Educational Problems Clinical Trial
Official title:
Ethical Committee at Researches of Ege University
Background: Primary aspect of hepatic navigation surgery is the identification of source
vascular details to preserve healthy liver which has a vascularity anatomy quite challenging
for the young surgeons. The purpose was to determine whether three-dimensional (3D) vascular
pattern models of preoperative computed tomography images will assist resident-level trainees
for hepatic surgery.
Methods: This study was based on the perception of residents who were presented with 5
different hepatic source vascular pattern and required to compare their perception level of
CT, and 1:1 models in terms of importance of variability, differential of patterns and
preoperative planning.
Results: All subspecialties agree that models provided better understanding of vascular
source and improved preplanning. Five stations provided qualitative assessment with results
showing the usefulness of porta-celiac models when used as anatomical tools in preplanning
(p=0.04), simulation of interventional procedures (p=0.02), surgical education (p=0.01). None
of the cases a scored less than 8.5. Responses related to understanding variations were
significantly higher in the perception of the 3D model in all cases, furthermore 3D models
were more useful for seniors in more complex cases 3 & 5. Some open-ended answers: "The 3D
model can completely change the operation plan" One the major factors for anatomical
resection of liver transplantation is the positional relationship between the hepatic
arteries and the portal veins. Conclusions: The plastic-like material presenting the hepatic
vascularity enables the visualization of the origin, pattern, shape, and angle of the
branches with appropriate spatial perception thus making the well-structured.
2.1. Research Design The study group consisted of Ege University, Faculty of Medicine general
surgery residents (n:22). A five-station carousel composed of vascular patterns such as
classical porta-celiac, portal vein type 2, portal vein type 3, separate branches origin of
celiac trunk and portal vein pattern located between the right and the left hepatic artery.
Each station contained the CT, and life size models of the cases. As data collection tool, a
descriptive rating scale was used to evaluate the perceptions of each of the methods (CT and
3D solid model) in terms of their usefulness in knowing the variations, perceiving the
problem, their effectiveness in differential diagnosis and preoperative planning.
Arterial variations were classified according to previous authors. In the classical anatomy,
the common hepatic artery arises from the celiac trunk to form the gastroduodenal and proper
hepatic arteries, and the latter dividing distally into right and left branches. Separate
branches origin of the celiac trunk such as the artery from the abdominal aorta were modeled
individually in cases of variant neighborhood. Portal variations were classified as the
portal vein types. Type 1 is the classical appearance, in which the right portal vein and
left portal are present as independent trunks. In type 2, the right anterior portal vein,
right posterior portal vein, and left portal vein trifurcate from the main portal vein. In
type 3, the right posterior portal vein comes directly from the middle portal vein, and the
left portal vein and right anterior portal vein emerge from a common trunk.
The study was approved by the suitably constituted Ethical Committee at Researches Department
of Ege University (18-5/45), within which the work was undertaken, and the study conforms to
the Declaration of Helsinki. Clinicaltrails number is EGE18-6.134.
2.2. Selection of the samples The patients in this study were chosen among the ones who
consulted to Ege University Faculty of Medicine, Department of General Surgery, Hepatobiliary
Surgery and Transplantation Division for diagnose between September 2016 and January 2018. CT
archives were screened and 100 eligible people (age: 18-62) with porta-celiac vascular
patterns were selected. Patients whose radiological imaging results were suitable for
modeling and the ones with no previous operation or pathology that may cause anatomical
differences were included in the study.
2.3. Stations Five case carousel that could serve as an example for variational hepatic
vascularity was defined with the consensus of experts in medical education, anatomy,
radiology and liver transplantation team. The carousel included the following 5 cases.
Case 1. Portal vein with Type 3 classification pattern. Case 2. Normal classification
porta-celiac vascular pattern. Case 3. Vascular pattern with the separate branch origin of
celiac trunk. Case 4. Portal vein between the right and the left hepatic artery. Case 5.
Portal vein with Type 2 classification pattern. 2.4. Image post-processing and segmentation
DICOM data from CT and MRI sections of the patients were obtained using free 3D Slicer
(version 4.10.1) software. Segmentations of the portal vein, hepatic vein, splenic vein were
automatically generated from the venous phase, while the celiac trunk and hepatic artery were
manually traced from the arterial phase.
2.5. Creating life-size patient-specific porta-celiac vascular model Model CT's were measured
in order to verify 1:1 modelling and the printing the process was carried out with 3D
printers of Mass Portal Pharaoh xd 20. Model production took a total of 24 hours; 4 for
segmentation, 3 for editing, 15 for printing, and 1 hour for post-print processing. Arterial
vessels were color-coded red, and the portal vein blue by the visualization team.
2.6. Quantitative assessment of model accuracy Measurements of the anatomical structures were
performed and compared between the original CT images, and the CT images of the 3D model. The
morphometric values such as inter-arterial distances (distances between arterial origins),
inter-venous distances and the distance between the artery and the vein were noted.
Measurements were compared for original CT images, the 3D rendered files, and the 3D vascular
models. The repetition rate of the measurements which were done by two autonomous spectators,
was 3 times at every scene and the mean values were taken as ultimate output and also
calculated for further statistical analysis. The spectators performed with exceptional
correlation (r=0.99, P<0.001).
2.7. Workshop During the workshop, 30-minute lectures were given by the expert team on
variable vascular pattern, arterial structures relationship with venous structures and models
in diagnosis. For each station, a period of 5-10 minutes was given.
2.8. Survey A multi-item survey was prepared to assess fellow's perception of residency
training. The survey was utilized by our group, understanding of patient vascular anatomy,
awareness of the changes based on variations, independent decision-making, differential
diagnosis, plan on key surgical steps, and preparation for unexpected bleeding. The answers
to the questions asked for each case were analyzed to include senior (3 years and over) -
junior (1-2 years) residents.
2.9. Statistical analysis Data are entered into SPSS 24.0 for statistical analysis.
Continuous variables were presented as mean ± standard deviation. Wilcoxon Signed Ranks Test
was used to determine any significant differences in the measurements between the original CT
images, 3D rendered images, the 3D model and CT images of the 3D model. Statistical
significance was defined as a p value of less than 0.05.
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