Greg Marchand, MD, a gynecologic surgeon at Marchand OBGYN in Mesa, Arizona talks about his recent world record, his new technique for “in-bag” morcellation and what these advancements mean for the treatment of malignant tumors.
Interview conducted by Ivanhoe Broadcast News in May 2017.
Tell me about this procedure that you pioneered, the “in bag” morcellation?
Dr. Marchand: Well after doing hundreds of cases laparoscopically, taking out tumors that I thought were benign; I realized I had to develop a technique to treat even larger tumors. After about 2014 the FDA put out that block box warning basically saying that morcellators weren’t very safe unless it was done in a contained environment. So I developed an “in-bag” morcellation technique that I would use on these large tumors. Trying to be a responsible surgeon, the options were either to develop an “in bag” morcellation technique where I could contain all the parts of the tumor or to cut the patient wide open; and I really thought that it wasn’t the best thing for my patients to cut them wide open. Over the course of doing hundreds of cases laparoscopically, I developed this technique that’s a little different than other “in bag” morcellation techniques. My technique relies on bringing the mass up to the instruments as opposed to going after it with the instruments. My technique also uses just blunt instrument to make sure you don’t rupture the bag in any way.
Therefore, morcellation would be cutting up the tumor inside the body and pulling it out?
Dr. Marchand: Right.
Is the “in bag” morcellation the part of the technique you pioneered?
Dr. Marchand: Yes. I pioneered a special “in bag” morcellation technique that can be used on very large masses. Previously on tumors that you suspected to be benign, it was more acceptable to do a morcellation that wasn’t contained. In 2014 the FDA put a black box warning out essentially saying that, it wasn’t the highest level of care because of the possibility of spreading an unexpected cancer throughout the abdominal cavity.
What’s the bag made out of?
Dr. Marchand: It’s a special plastic bag. Now there are different kinds of plastic polymers. A lot of plastics have a lot of strength to them, but one of the weaknesses that almost all bags have is the incidence of sharp instrument contact. A sharp instrument or an electric form of energy will often rupture the bag.
What tools do you use?
Dr. Marchand: I tried several different things, but ring forceps and placenta forceps seem to do the best job. They really get a good grip of tumor tissue and because they have rounded edges that they’re not really at risk of cutting the edges of the bag. As long as you’re keeping the bag good and taut during the technique.
Walk us through the actual procedure of what you are doing from start to finish.
Dr. Marchand: If we’re talking about just the technique, after collecting washings or samples from the pelvis, we’re going to proceed to to isolate the tumor without rupturing it. That’s going to mean dividing it from its blood supply and ligaments. It’s usually an ovary we’re talking about; so in that case you’ve got to cut off the suspensory ligament of the ovary as well as the infundibular pelvic ligament and the ovarian artery. Once you’ve got the mass free in the abdominal cavity, we carefully encapsulate the mass within a plastic bag and then the most important part of the procedure, to exteriorize the mouth of the bag. Then once you’ve got the tumor in the bag and the mouth of the bag outside of the patient that’s when my technique really gets to work. I then take out the tumor, piece by piece, until I’ve got the entire mass out of a very small hole.
And then what is the oncology portion of it, you were talking about cancer?
Dr. Marchand: As a gynecologic surgeon I often work hand-in-hand with gynecologic oncologists. Gynecologic oncology is a subspecialty of OB/GYN, where they’ve done extra training to complete a full staging procedure for ovarian cancer. While I’m proud of my technique and it certainly can be used to safely remove large cancerous tumors, I do rely on a gynecologic oncologist to be present and to finish the complete staging procedure. After I’ve gotten the large tumor out without spilling it, a gynecologic oncologist can complete the entire ovarian cancer staging procedure laparoscopically, as was the case in the world record surgery. Performing the procedure laparoscopically drastically reduces the patient’s pain and recovery time.
What’s the advantage of staging during the surgery?
Dr. Marchand: You would save the patient from having a whole second procedure and second bout of anesthesia. For most ovarian cancers, really the first step is staging the cancer to find out what stage it’s at and that determines future procedures or future treatment. With the addition of my technique even some the largest tumors may now be amenable to minimally invasive cancer staging. This is a big advantage in recovering from what would otherwise be a major surgery.
Would that be traditionally biopsy or am I on the wrong track here?
Dr. Marchand: You’re on the right track. But with ovarian cancer it’s not really a biopsy because you don’t want to break the capsule and spread the cancer. Therefor a biopsy, as you would have with a breast tumor, is not really on the table. You need to do a full surgery to find out the stage of the cancer. This could include using my technique to remove the large tumor but it also requires other surgical procedures to be done to realize the stage of the cancer.
Now for ovarian cancer the removal of the tumor is part of the staging, and there is no preoperative biosy performed – because it’s not safe, right?
Dr. Marchand: Right, ovarian cancer is staged surgically meaning you really have to do a staging procedure or surgery in order to get the stage of the cancer. That’s where my procedure really works quite well if you can do it at the same time as an ovarian cancer staging surgery. I’ve been able to combine this on occasion and with a gynecologic oncologist to do an ovarian cancer staging procedure. Then it’s really quite wonderful for the patient that you can complete the whole procedure through tiny holes in one shot.
And have all the answers right then?
Dr. Marchand: Absolutely.
You wouldn’t have the oncologist there unless you already knew it was cancer? Or is it you just suspect its cancer?
Dr. Marchand: Any mass where there’s any reasonable suspicion of it being a cancer, I would want to know what the diagnosis was before I left the operating room. In those cases I’d want to have a gynecologic oncologist available. This could mean right there in the room with me or available on call to come in right away.
They don’t necessarily have to be with you at the beginning of the surgery but you can call them in during the surgery?
Dr. Marchand: Right. In many procedures we do what’s called a frozen section. That’s where after I remove the tumor; I send the tumor to the pathologist who then gives me an immediate diagnosis. It’s kind of a special way to do pathology where they give you a quicker answer and then with that answer we can either go forward with the cancer staging procedure, or if it’s simply a benign tumor the procedure is done and we can just close up.
This is done while the patient is still in the operating room?
Dr. Marchand: Yes, and still asleep.
What kind of results have you seen so far?
Dr. Marchand: Well thankfully the majority of the masses I’ve performed my technique on have been benign. I’ve had wonderful results with patients who had very large tumors, in excess of ten centimeters going home with only small holes and often leaving the hospital the same day. It’s really rewarding to see the patients have such a quick return to daily activities, and such a good outcome.
How many years or how many patients, or both, have you used this procedure on?
Dr. Marchand: I’d estimate about nine hundred. Fortunately the vast majority have proven benign.
How many years?
Dr. Marchand: Since 2009 here, so its eight years now.
Would you consider this a medical breakthrough or more of an alternative for people facing this procedure?
Dr. Marchand: It’s still the classic ovarian cancer staging that has been done for decades, so I believe using my technique to perform the procedure through tiny holes would be more of a breakthrough. It’s really not any kind of alternative medicine. As far as using my technique, I think my technique is very good for performing “in bag” morcellation but it’s not the only technique. Where this technique really becomes exciting is when we find a cancerous tumor and then we combine removal of a very large cancerous tumor with a complete ovarian staging procedure. Then you’ve got a patient that came in, unfortunately has a diagnosis of cancer and instead of being put through two surgeries or instead of being put through a large open surgery they can wake up and they’re eventually able to go home that same day. I mean that’s going to be a lot less recovery and a lot less pain for the patient. A recent study just came out of Milan, the National Cancer Institute there in Italy that compared three thousand cases of ovarian cancer that was surgically staged. Fifteen hundred of them they staged laparoscopically and fifteen hundred staged through a large open incision. They found that in the laparoscopic cases that patients recovered more quickly, they were actually able to start chemotherapy a lot more quickly and they were able to get back in to their lives more quickly. That’s really a great benefit to somebody that’s just been diagnosed with cancer.
Let’s talk about the world record tumor that was seventeen centimeters, tell me a little bit about that, how you treated that one?
Dr. Marchand: Similar to any other case I, was aiming to be as careful as possible. I took the patient to the operating room and like all my patients I gave consent to them that I didn’t think it was going to be cancer but there was a possibility. I went forward and there was a seventeen centimeter tumor and luckily thanks to the shape of the tumor we were able to place the tumor inside a plastic bag safely and then safely exteriorize the mouth of the bag. From there I was able to use my laparoscopic technique, using my technique of in bag morcellation to remove the tumor piece by piece through the tiny incision. Unfortunately, the diagnosis then came back as a cancer when we got the frozen section. The gynecologic oncologist that I was working with at that time was nice enough to come right down. It was really quite fantastic that he was able to complete the entire staging procedure laparoscopically. Now in cancer we don’t ever say that something is cured until after a certain amount of time you have to wait to be sure the cancer is not going to return. In this case a patient may have gotten a cure on essentially an outpatient basis with an extremely minimally invasive procedure. That really has to mean quite a lot. When I had my procedure for testicular cancer, I was very fortunate that I had a good surgeon and that the technique for testicular cancer is already very minimally invasive. When I woke up from that procedure I really felt strong I felt ready to fight the cancer. I really hope that that’s the feeling I give my patients after these minimally invasive surgeries. Because I can imagine when you get one of those very large up and down midline incisions that you wake up in bed feeling like you’ve been hit by a train. I mean you really hurt you can’t move and I imagine it must be very tough for my patients in that situation to feel like they have the strength to fight the cancer. I mean they probably feel a lot more like giving up. I think that’s the worst thing a patient could have to feel after getting a diagnosis of cancer.
As a physician who has been through the experience it seems like your relationship with your patients with cancer have to feel a little bit different?
Dr. Marchand: Absolutely. I mean obviously the most terrifying thing in my life was the cancerous diagnosis. I’m very grateful to the surgeon that I saw. It was in 2010 that I was diagnosed with testicular cancer. I’m very fortunate to have a good surgeon and the technique she used was minimally invasive. I recovered very quickly and that’s part of the impetus for me to develop these techniques is to want to share that feeling. I woke up from surgery feeling strong, feeling like I could get back in to my life. I felt ready to fight the cancer.
Performing a laparoscopic staging on a 17 centimeter malignant tumor is quite a remarkable feat, but what made you seek out a “World Record?”
Dr. Marchand: After we did this procedure it was pretty remarkable and I discussed it with the gynecologic oncologist who also thought it was remarkable. I was talking with some of my colleagues about it and they really thought it was a novel thing to have done an ovarian cancer staging procedure laparoscopically on a seventeen centimeter tumor. As a result one of them actually said, you know that’s got to be some kind of a record. We joked about it a little and when I got back to the office I talked about it with my office staff. I’m blessed to have a really wonderful clinical staff here and sure enough they actually looked in to it and – it was a record. They did the necessary paper work and then the next thing I know a record certificate was awarded. I’m really grateful for my staff and I really hope that this record really can bring attention to minimally invasive surgery.
It wasn’t Guinness it was a different accrediting agency?
Dr. Marchand: Right. I did receive a Guinness world record for a surgery I performed several years ago, so when my staff was looking into it thet sought to have it approved by Guinness but Guinness said it was a little too specific. Because it was both the largest ovarian tumor that was staged laparoscopically, they said it was a little too specific to use. My wonderful staff here went ahead and checked and there are a lot of surgeons using The World Record Academy to recognize their records. Sure enough after we verified that it was the largest and they verified it was the largest, they awarded the certificate. I am certainly hopeful this will bring attention to minimally invasive surgery.
END OF INTERVIEW
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