At the recent Materialise World Summit (MWS) event in Belgium, one presentation across the packed two-day program stood out as a singularly impressive example of the normalization of 3D printing and additive manufacturing (AM).
The last decade has seen an increasing number of medical applications for 3D printing and AM, with many examples of medical and surgical procedures for improved patient outcomes around the world. An MWS keynote address given by Dr. Jonathan (Jay) Morris examined how 3D printing technology has made a significant and permanent impact on the daily clinical and surgical practices of the world-renowned Mayo Clinic. Dr. Morris referenced many cases where 3D printing has made a real difference, both in the approach to a case by the medical staff and to the outcome for the patient.
The USA-based Mayo Clinic operates across three main facilities in: Rochester, Minnesota; Phoenix, Arizona; and Jacksonville, Florida. Dr. Morris works at the Minnesota facility.
The organization’s mission is ‘to inspire hope and contribute to health and well-being by providing the best care to every patient through integrated clinical practice, education and research,’ and this was much in evidence in this presentation.
One of the dominant advantages of 3D printing in the medical field is obviously the ability to customize parts and models according to patient-specific data. This, together with the ability to print complex shapes, is the cornerstone of the clinic’s capabilities and increasing expertise.
Dr. Morris covered a wide range of 3D-printed medical applications, including anatomy models for surgical planning, patient-specific surgical tools and patient-specific implants. He also referenced ongoing research for bioprinting applications, being careful to delineate between what is possible now and the future potential to print human tissue.
Dr. Morris cited one of the earliest cases at the Mayo Clinic to benefit from 3D imaging and 3D printing technologies—the separation of conjoined twins, attached to each other at the chest. It got plenty of press-coverage at the time. A delightful ‘then and now’ slide showed the two babies in their separate car seats alongside the two little girls riding their bikes.
This success meant that more conjoined twins came for treatment. ‘What we found was that surgeons stopped looking at all of the data and started talking about what they know to do around the [3D] model,’ said Dr. Morris.
For a conjoined twins surgery, it is not unusual for over 60 medical personnel to be involved, with as many as four surgical teams from different disciplines, each of which must understand the steps involved in the procedure and their role in it. The 3D model is used for precisely communicating this and for prepping the operating room (OR).
Dr. Morris graphically illustrated that ‘someone’ has to make the critical decision of where to make the separation—across a liver, a bile duct and all of the associated veins and arteries. This is where 3D printing makes a difference in ‘bridging the gap from the unknown to the known,’ he said.
Before the advent of accurate 3D medical models, there were things they could never possibly know before opening a patient up in the OR. Medical imaging data (X-rays, computed tomography (CT) scans, even magnetic resonance imaging (MRI) scans) can only go so far in providing information, and there was always an element of the unknown before cutting. Physical interaction with a life-size 3D printed model allows surgeons to know more before the first cut.
‘Eventually, [using 3D printing] had to move beyond one-offs,’ continued Dr. Morris. Although referring specifically to the work at the Mayo Clinic, this has wider implications for the 3D printing industry. While the individual applications remain exciting, and at times inspiring, it is the normalization of the technology in the medical field that illustrates real progress.
Dr. Morris described how surgeons of every discipline have come to depend on the 3D printed patient-specific medical models ahead of their surgeries and appreciate the benefits that they bring to their knowledge, their workflow and, most importantly of all, to the outcome for their patients. So much so, that in Dr. Morris’s experience, once the surgeons ‘get it,’ they refuse to work without it.
The Mayo Clinic facilities carry out more than 76,000 surgical procedures each year, and 3D printing is increasingly being integrated to support the most complex cases. ‘There is no place in our lab we do not touch with 3D printing […] it’s just taken off,’ Dr. Morris confirmed.
The broad spectrum of activities includes anatomic models, patient education, medical education, surgical planning, custom cutting guides, custom implants, research, forensic/pathology, custom stent sizing, quality control, simulation, rapid prototyping medical devices, bioprinting and cell scaffolding.
Dr. Morris highlighted a six-step process that starts with patient data, specifically the imaging data that originates from CT or MRI scans. This data is imported into 3D printing software (in this case Materialise’s Mimics/3-Matic), before being segmented out and exported to CAD for designing-in elements of the model and conversion to stereoithography (STL) format (or equivalent). Then, 3D printing followed by post-processing—‘there’s usually a lot of post-processing,’ according to Dr. Morris.
The ecosystem involved in making 3D printing work is extensive and complex, and it takes expertise, experience and understanding to coordinate the process effectively for consistent results. But that is precisely what the Mayo Clinic team continues to do for an increasing number of complicated cases, tackling the bottlenecks that occur at various steps in the process. A distinct advantage that Dr. Morris cited at the Mayo Clinic is an integrated approach. Multiple disciplines—virtual planning, design, 3D printing and surgical teams, for example—are altogether under one roof, facilitating communication and progress.
Throughout his presentation, Dr. Morris highlighted many 3D printing case studies showing how the technology has improved treatment and care. He cited congenital scoliosis (spine deformities), which involve extremely complex surgeries due to the complexities of spinal anatomy. From the experience garnered with 3D printing spinal models, the clinic quickly advanced to 3D printing spines with tumors. ‘And once we went to tumors, there was no turning back,’ said Dr. Morris.
Other clinical cited by Dr. Morris were craniomaxillofacial surgery, thoracic surgery, urology—renal sparing surgery, orthopedic/orthopedic oncology surgery, cardiology and neurosciences.
Dr. Morris said that the benefits of 3D printed models for surgeons are matched by the benefits in explaining diagnoses and treatments to patients. Now everyone in the OR, including the patient, understands (to varying degrees) what is going to happen. Patients do not understand their MRI and CT data—even with intense explanations, it is extremely difficult for a layman to interpret this data. Dr. Morris is confident that a 3D physical model provides the patient with the means to give their ‘true informed consent’ prior to surgery.
Benefits to the patient can be seen through the surgical results. One 33-year-old female patient cited by Dr. Morris, a new mother, discovered a hard palette lump that required intensive radiological and chemotherapy treatment as well as surgery. Treatment involved surgical models for planning and patient-specific reconstruction, virtual planning and patient-specific surgical guide production.
The planning and reconstruction of the jaw, the teeth and the surgical tools was done co-operatively with the different doctors involved, in the shortest possible timeframe. One of the greatest motivations for achieving the best reconstruction possible is that cancer patients—primarily concerned about eliminating the cancer—are also extremely anxious to know how long it is going to be before they can go out in public, look normal and eat. Very human questions that the Mayo clinic is now able to go some way to addressing with positive outcomes.
Dr. Morris’ presentation was positive and upbeat, but he did not shy away from confronting the challenges still to be faced before 3D printing technology can reach its full potential. Notably, he cited: payment structures; time to model (segmentation software, ‘still the bane of our existence’, and design time); print time (particularly for large models) and print reliability; quality control; in-hospital infrastructure; manufacturing infrastructure; software; and post-processing.
Despite these challenges, which are not insurmountable, the Mayo Clinic continues as a beacon for integrated, fully operational 3D printing facilities. It truly is, in Dr. Morris’s words, ‘always about the patient.’