Thoracic surgeon Farid Gharagozloo, M.D., hasn’t found the answer yet for malignant pleural mesothelioma, but he has developed a surgical expertise in robotics that could alter dramatically the future of treatment for this disease.
It is a much-needed breakthrough.
Gharagozloo, head of the thoracic oncology program at the University of Arizona Health Network, has begun successfully using the da Vinci Surgical System Robot to help perform the extrapleural pneumonectomy, making it a safer, and a more complete procedure.
“Without a doubt this is a game changer for mesothelioma,” Gharagozloo told Asbestos.com in a recent interview. “It will take us out of the rut we’ve been in for too long with this disease. It’s not about the sexiness of using a robot. It’s about a new and a much better way to do this surgery. It’s about giving your patients the best chance to live.”
According to the University of Arizona, Gharagozloo became the first surgeon in the world to use the robot for the extrapleural pneumonectomy (EPP) in January. He has performed the complex surgery five times since then, and all six of his patients today are doing well, which is a promising success rate for mesothelioma surgery.
“There still is a lot of work to do. This isn’t the golden ticket, but it’s going to make a huge impact, and change the way we look at mesothelioma,” he said. “The use of the robot with this surgery is revolutionary.”
Mesothelioma, which is caused by exposure to asbestos, is a rare but aggressive cancer without a cure. It attacks the lining of the lungs in most cases. After diagnosis, the majority of mesothelioma patients pass away within 18 months. Much of the treatment, and even surgeries, are palliative.
The EPP traditionally is the most aggressive surgery a patient with mesothelioma can have. It involves removing an entire lung, the lining, the diaphragm, and part of the covering surrounding the heart. It is a major surgery with considerable risk. If tolerated well, the EPP can prolong a life for a few more years. But too often, an elderly patient isn’t strong enough to fully recover, struggles afterward, and still passes within a year.
Even within the medical field, there is considerable debate about EPP and whether it should be done today. Some prominent thoracic surgeons now shun the EPP in favor of the pleurectomy/decortication surgery, believing that EPP morbidity is too high and the risks outweigh the rewards. Too many things can go wrong and the aggressive nature of the surgery is a lot for a cancer patient to recover from, critics of the EPP say.
Proponents of the pleurectomy/decortication surgery, which spares the lung instead of completely removing it, say the EPP procedure leaves patients with considerably reduced lung function because they only have one remaining lung after the surgery.
Gharagozloo believes his robot can change the results, and change the perception of the surgery, giving patients new hope and a better chance of recovering from the surgery. He also believes other thoracic surgeons will follow his lead.
“There is a night and day difference in terms of recovery from my surgery,” Gharagozloo said. “Instead of being on a ventilator the day after surgery, the patient is sitting up in a chair the next morning reading the newspaper. Instead of a two- to three-week recovery in the hospital, it’s six to seven days. This changes the post-operative course for a patient. All the signs today are pointing to the fact that in general, this is the way to get us out of the mud with mesothelioma.”
Robotic surgery has been used for more than a decade, but primarily for less-invasive procedures. Only in the last six to seven years have thoracic surgeons begun using it in the chest. Gharagozloo, a pioneer in robotics, was the first to use it with something as extensive as the EPP.
One of his six surgeries was a patient who had come for a second opinion after being at Brigham & Women’s Hospital in Boston, which is considered the mecca of mesothelioma surgery.
“This isn’t rocket science what I’m doing,” Gharagozloo said. “But from an imaging standpoint, using the robot is like driving a new sports car instead of a Model T Ford. It allows us to take out the tumor better. There is less chance of recurrence. We started with the concept of: ‘How do we make this a safer, and a better cancer surgery?’ We’ve done that now.”
Robotic surgery allows for more precise movement and better maneuverability during the operation. Surgical cuts are made with tiny instruments attached to a robot and controlled remotely by a surgeon at a computer board. With a small camera attached, it also allows a more magnified view of the areas being effected. The microscope camera is much keener than that of the naked eye of the surgeon. The chest still must be opened, but now the robot goes inside instead of the surgeon.
“It’s just a better pair of scissors to do the surgery with. Adding the robot doesn’t complicate the surgery. It makes it easier, actually. It’s tiny robot arms instead of my hands in there,” he said. “One of the issues in the past was getting into all the little crevices and getting the tumor out completely. This helps us do that.”
The robotic surgery shortens the recovery time because it dramatically reduces blood loss during an EPP surgery. The robotic hands seal the open blood vessels almost immediately, which can’t be done during the traditional surgery, where considerable blood is lost.
The need for extensive blood transfusions is often what causes problems in recovery after the EPP, overworking the other vital organs and putting too much stress on the remaining lung. It’s one reason for the high rate of failure with the traditional EPP. People can live fine with one lung, but it has to be working optimally.
The robot also can simplify the mesothelioma staging process before the surgery. Many times surgeons don’t know exactly how much the mesothelioma has metastasized until the surgery is underway.
Gharagozloo can use the robotic camera, through tiny holes, to look inside a patient before he starts the EPP surgery. Three times already, he took a closer look at a surgical candidate with the robot and decided against moving forward.
“This allows us to do the surgery only on the cases with the best chance of doing well,” he said. “In the past, quite frankly, that’s been a problem that all thoracic surgeons have faced. You get in there and find an unplayable hand. But if you just back out, the patient does worse. The robot can make sure a person doesn’t go through this surgery unless he has a reasonable chance of success.”
Gharagozloo already has attracted considerable interest from the mesothelioma community. In his career, he has performed more than a 1,600 robotic surgeries, which is more than anyone else in America. Using it for an EPP took considerable preparation, first using animal and cadaver tests.
“Robotics in thoracic surgery is a game changer, and we’ve embraced it with open arms,” he said. “We want to change the story now of mesothelioma.”