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Edito : L’impression 3D va-t-elle révolutionner la médecine avant l’industrie ?
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Il y a presque un an, en mai 2013, j’écrivais un éditorial consacré à l’impression 3D comme moteur d’une nouvelle révolution industrielle (Voir Editorial RT Flash). Mais en moins d’un an l’impression 3D a fait des progrès fulgurants et est en train de sortir bien plus rapidement que prévu des laboratoires et des usines pour toucher le grand public et transformer notre vie quotidienne.
C’est ainsi qu’il y a quelques jours, l’enseigne de bricolage Leroy Merlin a inauguré à Paris les premiers "ateliers 3D" et a également ouvert à Angers un espace dédié, permettant aux clients de concevoir leur objet sur un logiciel et de l’imprimer en 3D. Côté matériel, on trouve aujourd’hui d’excellentes imprimantes 3D grand public à moins de 1000 €. Quant au marché mondial de l’impression 3D, il devrait passer, selon les dernières prévisions publiées par Canalys Research, de 3 milliards d’euros cette année à 12 milliards d’euros à l’horizon 2018.
Mais si l’impression 3D va révolutionner la production d’objets manufacturés et être au cœur de l’usine du futur que l’on voit déjà émerger, il se pourrait bien que cette technologie aux potentialités immenses révolutionne, avant même l’industrie, l’ensemble du secteur de la santé et de la médecine.
Parmi le déferlement d’applications récentes des technologies d’impression 3D en médecine et en chirurgie, certaines méritent d’être évoquées car elles constituent les prémices d’une nouvelle révolution scientifique et médicale sans doute aussi considérable que celle des antibiotiques ou des greffes d’organes au siècle dernier. En décembre 2013, des ingénieurs de l’Université de Wollongong, en Australie, ont par exemple développé BioPen , un « stylo » qui utilise comme « encre » des cellules souches et permet la régénération d’un os ou la réparation d’un cartilage. Dans ce cas précis, les cellules utilisées sont produites dans des réacteurs de croissance à base d’algues, puis recouvertes d’une couche de gel (Voir University of Wollongong).
Il suffit ensuite d’exposer cette « pâte » cellulaire à un faisceau de lumière ultraviolette pour la solidifier. L’un des avantages majeurs de cette technique est qu’elle permet d’injecter des cellules souches exactement sur les lésions à traiter. Ces cellules vont alors se multiplier et se différencier en différents types de cellules spécialisées. La même technique peut d’ailleurs être utilisée pour diffuser localement différentes molécules thérapeutiques.
Autre avancée : il y a deux mois, une équipe américaine de l’université Cornell, dirigée par Lawrence Bonassar, a réussi à fabriquer en une seule journée, grâce à l’impression 3D, une véritable oreille fonctionnelle à partir d’une image tridimensionnelle de l'oreille d'un patient (Voir Cornell). Les chercheurs ont constaté que, trois mois après l’implantation de cette « bioreille », sur le patient, celle-ci avait produit suffisamment de cartilage naturel pour remplacer le moule initial constitué de collagène.
Les chercheurs précisent que cette nouvelle technique est bien moins lourde et complexe à mettre en œuvre que les méthodes actuelles couramment utilisées dans ce type de reconstruction chirurgicale. En outre, cette approche permet de concevoir et de fabriquer rapidement une oreille parfaitement personnalisée, dont la forme et la taille correspond exactement aux besoins du patient. La même équipe travaille à présent sur la possibilité d'utiliser des cellules de cartilage humain d'oreille, afin de réduire de manière décisive les risques de rejet.
Il faut également souligner le cas, largement évoqué par les médias américains, d’un nourrisson, Garrett Peterson, né il y a 18 mois avec un problème de malformation cardiaque connue sous le nom de tétralogie de Fallot. Dans cette pathologie, le cœur ne possède pas de valve pulmonaire et de ce fait, l’enfant est incapable de respirer par ses propres moyens et doit être assisté dès sa naissance par des appareils respiratoires (Voir CNET).
En mai 2013, les parents de ce bébé ont appris qu’un autre nouveau-né âgé de quelques semaines et souffrant lui aussi de tétralogie de Fallot, avait été sauvé grâce à un dispositif imprimé en 3D. Ils ont alors pris contact avec les médecins qui avaient réalisé cet exploit au sein de l’Université du Michigan. Ceux-ci ont pu très rapidement concevoir et fabriquer sur mesure une attelle trachéale pour Garrett, en utilisant un bio-polymère appelé polycaprolactone.
Cette prothèse a alors été cousue sur les bronches du bébé en janvier 2014 et, depuis cette intervention, Garrett apprend progressivement à se passer de l’assistance respiratoire.
Autre exemple des potentialités de l’impression 3D en médecine et en chirurgie : il y a quelques semaines, un autre bébé de 14 mois, né avec quatre malformations congénitales du cœur, devait subir une lourde intervention qui risquait de mettre sa vie en danger au Kosair Children's Hospital de Louisville aux Etats-Unis (Voir University of Louisville).
Pour préparer dans les meilleures conditions cette opération très risquée, l’équipe soignante s’est alors tournée vers l'Université de Louisville qui possède un centre de compétences reconnu en matière d’impression 3D. Ce centre a réussi à fabriquer en une journée, à partir d'un simple scanner, une réplique très exacte du cœur de l'enfant. Le modèle ainsi obtenu a permis aux chirurgiens de visualiser précisément l'intérieur du cœur malade et de mettre au point une stratégie opératoire parfaitement efficace et comportant un minimum de risques pour le jeune patient. Celui-ci a finalement été opéré avec succès grâce à cette modélisation par impression 3D.
Il y a un peu plus d’un mois, le 12 mars, des chirurgiens anglais ont pour leur part utilisé pour la première fois l’impression 3D pour reconstruire le visage d'un de leurs patients, Stephen Powers, un jeune homme de 29 ans victime d’un terrible accident de la route il y a deux ans (Voir BBC).
Ce patient avait conservé depuis son accident d’importantes lésions au visage provoquées par ses multiples fractures de la mâchoire et du nez. Rapidement, les chirurgiens se sont aperçus qu’ils ne parviendraient pas à lui reconstruire correctement un visage en recourant uniquement aux techniques chirurgicales classiques. Ils ont alors décidé d’utiliser toutes les potentialités des nouvelles techniques d’impression 3D pour relever ce défi chirurgical hors norme.
L’équipe chirurgicale s’est appuyée sur des images obtenues par tomidensitométrie - une technique utilisant des rayons X pour visualiser les structures internes du corps - ce qui lui a permis de modéliser et d’imprimer un modèle 3D du crâne de Stephen Power tel qu'il se présentait avant son accident. Là aussi, ce modèle a constitué un guide irremplaçable pour simuler l’intervention très complexe de reconstruction faciale et crânienne du patient. L'impression 3D a également permis aux médecins de fabriquer plusieurs implants sur mesure, exactement adaptés à la morphologie de Stephen Power.
« Le recours à l'impression 3D permet de supprimer toute incertitude et améliore considérablement la précision du travail de reconstruction », souligne Adrian Sugar, l’un des chirurgiens ayant participé à l'opération. « Les résultats n’ont rien à voir avec ce que nous pouvions espérer obtenir avant l’utilisation de cette technique », ajoute-t-il.
Finalement, Stephen Powers a été opéré avec succès pendant huit heures en février 2014 et il est considéré comme le premier patient au monde à avoir bénéficié, à tous les stades de son intervention, des nouveaux outils de modélisation et d’impression 3D. Cette opération très médiatisée est à présent l’objet d’une exposition au Science Museum de Londres intitulée « le futur s’imprime en 3D ».
Ces derniers mois, une nouvelle étape était franchie par une équipe de chirurgiens néerlandais de l’Université d’Utrecht. Grâce à une imprimante 3D, ces médecins sont parvenus à fabriquer un crâne en plastique totalement identique à celui d’une patiente souffrant d’une grave maladie. Ils ont ensuite réussi à implanter cette prothèse crânienne sur mesure sur une jeune femme de 22 ans. C’est seulement trois mois après cette intervention exceptionnelle que les chirurgiens se sont décidés à révéler, le 29 mars dernier, qu’elle avait été un succès complet (Voir UMC Utrecht).
Atteinte d’une pathologie rare provoquant un épaississement progressif de son crâne vers l’intérieur qui risquait de détruire son cerveau, cette jeune patiente est la première au monde à vivre avec une boîte crânienne en plastique entièrement fabriquée par impression 3D.
Pour préparer cette intervention sans précédent, les chirurgiens ont exploité le relevé numérique complet du crâne de la patiente, obtenu par scanner, puis ont conçu un modèle informatique 3D de ce dernier. En coopération avec une firme australienne spécialisée dans l’impression 3D, cette équipe néerlandaise a réussi ensuite à fabriquer une copie en relief de ce crâne en plastique. Grâce à l’emploi de ces différentes techniques, les chirurgiens ont pu retirer la partie supérieure lésée de la boîte crânienne de la jeune femme et la remplacer par la copie préalablement obtenue par modélisation et impression 3D.
Aux dernières nouvelles, la patiente se porte bien et récupère progressivement ses fonctions cérébrales altérées par sa maladie. L’équipe néerlandaise ayant réalisé cette intervention précise que cette technologie devrait être étendue rapidement aux patients victimes de traumatismes crâniens mais également à certains malades souffrant de tumeurs cancéreuses nécessitant des interventions chirurgicales complexes suivies de reconstruction cellulaire des tissus.
Tel a été le cas récemment en Chine où des médecins de l'hôpital de Xiangya ont réalisé une modélisation 3D du crâne d’un patient atteint par une tumeur particulièrement mal placée dans le cerveau. Afin de pouvoir extraire en toute sécurité cette tumeur située à proximité du nerf optique de l’artère carotide, l’équipe du docteur Li Xuegen a préparé l’opération soigneusement en s’appuyant sur le modèle 3D de la tête du patient, incluant notamment les réseaux nerveux et vasculaires. Cette nouvelle technique opératoire devrait permettre à l’avenir de réaliser des interventions très délicates en diminuant sensiblement les risques pour le patient et en améliorant considérablement sa qualité de vie.
En France, une imprimante 3D a fait depuis peu son entrée dans le service de chirurgie maxillo-faciale de l’hôpital du Bocage, à Dijon et elle a déjà profondément bouleversé la préparation et l’exécution des interventions touchant la face. « Jusqu’à présent, les médecins se contentaient d’imaginer l’opération mentalement », précise le professeur Narcisse Zwetyenga, qui dirige un service spécialisé dans la reconstruction des structures osseuses du visage.
Désormais, grâce aux extraordinaires possibilités de cette imprimante 3D, les médecins et chirurgiens peuvent effectuer des modélisations extrêmement précises pour préparer les opérations les plus complexes du visage de la face. Concrètement, il suffit en général de sept à huit heures pour réaliser ces modèles 3D personnalisés du visage des patients devant subir une intervention. « La préparation et la simulation en trois dimensions de ces interventions souvent délicates rend ces dernières bien moins lourdes mais également moins longues et moins risquées pour le patient » ajoute le docteur Zwetyenga qui conclut en se disant convaincu que les prochaines générations d’imprimante 3D permettront non seulement l’impression de matériaux biocompatibles directement implantables, pouvant se substituer aux os et au cartilage mais pourront également « imprimer » des tissus humains et même, à plus long terme, des organes complets…
Si cette perspective relève encore aujourd’hui de la science-fiction, plusieurs équipes de recherches dans le monde y travaillent déjà activement. C’est le cas par exemple de l’équipe de Hod Lipson, chercheur à l’Université Cornell, aux États-Unis, qui travaille sur l’impression de ménisques à partir de cellules de mouton et espère pouvoir réaliser un ménisque humain complet par impression 3D d’ici 5 ans…
Le professeur Stuart Williams, biologiste cellulaire à l’Université de Louisville, Kentucky travaille lui sur un projet beaucoup plus ambitieux : la fabrication d’un cœur biocompatible qui serait composé de cellules provenant de l'organisme du patient.
L’idée de départ du professeur Williams est de parvenir à imprimer les différents constituants d’un cœur humain, de manière à pouvoir ensuite les assembler pour obtenir in fine un cœur parfaitement fonctionnel. Pour atteindre un tel objectif, cette équipe va devoir surmonter de nombreux obstacles mais aucun ne semble infranchissable pour ces chercheurs très enthousiastes. Dans ce projet, le matériau utilisé par l’imprimante 3D sera constitué d’un savant mélange de différents types de cellules et de gel. Ensuite, les différentes parties du cœur seront imprimées et les cellules vivantes se développeront alors ensemble pour constituer un tissu cardiaque fonctionnel.
Selon le professeur Williams, la principale difficulté de cet ambitieux projet réside dans le fonctionnement synchronisé des différents types de cellules assemblées artificiellement. Parmi les autres obstacles à surmonter, les chercheurs devront également parvenir à fournir assez d’oxygène à cette biostructure pour qu’elle puisse survivre jusqu’à la transplantation.
Le professeur Williams se veut résolument optimiste et se dit convaincu que les risques de rejet d’une telle transplantation seraient sensiblement moins grands que ceux rencontrés actuellement en utilisant les greffes d’organes ou les implantations de cœur artificiel. Il est vrai que ce cœur biocompatible sera conçu à partir des propres cellules du patient, ce qui devrait, en théorie, rendre inutile le recours aux médicaments immunosuppresseurs. Le professeur Williams espère être en mesure de réaliser les premiers essais cliniques sur l’animal de son cœur « imprimé », d’ici cinq ans, avant de passer à l’homme à l’horizon 2025. Les premiers patients qui pourraient bénéficier de cette technique révolutionnaire seraient par exemple ceux souffrant d’insuffisances cardiaques et incapables de supporter un cœur artificiel.
Mais en attendant le cœur réalisé par impression 3D, cette technique révolutionnaire ne cesse d’étonner et de permettre des avancées qui auraient été considérées comme inimaginables il y a seulement quelques années. Parmi les dernières en date, il faut citer l’impression du premier microtissu fonctionnel en janvier dernier, en l’occurrence un tissu proche du foie et qui produit de l’albumine, une protéine-clé qui intervient dans plusieurs fonctions physiologiques (Voir Organovo).
La France, on l’ignore trop souvent, est également pionnière dans ce domaine stratégique de l’impression 3D à finalité médicale, grâce notamment aux remarquables travaux de l’Inserm de Bordeaux en bio-ingénierie tissulaire. Cette équipe a développé dès 2005 une technologie originale de bio-impression, combinant haute résolution et haut débit, baptisée « Impression biologique assistée par laser (LABP) ». Ce laboratoire vient également de mettre au point la première bioimprimante 3D par laser au monde, capable d’imprimer jusqu’à cinq types cellulaires différents. Mais ces chercheurs, résolument tournés vers l’avenir, travaillent déjà sur des techniques qui permettront d'imprimer directement dans l'organisme afin de disposer de nouveaux outils thérapeutiques permettant une réparation tissulaire et cellulaire personnalisée, assistée par ordinateur.
On mesure mieux les enjeux scientifiques, économiques et industriels considérables de cette révolution technologique quand on sait que le marché mondial de l’ingénierie cellulaire, estimé aujourd’hui à 12 milliards d’euros, pourrait doubler pour atteindre 24 milliards d’euros en 2018, selon une étude de MedMarket Diligence.
Il est frappant de constater à quel point cette révolution technologique de la bio impression 3D repose sur de nouvelles approches transdisciplinaires associant très étroitement biologie, physique, chimie et informatique et nous devons tirer les enseignements de cette multidisciplinarité pour mettre en place des structures de recherche plus souples et plus réactives, associant beaucoup plus étroitement recherche fondamentale et appliquée mais également recherche publique et privée.
Il faut également souhaiter qu’en cette période de crise financière généralisée et de restrictions budgétaires, nos responsables politiques sachent faire preuve d’une vision à long terme et perçoivent l’immense intérêt de cette révolution scientifique et technique en cours. Il est en effet capital pour notre Pays de conforter son excellence dans ce domaine qui est déjà en train de révolutionner la médecine et la santé et va profondément transformer notre vie quotidienne avant la fin de cette décennie.
René TRÉGOUËT
Sénateur Honoraire
Fondateur du Groupe de Prospective du Sénat
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Sipped slowly in front of a blazing fire, it tastes just as good at the kitchen table where the pot and ladle sit nearby to furnish second helpings. An antidote to wicked winter weather, these soups can be made of single or multiple underground-growing vegetables, from carrots to sweet potatoes to celery root. They take on extra flavor with the addition of juices from tomato to grapefruit and dried spices from cayenne to curry. They can turn out homely or exotic. They eliminate the craving for tea or coffee, adding higher nutritional value and eliminating anxiety-inducing caffeine.The celebratory soup gets a holiday dinner off to a glittering start. Ladled from a beautiful tureen into shallow soup bowls or pretty teacups, the surfaces can be enhanced with a sprinkle of finely minced chives or citrus zest, or a scant teaspoonful of sour cream. Use an elegant vegetable, like artichoke hearts or avocado, in the starring role, although Yukon gold potatoes work, too.SOOTHING CREAM OF CARROT SOUP WITH GINGERMakes 6 servingsSwitch the carrot with sweet potato, the ginger with smoked paprika, or substitute orange juice for the cup milk for a whole new soup. Keep seasonings spicy for extra warmth.2 tablespoons unsalted butter 1 medium onion, coarsely chopped1-1/2 pounds carrots, peeled and coarsely chopped3 tablespoons chopped fresh ginger6 cups chicken stock1 cup whole milk1 cup half-and-half salt, freshly ground black pepper, to tasteIn a pot, melt butter over low heat. Add onions, and cooking, stirring, until tender, about 15 minutes. Raise the heat to medium-low, then add the carrots and ginger; cook, stirring, until carrots are falling apart soft, about 20 minutes.Add chicken stock to the pot. Bring just to a boil, then lower to a simmer, stirring from time to time, about 20 minutes. Remove soup from the heat. 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