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.

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“We are getting to the point where we can really start to revolutionize rectal cancer care.”

– Dr. Shady Ashamalla, surgical oncologist, Odette Cancer Centre

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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.

Toronto composer Michael White was back in the recording studio, just three weeks after undergoing a cutting-edge procedure for cancer treatment.

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

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However, that traditional approach is expanding with the creation of The Centre for Perioperative Brain Health at Sunnybrook.

Anesthesiologists are now venturing far beyond the operating room, helping ease the anxiety and discomfort many patients feel before surgery, delivering highly specific pain control, cutting down on the side effects of narcotics, and taking aim at the confusion and memory problems many patients face long after they leave the hospital.

Before: Finding the calm before surgery

Laura Perez had never undergone surgery. Scheduled for an obstetric surgical procedure, the 40-year-old Toronto resident was understandably nervous.

Although she has uncles who are physicians and she knew she’d be in good hands, the unknown represented by the surgical ward left her uneasy. “I knew this would be something different,” says Laura. But one week before her operation, she visited Sunnybrook’s interactive lab where the unknown became known.

“I was given a special pair of goggles by the research assistant and told to press Play,” she says. Laura then watched a six-minute virtual reality video that would take her from the first moments in the surgical ward right into the brightly lit operating room, amid comforting words from nurses and physicians.

“If I turned my head, I could see all around the room,” Laura says of the video, filmed with six 360-degree cameras. “It was very informative and very calming to know what would happen.” And on the day of her surgery, her angst had been dialed down by that virtual reality pre-op tour, courtesy of Dr. Fahad Alam.

Laura Perez watched a 360° virtual reality video to prepare for surgery. (Photography by Doug Nicholson)

Dr. Alam, an assistant professor at the University of Toronto’s Department of Anesthesia, is well aware of the apprehension surgical patients feel, which can cause symptoms like high blood pressure and an elevated heart rate. This can affect as many as 80 per cent of patients, he says.

Research has also shown that heightened anxiety results in slower healing, a greater need for medications after surgery, as well as higher death rates. This prompted Dr. Alam to align his interest in education, expertise in anesthesia and knowledge of technology to create Sunnybrook’s virtual reality lab where, with a dose of creativity, his virtual reality movie was born.

To view it, patients don virtual reality goggles and circuit through the pre-op experience. They’re made to feel they’re on a stretcher, with nurses and physicians speaking to them, and then wheeled into the operating room, where monitors are attached, beeping begins and anesthesiologists explain what will happen. The video ends as the oxygen mask is placed on the patient’s face.

“I hear ‘cool’ and ‘ah’ all the time,” Dr. Alam reports. “Some say they now know what [surgery] feels like.” Notes Laura, “The video would be a good experience, especially for the young or someone who’s never had surgery.”

Dr. Alam’s team is in the process of studying a diversity of patients to measure their before- and-after anxiety levels with the hope that the six-minute chunk of virtual reality will erase weeks of pre-op jitters and lead to better post-op outcomes.

“The potential for using virtual reality is just at its start. There are so many possibilities,” says Dr. Alam. “We have also started creating videos for patients to view before getting epidurals, seeing a radiologist or getting a nerve block, just to name a few examples.”

During: Regional versus general

All forms of anesthesia provide pain control, but in different ways. Regional anesthesia numbs just a small part of the body, and is most commonly used for minor surgeries. In contrast, general anesthesia causes the patient to become unconscious for a period of time, affecting the brain and whole body in various ways.

“Once the patient is under the intense lights of the operating room, they are administered a combination of drugs which can suppress brain function, relax muscles or facilitate mechanical breathing,” says Dr. Stephen Choi, a staff anesthesiologist at Sunnybrook. “The more medications you give, the deeper the effect. It’s like a light dimmer switch, but you don’t want to turn things down excessively.”

But these drugs, important as they are, come with possible side effects. All anesthetics can lower the heart rate and reduce blood pressure, sometimes to dangerous levels. The challenge is to give the least amount possible to facilitate surgery and keep the patient safe. After surgery, exposure to anesthetics can result in confusion and potentially long-term memory loss. That’s why giving the least amount necessary is so critical, says Dr. Choi.

Along with Dr. Beverley Orser, the Department of Anesthesia’s director of research, Dr. Choi, who is also an assistant professor in the University of Toronto’s Department of Anesthesia, has developed ways for patients, like Elizabeth Cesar, to recover faster, use fewer painkillers and experience less pain overall.

Elizabeth Cesar was given a peripheral nerve block, a local anesthetic that relieves pain by interrupting pain signals to the brain. (Photography by Kevin Van Paassen)

After Elizabeth awoke from surgery for her right shoulder in 2014, she almost skipped to her car.

“I felt so good,” recalls the 58-year-old Hamilton resident. “By the end of the first week, I was off pain medications.”

Contrast that with her first shoulder surgery in January 2013. For eight weeks following the operation, she was taking a heavy dose of painkillers, and 10 months after surgery, she said to her doctor, “Fix my shoulder or cut it off.”

Her suffering eventually led her to Sunnybrook’s Holland Orthopaedic and Arthritic Centre and surgeon Dr. Patrick Henry for her most recent surgery, where an anesthesiologist applied a carefully managed nerve block to reduce pain.

Elizabeth was given a peripheral nerve block, which involves injecting a local anesthetic onto or near specific nerves for temporary pain control, to relieve pain by interrupting how pain signals are relayed to the brain.

“With the nerve block, I was able to get ahead of the pain before it became overpowering,” says Elizabeth.

Dr. Choi says that orthopaedic surgery, such as Elizabeth’s, is well suited to regional anesthesia. When the nerve block is administered, the patient can have no feeling in the area for up to 24 hours.

As well, when ultrasound-guided regional anesthesia (UGRA) is used, as it was in Elizabeth’s case, less anesthetic, if any at all, is required so the patient’s mental capacity is affected as little as possible.

With general anesthesia, mental functions can be compromised, triggering the following questions from Dr. Choi: “Does intense exposure to anesthesia induce permanent change? Are there long-lasting effects to memory? People wake up and seem normal, but are they?” As with many valuable discoveries, Dr. Choi’s curiosity has been the motivation for his work with UGRA.

With UGRA, the physician can locate more accurately the specific nerve that requires anesthesia. The success rate is about 95 per cent, compared to the 85-per-cent success rate using “landmark-based” techniques, which means the nerve is in a general area and needs to be found based on physiology and past practice.

Another advantage of using regional anesthesia is its superior form of pain control. And given the growing concern about opioids – including the risks of overdose and addiction – UGRA may be better for long-term recovery, Dr. Choi points out.

The goal now, says Dr. Choi, is to train more physicians to use UGRA, which, in smaller settings such as rural hospitals, would be a significant advantage.

After: Effects on memory, not forgotten

Back at Sunnybrook’s Centre for Perioperative Brain Health, Dr. Orser and her team are conducting preclinical laboratory research, trying to determine what causes brain problems after surgery, like memory loss. “We have to begin by quantifying the problem,” says Dr. Orser. “Patients look okay and ready to go home after surgery, but about 30 per cent may still be struggling with memory problems.”

Seniors and those who have had repeated surgeries are at higher risk. Laboratory research shows that some of the drugs commonly used by anesthesiologists trigger what’s known as memory-blocking receptors in the brain, notes Dr. Orser. When the receptors are activated by exposure to the anesthetic drugs or by inflammation, long-term memory loss may occur. “Such changes may contribute to the problems we see in patients after surgery. We know of people who came in for knee surgery but developed post-op deficits, such as delirium or memory loss,” she says.

So far, Dr. Orser’s preclinical research work has shown that when anesthesia is used and it interacts with receptors in the brain’s hippocampus – considered to be the centre for emotion, memory and the autonomic nervous system – the memory-loss properties of the drugs are heightened.

“For the longest time, we assumed these drugs were eliminated and the brain goes back to the baseline,” Dr. Orser says. “But that’s not the case. The effects of these drugs can linger for a long time.”

In order to understand the frequency and severity of the deficits in humans, Dr. Orser and her team have started a study with patients undergoing hip and knee surgery. The hope is to have more information by next year.

It’s another way anesthesiologists at Sunnybrook, are venturing beyond their traditional operating-room roles to examine the interplay between surgery, medications and brain function.

“It’s a change in focus for anesthesiologists,” Dr. Orser points out. “We are stepping outside the operating room because we want to make the whole surgical journey better for our patients.”

Words matter

– by Mary Gooderham

Anxiety before surgery is common among patients who are not with their loved ones and nervous about the procedure ahead.

Such pre-op jitters can be associated with post-op complications, including increased wound infections, slower recovery rates or even higher mortality in cardiac procedures.

“Surgery is not a small thing; it’s a nerve-wracking experience,” says Dr. Fahad Alam, an anesthesiologist and medical education researcher at Sunnybrook, noting too that hospitals try to allay patients’ worries through the implementation of the pre-anesthetic clinic, medications, calming music or hypnotic talk piped into the sound systems in operating rooms.

Dr. Alam is the head of a 150-patient pilot study underway at Sunnybrook to determine if soothing words or a rousing pep talk from a loved one before surgery might help. in the pilot program, called Humanizing the Perioperative Experience, a close friend or relative records an “I love you” or “good luck!” video message during the patient’s visit to the hospital’s pre-operative clinic. “Anything to reduce anxiety,” says Dr. Alam.

The sentiments are loaded onto an iPad and played continuously for the patient during the wait for surgery. Doctors then test if there is an impact on heart rate, blood pressure and cortisol levels, all of which are related to stress.

If the video messages prove effective, Dr. Alam hopes a more extensive study will investigate whether calming messages reduce surgical complications and improve outcomes.

The post Today’s role of the anesthesiologist goes far beyond the operating room appeared first on Your Health Matters.

For 15 years, a Toronto woman endured severe depression, without getting relief from medication or other treatments.

With no end to this chronic condition in sight, she agreed to enroll in a clinical study of a new treatment known as deep brain stimulation (DBS), which delivers electrical stimulation to targeted areas in the brain and blocks abnormal nerve signals.

Within 10 months, the debilitating symptoms of depression became more manageable. One year later, the woman was well, says Dr. Anthony Levitt, chief of the Hurvitz Brain Sciences Program.

One of a number of treatments that fall under the term neuromodulation, DBS is an example of the high-tech procedures that will become available within the Hurvitz Brain Sciences Program at Sunnybrook.

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“It’s a whole new way of looking at mental health treatment”
– Dr. Anthony Levitt [/mks_pullquote]

Neuromodulation is the process of altering the brain’s circuitry by directly intervening inside the brain. Electrical, ultrasound or magnetic energy is used to change the brain’s circuitry or disrupt pathways.

The field of neuromodulation is rapidly evolving, and Sunnybrook has been leading the charge. As part of the goal to deliver care that’s tailored to the patient, Sunnybrook will house a Centre for Neuromodulation (CFN).

“Rather than a one-size-fits-all solution, we will provide individualized care,” says Dr. Nir Lipsman, a neurosurgeon and scientist at Sunnybrook. “Our ability to offer the full range of neuromodulation strategies all in one place will make this program unique on a global scale.”

Discoveries from neuromodulation techniques are opening up new treatment possibilities for people with conditions such as depression, obsessive compulsive disorder, schizophrenia and anorexia nervosa. “It’s a whole new way of looking at mental health treatment,” says Dr. Levitt, one of the lead physicians in charge of establishing the CFN.

“For the last 40 years, we’ve talked about mental illness as being a “chemical imbalance.” That understanding has helped, but our treatments remain 50 to 60 per cent effective and relapse is unfortunately still too frequent,” he says. There is renewed hope that understanding mental illnesses as brain circuitry disorders will provide a quantum leap forward in treatment: if mental illnesses are circuitry disorders, then once the malfunctioning circuits are found, they can be adjusted.

Cutting-edge and minimally invasive techniques, such as DBS and high intensity-focused ultrasound (HIFU), will be used at the CFN to modulate dysfunctional circuits for conditions as varied as dementia, stroke, depression and anxiety.

The rising prevalence of neuropsychiatric disorders is driving the urgency to find new treatments for these conditions. The number of Canadians with dementia is expected to double from 747,000 in 2011 to 1.4 million by 2031, while major depression has already become the number one cause of chronic illness and lost productivity worldwide.

Dr. Anthony Levitt, chief of the Hurvitz Brain Sciences Program.

Neuromodulation, one response to the coming crush, has become one of the fastest-growing areas in neuroscience and a new frontier for treatment of brain disorders.

Existing techniques, such as more invasive surgical procedures or electroconvulsive treatment (ECT), also adjust circuitry but lack precision and have side effects that are unacceptable to many patients. The use of HIFU, meanwhile, can much more precisely direct energy to the appropriate location in the brain and can modulate pathways that are not working as they should be, while leaving normally functioning circuits intact.

Already, protocols for the use of neuromodulation are being developed. “Our goal is to work on techniques to reach as many patients as possible,” says Dr. Lipsman.

“If we can change the abnormal pathways in the brain that are leading to these mental illnesses, it is entirely possible that we might be able to offer not just treatment, but a cure for some patients,” he says.

Focused ultrasound

A non-invasive procedure, focused ultrasound uses high-frequency acoustic waves that reach hard-to access areas in organs such as the brain or prostate.

Focused ultrasound is used in combination with magnetic resonance imaging (MRI), which allows physicians to see the geography of the brain in real time as the procedure is carried out.

After being given a local anaesthetic, the patient is outfitted with a “helmet” that contains more than 1,000 individual sources of ultrasound. “The multiple sources are necessary because ultrasound does not pass very well through bone,” says Dr. Nir Lipsman, a neurosurgeon and scientist at Sunnybrook. The MRI is used to determine which region of the brain will be targeted. “The real-time nature of MRI further allows physicians to direct the helmet’s multiple sources of ultrasound to focus on a precise target, coming to within one millimetre of accuracy,” says Dr. Lipsman.

Years of experience and research have helped determine which areas of the brain are dysfunctional in specific disorders. For example, a less than five millimetre area in the brain’s thalamus is where abnormal activity occurs in patients with Essential Tremor. MRI-guided focused ultrasound was used at Sunnybrook for the first time in 2012 to cure a man with severe tremors. In the case of depression, the brain’s anterior cingulate area could also be targeted.

For anxiety or obsessive-compulsive disorder, the focus would be the anterior limb of the brain’s internal capsule, says Dr. Lipsman. Trials investigating focused ultrasound for these disorders are expected to begin at Sunnybrook within the year.

After the target is found, the power is increased “and HIFU heats the tissue and destroys neurons, tumours or other problem areas. You see the lesions develop before your eyes,” Dr. Lipsman says.

Risks such as infection or bleeding in the brain are virtually eliminated because HIFU is non-invasive, performed without making a hole in the skull. And because patients are awake, they can report problems such as a pins-and-needles feeling or weakness, which may indicate the target is off.

Deep brain stimulation

Deep brain stimulation (DBS) is an invasive procedure that uses electrodes to stimulate certain parts of the brain. DBS has been in use for over 25 years to treat Parkinson’s disease, and Sunnybrook’s Centre for Neuromodulation intends to explore DBS to treat conditions such as anorexia and depression, according to Dr. Lipsman.

Before the procedure, neurosurgeons use an MRI to locate the target within the brain where electrodes will be implanted, to disrupt electrical nerve signals that generate symptoms.

Two electrodes are then inserted on each side of the brain through a hole made in the skull. The tip of the electrode is positioned within the targeted brain area. An extension wire is then passed under the skin of the head and neck, to a battery pack, implanted under the skin beneath the collarbone. The battery provides constant electrical stimulation to the brain.

All photography by Doug Nicholson

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