Analysis: the rapid development of new technology is helping with critical
decisions in colorectal cancer surgery
By
<https://www.ucd.ie/medicine/ourcommunity/ourstaff/featuredstaff/professorro
nancahill> Ronan Cahill, <https://www.ucd.ie/> UCD
Think for a minute that you are a patient needing cancer surgery and that
you're lying on the operating table just before your anaesthesia. Of course,
you want it over as quickly as possible. You want it to be as complete as
needed for cure. You also want no more than the cancer alone to be excised
so the least impairment results.
Surgeons have long balanced these contradictory requirements. Asking has he
or she done the operation before is a good question, but the issue in the
surgeon's mind is that it's the first time you, the patient, are having this
surgery. Predictions of the future for any individual is really difficult as
we can only apply probabilities from other peoples' experiences.
Every operation is made up of a series of small components. Both removing a
cancer and then reconstructing the remaining tissues comprises many little
steps. For everything to go well, each part needs to go well which is why
surgeons continually check and confirm correctness of every step serially.
This is usually done by subjective measures, best judgement, at a time when
there is a lot to consider and the clues are very subtle.
We've been working to develop technology to help with such critical
decisions in surgery and are already seeing its benefits across the world.
It's also going to get much better soon. In the future, this can involve
smart robots and automation. Current robots such as the
<https://www.intuitive.com/en-us/products-and-services/da-vinci/systems> Da
Vinci system right now do nothing to help with visual, cognitive or
biophysical interpretations. At present, we are using much simpler, less
costly technology to provide decision-support for patients undergoing
surgery for <https://en.wikipedia.org/wiki/Colorectal_cancer> colorectal
cancer within the time-frame that's needed in surgery, that is within
moments.
Colorectal cancer is important as it's a common disease that affects about
2,000 people of both genders in Ireland each year. It's second only to
<https://www.cancer.ie/cancer-information-and-support/cancer-types/breast-ca
ncer> breast cancer in women and
<https://www.cancer.ie/cancer-information-and-support/cancer-types/prostate-
cancer> prostate cancer in men in incidence and to
<https://www.cancer.ie/cancer-information-and-support/cancer-types/lung-canc
er> lung cancer in mortality. Surgery is the best chance of cure, but it has
some dangers. Any imperfection in intestinal healing after operation risks
big consequences including <https://en.wikipedia.org/wiki/Sepsis> sepsis,
<https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/septi
caemia> septicaemia and <https://www.nhs.uk/conditions/peritonitis/>
peritonitis as the bowel spills its bacteria. Misery as well as organ
failure and even death can result and sometimes a bag (
<https://www.nhs.uk/conditions/colostomy/> 'stoma') is needed to reduce or
treat these risks. Sadly, these problems happen even in the best of centres.
Most elective colorectal surgery is done now with keyhole or laparoscopic
instruments through small (circa 1 cm) incisions. One of these instruments
is a camera connected to a computer that allows digital recreation and
display of the internal view for all the operating team to see. These images
guide their actions and allow decisions to be made. Although it's been
around since the 1980s, we've been working hard to really bring this type of
surgery into the 21st century by ensuring it is advanced and adapted to help
perfect decision-making during surgery everywhere it is done.
Colorectal cancer is important as it affects about 2,000 people in Ireland
each year
The first thing we've discovered is that using a broader range of light from
the camera then just 'white-light' helps a lot. By extending the light's
range into the infra-red zone (i.e. just slightly beyond the violet stripe
of a rainbow), we can safely see some millimetres into human tissue rather
than just reflecting the surface. By also administering via a drip a safe
dye that is turned fluorescent by this energy, dynamic blood supply or lymph
flow and nodes can be revealed in real-time. This can help ensure conditions
in the tissue are as good as possible before attempting to join parts of the
bowel back together taking some of the subjectiveness out of it. This is
only possible by the computerized camera being primed to detect the energy
which is otherwise invisible to the human eye.
Although the basic concepts are quite old, their application in this surgery
is new and greatly helped by innovations in optical instrumentation. The dye
is really affordable and people rarely have any sort of reaction to it,
making it much safer than many other drugs in use. What we've seen with this
simple technology is that even experts can have their judgment helped as
often as in one in every 20 operations. This seems to be particularly the
case with patients who would otherwise suffer the most terrible
complications. While we are doing an international randomised control trial
to definitely prove it, this potentially is the largest increase in safety
in this type of surgery that we've seen in recent times.
Our better understanding of surgery that has come from this work has further
meant that we have begun to apply this concept to identification of cancer
tissue during surgery. For the first time, we are able to visually exploit
during surgery the fact that cancers possess "angiogenesis" as a hallmark
feature (meaning their blood supply is different to healthy tissue) to
better personalise the operation.
The patient can have their surgery with all the benefits of the experience
continually contributed by surgeons everywhere, to make things better again
for each person
This should soon allow surgeons understand better the degree of disease
present, even more accurately than that detected by preoperative scans and
the unassisted human eye during surgery. By enabling human-machine
synergistic collaboration for optimum decision-making, the surgeon can soon
be supported by the best of data-analytics available for each case. The
patient can have their surgery with all the benefits of the experience
continually contributed by surgeons everywhere to make things better again
for each person.
To make this a reality, we are working with smart people in every sector.
This includes expert surgeons in the <http://mater.ie/> Mater Hospital,
leading engineers in <http://ucd.ie/> UCD, talented computer programmers,
mathematicians and artificial intelligence specialists in
<https://www.research.ibm.com/> IBM Research, innovative digital pathology
developers in <https://www.deciphex.com/> Deciphex and major surgical
camera manufacturers like <https://www.stryker.com/> Stryker Corporation.
We are working with fantastic applied chemists in the <http://rcsi.com/>
RCSI who can make smarter, more sensitive dyes along. Our network of
international surgeons can ensure systems are as good as possible, as safe
as possible and that all important details are secure and citizen rights
regarding data management are assured. This has all been enabled by the
Irish government via <https://www.enterprise-ireland.com/en/> Enterprise
Ireland through its
<https://dbei.gov.ie/en/What-We-Do/Innovation-Research-Development/Disruptiv
e-Technologies-Innovation-Fund> Disruptive Technologies Innovation Fund.
Right now, we've a great tool in use for major cancer operations - and its
going to get even better soon.
<https://www.ucd.ie/medicine/ourcommunity/ourstaff/featuredstaff/professorro
nancahill> Prof Ronan Cahill is Consultant Colorectal Surgeon at
<http://mater.ie/> Mater Misericordiae University Hospital and Professor at
the <https://www.ucd.ie/medicine/precision%20surgery/> UCD Centre for
Precision Surgery at the <https://www.ucd.ie/medicine/> School of Medicine
at <http://ucd.ie/> UCD.
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