Yoav Medan: Ultrasound surgery -- healing without cuts

Prevoditelj: Senzos Osijek Recezent: Tilen Pigac - EFZG

Over the last 13 years --

Tijekom posljednjih 13 godina --

one, three, 13 years --

jedne, tri, 13 godina --

I've been part of an exceptional team at InSightec in Israel

bio sam dio jedinstvenog tima u InSightec-u u Izraelu

and partners around the world

i partneri iz cijelog svijeta

for taking this idea, this concept,

zbog provođenja ove ideje, ovog koncepta,

noninvasive surgery,

neinvazivne operacije,

from the research lab to routine clinical use.

od istraživačkog laboratorija do rutinske kliničke upotrebe.

And this is what I'll tell you about.

I to je ono o čemu ću vam govoriti.

13 years --

13 godina --

for some of you, you can empathize with that number.

neki od vas mogu suosjećati s tom brojkom.

For me, today, on this date,

Za mene , danas, ovaj dan,

it's like a second bar mitzvah experience.

ovo je poput druge bar mitzve.

(Laughter)

(Smijeh)

So this dream

Dakle, ovaj san

is really enabled

je zapravo omogućen

by the convergence

konvergencijom

of two known technologies.

dviju poznatih tehnologija.

One is the focused ultrasound,

Jedna je fokusirani ultrazvuk,

and the other one is the

a druga je

vision-enabled magnetic resonance imaging.

magnetna rezonanca koja omogućava slikoviti prikaz.

So let's first talk about focused ultrasound.

Pa, hajdemo prvo razgovarati o fokusiranom ultrazvuku.

And I hold in my hand

Ja u ruci držim

a tissue-mimicking phantom.

fantoma koji predstavlja tkivo.

It is made out of silicon.

Napravljen je od silikona.

It is transparent, made just for you.

Proziran je, napravljen samo za vas.

So you see, it's all intact,

Kao što vidite, sve je netaknuto,

completely transparent.

potpuno prozirno.

I'll take you now to the acoustic lab.

Sada ću vas odvesti do zvučnog laboratorija.

You see the phantom within the aquarium.

Vidite fantoma u akvariju.

This is a setup I put in a physics lab.

Ovo je instalacija koju sam sastavio u laboratoriju fizike.

On the right-hand side,

Na desnoj strani

you see an ultrasonic transducer.

vidite ultrazvučni transduser.

So the ultrasonic transducer

Dakle, ultrazvučni transduser

emits basically an ultrasonic beam

emitira zapravo ultrazvučnu zraku

that focuses inside the phantom.

koja se fokusira unutar fantoma.

Okay, when you hear the click,

OK, kada čujete klik,

this is when the energy starts to emit

tad će se energija početi emitirati

and you see a little lesion form

i vidjet ćete malu leziju

inside the phantom.

unutar fantoma.

Okay, so everything around it

OK, dakle, sve okolo

is whole and intact.

je čitavo i netaknuto.

It's just a lesion formed inside.

Imamo samo leziju formiranu unutra.

So think about, this is in your brain.

Zamislite da je ovo u vašem mozgu.

We need to reach a target inside the brain.

Mi trebamo dosegnuti metu unutar vašeg mozga.

We can do it without harming any tissue.

Mi to možemo učiniti bez ozljeđivanja bilo kojeg tkiva.

So this is, I think,

Ovo je, po mom mišljenju,

the first kosher Hippocratic surgical system.

prvi kosher hipokratični operacijski sustav.

(Laughter)

(Smijeh)

Okay, so let's talk a little bit about ultrasound,

OK, hajdemo malo pričati o ultrazvuku,

the force of ultrasound.

o snazi ultrazvuka.

You know all about imaging, right, ultrasound imaging.

Vi znate sve o slikama, je li tako, o ultrazvučnim slikama.

And you know also about lithotripsy --

I također znate o litotripsiji --

breaking kidney stones.

razbijanju bubrežnih kamenaca.

But ultrasound can be shaped

Međutim, ultrazvuk može biti oblikovan

to be anything in between,

da bude bilo što između,

because it's a mechanical force.

jer je on mehanička sila.

Basically, it's a force acting on a tissue

U osnovi, to je sila koja djeluje na tkivo

that it transverses.

koje mu se preprečava.

So you can change the intensity, the frequency,

Tako da možete mijenjati intenzitet, frekvenciju,

the duration, the pulse shape of the ultrasound

trajanje, oblik pulsa ultrazvuka

to create anything

kako bi oblikovao bilo što

from an airbrush to a hammer.

od zračnog kista do čekića.

And I am going to show you

A ja ću vam pokazati

multiple applications in the medical field

višestruke primjene u polju medicine

that can be enabled

koje mogu biti omogućene

just by focusing,

samim fokusiranjem,

physically focusing.

fizikalnim fokusiranjem.

So this idea

Stoga, ova ideja

of harnessing focused ultrasound to treat lesions in the brain

o korištenju fokusiranog ultrazvuka za liječenje lezija na mozgu,

is not new at all.

nije uopće nova.

When I was born, this idea was already conceived

Kada sam rođen, ova ideja je već bila začeta

by pioneers such as the Fry brothers

od strane pionira poput braće Fry

and Lars Leksell,

i Larsa Leksella,

who is know actually

koji je također poznat

as the inventor of the gammaknife.

kao izumitelj gamma noža.

But you may not know

Ali ono što možda ne znate

that he tried to perform lobotomies in the brain,

je da je on pokušao izvesti lobotomiju mozga,

noninvasively,

neinvazivno,

with focused ultrasound in the '50s.

s fokusiranim ultrazvukom u pedesetima.

He failed,

On nije uspio,

so he then invented the gammaknife.

pa je onda izumio gamma nož.

And it makes you ponder

Zanima vas zašto

why those pioneers failed.

ti pioniri nisu uspjeli.

And there was something fundamental

Tu je postojalo nešto osnovno

that they were missing.

što im je nedostajalo.

They were missing the vision.

Nedostajala im je slika.

It wasn't until the invention of the MR

Tek nakon izuma MR-a

and really the integration of MR

i istinske integracije MR-a

with focused ultrasound

s fokusiranim ultrazvukom

that we could get the feedback --

mogli smo dobiti povratnu informaciju --

both the anatomical and the physiological

i anatomsku i fiziološku

in order to have a completely noninvasive, closed-loop

s ciljem postignuća potpuno neinvazivne,

surgical procedure.

operacije zatvorene petlje.

So this is how it looks, you know,

Dakle, ovako izgleda

the operating room of the future today.

operacijska sala iz budućnosti danas.

This is an MR suite with a focused ultrasound system.

Ovo je MR odijelo s fokusiranim ultrazvučnim sustavom.

And I will give you several examples.

A ja ću vam dati nekoliko primjera.

So the first one is in the brain.

Dakle, prvi je na mozgu.

One of the neurological conditions

Jedan od neuroloških stanja

that can be treated with focused ultrasound

koji je moguće liječiti fokusiranim ultrazvukom

are movement disorders,

su poremećaji motorike,

like Parkinson's or essential tremor.

poput Parkinsonovog ili esencijalnog tremora.

What is typical to those conditions,

Ono što je tipično za ta stanja,

to essential tremor for example,

primjerice za esencijalni tremor,

is inability

je nemogućnost pacijenata

to drink or eat cereal or soup

da piju ili jedu žitarice ili juhu

without spilling everything all over you,

bez prosipanja svega po sebi,

or write legibly so people can understand it,

ili da čitljivo pišu kako bi ljudi mogli razumjeti,

and be really independent in your life

te da su uistinu neovisni u svom životu

without the help of others.

bez pomoći drugih ljudi.

So I'd like you to meet John.

Volio bih da upoznate Johna.

John is a retired professor of history

John je umirovljeni profesor povijesti

from Virginia.

iz Virginie.

So he suffered from essential tremor for many years.

On je bolovao od esencijalnog tremora mnogo godina.

And medication didn't help him anymore.

I lijekovi mu više nisu pomagali.

And many of those patients refused to undergo surgery

I mnogi od tih pacijenata odbijaju podvrći se operaciji,

to have people cut into their brain.

dopustiti ljudima da im režu mozak.

And about four or five months ago,

Prije četiri ili pet mjeseci,

he underwent an experimental procedure.

on je podvrgnut eksperimentalnom postupku.

It is approved under an FDAIDE

On je odobren od strane FDAIDE

at the University of Virginia

na Sveučilištu Virginia

in Charlottesville

u Charlottesvillu

using focused ultrasound

koristeći fokusirani ultrazvuk

to ablate a point in his thalamus.

kao oštricu, ciljna točka bila je u njegovom talamusu.

And this is his handwriting.

A ovo je on rukom napisao.

"On June 20th," if you can read it,

“Lipanj 20.,” ako možete pročitati

"2011."

“2011”.

This is his handwriting

Ovo je rukom napisao

on the morning of the treatment

u jutro tretmana

before going into the MR

prije odlaska na MR.

So now I'll take you through

Sada ću vam pokazati

[what] a typical procedure like that looks like,

kako tipični postupak izgleda,

[what] noninvasive surgery looks like.

kako neinvazivna operacija izgleda.

So we put the patient on the MR table.

Stavimo pacijenta na MR stol.

We attach a transducer, in this case, to the brain,

Pričvrstimo transduser, u ovom slučaju na mozak,

but if it will be a different organ,

ali ako bi u pitanju bio drugi organ,

it will be a different transducer attached to the patient.

bio bi drugačiji transduser pričvršćen na pacijenta.

And the physician

Zatim liječnici

will then take a regular MR scan.

naprave normalanu MR sliku.

And the objective of that?

Koja je svrha toga?

I don't have a pointer here,

Nemam pokazivač ovdje,

but you see the green, sort of rectangle or trapezoid?

ali možete li vidjeti zeleni pravokutnik ili trapez?

This is the sort of general area of the treatment.

To je glavna regija za tretman.

It's a safety boundary

Postoji sigurna granica

around the target.

oko mete.

It's a target in the thalamus.

Meta je talamus.

So once those pictures are acquired

U onom trenutku kad se slike dobiju

and the physician has drawn

i liječnk nacrta

all the necessary safety limits and so on,

sve potrebne osiguravajuće granice i tako dalje,

he selects basically a point --

on zapravo odabire točku --

you see the round point in the middle where the cursor is --

vidite okruglu točku u sredini gdje je pokazivač --

and he presses this blue button called "sonicate."

i pritisne plavi gumb nazvan “ozvuči”.

We call this instance of injecting the energy,

Mi taj trenutak ubrizgavanja energije

we call it sonication.

zovemo ozvučivanje.

The only handwork the physician does here

Jedini ručni rad koji liječnik ovdje

is moving a mouse.

radi je pomicanje miša.

This is the only device he needs in this treatment.

To je jedini uređaj koji mu je potreban za ovaj tretman.

So he presses "sonicate," and this is what happens.

Kad on pritisne “ozvuči” ovo se dogodi.

You see the transducer, the light blue.

Vidite transduser, svijetlo plavi.

There's water in between the skull and the transducer.

Ovdje je voda između lubanje i transdusera.

And it does this burst of energy.

Ona radi ovu eksploziju energije.

It elevates the temperature.

To podiže temperaturu.

We first need to verify

Prvo moramo potvrditi

that we are on target.

da smo na meti.

So the first sonication

Tako da je prvo ozvučivanje

is at lower energy.

na nižoj energiji.

It doesn't do any damage,

Ono ne radi nikakvu štetu,

but it elevates the temperature

nego podiže temperaturu

by a few degrees.

za nekoliko stupnjeva.

And one of the unique capabilities

Jedna od jedinstvenih sposobnosti

that we leverage with the MR

MR-a

is the ability to measure temperature noninvasively.

je neinvazivna sposobnost mjerenja temperature.

This is really a unique capability of the MR.

To je uistinu jedinstvena sposobnost MR-a.

It is not being used

To se inače ne koristi

in regular diagnostic imaging.

u normalnoj dijagnostici.

But here we can get

Ali ovdje, mi možemo dobiti

both the anatomical imaging and the temperature maps in real time.

i anatomski prikaz i temperaturne mape u stvarnom vremenu.

And you can see the points there on the graph.

Možete vidjeti točke ovdje na grafu.

The temperature was raised

Temperatura je privremeno podignuta

to 43 degrees C temporarily.

na 43 stupnja C.

This doesn't cause any damage.

To ne uzrokuje nikakvu štetu.

But the point is we are right on target.

Bit ovoga je da smo točno na meti.

So once the physician verifies

Jednom kad liječnik potvrdi

that the focus spot is on the target he has chosen,

da je točka fokusa na meti izabrana,

then we move to perform

onda učinimo

a full-energy ablation

punoenergetsko odsijecanje

like you see here.

kao što ovdje možete vidjeti.

And you see the temperature rises

Možete vidjeti da temperatura raste

to like 55 to 60 degrees C.

na otprilike 55 do 60 stupnjeva C.

If you do it for more than a second,

Ako to radite duže od sekunde,

it's enough to basically destroy

to je dovoljno da uništite

the proteins of the cells.

sve proteine u stanici.

This is the outcome from a patient perspective --

Ovo je ishod iz pacijentove perspektive --

same day after the treatment.

isti dan nakon operacije.

This is an immediate relief.

Ovo je trenuračno poboljšanje.

(Applause)

(Pljesak)

Thank you.

Hvala.

John is one of [about] a dozen

John je jedan od desetak

very heroic, courageous people

vrlo hrabrih ljudi

who volunteered for the study.

koji su volontirali u ovoj studiji.

And you have to understand

Morate razumjeti

what is in people's mind

što je tim ljudima na pameti

when they are willing to take the risk.

kada su odlučni prihvatiti taj rizik.

And this is a quote from John after he wrote it.

Ovo je Johnov citat nakon što je to napisao.

He said, "Miraculous."

Rekao je: „Ovo je čudo.“

And his wife said, "This is the happiest moment of my life."

A njegova žena je rekla : „Ovo je najsretniji trenutak moga života.“

And you wonder why.

Pitate se zašto.

I mean, one of the messages I like to carry over

Hoću reći, jedna od poruka koju želim poslati je

is, what about defending quality of life?

kako zaštititi kvalitetu života?

I mean, those people lose their independence.

Ti ljudi izgube svoju neovisnost.

They are dependent on others.

Ovisni su o drugima.

And John today is fully independent.

Danas je John potpuno neovisan.

He returned to a normal life routine.

Vratio se normalnoj životnoj rutini.

And he also plays golf,

Također igra golf,

like you do in Virginia

kao što se to radi u Virginiji

when you are retired.

kad si umirovljen.

Okay, so you can see here the spot.

Ok, možete ovdje vidjeti ovu maglu.

It's like three millimeters in the middle of the brain.

Otprilike 3 mm u sredini mozga.

There's no damage outside.

Nema štete vani.

He suffers from no neurodeficit.

On ne boluje od neurološkog deficita.

There's no recovery needed, no nothing.

Nije potreban oporavak, ništa.

He's back to his normal life.

Može se vratiti svom normalnom životu.

Let's move now

Prijeđimo sad

to a more painful subject.

na bolniju temu.

Pain is something

Bol

that can make your life miserable.

može učiniti vaš život lošim.

And people are suffering from all kinds of pain

A ljudi pate od različitih bolova

like neuropathic pain, lower-back pain

poput neuropatskih bolova, bolova u križima

and cancer pain from bone metastases,

te bol koju izazivaju koštane metastaze,

when the metastases get to your bones,

kada metastaze dođu do vašeg mozga,

sometimes they are very painful.

ponekad je vrlo bolno.

All those I've indicated

Sve ovo što sam nabrojao

have already been shown

pokazalo se

to be successfully treated

da može biti uspješno liječeno

by focused ultrasound

fokusiranim ultrazvukom,

relieving the pain, again, very fast.

uklanjajući bol, opet, vrlo brzo.

And I would like to tell you

Htio bih vam pričati

about PJ.

o PJ.

He's a 78 year-old farmer

On je 78- godišnji farmer

who suffered from -- how should I say it? --

koji je bolovao od -- kako da to kažem? --

it's called pain in the butt.

zove se bolovi u guzi.

He had metastases in his right buttock,

Imao je metastaze u svom desnom dijelu stražnjice,

and he couldn't sit

sjediti nije mogao

even with medication.

čak ni s lijekovima.

He had to forgo all the farm activities.

Morao je zaboraviti sve aktivnosti na farmi.

He was treated with radiation therapy,

Liječen je radioterapijom,

state-of-the-art radiation therapy,

najsuvremenijom radioterapijom,

but it didn't help.

ali nije pomoglo.

Many patients like that favor radiation therapy.

Mnogim pacijentima poput njega pomaže radioterapija.

And again, he volunteered

Dakle, on se prijavio

to a pivotal study

za središnju studiju

that we ran worldwide,

koju smo proveli širom svijeta,

also in the U.S.

također u SAD-u.

And his wife actually took him.

Zapravo ga je dovela njegova žena.

They drove like three hours

Vozili su se oko tri sata

from their farm to the hospital.

od njihove farme do bolnice.

He had to sit on a cushion,

Morao je sjediti na jastučiću,

stand still, not move,

mirno stajati, bez micanja,

because it was very painful.

jer je bilo vrlo bolno.

He took the treatment,

Primio je tretman

and on the way back,

i na povratku

he drove the truck by himself.

on sam je vozio kamionet.

So again, this is an immediate relief.

Ponavljam, ovo je trenutačno poboljšanje.

And you have to understand

Morate razumjeti

what those people feel

kako se ti ljudi osjećaju

and what their family experiences

i što njihove obitelji iskuse

when it happens.

kad se to dogodi.

He returned again

On se vratio

to his daily routine on the farm.

svojoj dnevnoj rutini na farmi.

He rides his tractor.

Vozi traktor.

He rides his horse to their mountain cabin regularly.

Redovito jaše konja kad ide u njihovu planinsku kolibu.

And he has been very happy.

Te je vrlo sretan.

But now, you ask me,

Sad me pitate,

but what about war, the war on cancer?

ali što s ratom protiv raka?

Show us some primary cancer.

Pokaži nam neki primarni karcinom.

What can be done there?

Što bi se tu moglo učiniti?

So I have good news and bad news.

Imam dobre i loše vijesti.

The good news: there's a lot that can be done.

Dobre vijesti: postoji puno toga što se može učiniti.

And it has been shown actually outside of the U.S.

I to je zapravo pokazano izvan SAD-a.

And doing that in the U.S.

U SAD-u

is very painful.

je to vrlo bolno.

I don't see, without this nation

Ne vidim kako bi se to ostvarilo

taking it as some collective will

bez da ova nacija na to gleda kao nekakvu kolektivnu volju

or something that is a national goal to make that happen,

ili tako nešto što je nacionalni cilj

it will not happen.

koji se treba ostvariti.

And it's not just because of regulation;

Nije samo zbog odredbi,

it's because of the amount of money needed

također i zbog svote novca koja je potrebna

under the current evidence-based medicine

na trenutnoj

and the size of trials and so on

medicini utemeljenoj na dokazima

to make it happen.

te veličini kliničkih pokusa itd.

So the first two applications

Prve dvije primjene

are breast cancer and prostate cancer.

su rak dojke i rak prostate.

They were the first to be treated by focused ultrasound.

Oni su prvi liječeni fokusiranim ultrazvukom.

And we have better-than-surgery results in breasts.

U slučaju dojke imamo rezultate koji su bolji od rezultata dobivenih operacijom.

But I have a message for the men here.

Ali ovdje imam poruku za muškarce.

We heard here yesterday Quyen

Jučer smo ovdje čuli Guillena

talking about the adverse event trait

kako govori o negativnom učinku poteza

in prostate cancer.

kod raka prostate.

There is a unique opportunity now

Sada postoji jedinstvena mogućnost

with focused ultrasound guided by MR,

s fokusiranim ultrazvukom nadgledanim MR-om

because we can actually think about

jer sad zapravo možemo razmišljati o

prostate lumpectomy --

uklanjanju kvržica na prostati --

treating just the focal lesion

tretirajući samo fokalnu leziju

and not removing the whole gland,

te ne odstranjivanju cijele žlijezde

and by that, avoiding all the issues

te time izbjegavajući sve probleme

with potency and incontinence.

s potencijom i inkontinencijom.

Well, there are other cancer tumors in the abdomen --

Postoje i drugi tumori u abdomenu --

quite lethal, very lethal actually --

prilično malo, zapravo jako malo --

pancreas, liver, kidney.

gušterača, jetra, bubreg.

The challenge there

Izazov ovdje

with a breathing and awake patient --

s budnim pacijentom koji diše --

and in all our treatments,

a u svim našim tretmanima

the patient is awake and conscious

pacijent je budan i svjestan

and speaks with the physician --

i priča s liječnikom --

is you have to teach the MR some tricks

je da moramo naučiti MR neke trikove

how to do it in real time.

kako da to napravimo u stvarnom vremenu.

And this will take time.

A to zahtjeva vremena.

This will take two years.

To traje dvije godine.

But I have now a message to the ladies.

Sada imam poruku za dame.

And this is, in 2004,

U 2004.

the FDA has approved MR-guided focused ultrasounds

FDA je odobrila upotrebu MR-om nadziranog fokusiranog ultrazvuka

for the treatment of symptomatic uterine fibroids.

za liječenje simptomatičnih mioma maternice.

Women suffer from that disease.

Mnoge žene boluju od ove bolesti.

All those tumors

Svi ti tumori

have heavy bleeding during periods,

uzrokuju teška krvarenja tijekom menstruacijskog ciklusa,

abdominal pressure, back pain,

pritisak u abdomenu, bol u leđima,

frequent urination.

učestalo mokrenje.

And sometimes, they cannot even conceive and become pregnant

A ponekad, one ne mogu začeti i zatrudnjeti

because of the fibroid.

zbog mioma.

This is Frances.

Ovo je Frances.

She was diagnosed with a grapefruit-sized fibroid.

Diagnosticiran joj je miom veličine grejpa.

This is a big fibroid.

To je velik miom.

She was offered a hysterectomy,

Ponuđeno joj je uklanjanje maternice,

but this is an inconceivable proposition

ali to je neprihvatljiv prijedlog

for someone who wants to keep her pregnancy option.

nekomu tko želi zadržati opciju trudnoće.

So she elected to undergo a focused ultrasound procedure

Stoga je izabrala podvrći se fokusiranom ultrazvuku

in 2008.

u 2008.

And in 2010, she became a first-time mother to a healthy baby.

2010. prvi put je postala majka zdravom djetetu.

So new life was born.

Tako je rođen novi život.

(Applause)

(Pljesak)

So in conclusion,

U zaključku

I'd like to leave you with actually four messages.

htio bih vas ostaviti zapravo s četiri poruke.

One is, think about the amount

Jedna je da razmislite o količini

of suffering that is saved

patnje od koje su spašeni

from patients undergoing noninvasive surgery,

pacijenti koji se podvrgnu neinvazivnoj operaciji,

and also the economical and emotional burden

također i ekonomski i emocijalni teret

removed from their families and communities

kojeg su oslobođene njihove obitelji i zajednica

and the society at large --

te društvo općenito --

and I think also from their physicians, by the way.

usput, također i njihovi liječnici.

And the other thing I would like you to think about

Druga stvar o kojoj bih htio da razmislite je

is the new type of relationship

novi odnos

between physician and patients

između pacijenta i liječnika

when you have a patient on the table

kada imate pacijenta na stolu

[who] is awake and can even monitor the treatment.

koji je budan i može čak pratiti tretman.

In all our treatments,

U svim našim tretmanima,

the patient holds a stop sonication button.

pacijent drži gumb za zaustavljanje ozvučivanja.

He can stop the surgery at any moment.

On može prekinuti operaciju u bilo kojem trenutku.

And with that note,

I s tom porukom

I would like to thank you for listening.

htio bih vam zahvaliti na slušanju.

(Applause)

(Pljesak)