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ROBOTIC PANCREATECTOMY SPEEDS RECOVERY TIME
Eighty-year-old Lois Taylor is getting a big kick out of telling everyone she knows that she’s a celebrity.
And she’s not wrong. Lois is the first person at Vanderbilt University Medical Center (VUMC) to undergo a fully robot-assisted, minimally invasive colon and liver resection to remove cancer performed by two surgeons under a single anesthesia.
The Russellville, Kentucky, resident came to VUMC after a routine colonoscopy in her hometown revealed a 3-centimeter lesion. She was referred to a surgeon and was shocked to learn the diagnosis: stage 4 colon cancer. Imaging revealed that her cancer had metastasized to her liver.
Overwhelmed, Lois listened to two proposals to treat the cancer from clinicians at other medical facilities. Both involved open surgeries, meaning large, open incisions to remove cancerous tissue. She was also told she wouldn’t likely be scheduled for surgery for a month or longer.
Her daughter, Geneva Taylor, has always marveled at her mom’s unflagging vitality and positivity. But she wasn’t so sure she could survive one or two major, open surgeries at her age, especially knowing there would be an extended period of postsurgery recovery and rehabilitation, likely followed by chemotherapy.
Geneva, who is Lois’ only child, is determined that one day her mom will hold her first grandchild, and both women were not at all convinced they heard the best option to make that possible.
“I CALLED VANDERBILT AND WAS CONNECTED" to a patient advocate who, after they taught me how to share her records, bumped Mom’s appointment up to the very next week,” Geneva said. “That was amazing because when you hear that your mom has stage 4 cancer, you don’t want to wait a month or six weeks just to establish new patient care.”
The pair met with medical oncologist Rajiv Agarwal, MD, assistant professor of Medicine, Hematology and Oncology at Vanderbilt-Ingram Cancer Center. The mother and daughter quickly noticed a difference in how they were involved in decision-making during the consultation. Agarwal turned his computer screen around so they could follow along as he pointed out areas of concern on the scans of Lois’ colon and liver. He answered every question and put them both at ease.
Agarwal recommended an immediate consultation with his surgical colleague Kamran Idrees, MD, MSCI, MMHC, Ingram Associate Professor of Cancer Research, chief of the Division of Surgical Oncology and Endocrine Surgery, and director of Pancreatic and Gastrointestinal Surgical Oncology. Idrees has a global reputation as a leader in innovative surgical approaches to pancreatic and gastrointestinal cancers and is highly skilled in robot-assisted procedures.
“Ten years ago, we likely would have done at least one of these surgeries open or both of them open,” Idrees said. “We had a frank discussion with Lois and her daughter, Geneva, about the pros and cons of doing this procedure. The simultaneous presentation of liver metastases with a stage 4 presentation of colorectal cancer is not common, but we felt like she had a good functional status. We felt that she could tolerate both surgeries. And we know for a fact, that when we do robotic surgeries, we can do the same oncological or cancer operation that we need to do, and the recovery is faster.
“The liver is a completely sterile organ, so the risk of any infectious complication is really low. The colon is the polar opposite, full of bacteria. When the goal is to combine the two procedures, then the risk of infection goes up slightly. In carefully selected patients we can do the resections simultaneously,” Idrees said.
“Dr. Idrees involved Mom in the decision-making,” Geneva said. “He showed us the lesions on her liver and explained the difference between open surgery or a robotic surgery. After weighing our options and knowing Mom is 80, we knew we didn’t want her to have to recover from being open from basically sternum to pelvis. We decided we really wanted to do a robotic surgery. ”
In open surgery, a large incision is made in the abdomen or pelvis, and the procedure is performed by a surgeon’s hands. In robot-assisted surgery, a surgeon manipulates a robot’s surgical tools through much smaller incisions while guided visually by a high-definition image captured by a three-dimensional camera on the tip of one of the robotic arms. Additional imaging such as CT or MRI scans can also be referenced for guidance during robot-assisted procedures.
The magnified view, as well as the dexterous, slender robotic arms allow the surgeon to clearly see and access areas that can often be difficult with traditional surgical techniques. Robot-assisted surgery typically results in less postoperative pain and fewer complications, as well as fewer days in the hospital and a quicker recovery time. This means if chemotherapy is required after cancer is surgically removed patients can begin this next stage of treatment sooner.
“Some might make the argument that for an 80year-old patient combining two big surgeries does not make sense,” Idrees said. “On the other hand, putting someone this age through two different anesthetics and two surgeries at two different points in time may not be wise. You have to use clinical judgement in conjunction with the anesthesia team and all the involved parties. We felt like we could do it; we knew it was technically feasible; and we felt it would benefit this patient.”
Lois said she was never nervous about the procedures.
“I knew I had to have it done,” she said. “So, I said, ‘Get it out of here!’”
Idrees explained that he was one-half of the surgical equation, as he would be addressing only the cancer in Lois’ liver in the operating room. He knew just who to call for the colon resection — his colleague and expert in robot-assisted surgeries, Aimal Khan, MD, FACS assistant professor of Surgery.
“I called the OR scheduler, Dora Snider, who’s incredible,” Khan said. “I told her we need to do this now, and we need to find time on a robot. You can’t just walk in, and a robot is waiting for you. Dora found us the room and the robot. We cleared our schedules, and we were operating within a week.”
Although they each had a game plan for their own surgery going in, the surgeons met in the operating room before the procedures began to marry the plans together and set up the robot, so both parts of the operation could be performed using the same incisions. The goal was to be as minimally invasive for their patient as possible, despite performing two significant procedures.
The surgeons marked where the incisions would best be placed for the access they needed, then they made small compromises, so only one set of incisions would be used to easily and safely achieve both resections.
Then Idrees began his surgery. A liver resection, or hepatectomy, is considered a technically difficult surgery, whether a surgeon is assisted by a robot or not. One reason is because the liver is laced with a network of small and large blood vessels, which can lead to substantial bleeding. The procedure is best performed by a highly experienced surgeon, such as Idrees, who can carefully navigate these vessels to remove only the cancerous tissue, leaving a clear margin.
During the surgery, Lois had enough blood loss that she required the transfusion of blood products. The surgeons and anesthesiology team watched her vital signs closely and paused to confer on whether it was wise to continue with the colon resection. Lois’ safety was always first in mind.
After a short break, she had stabilized, and Khan was able to begin the colon resection. An important factor for patients undergoing colorectal cancer surgery is the potential need for a colostomy. “Our anesthesia colleagues did an excellent job of stabilizing her in the middle of surgery, so I was able to remove the cancer and connect her colon back together, avoiding a colostomy,” Khan said.
Lois was up and walking unassisted within 24 hours of surgery. After she was discharged from the hospital, she went back home to Russellville, Kentucky, to continue what she calls an easy recovery. Geneva laughs when sharing that she would remind her mom to take her postsurgical medication, gabapentin, and Tylenol, for pain. Lois would often take just one Tylenol because she felt she didn’t need the prescription medication.
“I never got really sore after surgery,” she said. “Just a tiny bit, and it never bothered me once I got home. I got a little bit sick from the anesthesia, but I always do. That was it.”
Lois is finishing a 12-week course of chemotherapy overseen by Agarwal for “insurance” against a recurrence of the colon cancer, but she said it’s been much easier than she anticipated. She’s back to baking her famous rum cakes (she even treated Agarwal and his staff to one) and whipping up Southern-style meals for her family.
“I’m doing great,” she said. “I get tired more easily, but I haven’t been sick whatsoever. I’ve never taken any medicine for nausea. I’m gaining some weight, too. Everybody at Vanderbilt did such a great job taking care of me, and I’m so thankful for them.”
Khan and Idrees are hopeful that this success with synchronous robot-assisted colon and liver resections will lead to more such procedures at the Medical Center when the right patients are identified.
“It’s one of those things that when you do it, people then start realizing that we have the ability and the tools,” Khan said. “Not every patient will be a candidate for this, but for the patients that are, the benefits are going to be tremendous. And it may mean the difference between recovering from the surgery and maybe never recovering from it.”
For Idrees and Khan, the logic behind combining the two surgeries in one operating room, assisted by one robot, was never about achieving a first at the Medical Center, but rather about doing the best procedure to benefit the patient most with the highest likelihood of a good postsurgical outcome.
“The way I see it as a division chief, if we were going to move forward, the goal is always the best possible patient outcome, not personal accolades,” Idrees said. “Lois’ overall care highlights the strength of Vanderbilt-Ingram Cancer Center in regards to comprehensive multidisciplinary care, with multiple specialties including medical oncology, surgery and anesthesia under one roof, for cancer patients.”
“These are two major surgeries,” Khan said. “You must have the perfect team to do this. I would love to think that this success was the result of Dr. Idrees and my technical prowess, but it wasn’t. It was the OR staff, anesthesia and the nurses who help us with the robot. It was having the right technology. It was being here at VUMC where we have one of the best anesthesia teams in the country who can step in if a patient begins having issues. It was a team effort every step of the way.”
ROBOTIC PANCREATECTOMY SPEEDS RECOVERY TIME
Johnny Cleveland thought he was having a heart attack when he went to a community hospital, but medical imaging revealed something suspicious with his pancreas.
The retired educator from Red Bay, Alabama, then went to Birmingham for more testing where he was diagnosed with an intraductal papillary mucinous neoplasm — a cyst in the duct of his pancreas that put him at very high risk for pancreatic cancer. The duct had swollen to four times its normal size. Cleveland knew he needed complicated surgery, so researching his options, he learned about the Vanderbilt surgical team led by Kamran Idrees, MD, MSCI, MMHC, Ingram Associate Professor of Cancer Research.
Idrees, chief of the division of Surgical Oncology and Endocrine Surgery, specializes in difficult-to-perform procedures. His patients include those with pancreatic and other abdominal cancers, as well as premalignant conditions, who have been told their tumors are inoperable. Cleveland went to his initial appointment with Idrees expecting to hear about wide incisions, an extended hospitalization and a long recovery time.
Even though he had a total pancreatectomy — which in his case entailed removing his whole pancreas along with his gallbladder, spleen, duodenum, parts of the stomach and bile duct — Cleveland had only small incisions with no wide cuts. Idrees, working alongside Sekhar Padmanabhan, MD, assistant professor of Surgery, performed the pancreatectomy utilizing robotic technology. They then created two separate connections, one between the bile duct and small intestine, and a second connection between the stomach and the small intestine robotically.
Robotic surgery requires a highly skilled surgeon, who, from a console, uses a powerful camera to see inside the body and controls miniature surgical instruments that can be rotated in ways beyond the dexterity of the human hand.
“I had seven holes produced instead of being cut from side to side and split up and down,” Cleveland said. “My hospital stay was very minimal. It was five days instead of 10-14.”
Idrees has utilized robotic technology for pancreas surgeries since 2019 and has performed more than 100 procedures with colleagues. However, Cleveland was his first patient to undergo a total pancreatectomy utilizing robotic surgery.
Pancreatic surgeries are performed to address premalignant conditions and cancer.
“Robotic surgery offers the advantages of quicker recovery time, shorter length of stay, quick healing and less pain medication requirements,” Idrees said.
Surgeons share parallel journeys
The parallel paths that surgeons Kamran Idrees and Aimal Khan took to combine their skills in an operating room in Nashville, Tennessee, took several decades and more than 7,000 miles.
Khan, MD, assistant professor of Surgery, remembers his first visit to Vanderbilt University Medical Center (VUMC) in 2020 when he was being interviewed as a potential faculty member.
He and Idrees met for dinner and learned that they’d both come from the same state in northern Pakistan (Khyber Pakhtunkhwa) and the same town (Peshawar). In fact, they also both attended the same highly regarded military boarding high school (Cadet College Kohat), nearly an hour’s drive from their hometown.
Then, in mirror step, they attended the same medical school (Aga Khan University) nearly 900 miles from Peshawar in southernmost Pakistan. The two even completed a portion of their surgical training in the United States at the University of Alabama at Birmingham Medical Center. Idrees completed a general surgery residency there in 2008, and Khan completed a minimally invasive and robotic gastrointestinal surgery fellowship there in 2019.
“The funny thing is that we met at VUMC for the first time in our lives,” Khan said. “Dr. Idrees is 14 years my senior. The more he and I chatted, the more we found out we had in common. He said, ‘So basically, you’ve been following me around for 15 years. Everyplace I go, you go too!’
“Now, we frequently collaborate in research and clinical care of colorectal cancer patients. It’s the beauty of the American dream.”
Asked if the two surgeon’s eerily similar backgrounds are beneficial during their collaborations, Khan laughed.
“Well, sometimes the nurses can’t understand us!” he said.
Joking aside, the pair acknowledge that the similarity of their paths has proven serendipitous for their work together, both in the operating room and in the clinic.
“Knowing each other’s credentials and knowing the journey we had to take to come to this place, I think gives us a sense of trust with each other,” Khan said.
Idrees looks at their backgrounds and sees two men who have been laser-focused from the start to find success.
“It’s very rare the way our paths have gone,” Idrees said. “The road to become a surgeon is not easy in the first place. It takes a lot of perseverance. We didn’t go to Ivy League schools. We had to make our way and prove ourselves at each step to be successful. We both did surgical residencies. Then, although most people do one fellowship, we both did two. I did a surgical oncology fellowship at University of Pittsburgh, then a liver and pancreas surgery fellowship at Washington University in St. Louis. He did a minimally invasive surgery fellowship at UAB and a colorectal surgery fellowship at Baylor. We are both driven by the same thing: to do the very best for our patients and to move the field forward.”
Khan is grateful his journey connected with Idrees’ at VUMC so they can work together.
“For us, it began at that first dinner — just hanging out and getting to know each other,” Khan said. “We go to each other’s homes; we invite each other over for dinner. My son’s birthday is coming up soon, and Dr. Idrees will be there. We’re just so lucky to be working in this place, at Vanderbilt, which helps give us the foundation to build these relationships on. These relationships then act like a primer to help our patients.”
