Tuesday, December 29, 2009
Most surgeons think they have this (surgical magnetism) inherently. But I'm not talking about surgical machismo. I am talking about the use of magnets in surgery. Magnet technology continues to advance, and surgical techniques continue to evolve into less invasive methods. Utilizing magnets in surgery is part of the next advance in minimally invasive surgery.
Researchers have been experimenting with using magnets to perform sutureless anastomoses such as depicted in the diagram above*. This technique could bring about a completely endoscopic gastrointestinal anastomotic procedure that will eliminate the need for general anesthesia and operating room time.
** Porcine gastrointestinal anastomosis created using magnet.
This has great potential to reduce the time needed for hand-sewn anastomoses. It can decrease costs associated with stapled anastomoses and has potential for decreasing the occurrence of early anastomotic leak. Therefore its use won't be limited to just minimally invasive approaches, but could be used in standard general surgical operations as well.
*** Augmenting NOTES surgery without need for laparoscopic ports.
Already we are seeing the first uses of magnets to assist in anchoring specialized laparoscopic instrumentation to the anterior abdominal wall, thus replacing standard transabdominal wall port placement as noted in the cartoon above. This has great advantages, not only in decreasing wound complications and potential port-site hernias, but it also will allow the surgeon to maneuver the instrumentation into any location without the downside now associated with fixed-trocar positions. The camera can move for improved viewing angles. Retracting instruments can be placed at will, without creating more holes in the abdominal wall. Working instruments can be moved to new sites at will for improved working angles.
(Image: Royal College of Surgeons / Scuola Superiore Sant'Anna)
Finally, the future of magnets, coupled with MEMS (micro-electro-mechanical systems) and robotics will introduce an era of general surgery that will be revolutionary. Current robotic setups are ginormous beasts that require massive resources and time to setup. Future robots will be deployed using NOTES or SILS techniques and have the capability to assemble themselves from multiple smaller units, such as that depicted above. The ARES (Assembling Reconfigurable Endoluminal Surgical system) robot is one such future concept. Imagine if your surgeon was able to deliver robots either via a single small incision or natural orifice, then control the unit or units via the wireless network from a simple control station. No time consuming setup. Much less expensive. Much more ergonomic with improved control and visualization. This is the future of minimally invasive surgery.
*AA Kutzetzov et. al. Application of magnetic devices and sorbents in gastrointestinal surgery; European Cells and Materials Vol. 3. Suppl. 2, 2002 (pages 179-180)
**C Myers et. al. Using external magnet guidance and endoscopically placed magnets to create suture-free gastrointestinal anastomoses; Surg Endosc DOI 10.1007/s00464-009-0735-5 Published online 24 Dec 2009.
***J Raman et. al. Role of Magnetic Anchors During Laparoendoscopic Single Site Surgery and NOTES; J Endourology Vol 23(5), May 2009
Sunday, December 20, 2009
My son performing his magic
It is abundantly clear to anyone and everyone that the spending on health care is unsustainable. We simply cannot continue on the current pathway without the country collapsing under the weight of health care cost. I am not sure that I have heard any good answers coming from our leaders. Most of our politicians on the left seem to want believe that the government is the answer. Unfortunately, most of the politicians on the right seem to think that "the doctors" have the answer. Quite frankly, I am not sure I have heard any great answers coming from my peers. To me this is not just a clinical problem (although there is a lot that can be done on that end) but it is as much or more of an economic and business problem. "Doctors" are not economists and while many are forced to be business men and women, most are not very good at it. Ultimately, this is a pretty uncertain time with extraordinary challenges that await us. So, when challenged, I go to my happy place. That place is technology and innovation.
Now sitting in my happy place, I found myself listening to Robert Metcalfe presenting a radical concept concerning the future of energy. For those of you who do not know who Bob Metcalfe is.... well.. in a nutshell, he invented Ethernet, created the company 3Comm, made a bunch of money, then became a venture capatilist... and poof.. now he is out to solve the world's energy problem (hope that wasn't too simplistic for you Bob :)). Nonetheless, I found myself drawn into his talk about energy, and how the Internet should be a guide for solving the energy problem. He talked about how we will most certainly use more energy (not less), and that rationing the use of energy is a foolish endeavor (I am paraphrasing). In fact, we will see radical improvements in both the creation of energy, but also the we should see further advances in energy efficiency. His message is that we should not be spending all our resources on "Green" energy, but that we should recognize that technology will advance to a point in which we will have a "squanderable abundance" of cheap and clean energy.
(image from: http://fee.org/articles/tgif/markets-ration-health-care/)
Well, this talk from Bob Metcalfe really sent my mind for a spin, because I kept thinking that he was talking about health care! Energy = health care. Green energy = health care reform. Rationing Energy = Rationing health care. WOW!.... I felt like maybe I was onto something. So if you're with me, then maybe you can see the possibility that if energy can become cheap, clean and squanderable, then health care might become cheap, safe and squanderably abundant (stick with me... I don't know if 'squanderable and squanderably are even real words). For this to happen, health care needs something radical. Something that has happened to every industry. Health care needs "disruptive innovation".
In 1997, Prof. Clayton M. Christensen coined the term "Disruptive Innovation" in his seminal book "The Innovator’s Dilemma". He has subsequently published "The Innovator's Prescription" this year (2009) covering the health care dilemma (I still have yet to read this... I will very very soon.). Despite my lack of education comparative to Dr. Christensen, I will tread out on these dangerous waters and deliver the rest of my opinions. Simply put, disruptive innovation is any technology or business / clinical practice that brings about a radical decrease in cost or creation of a new market. We have seen disruption in the transportation, textile, communication, entertainment and food industries to name a few. Since health care is said to be an industry... why would we not expect to see a disrupting technology here? I think we will and here are a few examples of what may change the economics of medicine.
|GE's Vscan portable ultrasound|
The future of radiology is directly linked to advances in computer technology. Computer technology continues to advance at a pace that is consistent with Moore's Law and thus will radiology. Devices such as the ultrasound pictured above will become so portable and inexpensive that we will treat it like a thermometer. Ionizing radiation dangers will decrease dramatically as detectors improve so much that the doses needed for imaging will be minuscule. Images will be interpolated and reconstructed so that we will be able to view inner space with life-like realism. This imaging may cost more, but the effects of being able to make accurate and reliable diagnoses will lower the complication rates of missed or delayed diagnoses. Radiology will have a disrupting effect on health care and costs will come down as a result.
Carbon nanotubes for the instant detection of bacteria
The medical laboratory industry is going to be turned upside down. Just like digital cameras have replaced sending your film off to get developed while you wait and wonder what will actually show up... so will it be will all things we otherwise have sent to the lab. Nanotechnology will replace "the lab". We will check most everything at the point of care with immediate results, for cheaper than ever before. In fact, when you check in to the hospital, we will put a few sensors on you (or in you) that will cost a few dollars a pop. These sensors will constantly check your blood for hundreds of parameters on a near continuous basis. If you have an infection, the nanodetector will know it before it becomes a systemic problem AND it will know exactly what bacteria is causing a problem. Sepsis (a leading cause of death in hospitals) will become a thing of the past. Nanotechnology will completely disrupt health care and costs will plummet.
Nanobees kill tumor cells at Washington University in St. Louis, MO
Nanotechnology will also allow medicine to change radically, albeit at a slower pace than other areas. Technology will allow for the delivery of therapeutic agents to a much more focused target. We will see dramatic decreases in unwanted side-effects. In oncology, we will be able to target tumors without the collateral damage seen with conventional chemotherapy. Antibiotics as we know them will become a thing of the past, as we learn how to completely destroy only the pathogenic bacteria.
Surgery will see amazing advances in transplant and reconstruction. Tissue engineering continues to advance and in 20 to 30 years organ transplant may be possible without the need for organ donors or immune suppression. When this occurs, cost associated with the care of patients with heart, lung, liver, or kidney failure will drop radically. The cost reduction due to surgical cures associated with diabetes, kidney failure, and cirrhosis will free up hundreds of billions of dollars.
Wellman Center for Photomedicine at Massachusetts General Hospital
Even general surgeons will benefit from the revolution in technology. In the near future we will re-approximate wounds with LASER instead of sutures. Wounds will become sealed by applying a photomaterial to tissue edges and then approximate them under a laser light that causes the material to create a seal - somewhat like velcro at a nanoscale. This will decrease tensile forces by spreading them out over a greater surface area. It will additionally create an immediate biologic barrier. Thus, complications associated with wound infection and wound disruption will drop dramatically. Latent incisional hernias will become a rare complication of abdominal surgery. "Laser suturing" will become disruptive in surgery.
|Advanced Health Information Display Concept Proposed By Dr.'s JF Sucher and SL Jones|
Finally, I will end with health care information. There are so many other areas poised to disrupt health care, but this is the one area that can make or break it. So much depends on information and unfortunately I feel that we remain bogged down in data input. Our physicians, nurses and other health care professionals have become slaves to data entry. This trend appears to continue unabated and is consuming an incredible amount of resources. Add to that, it creates piles upon piles of refuse because its collection is meant for anything but actually caring for our patients. In other words, we have a mountain of data with little return of information. Its information that we so desperately need. With information we can drive advanced decision support, and decrease the requirements for unnecessary tests and procedures. If we can radically revamp our information network and how we view ownership of data, we could save hundreds of billions of dollars. Needless duplication of tests occur every day due to lack of implementing a nationwide system of health care communication. Silos of information exist on individual patients, scattered throughout various physicians, clinics, labs, hospitals and diagnostic centers. Does anyone get this? The information about me belongs in one secure place that I can control with my doctors. There is so much more to talk about... but I need to go operate on a patient that has been to 5 different hospitals over the past 6 years and has seen more than 20 doctors. How much do you think I know about this patient's history from the patient.... how much information do you think I can get from the other hospitalizations?
We still have great challenges ahead. But I see a bright future for saving health care through disruptive innovation.
Thursday, December 17, 2009
As many of you know, I have taken a break from my academic surgical practice to attend the Army's Officers Basic Leaders Course (OBLC) - Reserve Component in preparation for deployment to Afghanistan. I returned from this school 2 weeks ago, and quickly prepared my presentation on "Disruptive Innovation" for The Methodist Hospital's Department of Surgery Grand Rounds (more on that later). So, as I sit here on call at the hospital and happy to have had a successful presentation completed, I thought to myself that I would like regale the reader with why someone like myself would decide to "join the Army". In doing so, it occurred to me how many great people that I've met. These people helped me see that American patriotism is alive in many others.
When I speak of patriotism, I am speaking of service to one's country with the motive to help others. I am not talking about patriotism that spews hatred for anyone or anything not American. That isn't patriotism. That's just hatred. Patriotism is good and charitable. Below is my story.
OBLC is an introductory course for new Army medical officers. Not quite "basic training", but rather, it is designed to equip a new officer with the basic knowledge needed to function in the military. However, this wasn't my first dance with the Army. Over 25 years ago, I enlisted straight out of high school (that's me in the photo above, wearing a CVC helmet and a dust rag over my face because sand tends to choke you up in the New Mexico desert). I entered as a private and proudly became a 19D Cavalry Scout. I served for 2 years of active duty and 4 years of reserve duty, leaving the Army just before the first Gulf War. I spent my entire active duty at Ft. Bliss, Texas with the 2d Squadron, 3d Armored Cavalry Regiment, and never served in combat.
I am on the right with the M16A1 (yes... I know Sgt Taylor appears to be pointing that M1911 at me)
I am very proud of my prior service. I enjoyed the military life and my job was very exciting (at times). But, like most things in the Army, the majority of time is quite boring. Fortunately for me, I did well, I learned from my experience and I went on to my civilian life to gain my advanced education, finally becoming a surgeon and specializing in acute care surgery, trauma and critical care. However, I always felt that I was missing a piece of myself. I felt disconnected and I always new which connection needed to be re-established. I needed to get back to the Army (especially in this time of need) with the relatively rare skill-set that I now possess.
First, I gained full clearance from my wife (who quite frankly is giving up more than me so that I may help our soldiers). Then, I was then fortunate to have an employer, chairman and partners who supported my return to the Army Reserves. As I prepare to deploy to Afghanistan, I wanted to say thank you to all those people who are supporting my mission to help our men and women in combat. I have learned a huge lesson. It takes an enormous amount of support to allow me to serve my country. All the people that I leave behind must work harder, and... they will worry for me. I Thank you all!
My experience at OBLC was outstanding. The leadership and ex-NCO instructors were fantastic professionals. The people that I met are all top-notch. I was amazed to meet so many individuals who had served many years as enlisted soldiers, only to gain advanced degrees and re-apply themselves as Army medical officers. Patriotism and service to country are alive and well in these Americans.
Here I am (on the right again but 23 years later) with Major Yamaguchi at Camp Bullis
Above, you see me pictured with Major Kai Yamaguchi, a transplant surgeon in Vermont. Dr. Yamaguchi did not have to come to OBLC. He did not have to volunteer for deployment oversees. He, and most everyone I met, felt called upon ("obligated" does not fit correctly in this sentence) to serve. I know this is my calling. I know, because I felt something that I never felt before. I feel something unexplainable. Its kind of like telling someone that they will know what love is when they know.
I met Lieutenant Paul Van der Voort. Paul is a CRNA in New York. He joined the Army after 9/11 and were's a tattoo commemorating the men and women who were murdered on that day. Paul has a heart of gold and is as tough as nails. He is what exemplifies the hardiness of New Yorkers. He is a great American.
Lt. Mike Sarber was a combat medic during the Gulf War. He is now a critical care nurse and will become a CRNA. Mike is a motivated, unstoppable, intelligent officer. He knows how to get the job done and he does it well. He is inspiring and a leader.
On my right is Lt. Vicky Tubens. Vicky is a terrific nurse. Despite being from New York, she is soft spoken and always appears happy. She works hard but is never boastful. She is just the type of person you enjoy working with because you know that she does not have some ulterior motive... she simply loves to help people. On my left is Lt. Jody Thorpe. Jody joined the Army immediately after 9/11 as an enlisted soldier and as a young mother. She has served in Landstuhl and now has become a nurse and an officer. Jody is cool and professional. I admire her for her ability to raise a child and serve our country with a smile. People like Jody (and most definitely, my wife Mary) are incredible. Their ability to work, raise children and attend school simply makes men look like little cry babies.
Last, but certainly not least is Capt. Shane Taylor. Capt. Taylor is now a dentist who served during Gulf War I as a combat engineer. He was my "Battle Buddy" during OBLC and I was darn lucky for it. Capt. Taylor was more of an "under the radar" kind of guy. You could not tell the depth that he had personally nor professionally. He was happy just being a friend. Interestingly, he should be a Major or possibly a LTC, but some paper work SNAFU put him in the National Guard as a Captain. He didn't say anything about it. Only after some time of getting to know him, and by me asking directly did he even mention the error. The point being that he was there serving with a smile.... not griping about some stupid rank on his chest. Capt. Taylor is a fine gentlemen and a heck of a terrific land-navigator (He made this old Cav Scout look great during the land navigation courses).
These are just a few examples of the many many many people that I had the fortune to spend a few weeks with in Fort Sam Houston. There really are so many more, but I fear any reader would be quite bored if I droned on any longer. I know they're not super heroes. I know that if you saw them on the street, they would be just like anyone else. But they're not. They are people that really care about others and they will help others knowing the sacrifice that it will take from themselves and their families. They volunteer their time and their skill for the men and women of our Armed Forces. They are great people. God bless them.