liver

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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As patients demand greater access to interventional and minimally invasive digestive care treatments, clinicians must be knowledgeable on the newest technologies and innovations. These are the market forces of healthcare at work. – Dr. Michel Kahaleh.

NewYork-Presbyterian, Columbia University College of Physicians and Surgeons, and Weill Cornell Medical College are pleased to extend an invitation to the Third Annual Peter D. Stevens Course on Innovations in Digestive Care accredited course to be held on April 10th and April 11th in New York City. The Co-Directors, Dr. Frank G. Gress, Dr. Michel Kahaleh, Dr. Amrita Sethi, and Dr. Robbyn Sockolow, recently met to discuss the rational behind this year’s program. What follows is a summarized transcript of their conversation.

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Question: What is the history behind the Third Annual Peter D. Stevens Course on Innovations in Digestive Care?

Answer: The course is a tribute to Dr. Peter D. Stevens, a beloved leader in the field of digestive care. Dr. Stevens was a faculty member of the GI Division of NYP/Columbia University Medical Center who died three years ago.

Q: How is the Digestive Care course structured?

A: The course is divided into three-hour sessions covering the esophagus, pancreas, GI lumen, colon & rectum, and the hepatobiliary system. The sessions are held at separate times so participants can attend all five. The course is taught through didactic sessions, hands-on animal tissue labs, and live cases sessions.

Q: What is the advantage to having a course on the entire digestive system?

A: Gastroenterological clinicians treat and diagnose all parts of the digestive system. Patients will at times present with more than one gastrointestinal condition. Since the technologies and procedures used to treat these are similar, it only makes sense to combine these topics into one program.

Q: What is the value of live cases sessions?

A: Unforeseen complications or challenges can occur during a live case and attendees can see how experts in the field manage these. This wouldn’t happen during a lecture or a prepared demonstration.

Q: How are the live cases sessions organized?

A: The live cases aren’t always known ahead of time. The hospital would never delay the care of a patient for the sake of a course. But being a tertiary care institution, NYP/Columbia is presented with complex cases daily. This provides for interesting learning experiences that would not be available elsewhere.

Q: Where will the course be held?

A: This year, the course will on the NewYork-Presbyterian/Columbia University Medical Center campus in northern Manhattan. NYP/Columbia is fortunate to have a start-of-the-art endoscopic lab and a brand new endoscopic suite. Attending clinicians can learn how to use equipment that may not be available in their offices or centers.

An example would be the new SpyGlass Direct Visualization System used for cholangioscopy. This is a 6,000 megapixel fiber optic cable used to image the bile and pancreatic ducts. When using this scope, physicians have better views of the diseased areas, can more accurately diagnose and in some cases intervene in one procedure.

Another exciting technology for presentation will be Confocal Laser Endomicroscopy (CLE). CLE allows for the viewing of cells in the body as if they were under a microscope. Cancers can be seen at earlier stages without the need for a biopsy.

Q: What will be covered in this year’s presentations and cases?

A: Dr. Sethi is presenting on “Endoscopic Innovations in Bariatric Surgery.” This will include endoscopic methods to treat complications arising from bariatric surgeries, as well as primary endoscopic procedures for weight loss.

Endoscopic Submucosal Dissection (ESD) will be discussed and might be part of a live case. Used mostly in the bowel, ESD allows for the removal of submucosal tissue down to the muscle level by a needle knife. This is state of the art care in Asia but new to the United States. As a minimally invasive procedure, patients can avoid the risks of open surgery.

Dr. Kahaleh will discuss and demonstrate Peroral Endoscopic Myotomy (POEM). In the past, many achalasia patients were treated with balloon dilation or open surgical procedures. POEM treats achalasia by making an incision in the muscles and the lower sphincter of the esophagus. This allows the muscle to relax and opens the lumen.

Q: What else would be important to know about this year’s course?

An important part of this year’s course is the large number of medical industry supporters. To prevent any conflicts of interest, every GI related company was invited to participate. Attending physicians can see and use all digestive care device technologies on the market.

For more information about the Third Annual Peter D. Stevens Course on Innovations in Digestive Care contact Jessica Scully at 212-304-7817 or at jas2134@cumc.columbia.edu.

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