CURE

WINTER / 2012

New Surgical Techniques Are Cutting Edge

New surgical techniques can limit the risk of postoperative complications in patients with cancer.

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Removing the stage 1 tumor on Kathy Leiser’s lung required only three small incisions in a minimally invasive laparoscopic procedure, one of a range of tools and techniques capable of limiting postoperative complications.

Removing the stage 1 tumor on Kathy Leiser’s lung required only three small incisions in a minimally invasive laparoscopic procedure, one of a range of tools and techniques capable of limiting postoperative complications.

Still, soreness remained nearly nine months after the surgery at Vanderbilt-Ingram Cancer Center in Nashville, Tenn., says Leiser, 63. “Recently, I saw my pulmonologist, and he said it might take as long as a year for everything to heal up,” she says. “It was laparoscopic, but they still went between my ribs.”

Risk of complications exists even with the least invasive surgeries, and efforts to limit postoperative problems begin in the days before surgery, continue during each procedure and extend into each patient’s recovery.

[Read "Preparing for Surgery"]

Minimizing Surgery's Effects

Determining the appropriate type of surgery by balancing risks against potential benefits is a key early step in limiting problems, says Eric Grogan, MD, the thoracic surgeon who treated Leiser.

For example, traditional open surgery generally requires an incision large enough to provide a surgeon direct visual and physical access to a tumor or treatment area.

“The larger the tumor is, and the more invasive the operation is, certainly the more complications that may arise,” Grogan says. “If one can ensure that it’s the correct cancer operation with a less invasive approach, it’s logical the less invasive approach should be chosen.”

Minimally invasive surgeries use tools such as a laparoscope, a telescoping camera system inserted via a small incision. But, there are several forms of these procedures, many with benefits for cancer surgeries. In lung surgery, for example, video-assisted thoracoscopic surgery (VATS) uses a scope to send a small video camera into the patient’s body, while surgical instruments enter through separate incisions. “It uses the camera to assist the lung resection, so you don’t have to crack or spread the ribs,” Grogan says. “Everything should be the same oncologically as a traditional open surgery, but there’s less pain.”

The larger the tumor is, and the more invasive the operation is, certainly the more complications that may arise.

—Eric Grogan, MD

Other forms of minimally invasive surgery include robotic surgery, which relies on a computer or a remote manipulator to guide and control the endoscope and other instruments. Single-incision operations allow surgeons to visualize and work through a lone opening instead of multiple openings. Natural orifice translumenal endoscopic surgery (NOTES) inserts a flexible endoscope into an opening, such as the mouth, and allows instruments to go through that scope to perform procedures.

As attractive as these approaches may be, there is still limited information as to whether patients actually have better outcomes compared with standard surgery. And there may be some disadvantages, as well: The surgeon may not have the same field of vision to properly control a complication, such as excessive bleeding, and may not have the same ability to feel the tissue and avoid structures, such as nerves.

“Minimally invasive procedures now represent about half of all cancer surgeries we do,” Grogan says. “Ten years ago, 95 percent would have been traditional open surgeries. The minimally invasive approaches have changed the risks-benefits ratio a bit because it has slightly reduced the risk of the operation.”

Laparoscopic surgery also represents one of the biggest innovations to prevent surgical scarring in the past 20 years, and it limits a range of other postoperative complications, says Christopher Mantyh, MD, chief of gastrointestinal and colorectal surgery at Duke University Medical Center in Durham, N.C.

“The idea is that you limit the incision length, so you can use very small instruments, and the amount of scar is reduced,” he says. “It has been shown that laparoscopic surgery has a lower site infection rate, a lower post-op hernia rate and improved patient satisfaction.”

Clotting Complications

While new surgical techniques can improve the odds of limiting postoperative complications, inherent risks exist with any procedure. For many cancer patients who undergo surgery, whether minimally invasive or traditional open, formation of blood clots pose one of the most serious potential problems.

“This is for liver cancer, colon cancers, gastric cancers and across the board,” Mantyh says. “The reason is that these are big operations that last a long time. People with cancer, their blood clots a little more readily than people without cancer.”

The complication, venous thromboembolism, can include deep vein thrombosis (a blood clot in a deep vein, usually in the legs) or pulmonary embolism (a blockage of one or more arteries in the lung). “That is something that hopefully doesn’t happen often, but when it does happen, it can be fatal,” Mantyh says.

A 2012 study considered the instances of venous thromboembolism in 43,808 operations across 11 types of cancer surgeries, including breast resection, prostatectomy, lung resection and cystectomy (removal of the bladder). The results varied somewhat—from 1 in 357 to 1 in 14 among patients with different cancers—and researchers stated that data suggests both tumor type and resection magnitude impacted a patient’s risk.

Limiting the risk of clots is a priority. For example, Mantyh says one approach, and one he uses, relies on administering heparin, which prevents blood from clotting. “We continue the drug after surgery, once the patient goes home,” he says, “and we may give it to them for up to two weeks.”

Infection Protection

Possible postoperative complications extend beyond blood clots, yet tracking those complications can be difficult for many hospitals, according to the American College of Surgeons, which is why the organization created the National Surgical Quality Improvement Program (NSQIP). “This is a program that’s growing by leaps and bounds,” Mantyh says. “It gives you a snapshot of how your hospital is doing, and it gives a national snapshot every six months.”

Hospitals also have a financial incentive to participate and improve performance. In the case of problems considered preventable by the hospital—one example is infection of surgical sites—insurance programs, such as Medicare, increasingly refuse to reimburse for the treatment.

It has been shown that laparoscopic surgery has a lower site infection rate, a lower post-op hernia rate and improved patient satisfaction.

—Christopher Mantyh, MD

Unlike previous efforts, which might consider whether a hospital followed recommended procedures, NSQIP focuses on distinct complications, Mantyh says. “It’s a very powerful tool, and you can drill down to specific types of surgery or even to a specific surgeon.” Often a comprehensive strategy, not one technique, is necessary to eliminate possible complications from cancer surgery. For example, the prevention of surgical site infections will not change by one measure, Mantyh says. Instead, surgeons must consider a multifaceted approach, including antibiotics, the careful monitoring of glucose (blood sugar) levels and the controlled warming of a patient’s body after surgery to promote infection-free healing.

Similarly, a procedure requiring anesthesia brings the possibility of pneumonia or extended periods with a patient having to use a ventilator. “In the bad old days, without new techniques, you’d give patients five or six liters of fluid, and that fluid could leak into the lungs and cause pulmonary edema,” he says.

Now, a system known as goal-directed therapy allows the anesthesiologist to carefully monitor heart function to determine the proper amount of fluids a patient receives during surgery, lessening the chance of complications, Mantyh says.

Outweighing the Worry

Even the type of surgery can have unique requirements. When operating to treat rectal cancer, a surgeon must take care to spare specific nerves, guarding against the possibility of inhibiting bladder or sexual function, Mantyh says.

For patients with lung cancer, such as Leiser (whose cancer was discovered when she volunteered for a Vanderbilt-Ingram Cancer Center study to evaluate lung cancer screening techniques), potential benefits outweighed any worry about postoperative complications.

Debilitating pain and nausea from medication to control the discomfort made her recovery a challenge, even though she had minimally invasive surgery with no other significant complications.

“The surgery had to be done,” she says. “If they had told me before surgery that I was going to be in pain for two months afterward, it wouldn’t have mattered.”

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