Return to Research+Publications This article appeared in the April 16th issue of The Orange County Register. Author: Mayrav Saar Photos: Ygancio Nanetti More with Less: Medical science tries to fight disease with minimally invasive procedures The future promises virtually painless medicine. "Smart" surgical tools that will disable rather than allow surgeons to make the wrong cut. Viruses that are genetically engineered to deliver medicine, rather than illness, to the body. Tiny robots dispatched through the blood stream like minute vigilantes, looking for a rumble with diseased cells.		Dr. Kenneth Chang introduces a probe into patient Arnold Wroblewski's esophagus. Guided by monitors, he will take several biopsies of a pancreatic tumor. Then, using an endoscope, he will administer a new type of altered gene therapy in hope of fighting the cancer.
Researchers around the world are working on new minimally invasive procedures, and the standard line is that any given technology is "five to 10 years away" from reality. But some of that technology is much, much closer. The University of California, Irvine, last year purchased a da Vinci Surgical System, which uses robotics and real-time 3-D video to do laparoscopic surgeries. St. Joseph Hospital is in the process of purchasing a da Vinci, too. Saddleback Memorial Medical Center recently started offering Deep Brain Stimulation procedures, which involve running a pulsating wire through a tiny incision in the scalp to control the tremors of Parkinson's disease. Hoag Memorial Hospital Presbyterian is preparing to use video-assisted robotic surgery in its cardiac surgery department. So what happens when your doctor tells you that she wants you to try the stuff of tomorrow today? Since the 1960s, researchers have been trying to make medicine less invasive, less painful and more precise. While doctors can't eradicate disease with "Star Trek" exactness, physicians are now able to offer less devastating alternatives to drastic surgeries and toxic medication. But as medicine marches toward the future, patients need to understand their options. Small Tools, Big Questions UCI gastroenterologist Dr. Kenneth Chang is director of the Chao Comprehensive Digestive Disease Center, which opened in February with a team of internists, gastroenterologists, oncologists and laparoscopic surgeons who tackle any number of digestive diseases and disorders. The team also focuses on innovative, experimental procedures that offer patients the opportunity to choose easier treatments that have faster recovery times and smaller incisions, if any incisions at all. He and his team screen patients to see if they are appropriate candidates for experimental procedures that could help push medicine in new, less trying directions.
"If a patient came to me and said, 'I don't want to be a guinea pig,' we offer standard therapies-chemotherapy, radiation and so on," Chang said. For those who are intrigued by the latest technology, Chang suggests the experimental minimally invasive procedures. But he explains that not everything is known about all of these procedures' safety and efficacy. And even minimally invasive procedures that have been around for a decade-such as the laparoscopic removal of the kidney-might not be your particular physician's strong suit. So Chang recommends patients question their doctors as vigorously about small incisions as they would about great big ones.		Arnold Wroblewski has an altered gene injected into his pancreatic tumor during a minimally invasive surgery in February at UCI.
He suggests asking: If it's a clinical trial, ask, "What is the concept behind this? How does it differ from the standard treatment, and what data are available about it?" Sometimes it could just be animal data because they haven't tested it in humans yet," Chang said. What is known about the safety of the minimally invasive procedure vs. the standard procedure? Recovery time is likely to be quicker for the minimally invasive procedure-generally the smaller the incision, the less blood loss there is and the faster the patient goes home. But what about the safety of the procedure itself? "They need to hone in not just on the efficacy but on what the potential complications are," Chang said. How long will you be under anesthesia? Some physicians who are just learning a technique will take longer to do a minimally invasive procedure than a standard operation. How many of these procedure has your doctor done? If it were your mother, would you recommend she have this done? "In some ways, that's the best question," Chang said.
Fixing big problems with small solutions. enlarge image
A Hurricane of Tiny Forces Patients also need to know that newer isn't always better. Dr. Aiden Raney, medical director of Hoag's cardiac surgery department, said he looks warily at the expensive new tools that promise small cuts and faster recovery time. Often what isn't state in the flossy brochures doctors get is whether the procedures are any less precise than standard surgery. Two years ago, Raney sat in on a minimally invasive surgery that used an "intuitive device," or robot to replace a patient's heart valve. After the surgery, the physicians discovered that the valve was leaking. The patient was cut open and a standard valve replacement was done. "I can't compromise a valve repair just so my patients can have a smaller incision. I'm not helping the patient," Raney said. "I'm not against it, by any means, but it's not ready for prime time." Raney conceded that the techniques will never be ready for wide-spread use, if they're not tested out a brave few. One week before Christmas, doctors told Arnold Wroblewski, 73, that he had a large cancerous tumor in his pancreas. It was too big to remove surgically. He could get radiation to try and shrink the tumor, while taking chemotherapy to fight the cancer. But Chang had another idea. He proposed Wroblewski participate in a phase-1 clinical trial to test whether a virus containing the DNA of an immune-cell protein, injected through an endoscope directly into the pancreatic tumor, could deliver a disease-fighting protein right to the cancer's front door. "After rolling this around in my mind for about a day or two, I though, 'Why not?'" Wroblewski said. On March 21, Wroblewski had his final biopsy to see if he has any remaining cancer cells. His tumor was reduced by at least 65 percent. What remains is mostly scar tissue and will be removed surgically. Wroblewski is glad he made the decision he did. "The results that I understand from it are sort of mind-boggling to me that it almost makes me cry to think about it," he said. "I feel so lucky."

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