Minimally Invasive Surgical Approaches

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic, overseeing our Taussig Phase I and Sarcoma Programs. Today, I'm happy to be joined by Dr. Conor Delaney, President and CEO of the Cleveland Clinic Florida region. He's talked to me today about minimally invasive surgery approaches and recovery from surgery. Welcome Conor.

Conor Delaney, MD, PhD: Dale, thanks very much for having me along. Appreciate the opportunity.

Dale Shepard, MD, PhD: Absolutely. Maybe just to start, you can briefly let us know what's your role here at Cleveland Clinic?

Conor Delaney, MD, PhD: My role has transitioned recently in that I've just taken over as CEO and president for Cleveland Clinic Florida region, which encompasses our hospital at Weston, but also four new hospitals up the East Coast at Martin Health and Indian River and we're going to be expanding further throughout the state over time. And obviously that's a full service region, including cancer surgery and cancer treatment throughout the region.

I've just come out of a role for the last five years as chair of our Digestive Disease and Surgery Institute, which has been an incredible experience with our team. And obviously we've collaborated very closely with Taussig Cancer Institute because so many cancers come to be treated with medical or radiation therapy through initial surgery or surgery during the course of treatment. And obviously what we aspire to here at the clinic is to provide the best patient experience and to provide the best place to be treated for patients. And so my background coming into this is really as a colorectal surgeon. I've been a colorectal surgeon for 25 years and have a practice of complex colorectal cancer and re-operative but also minimally invasive surgery for colorectal cancer and inflammatory bowel disease.

Dale Shepard, MD, PhD: I guess maybe just to start, let's just kind of define what is considered minimally invasive surgery.

Conor Delaney, MD, PhD: Yeah, so minimally invasive surgery started really probably in the around 1990, early nineties. And it started initially we started really just doing it for a gallbladder surgery and instead of making a six or eight inch incision under the ribs, we could do it with a couple little ports. And around the time I came into practice, we were just finishing a thing called the COST trial, which was a randomized controlled trial of a laparoscopy against open surgery for colon cancer. Because back at the turn of the millennium, we didn't know it was safe and there were all these worries that we mightn't do as adequate a cancer operation. And so we finished that and were able to prove in a very scientific way that minimally invasive surgery is just as good for all of the oncological outcomes. And of course the additional benefit is that you get a lot of the short term improvements and recovery from surgery and reduction in other complications.

We now know from robust studies and meta analysis that we do these operations using a couple of five millimeter incisions for instruments and a three to five centimeter incision to take the specimen out, instead of a 20 or 30 centimeter incision that we're doing at least as good a cancer operation and giving the patient a quicker and safer and lower complication recovery from surgery.

Dale Shepard, MD, PhD: Wow, those are all great benefits, but in terms of the number of patients who sort of get benefit from this, when we think about traditional open surgeries and minimally invasive, what percentage of patients do you think now get minimally invasive surgeries?

Conor Delaney, MD, PhD: It's a little bit different depending on diagnosis. And at the end of the day, it comes down to the individual patient and I'll talk about that. But in our practice, it's probably, 80, maybe even 90% or more of the primary cancers. We get sent a lot of patients with complications or with disease that's involving other organs and some of that we can do minimally invasively, but most things we would approach and it's always a decision of let's do it minimally invasively, unless there's a specific reason not to. Almost everybody gets assessed for it, unless they're very, very obese or they've had very major or multiple prior abdominal operations. Pretty much everything else we can do minimally invasively now.

Dale Shepard, MD, PhD: And are there any particular cancers that are less likely to benefit from minimally invasive surgeries? You said it varies across cancers, which makes sense. Are there some that we need to make more progress or there's more or less benefit?

Conor Delaney, MD, PhD: Yeah, actually it's not that way. It looks like, when you put all of the literature over a couple of decades together now, it looks like the benefits are actually fairly robust across all types of cancer and all types of operation. And those benefits are less pain for patients, less scarring for patients, fewer wound infections, fewer postoperative complications and getting back to normal health earlier and getting back home earlier. And they're all fairly robust. It more comes down to the technical side of it.

If you think of colon cancer now, there are very few colon cancers that we can't do minimally invasively. When you think of rectal cancer, it's a little more complicated. When we're operating on the rectum, obviously the rectum is in the pelvis and the pelvis particularly in a tall, heavy male is a fairly narrow cone that we operate within. And if you've got a big bulky rectal tumor, they can be technically more complicated to do, but we still approach most of them laparoscopically. And then there's other cancers like liver cancer. There aren't many surgeons nationally who do laparoscopic or minimally invasive liver cancers. We have a team here who do it and specialize in it and it takes a little bit of extra training and technique and understanding of the anatomy. But then again, once you can do it, the patient gets all of those benefits perioperatively.

Dale Shepard, MD, PhD: What's the biggest driver, for physicians that are listening, they may be considering who should do their patient's surgery, what should they be looking for? Is it just volume? Is it other support that's available? What would drive a community surgery versus more of an academic setting?

Conor Delaney, MD, PhD: Right. well you tick many of the important boxes and the one I would add to that is kind of process. Volume's important. There are very few people who are doing a couple of cancers a year or a couple of cancers a month even, or particularly for colon, I'm thinking of my specialty. A couple of colon operations a month that are going to be as practiced as somebody who's doing several a week. Volume helps, but it's not everything. There are certainly good people who are only doing a few cases, but that's important.

It's the ancillary services, one of the wonderful things, as you know here at the clinic is that we've got such a great multi-disciplinary team. And I think nowhere is that more important than around cancer. We've got medical oncology and radiation oncology and radiology and et cetera and what have you as a team and all of the social support and everything that we can bring to every patient. And that's really critical. And then along with that, is some of the process and structure. Things like tumor boards and multidisciplinary conferences and it becomes even more important in the colorectal space for rectal cancer, because so frequently now we'll give neoadjuvant therapy and that becomes a team or a group discussion. It's very highly individualized and tailored towards anatomy and tumor specific findings and the continence of a patient so we don't do an operation that's technically great and leave the patient incontinent, but there are all those factors. It's process, it's structure and perhaps at the end of the day, most important it's experience.

And fortunately or unfortunately, one of the great and yet challenging things about surgery is that we can do an awful lot to help a patient in a very short period of time and often cure them and sometimes not even need you guys, but if it's not done well, the patient, they can be a disaster with complications and bad outcomes. It's a critically important part of the decision making process is to make sure the patient is going to the right team.

Dale Shepard, MD, PhD: We're perfectly fine if they don't have to see us on the med onc side.

Conor Delaney, MD, PhD: There you go.

Dale Shepard, MD, PhD: I guess just to fine tune that a little bit, I guess the question is, are there patients that in particular that stand out, that you think that really should get that second opinion here? You mentioned rectal cancers. That sounds like maybe one that if there's a consideration, but are there people that really should come here?

Conor Delaney, MD, PhD: Yeah, I think there are, there's a couple of highlights in the colorectal space, particularly. For colon cancer, sure we've got people who are doing an awful lot of it, but particularly the ones that are more locally invasive and locally advanced and if they're preoperatively imaged either have metastatic disease or a nodal burden, because they'll need a much more careful operation for the lymph nodes. And then if they have metastatic disease, we'll also be able to do a synchronous operation and save the patient a surgery.

For rectal cancer, arguably most or all of them, actually, it's pretty scary. If you look at national data, most of the hospitals in the country that do rectal cancer, do fewer than 10 and many fewer than five cases a year. And again, when you think of the variations in how these cancers can present and the difference between two centimeters from an anal sphincter versus 10 centimeters from an anal sphincter, doing just a handful of those cases a year is really problematic. Rectal cancer, yeah, I would argue pretty much anything.

And then there's fairly nuanced things that we end up seeing a lot of that are very important. One would be familiar conditions like familial polyposis because the way we manage those cancers, whether they're colon or rectal are often very different. And they're based on algorithms based on genetics and family history. And we'll sometimes be taking out the colon and the rectum and doing an ilial or small bowel pouch to help the patient stay continent.

And then the other big area is these locally advanced rectal cancers and also recurrent rectal cancers. In the best of hands, recurrence of rectal cancer should be around 3% in the pelvis. A lot of places, it wouldn't be that and so we do get to see a lot of recurrent rectal cancer, but they're significantly more complex to manage and they will require the same multidisciplinary care, imaging, radiation, but sometimes more that will often involve plastics. We'll be doing flaps for reconstruction, urology we may be taking out bladder as well with an exenteration and sometimes even part of the sacrum or sometimes part of a blood vessel. And so we've got very significant multidisciplinary teams for these, either most advanced tumors or recurrent tumors.

Dale Shepard, MD, PhD: Are there any particular clinical trials we're working on right now to help further the field in minimally invasive surgery?

Conor Delaney, MD, PhD: The techniques now we have down pretty well. We developed them and contributed to developing them close to 20 years ago now. We understand what we need to do and the anatomy of these operations is very well understood. The two probably areas that we're looking at most are technology. And so whether that's trials of whether we're seeing, if robotics helps, so we've got a robotics program or we're evaluating that versus laparoscopy, whether there are certain cases that that can be done better that way it's not clear yet, but it's something we do. And it's part of our evaluation. And then particularly the perioperative recovery.

Again, it's almost 20 years now since we started working on how we enhance recovery after surgery. It used to be that somebody would come in and have an operation for any colorectal condition or any abdominal condition and you'd get a nasogastric tube and you'd lie in bed for a few days. Until your bowel function recovered, you weren't given anything to eat or drink and you'd lose a lot of muscle strength and go home a week or 10 days later. Now we have changed all of that and so we do continuous studies to improve how we look after these patients after surgery. Now we know it's safe to feed them immediately after surgery, we can use special nerve blocks to get them off opioids. We'll have a lot of people actually go home the day after a major colon resection, and they're taking Tylenol only, nothing else.

And so those studies are continuing around how we improve the safety in perioperative recovery. And then we have a number of other studies going on around a wound infection for open cases, because we almost never see it with laparoscopy and other things. But the biggest groups are seeing to still prove if we can improve the techniques that are already working well and improve the perioperative care.

Dale Shepard, MD, PhD: And what do you think has driven the most progress in that perioperative care? Is it again, back to the available support? Is it really more the techniques like the nerve blocks or things? What do you think has been the primary driver for that?

Conor Delaney, MD, PhD: Yeah. Great question. It's a few different things. It's a little bit of the preoperative optimization. It's a little bit of standardizing what happens during surgery. It's a little bit of minimizing blood loss. If I'll do a laparoscopic colorectal resection, usually the patients will lose less than 20 mils of blood. It's particularly the postoperative order sets. We get them up walking sometimes the afternoon of surgery, certainly the next day. And what that means is they don't lose that muscle strength by lying in bed for five days. And we actually feed them early. We let them drink, we let them eat so they get the nutrition and protein and they guess get less catabolic. We give them exercises to breathe so they don't get pneumonias. And then particularly important, we give them multimodal analgesia. Meaning, it's not just giving somebody a morphine PCA, but we're giving them a cocktail of a local anesthetic nerve block, acetaminophen, nonsteroidal, sometimes nerve blockers like gabapentin and then we really tend to keep opioids for breakthrough pain. And so all of those different things have come together just to transform how patients recover after surgery.

Dale Shepard, MD, PhD: One of the words you used was standardization. Here at the clinic, we have these care paths that sort of lay out standard practices in many, many areas. Is that care path process really what has driven standardization? And what does that look like if that's the case in terms of getting everyone to agree to do the same things?

Conor Delaney, MD, PhD: Well, I guess when I think of care paths, I think of them in kind of two areas, there's the kind of care path for diagnosis and treatment of cancer that we have, which we'll break out by stage and that soup to nuts of diagnosis to multimodal assessment, like we talked about with a team and then deciding on the right surgery and oncologic support, et cetera and radiation, if it's needed. There's kind of that care path, this care path is a much smaller circle within that Venn diagram. And it's the kind of perioperative care path. And absolutely, we initially wrote these pathways back in the year 2000 and they honestly haven't changed a whole lot. We've tweaked them year by year and every now and again, we've done a study that's had to change like the nerve block studies, for example, but they've been around for two decades now and they're arguably they're standard of care.

And absolutely it's done by consensus and evidence and communication among teams. And when I talk about teams, I mean more than just the surgeon coming in and writing an order, this is nursing, this is physical therapy. This is including the patient as a key part of that team. I'll give you an example how important it is to include the patient, obviously, for very many reasons, but if you've got somebody who's well read and they think the average stay after surgery is about seven and a half days and you come into the day after surgery and say, "Okay, you're ready to go home." That's not going to work very well. But if you're talking to the preop and they say, "Look, 30, 35% of people go home the first day after surgery and another 35% go home the second day and this is the home support you'll need. And this is what you'll have and this is the chance of percent complications," and the really informed, they become a really important part of the team and decision making and honestly, they end up driving a lot of it themselves.

Dale Shepard, MD, PhD: That's great. Getting expectations is huge.

Conor Delaney, MD, PhD: Always in life.

Dale Shepard, MD, PhD: Yeah, no, absolutely. What do you think is going to be the next big break? Where are we looking? What's going to be the biggest thing in terms of impact for patients?

Conor Delaney, MD, PhD: I think the surgical techniques will continue to refine and that's probably going to be gradual. I think the biggest transformative thing is the work we're doing and studies we're doing around non-operative surgery for rectal cancer. Obviously that's well understood with the Nigro protocol for anal cancer that many people will get a complete response and not need surgery. But it's been much more hotly debated or contested for rectal cancer, but we now have an increasing evidence base that this is safe for a select percentage of patients. And so I think that's probably the biggest transformative thing. We have protocols to decide who's appropriate to evaluate for that. We'll give people radiation and chemotherapy upfront, which I think is a good transition. That means more of them complete their chemotherapy for obviously appropriate cases. And then we find that some of these patients get a complete response. We have protocols to watch them very carefully. I think that's probably for the colorectal cancer space, that's probably the most transformative change for how patients do.

Dale Shepard, MD, PhD: Well Conor, I appreciate all of your insights today, as you've been very helpful in terms of bringing us kind of up to speed with where things are and where things can be. Any additional comments?

Conor Delaney, MD, PhD: No, I just thank you for the opportunity. I think you add that to, the one group I forgot to mention that's obviously a critical part of the teams, are our genetic teams. And I guess I alluded to a familial polyposis and the familial cancers, but they're another critical part. And so obviously that's really important as we go forward, both based on diagnosis of younger patients and management of the genetics and deciding what to do and what to do with their families, but then also particularly for these familial cancers.

We have the Weiss Center as where we see an awful lot of these familiar cancers from around the country and around the world, indeed. And that's the other transformative part of management that many of these patients can be managed with either an operation that removes colon and rectum and gives them an internal ilial or J-pouch with or without a temporary stoma. But for selected patients that we don't necessarily need to take out all of the colon or rectum, but it's based on very standardized pathways that we've a lot of experience in. I think that's another transformative part of care that needs an experienced team.

Dale Shepard, MD, PhD: Well, thank you very much for being with us today.

Conor Delaney, MD, PhD: Great pleasure, Dale. Thank you again for asking me.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud or wherever you listen to podcasts. And don't forget you can access real time updates from Cleveland Clinic's cancer center experts on our Consult QD website, at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.