Minimally invasive surgery is not just a technique, says surgical oncologist Dr. Shady Ashamalla (above). “It’s a philosophy of care.”
Sunnybrook’s novel surgical procedure for treating rectal cancer is being adopted by a network of specialists
After a close friend of Michael White’s died of rectal cancer in his early 50s, the disease, which for some has few warning signs, preoccupied Michael’s mind. “It was so horrific to see my friend die,” he recalls. “I didn’t want to go through that.”
A composer in Toronto who creates music for Hollywood films and television, Michael is a 57-year-old father of two adult children. He had done two tests to check for hidden blood in his stools, which could be a sign of cancer, and they showed no signs of trouble. But in July 2016, he had a colonoscopy that revealed a rectal tumour.
Michael was soon referred to Dr. Shady Ashamalla, a surgical oncologist at Sunnybrook’s Odette Cancer Centre and a Canadian pioneer in the use of minimally invasive surgery for rectal cancer. “Dr. Ashamalla was really direct with me,” he recalls. “He never sugar-coated anything, but I never doubted he could do it.”
At Sunnybrook, distinct patient-centred protocols that improve outcomes for cancer patients like Michael are being developed and finessed. “We strive to minimize the impact of our medical intervention on patients’ lives,” Dr. Ashamalla explains. “The goal is to treat and cure the patient and do it in the least invasive way possible. Minimally invasive surgery is not just a technique we employ with advanced instruments; it’s a complete philosophy of care.”
If Michael had cancer surgery just a few years ago, the experience would have been completely different. The pain and recovery time would have been greater because a long incision would have been made in his abdomen to reach and remove his rectum, leaving him with a permanent colostomy.
“We are getting to the point where we can really start to revolutionize rectal cancer care.”
– Dr. Shady Ashamalla, surgical oncologist, Odette Cancer Centre
For Michael’s surgery in October 2016, Dr. Ashamalla used what’s known as TaTME – transanal total mesorectal excision.
In this procedure, used for large rectal cancers, the surgeon removes a portion of the rectum through the anus and then reattaches the colon to the remaining rectum or anus to make a new connection. It’s all done through transanal laparoscopic surgery, which avoids incisions, offers greater accuracy during surgery, and is safer for the patient. The procedure also speeds up recovery time.
“If I’d have had the old surgery, I would’ve been in the hospital much, much longer,” Michael says. Following the six-hour surgical procedure, he spent four days in hospital. One week later, he was walking 30 minutes each day. Three weeks later he had returned to the recording studio where his co-workers had no inkling he had undergone cancer surgery. And after three and a half months, he was back on the ice, playing hockey.
“The procedure not only saved my life, it saved my quality of life,” he says.
Dr. Ashamalla’s history with this minimally invasive technique started in 2014 after he read about the new rectal cancer treatment being done in Europe. The same year, he went abroad to further his training in the procedure, which was developed by a Spanish doctor, Antonio de Lacy. In spring of 2015, Dr. Ashamalla performed his first procedure and, since then, he and his Sunnybrook team have performed more than 150 of the procedures.
“We kept track of all of our outcomes and quickly realized the results were superior,” he says. “What was an 8- or 10-day hospital stay became a three- or four-day stay but, more importantly, by minimizing the impact of the surgery we were able to get patients back to their normal quality of life much quicker.”
Recognizing the value of shorter hospital stays and improved results, Dr. Ashamalla and his team pushed the procedure forward. “We were thinking about the big leap – new equipment, new nursing training, raising the capital investment. I felt very fortunate at the time to be supported and empowered by Sunnybrook to grow and implement cutting-edge technology, despite the initial investment,” Dr. Ashamalla recalls.
But as with many novel, and promising, surgical procedures, there must always be balance between spreading the new training widely to other surgeons while absolutely ensuring patient safety. “The question became: How do you disseminate it [the procedure] widely? How do you train surgeons to do an operation that is better for patients while making sure the quality is not compromised during their learning curves?” Dr. Ashamalla notes.
“At Sunnybrook, we are national leaders in bringing new techniques to the country, and by extension we must be leaders in safely disseminating that knowledge as broadly as possible,” he says.
Proctorship became key. In June 2016, Dr. Ashamalla organized the first Canadian conference on transanal total mesorectal excision in Toronto. Eleven international experts introduced the procedure to more than 250 rectal surgeons from every Canadian province.
That initial gathering led to the formation of the Canadian TaTME Proctorship Network. Since then, the network, in partnership with the University of Toronto, has been offering a one-day proctorship course that teaches rectal cancer surgeons each step of the procedure and allows them to technically practise it. “The whole concept was to develop a model for a rigorous structured introduction of innovative surgical techniques,” Dr. Ashamalla explains.
After the course, the network can link the surgeons to proctors who are geographically closest to allow them to observe transanal total mesorectal excision surgeries with the proctor and subsequently be coached through their initial cases. Because the surgical procedure is very technically challenging, only doctors who do a high volume of rectal cancer surgeries are suitable. Specialization is crucial. “We know that volume and outcomes are linked,” notes Dr. Ashamalla.
As Sunnybrook’s chief of surgical oncology, Dr. Danny Enepekides supports the proctorship program. “This procedure is not something a novice can pick up after a day and then start doing. It is an advanced technique,” he notes.
As minimally invasive surgery becomes the future, such advanced techniques require more than a day or two of training, Dr. Enepekides says. In the case of transanal total mesorectal excision, as surgeons become skilled at the procedure, they then become proctors. “We’re looking to continually build a network,” he says.
Approximately 80 surgeons have taken part in Dr. Ashamalla’s proctorship sessions thus far. Some are ready to bring this minimally invasive surgery to their city hospitals while others continue to learn. “This procedure is a game changer for rectal cancer,” Dr. Ashamalla says. “We are getting to the point where we can really start to revolutionize rectal cancer care.”
For Michael, the value of the procedure is his life. While he is not burdened by a colostomy or required to consume heavy-duty post-operative drugs, his follow-up care does include CT scans and colonoscopies. In November 2017, Dr. Ashamalla performed a routine colonoscopy on Michael. “Everything was okay,” Michael reports.
All photography by Kevin Van Paassen