phases.
Following image
acquisition by the CT-scan, segmentation is necessary where
anatomical and pathological structures are selected along
different slices and then combined
to obtain a three-dimensional object. This technique
also facilitates efficient
localization of the tumor and its
abutment as well as a map of the patient’s
blood vessels. The latter can present normal and
pathological structural variations. A key point brought out by the authors of the consensus
[3] is the great diversity of anatomical variations in hepatic blood vessels
found in the general population. Exact visualization of these variations must be obtained in order to anticipate reconstructive surgery or vascular excision. This risk is high in cases of borderline
tumors. The consensus of experts recommends a
high-quality visualization of the following blood vessels: superior
mesenteric artery, portal
vein, superior mesenteric
vein, splenic vein, middle colic vein and gastro-colic venous trunk.
Benefits of 3D-printed
models in pancreatic surgery
Yang and Huang [8]
reported on the current status of 3D printing for pancreas surgery. In the
cases of tumours of the pancreas head, surgery is highly complex and requires
an in-depth understanding of location, size and the relationship of the tumour
with the vessels and organs surrounding it. In a best-case scenario, this will
allow for conservative surgery (enucleation). Having access to a “hands-on”
model makes it possible to remedy spatial gaps. Yang and Huang [8] highlight
the advantages with regard to surgical planning and the possibility of
visualising the required surgical steps. During the operation, healthy margins
are easier to find, and this reduces operating time. In addition, the authors
also note the advantage of having 3D models when explaining surgery to the
patient beforehand.
Zheng et al. [9]
report on the benefit of 3D printing in pre-operative planning in comparison to
3D visualization. They compared two groups of trainee surgeons evaluating cases
of pancreatic cancer: the first group on the basis of 3D-imaging and the second
based on printed 3D models. Following the evaluation, the participants
undertook a subjective test to examine the quality of the surgical plan (QSP)
to assess knowledge of patient anatomy and pathophysiological features, the
operative plan (surgical steps, safe approach, protection of vital structures)
and preparation for unexpected events. The test was prepared by experts in the
field of pancreatic medicine. Findings indicated to the superiority of 3D
printing for surgical planning, where evaluation of the 3D-printed models
resulted in significantly higher QSP scores compared to the 3D-rendered models.
The key advantages were the input of touch with added sensation of textures and
forms as well as the mental link between tactile and visual perception of the
patient’s anatomy.
Endo et al. [10]
conducted a feasibility study within their hospital to test the possibilities
of segmenting and 3D printing a healthy pancreas. They concluded that the
virtual model was more useful in simulating surgical gestures, whereas the
physical model led to improved detection of sizes and abutment between
anatomical structures.
Seyama et al. [11]
examined the feasibility of using 3D printed pancreas models for pre-operative
planning and navigation in 8 patients undergoing pancreatic surgery. In all
cases, the planned pancreatic resections were successful, showing that 3D
visualisation and printing can be useful in pancreatic surgery. The authors
believe the use of 3D-models led to better pre-surgical approaches and
increased accuracy in their anatomical markers during the operation.
Yasunaga et al. [12]
undertook a study on the added-value of visualization and 3D-printing on a
series of patients requiring laparoscopic pancreatectomy for benign or
malignant low-grade tumors. As with the other authors, they studied CT-scans
and then produced segmentations and 3D impressions detailing the different
structures by colour. They reported that there is a true gain in term of
blood-loss, operating time, and length of hospitalisation. They concluded that
effective pre-surgical preparation of gestures and sequences to be completed,
linked to optimal intra-operative navigation, is essential to surgical success.
Marconi et al. [13]
compared conventional contrast CT scans, virtual 3D reconstructions, and
3D-printed models in their effectiveness in demonstrating the relevant anatomy
of 15 patients requiring abdominal surgery (splenectomies, nephrectomies and
one pancreatectomy). After randomly evaluating each method of visualisation,
ten medical students, ten surgeons and ten radiologists undertook a
multiple-choice test. The goal of the exercise was to be able to recognise
certain anatomical structures, with their surrounding abutments, as an
indication of being able to prepare a pre-operative plan. Ultimately, the 3D
reconstruction and printed model led to a better comprehension of the anatomy
in comparison to the visual survey of a simple 2D cut. The advantage of 3D
virtual images was attributed to the fact that they can be rotated in three
dimensions, thus giving an impression of depth and improving spatial
orientation, although it was difficult to interpret the distances between
anatomical structures. The authors conclusion was that a surgical plan could,
therefore, be easily produced.
Disadvantages and limitations of 3D printing
One of the
limitations of 3D-printing is that the expertise of a radiologist is required
to complete segmentation of the CT-2D images, which, in turn, allows the 3D
model to be printed [13]. Costs of the technique is also a concern in general
[4, 5] and specifically to pancreatic imaging [14]. Furthermore, the time required
for creation of each model varies depending on anatomical complexity, image
quality and printer involved. In one study, the segmentation process was
standardised and completed in six hours, and the printing process varied
between eight and thirty hours [13]. In one case using industry-grade high
quality printer, the printing took 64 hours [14]. In a healthy pancreas [10],
which is undoubtedly less complex to interpret, a virtual model may require 3
hours and the 3D-printed model another 5 hours. This implies that organisation
of the surgical plan has to be adjusted. Visualization and 3D printing do
present an advantage in terms of comprehension of anatomy, spatial orientation
and pre-operative planning but, in order to maintain efficiency and speed, they
also involve the creation of specific protocols to speed the process of
creating the models.
Virtual reality as an alternative to printing
Andolfi et al. [14]
presented a case-report highlighting the benefits of 3D visualization and
virtual reality in determining the resectability of a pancreatic head tumour.
The case concerned a 56 year-old patient with an adenocarcinoma of the pancreas
head, for which a CT-Scan showed a borderline tumour in close contact to the
gastroduodenal artery but uncertain contact with the hepatic artery. Following
3D reconstruction of the CT sections and viewing the 3D virtual model in the
ImmersiveTouch™ virtual reality platform (ImmersiveTouch, Chicago, IL, USA),
the surgical team was able to determine that the tumor had invaded the hepatic
artery and offer the patient pre-op neoadjuvant chemotherapy. The surgeons were
also able to train prior to the real operation on the same virtual reality
ImmersiveTouch™ platform.
Although the
application of 3D printing for surgical preparation was not the focus of the
study by Andolfi et al. [14], the authors inform how useful it was in offering
explanations to the patient and their family members before surgery, and for
didactic purposes. Furthermore, they indicate the substantial disadvantages of
3D printing in matters of time consumption and the cost of acquiring and
producing professional material. Despite the apparent benefits of this
competitive technique compared to 3D printing, virtual reality will likely
never completely replace the use of physical models for surgical preparation.
PRACTICAL CASE STUDY
In order to test the feasibility of using 3D printing
in our unit, we brought together a group of experts comprised of visceral
surgeons, radiologists and 3D printing specialists. We initiated a 3D printing
exercise from a retrospective analysis of a patient with pancreatic tumor. A 48
years old patient was diagnosed with a one centimeter hypervascular lesion of
the pancreas head. This lesion exhibited all the characteristics of a neuro-endocrine
tumor by CT-scan (Figure 2). The
patient underwent an initial exploratory laparotomy to review the pancreas.
According to the
pre-operative radiology work-up, the nodule was close to the pancreatic head (Figure 2) and an enucleation was
envisaged. The intra-operative manual palpation did not indicate any location
of the tumor and the intra-operative ultrasound located the tumor within the
central part of the pancreas head without providing further precision. The
possibility of a cephalic duodeno-pancreatectomy was raised, but this procedure
was not performed at that stage because it was considered too disabling.
Trans-duodenal biopsies were performed with the final diagnosis of a stage G1
(WHO classification) neuroendocrine pancreatic tumor and resection of the
pancreas head was finally proposed.
Cephalic
duodeno-pancreatectomy was performed at a later stage, which was complicated by
epigastric pain associated with hemorrhagic shock accompanied by melena and
haematochezia 3 weeks post-procedure. A pseudo aneurysm of the stump of the
gastroduodenal artery that had ruptured and fistulized in a digestive loop was
diagnosed and treated by placing a stent through interventional radiology into
the hepatic artery, with favorable outcome. The CT images were reconstructed
using a standard iterative reconstruction algorithm with the following
parameters: slice thickness, 1.0 mm; slice interval, 1.0 mm; matrix size,
512x512; and medium smooth tissue convolution kernel (I26f). The
neuro-endocrine tumor was segmented from the abdominal CT scan images, using a
dedicated software (Vitrea®, Vital Images, Inc., Minnesota USA) by a
radiologist with expertise in cardiothoracic and vascular imaging. The 3D model
(Figure 3) was created in less than
three hours in our radiology service and printed (Figure 4) using a Stratasys J750 3D printer.
The opinion of our
group of experts is that availability of the 3D images and model could have
changed the management, such as avoiding the first exploratory laparotomy. It
is unclear if enucleating the tumor would have been possible, a procedure which
may have avoided the cephalic duodeno-pancreatectomy but the probability with
the help of the 3D images and the model was probably higher. We therefore see a
particular interest of this new diagnostic approach and direct attention to its
utility during the treatment of benign and malignant pancreatic tumors. Given
the retrospective aspect of the case study, we are unable to form any further
opinions other than concluding to a significantly different care when using this
new instrument.
LIMITATIONS OF THE SCOPING REVIEW AND CASE STUDY
The main limitation
of this scoping review is the narrow keyword search with respect to alternative
spellings and types of pancreatic tumors and languages. However, the review is
sufficient for the purpose of using the findings to test the feasibility of 3D printing in our unit with a case study.
The low number of identified articles indicated that a systematic review
on the subject can include more search terms and databases without major
additional effort. We did not conduct any quality assessment or risk of bias in
the studies we found and this is something that can be addressed with a
systematic review.
Also, we are unable
to form any further opinions about the use of 3D printing in our unit other
than concluding to a significantly different care when using this new
instrument in one patient only, due to the retrospective aspect of the case
study.
CONCLUSION
Three-dimensional
modelling and printing offer a new development in the management of patients
with pancreatic tumors. The limited number of articles currently available
offer some indication that it helps surgeons and radiologists in the
preoperative diagnosis and enhances the evaluation of the resectability of
pancreatic tumors, vascular invasiveness and the position of the tumor with
regards to the rest of the abutting structures. There is a general consensus
that the improvement of the pre-operative surgical planning process is
demonstrated in reduction of risks, complications, length of hospital stay and
operating time. Also, improvement in the intra-operative spatial orientation
allows for better localization of the tumor and precision of the surgical
gestures. Moreover, the studies indicate possibilities for surgical training
and aid when discussing with patients. The main disadvantages often quoted in
the literature are the time needed for segmentation and printing, the cost of
purchasing the necessary equipment and, finally, the need for an efficient
computer system combined with the availability and expertise of a radiologist.
In conclusion, although 3D printing has a clear
potential in the field of management of patients with pancreatic tumors,
clinical use of this application is still in its early stages except in certain
high-volume Asian institutions. Based on our study, 3D printing is accessible
to our hospital and is not considered a major technical challenge, but rather a
new method of using available resources. Since both the hardware and software
already exist and is used by other medical specialties, we propose that this
technique should be tested in controlled studies for the management of patients
with pancreatic tumors.
ADDITIONAL
FILE 1:
Pubmed
Search Strategy (Literature Search performed: February 02, 2019):
(3D
printing) AND pancreas:
("printing, three-dimensional"[MeSH
Terms] OR ("printing"[All Fields] AND "three-dimensional"[All
Fields]) OR "three-dimensional printing"[All Fields] OR
("3d"[All Fields] AND "printing"[All Fields]) OR "3d
printing"[All Fields]) AND ("pancreas"[MeSH Terms] OR
"pancreas"[All Fields])
(3D
printing) AND (pancreatic tumour):
("printing, three-dimensional"[MeSH
Terms] OR ("printing"[All Fields] AND "three-dimensional"[All
Fields]) OR "three-dimensional printing"[All Fields] OR
("3d"[All Fields] AND "printing"[All Fields]) OR "3d
printing"[All Fields]) AND ("pancreatic neoplasms"[MeSH Terms]
OR ("pancreatic"[All Fields] AND "neoplasms"[All Fields])
OR "pancreatic neoplasms"[All Fields] OR ("pancreatic"[All
Fields] AND "tumour"[All Fields]) OR "pancreatic
tumour"[All Fields])
(3D
printing) AND (pancreatic surgery):
("printing, three-dimensional"[MeSH
Terms] OR ("printing"[All Fields] AND "three-dimensional"[All
Fields]) OR "three-dimensional printing"[All Fields] OR
("3d"[All Fields] AND "printing"[All Fields]) OR "3d
printing"[All Fields]) AND (("pancreas"[MeSH Terms] OR
"pancreas"[All Fields] OR "pancreatic"[All Fields]) AND
("surgery"[Subheading] OR "surgery"[All Fields] OR
"surgical procedures, operative"[MeSH Terms] OR ("surgical"[All
Fields] AND "procedures"[All Fields] AND "operative"[All
Fields]) OR "operative surgical procedures"[All Fields] OR
"surgery"[All Fields] OR "general surgery"[MeSH Terms] OR
("general"[All Fields] AND "surgery"[All Fields]) OR
"general surgery"[All Fields]))
1. Varadhachary GR, Tamm EP, Abbruzzese JL,
Xiong HQ, Crane CH, et al. (2006) Borderline resectable pancreatic cancer: Definitions,
management and role of preoperative therapy. Ann 385 Surg Oncol Août 13: 1035‑1046.
2. Duran AH, Duran MN, Masood I, Maciolek LM,
Hussain H (2019). The additional diagnostic value of the three-dimensional
volume rendering imaging in routine radiology practice. Cureus 11: e5579.
3. Study Group of Pancreatic Surgery in Chinese
Society of Surgery of Chinese Medical Association, Pancreatic Committee of
Chinese Research Hospital Association, Digital Medicine Branch of Chinese
Medical Association, Digital Medicine Committee of Chinese Research Hospital
Association (2017) Zhonghua Wai Ke Za Zhi 55: 881‑886.
4. Yao R, Xu G, Mao SS, Yang HY, Sang XT, et
al. (2016) Three-dimensional printing: Review of application in medicine and
hepatic surgery. Cancer Biol Med Déc 13: 443‑4 51.
5. Martelli N, Serrano C, Brink H, Pineau J,
Prognon P, et al. (2016) Advantages and disadvantages of 3-dimensional printing
in surgery: A systematic review. Surgery 159: 1485‑ 500.
6. Takeshita K, Kutomi K, Haruyama T, Watanabe
A, Furui S, et al. (2010) Imaging of early pancreatic cancer on multidetector
row helical computed tomography. Br J Radiol 83: 823‑830.
7. Egorov VI, Yashina NI, Fedorov AV,
Karmazanovsky GG, Vishnevsky VA, et al. (2010) Celiaco-mesenterial arterial
aberrations in patients undergoing extended pancreatic resections: Correlation
of CT angiography with findings at surgery. JOP 11: 348-357.
8. Yang YY, Huang HG (2017) Development status
of three-dimensional printing technology in pancreatic surgery. Zhonghua Wai Ke
Za Zhi 1 oct 55: 795‑797.
9. Zheng Y, Yu D, Zhao J, Wu Y, Zheng B (2016)
3D Printout Models vs. 3D-Rendered Images: Which is better for preoperative
planning? J Surg Educ 73: 518‑5 23.
10. Endo K, Sata N, Kaneda Y, Koizumi M, Lefor
A, et al. (2011) Three-dimensional (3D) model of the pancreas using routine CT
data and a 3D printer: A feasibility study. Pancreas 40: 1321-1321.
11. Seyama Y, Kanomata H, Kudo H, Umekita N
(2016) Simulation and navigation using a 3D printed pancreas model in
pancreatic surgery. Pancreatology Août 16: S58.
12. Yasunaga M, Kojima S, Mikagi K, Kawahara R,
Sakai H, et al. (2018) Laparoscopic distal pancreatectomy using intraoperative
navigation system. HPB 20: S586.
13. Marconi S, Pugliese L, Botti M, Peri A,
Cavazzi E, et al. (2017) Value of 3D printing for the comprehension of surgical
anatomy. Surg Endosc 31: 4102‑4110.
14. Andolfi C, Plana A, Kania P, Banerjee PP,
Small S (2016) Usefulness of three-dimensional modeling in surgical planning,
resident training and patient education. J Laparoendosc Adv Surg Tech A 27: 512‑515.
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