Ahmad Abou Abbass, MD, FACS, Hepatobiliary and Pancreatic Surgeon, Mission Hospital in Viejo, California, talks about how robots are changing the chances of survival for those with pancreatic cancer.
When someone hears the words pancreatic cancer, they tend to cringe. Do people feel like it’s a death sentence?
ABBASS: Unfortunately, pancreatic cancer is one of the worst cancers that you can get. It’s not that common. Around 50,000 cases get diagnosed each year in the United States. However, most of these are advanced disease, or advanced stage. It is the third leading cause of cancer death in the United States. Most patients die eventually from the disease.
Are the symptoms that hard to recognize?
ABBASS: That’s one of the reasons why pancreatic cancer is so bad because most of the time patients don’t have symptoms until the disease is advanced. So, the tumor starts with one cell and grows until it gets to a certain size to cause symptoms by pushing on other structures. When the tumor grows to a certain size, it blocks the bile duct which causes back up of bile.
As far as your patient, Don, how big was his tumor?
ABBASS: His tumor was not that big. Don is one of the lucky people that caught his at an early stage. That’s the problem with pancreatic cancer. Most patients present with advanced stage where either the cancer has grown to a degree that it is not removeable with surgery, or it has invaded other vital structures, or has spread to the liver and other organs.
What is the traditional treatment for pancreatic cancer?
ABBASS: Traditionally, for early-stage cancer, the treatment has been to do surgery. Those are the patients that have a slim chance of curing this cancer and prolonged survival afterwards. The surgery is pretty invasive. It depends on the location of the tumor within the pancreas. The pancreas is a globular fatty organ in the back of the upper abdomen. That’s why some patients have back pain when they have this tumor. The problem with this kind of cancer is it usually presents more advanced because it does not cause symptoms in this area until it’s very large. We’re hoping when we do surgery for these, it’s still an early stage, but surgery for this kind of tumor is very delicate and very extensive. That’s why for years it’s been done via open surgery.
And you said the recovery is extensive?
ABBASS: For us to remove a part of the pancreas, we have to remove a part of the intestine and remove the gallbladder. We also have to remove part of the stomach and cut the bile back and then reconnect all these. It is as if you are rewiring the whole inside of the patient. It does take them a while to be able to eat and feel normal again. There are very big blood vessels in the area that come from the intestines and empty into the liver. That makes it a dangerous surgery. There’s potential for bleeding and even hemorrhaging during the surgery. It is a very extensive surgery. I’ve been trained on doing it open and that’s how I did it for years. That’s how probably more than 90% of surgeons in the country do it. There are very few surgeons who perform it through robotic surgery.
Can you explain more about robotic surgery?
ABBASS: The robot has been around since 2000, but really got embraced over the last 10 years. It is similar to laparoscopic surgery where we’re making a few tiny holes in the abdomen, like the size of a pencil. Then the surgeon controls the instruments and uses them manually. There’s this big machine that you connect those instruments to that move in multiple directions and do sophisticated work. It does not do any autonomous movements after we connect those instruments to the big machine. I go and sit on the side in the same room as the patient where I have a console. It’s like driving a machine. I sit in the driver’s seat and every move I do translates into a movement in the robot. I am one of the pioneers in robotic surgery. I’ve done around a thousand robotic cases since I started in 2015. So, during those years, I was doing Whipple surgeries open. At the same time, I was doing variety of other surgeries on the robot. Finally, last year and after extensive training, I started offering Whipple surgery.
How does it benefit the doctor and patient?
ABBASS: Whipple surgery takes around five to six hours. Usually when I do it open, I’m standing on top of the patient with my neck leaning down and I’m trying to get in at different angles. So, at the end of the day, you can imagine how much shoulder and back and neck pain I have after such surgery. On the robot, I’m sitting comfortably in one position with my back and arms rested. I can do surgery all day without having any issues or any problems for the patient. I make a big incision to reach the pancreas because it’s all the way deep in the abdomen. I put retractors, which actually pull on the ribcage and pull on the muscles. With the robot, I can make those tiny incisions that the instruments can reach. The robot also has a 3-D camera that magnifies nine times. So, I can reach into areas where it’s hard to reach. It’s much better than me doing the actual surgery open. I can see tiny structures and do a much better job with the robot. That translates for the patient smaller incisions and less pain. They are up and walking the next day. It also translates to faster recovery and shorter hospital stay. There is something about having the intestines exposed to air for a prolonged period of time and putting your hands on them because they become sluggish. If you do the exact same surgery without opening the abdomen and without touching any organs with the hands, for some reason, they come back faster. They need to get chemotherapy after surgery to prevent the cancer from coming back and the sooner they can start on chemo, the better for them. Some patients after open surgery, it takes them months to recover from the surgery and then the cancer comes back, or they would not even get to the point where they would be able to receive chemotherapy because they are still recovering from surgery. With the robot, my hope is that they are recovering faster and starting the chemo sooner.
What is the recovery time with the robotic surgery?
ABBASS: It is usually much shorter than the traditional open surgery, 4-6 days in hospital and 2-3 weeks recovery at home. Compared to 10-14 days in hospital and 4-6 weeks at home from open surgery.
Do you feel this is a cure?
ABBASS: We’re hoping to achieve a cure by doing the surgery for early-stage cancer. Unfortunately, pancreatic cancer is a terrible disease. It is considered a systemic disease even when found localized. Sometimes we don’t know how extensive the tumor is, or if it has spread to the regional lymph nodes. So, when I do the Whipple, I remove the lymph nodes that are around the pancreas even if those lymph nodes are involved or not, because the pathologist will look at them after I give him a specimen. If those lymph nodes are involved, unfortunately then cure becomes not feasible, but the patients would get some survival benefit from removing the tumor rather than leaving it alone and let it grow. Don had a very early-stage cancer. I’m very cautious in using the words cure or a survival of those patients, because even I’ve seen it from my personal experience, when you do it for early-stage cancer, most of the time they surprise you and it comes back. Even though you think you have cured the patient, it comes back a year or two later. There are patients who survive ten years and there are patients who die from other causes. Those patients are the ones that have the surgery and the ones that have an early-stage cancer.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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