Chabot

Innovations in GI/Endocrine Surgery

by Columbia Surgery on June 7, 2014

Surgeons expand the use of the surgical robot to benefit patients undergoing complex pancreatic and gastric operations.

Yanghee Woo, MD

Yanghee Woo, MD

Readers may have heard about surgical robots, which surgeons are using in increasing numbers across the country. At NewYork-Presbyterian/ Columbia, surgeons now use the surgical robot to perform gynecologic, urologic, colorectal, and a number of abdominal procedures. According to Yanghee Woo, MD, Assistant Professor of Clinical Surgery and Director, Global Center of Excellence in Gastric Cancer Care, it provides “phenomenal advantages” during operations to remove abdom­inal cancers, allowing surgeons to perform highly precise dissections, to retrieve lymph nodes without blood loss, and promoting faster recovery. She now performs almost all gastric (stomach) cancer operations with the surgical robot.

Based on Dr. Woo’s extensive training and clinical experience with the surgical robot, as well as careful observation of published data, the Division of Gastrointestinal (GI)/Endocrine surgery is now expanding its use of the robot to a broader range of pancreatic and abdominal operations. Together with John A. Chabot, MD, FACS, Chief, Division of GI/Endocrine Surgery and Executive Director, Pancreas Center, Dr. Woo performed the first robotic Whipple procedures at NYP/Columbia this year.

Methodical approach to adopting new technology

Dr. Chabot explains how the Division of GI/Endocrine Surgery has approached the prospect of incorporating the surgical robot into its toolbox.

“We have taken a very methodical approach in evaluating the surgical robot’s benefits in gastrointestinal and endocrine operations,” says Dr. Chabot. “Dr. Woo gained extensive experience during training with the world’s foremost experts in Korea. Following this, other surgeons in our division went through extensive, rigorous training. Once we had a well-trained team assembled, we then began choosing our cases very carefully in order to use the new technology in the safest way possible.” During this process of training and evaluation, some surgeons determined that using the robot did not offer sufficient benefits. James A. Lee, MD, Chief, Endocrine Surgery, found that it did not improve upon other methods of performing thyroid surgery. Dr. Woo found that using the robot to remove the gallbladder through a single incision was possible, but not worth the larger incision it required, especially to perform a surgery that is already so highly successful and low in risk. “There is no proven benefit in this instance, and the cost is significantly higher,” she says.

Benefits for complex abdominal surgery

However, the team has found the robot to be of great benefit for other types of procedures, including many colorectal, liver, and gastric operations. During complex operations, the robot is equipped with four arms that are inserted through small ports into the patient’s abdomen. The arm with surgical instrumentation is wristed, meaning that it can articulate in all directions. Another arm is equipped with three-dimensional, magnified camera technology that provides far better visualization than the two-dimensional visualization that is available during laparoscopic surgery. “These advances give us far more freedom of movement as well as precision” explains Dr. Chabot. Dr. Woo says that because of these capabilities, she is confident that she is able to do complex gastric operations better with the robot than without, even though studies have not yet confirmed her experience.

Initially, the GI/Endocrine division has used the surgical robot in patients with less advanced cancers or premalignant conditions. Patients could not have had any previous upper abdominal surgery, and their tumors could not be attached to major blood vessels that would require blood vessel reconstruction.

Although studies have not yet directly compared robotic and traditional abdominal operations, Dr. Chabot and Dr. Woo believe that the robot offers important advantages to patients by reducing surgical trauma overall. “We are seeing patients have shorter hospital stays and shorter recovery time overall. For patients with pancreatic cancer, one of the most important aspects is that this quicker recovery may allow them to start chemotherapy sooner than they otherwise would.”

On the horizon: improved visualization and surgical outcomes

“We have developed confidence in ourselves to do more advanced cases,” says Dr. Chabot. “Our primary goal has been to maintain safety by being prudent with this new technology.” With that foundation, the team anticipates that the surgical robot will facilitate important innovations in pancreatic surgery, particularly as it allows new forms of surgical visualization. New technologies under development include the use of various wavelengths of light and injected substances that allow surgeons to better detect the boundaries of tumors or to find disease that is not visible using natural light. These innovations may allow surgeons to perform cancer operations more effectively in the future, but they­ will require laparoscopic or robotic access. “The new tools coming down the line won’t be available through traditional incisions,” explains Dr. Chabot.

To learn more about pancreatic and GI/endocrine surgery, visit pancreasmd.org

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Offering long-term survival for patients with cancers of the abdominal lining

Diagnosis of cancer that has spread to the abdominal wall lining (peritoneum) is typically considered a lethal diagnosis. But at NewYork-Presbyterian/Columbia University Medical Center, many patients with these advanced cancers can expect long-term survival, thanks to refined surgical approaches and intra-abdominal chemotherapy.

Michael D. Kluger, MD, MPH

Michael D. Kluger, MD, MPH

According to Michael Kluger, MD, MPH, Assistant Professor of Surgery, abdominal mesothelioma, colorectal cancer, appendiceal cancer, and ovarian cancer commonly spread from their primary sites to the wall of the abdomen. When they spread, they line the wall of the abdomen with tumor deposits, which cause scarring, inflammation, obstruction of the intestines, and eventually death. Because these cancers typically do not spread outside the abdomen, it is possible to remove the visible tumor deposits (called cytoreduction surgery) and apply chemotherapy to treat any remaining microscopic disease. Research shows that intraperitoneal chemotherapy is highly effective under these circumstances, whereas chemotherapy given through the veins is less effective.

Columbia is one of a few programs in the nation highly experienced in performing complex, extensive cytoreduction surgeries. After removing the visible tumors, the surgeons insert ports for administering chemotherapy, close the abdomen, and infuse a single dose of heated intraperitoneal chemotherapy (HIPEC). After this, the operation is completed.

Without treatment, most patients face a life expectancy of about six months. After cytoreduction surgery and HIPEC, research shows a significant improvement in survival: 40% survival at five years for patients whose cancer spread from the colon; ten years average survival for patients with mucinous appendiceal cancer; and median survival of over 60 months for mesothelioma and ovarian cancer. Systemic chemotherapy is often administered after the operation. “If we decrease the overall burden of disease by removing all visible cancer and the primary lesions, systematic chemotherapy is potentially more effective,” says Dr. Kluger.

Success with this approach largely depends on the experience of the surgeon and program, cautions Dr. Kluger. “With the advent of inexpensive heated intraperitoneal chemotherapy pumps, more centers are beginning to treat patients with peritoneal cancers despite having little, if any, experience. A lot of judgments have to be made during these operations. Removing too much tissue can cause too high a risk of complications. In some cases an operation must be terminated. In other cases, we may have to remove one or more internal organs, and patients have to trust us to make the appropriate decisions during the operation. This is where experience comes into play.”

NYP/Columbia’s mesothelioma program, open since the 1990s, performs more surgeries for peritoneal mesothelioma than any other center in the United States. The outstanding reputation of this program draws patients from all over North America, including many who have been told they could not be treated.

When performing gastrointestinal surgeries, Dr. Kluger collaborates with John Chabot, MD, FACS, Chief of the Division of GI/Endocrine Surgery and Executive Director of the Pancreas Center (and the surgeon who introduced these operative techniques to NYP/Columbia), as well as Robert Taub, MD, PhD, Director of the Mesothelioma Center. For patients with ovarian cancer, Dr. Kluger assists Jason Wright, MD, Levine Family Assistant Professor of Women’s Health (in Obstetrics and Gynecology) and a specialist in gynecologic oncology. Colorectal Division Chief P. Ravi Kiran, MBBS and Steven Lee-Kong, MD, Assistant Professor of Clinical Surgery, provide expertise in cases of colorectal cancer. “Surgeons have to have a lot of comfort working in the abdomen to perform these operations, and our training and collaboration allows that,” says Dr. Kluger.

Not only does the center offer a multidisciplinary team with 20 years of surgical experience, but it also leads in research. Drs. Chabot and Kluger have been following the long-term outcomes of patients with peritoneal mesothelioma. Dr. Taub is conducting research on the penetration of various chemotherapy agents into the abdominal wall. Dr. Lewin is researching novel therapies for ovarian cancer including HIPEC, and Dr. Wright is Principal Investigator of numerous clinical trials in gynecologic cancers.

Dr. Kluger and his colleagues are available to discuss potential referrals by phone or to evaluate any patient who may be a surgical candidate. Full evaluations are performed to rule out distant metastases (spread of cancer to distant organs) and to ensure that patients are strong enough to withstand the effects of major surgery.

To learn more about these and other surgical advances at NYP/Columbia’s Department of Surgery, visit columbiasurgery.org

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