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3D Techniques Realizing Perfect Reconstruction of the Chest Wall of a Rarely Seen Aged Diabetic Patient
In the Surgery Emulation Classroom of the National Oncoplastic Microsurgery Training Class, the trainees are staring at the screen on which the operation video is played, they dare not blink lest any detail may pass by unnoticed. After the surgery is over, they all raised their thumbs and praised that such sophisticated oncoplastic microsurgery reconstruction done with 3D technology really broadens their horizon.
What indeed is this very difficult operation? We must start from what happened last year.
In October 2015, Prof. Li Zan, an expert from the Oncoplastic Surgery Department of the hospital met an unusual case involving a female patient. She was Ms. Zeng, 67 years old, who had visited many hospitals in different places to consult her disease. She was accompanied by her son who used to work outside for long times and neglect to care about his mother’s health. He did not know there had been a mass existing in his mother’s breast for 11 years until the mass broke about a year before and fluid seeped out from it. Ms. Zeng’s conditions deteriorated quickly. Moreover, she has mild Alzheimer’s disease and diabetics for many years. Biopsy of the mass in her right breast is diagnosed of granular cell tumor. Since the mass has invaded her chest wall and brought about festering infection there, she was rejected politely by many top-notch hospitals in the province. After the other patients recommended our hospital to her, she came to us to try her luck at the Breast Cancer Plastic Surgery Department (also the No. 3 Department of Head and Neck Surgery). Her son feels very regretted for overlooking his mother’s health, and pleaded Prof. Li Zan repeatedly to save his mother. Prof. Li comforted him and his families by saying “we will do our utmost to save the patient!”
After being hospitalized, Prof. Li Zan prescribed for the patient a series of regular diagnostic and treatment measures, like co-consulting with doctors from the Endocrinology Department to use artificial insulin to stabilize her blood sugar, using medicine to the ulcerated surface resulted from the masses on her chest wall, and using sensitive antibiotics to effectively control infection. Then, Prof. Li did another biopsy to double check that she contracted granular cell tumors. MRI shows the mass at the lower quadrant of her right breast has invaded the chest wall and pectoralis major muscle on the right side. The lymph nodes at her armpits swelled. Once we decided on using operation to remove the mass completely, we must remove the whole piece of breastbone and multiple pieces of ribs, which means her heart will be exposed and the colossal defect in her front chest will need repairing. Since the patient with a long history of diabetics and Alzheimer’s Disease may have poor obedience, the operation was very difficult and highly risky. Every small negligence might bring about irrevocable losses. Moreover, we had no mature experience from similar cases worldwide to refer to. Party Secretary Zhou Xiao attached great importance to this case and directed to organize cross-disciplinary group consultation. Prof. Li Zan submitted application and held co-consultation with experts from departments of thoracic surgery, orthopaedics, radiotherapeutic diagnosis, radiotherapy, breast medicine and surgery, etc, during which the experts collaborated in making a detailed and comprehensive treatment plan. Families of the patient were deeply moved by professionalism and humanities of doctors and nurses from Hunan Cancer Hospital. After Prof. Li informed them of the detailed operation plan, even though they clearly understood the operation might be life-threatening and the surgical injury was very large, they didn’t express a bit of doubt and insisted on doing the operation.
Leaders of the hospital and relevant departments thought importantly of this rare and difficult case and did their best to support the operation. The operation had two major challenges for which Prof. Li Zan from Oncoplastic Surgery Department and Prof. Xiao Gaoming from Thoracic Surgery Department respectively made the solution plans. The first challenge in the operation was that the bone defect of the chest wall left by tumor resection must be reconstructed with poly mesh and bone cement. Dr. Shi Lei rebuilt the 3D model of the patient’s chest with the patient’s CT data to visually and precisely present the anatomic information difficult to be shown on the X-ray, CT, MRI. He also made a life-size physical model with 3D printing techniques. He accurately simulated the resection area with the computer and physical model and designed the guide plate for implanting bone cement. The second challenge was the large defect resulting from removal of the large tumor from the chest. The heart and other organs in the chest will be exposed to the outside. Prof. Li Zan and Dr. Song Dajiang used the CT data to rebuild a 3D model of the soft tissues and blood vessels in the belly wall. Guided by Prof. Li Zan, Dr. Song Dajiang worked overtime late at night to collect critical operation data about the scope, depth and place of resection for the implanted tissue flap, and finished a perfect operation plan with possibly the lowest risks. After thorough preparation, Prof. Li Zan cooperated with academic leaders from several departments to confront the challenge by presiding over the operation on October 15. Prof. Yang Jinfeng from the Anesthesia Department and Prof. Xiao Gaoming from the Thoracic Surgery Department collaborated wholeheartedly on conducting the operation. During the operation, the mass and invaded tissues in the chest wall were removed together, which is as large as 15cm *15cm. Then the chest wall was repaired with poly mesh and bone cement under the guidance of 3D guiding plate. In order to avoid postoperative complications, omentum majus was removed to be replaced by bone cement scaffold for providing protection to the patient’s heart and lungs. In the end, they used the accurate 3D blood vessel design to remove inferior epigastric artery as large as 22cm * 14cm and repaired the huge chest wall defect with free deep inferior epigastric perforator flap. The operation lasted 11 hours. With close cooperation between doctors and nurses, the patient rehabilitated very fast after the operation and the flap healed quickly. Two weeks later, the patient was discharged. When the patient finished the re-examination, she and her family presented a silk banner to the hospital to express their appreciation for the doctors and nurses.
Party Secretary Zhou Xiao said this operation advanced development of both domestic and foreign medical techniques relating to the case. During the operation, they used 3D techniques to rebuild number and position of blood vessels, volume, position and invasion scope of the mass, and produce 3D guiding plate for accurate operation. Cross-disciplinary consultation together with 3D techniques provides new perspectives and experience for difficult oncoplastic surgeries.