University of Groningen
Innovation in surgical oncology Vrielink, Otis
DOI:
10.33612/diss.173351128
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2021
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Vrielink, O. (2021). Innovation in surgical oncology. University of Groningen.
https://doi.org/10.33612/diss.173351128
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Download date: 21-07-2021
Future perspectives
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FUTURE PERSPECTIVES
The ongoing development of various forms of minimally invasive surgery in the field of surgical oncology will continue to play an important role in the future. Since the emergence of minimally invasive surgery in the 1980s, innovation mainly focused on improving laparoscopy during the first years. Rapid technological advances in laparoscopic instruments and growing consensus led to a widespread adaptation of laparoscopy for an ever-growing number of procedures, not only in the field of surgical oncology, but also in other surgical specialties. Subsequently, continuous innovations led to the introduction of several other minimally invasive surgical techniques, including single incision laparoscopic surgery, natural orifice transluminal endoscopic surgery and robotics. Besides the introduction of surgical techniques several other advances have been made, for example in pre- and perioperative imaging.
Robotics
Robotic surgery has evolved immensely since its introduction. Following the FDA approval of the da Vinci® in 2000 and other robotic platforms, several studies have shown its safety and feasibility in general surgery. Advantages of the robotic system compared to laparoscopy are 3D visualization, elimination of the fulcrum effect, multi-degrees of freedom of movement, elimination of tremors, telesurgery and ergonomics.1 However, these technical advantages are not necessarily translated into superior outcomes.
Multiple studies have shown equivalent results comparing robotic to laparoscopic surgery with respect to the adequacy of oncologic resection and postoperative outcome.1 Most advantages of the robotic system are expected in advanced or complicated robotic procedures where there is a need for fine and complex movements. For example, some studies have shown lower complication rates in rectal surgery, possibly due to the improved accessibility of the robotic system in the narrow spaces of the pelvis.2,3 Important drawbacks of robotic surgery are the lack of haptic feedback, the requirement of dedicated, specially trained staff and most importantly the high costs of robotic platforms.1 However, these costs might change in the future with expiring of the patents of the first surgical robotic systems in coming years and market driven competition with other robot developers.1 Furthermore, new surgical robotic systems such as instruments with haptic feedback, an eye tracking system for the telecamera and robotic single port surgery will be developed and tested in the future, potentially further improving techniques and patient outcomes.1
Before the decision is made to implement a new technology, for example robotics, the question should be raised whether there is an advantage for the patient and/or the surgeon. Does the technology facilitate surgical performance, and more importantly
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does it lead to better outcome for the patient? Furthermore, medical innovation is an important factor of increasing health care cost, and the financial cost-benefit should be critically reviewed. In robotics, most advantages are expected in complex procedures and the robotic system should not be used for all surgical procedures, but should be reserved for those procedures in which most advantages of the system are expected. In addition, the implementation process should be properly managed and prepared in order to enhance patient outcome. It might be beneficial to perform robotic surgery only in high volume centres. In this way, a high annual caseload can be assured and a specialized and dedicated team can be organized, leading to better outcomes. Furthermore, implementing these innovations in mostly high-volume centres might lower the costs by utilizing it to its maximum potential.
Intraoperative imaging
Intraoperative guidance has advanced significantly with the appearance of numerous novel imaging technologies. These new intraoperative imaging modalities have the potential to enhance the surgeons understanding of anatomical structures and tumour margins in order to optimize resection of malignant tissue, while minimizing collateral damage. Near-infrared fluorescence (NIRF) can improve the visualization of vital anatomical structures during minimally invasive and open surgery.4 Besides real-time imaging of anatomical structures, NIRF imaging is also extensively explored for image- guided cancer surgery, making it possible to better define tumour location and tumour margins during the procedure in order to perform more radical resections.5 Molecular fluorescence imaging agents can be divided into non-targeted and targeted probes.
Non-targeted fluorescent probes, such as indocyanine green, have already been used intraoperatively for several indications.6 However, non-targeted fluorescent probes are not tumour-specific with a low specificity.6 Therefore, the development of targeted fluorescent probes, based on the molecular characteristics of cancer cells, is increasing.
Several targeted probes have already proven to be successful for various cancer types, such as ovarian and breast cancer, in phase one studies.6 Next to NIRF, several other imaging technologies are being developed and updated, including photoacoustic and nuclear imaging-based approaches.7 In photoacoustic imaging, optical illumination and ultrasound detection are merged.8 Current imaging technologies are limited in the detection of very small tumours and metastases. Multispectral optoacoustic tomography (MSOT) offers potential solutions to these problems, and can for example aid in the diagnosis and staging of melanomas by identifying the depth of invasion, potential nodal metastases and non-invasive identification of lymph nodes involved by tumour.9 The latter potentially reduces the necessity of extensive surgical resections accompanied with high rates of complications. Imaging of cancers using MSOT is also described in head and neck cancers and prostate, ovarian and breast cancer.
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Despite the promising results and potential benefits of the rapidly expanding number of intraoperative imaging technologies, these have been primarily tested in phase one studies. More research is necessary and large multicentre clinical trials are needed to evaluate the impact on patient outcome and survival before clinical translation and acceptance of intraoperative imaging technologies can be achieved.
Conclusion
In the field of surgical oncology, innovations such as minimally invasive surgery, robotics and perioperative imaging will continue to play an important role in the future. Despite the promising results of several innovations and advancements, some are still at an early stage and their superiority has yet to be proven. Therefore, a critical view is essential before a change in practice should be made and an innovation can be implemented into clinical practice. A balance must be found between the eagerness to incorporate the latest technology with a comprehensive understanding of what it really has to offer for the patient and whether it is actually better than the current treatment. Eventually, the ultimate goal of innovation is to improve patient outcome in a cost-effective manner.
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REFERENCES
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2. Mushtaq HH, Shah SK, Agarwal AK. The current role of robotics in colorectal surgery. Curr Gastroenterol Rep. 2019 Mar6;21(3):11. Doi 10.1007/s11894-019006776-7
3. Cheng CL, Rezac C. The role of robotics in colorectal surgery. BMJ 2018 Feb 12;360:j5304. Doi:
10.1137/bmj.j5304
4. Schols RM, Connell NJ, Stassen LP. Near-infrared fluorescence imaging for real-time intraoperative anatomical guidance in minimally invasive surgery: a systematic review of the literature. World J Surg. 2015 May;39(5):1069-79. Doi 10.1007/s00268-014-2911-6
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