Yoav Medan: Ultrasound surgery -- healing without cuts

Translator: Lenka Tušar Reviewer: Tilen Pigac - EFZG

Over the last 13 years --

Zadnjih trinajst let,

one, three, 13 years --

ena - tri, trinajst let,

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

sem bil del izjemne ekipe izraelskega zdravstvenega podjetja

and partners around the world

InSightec in partnerjev po vsem svetu,

for taking this idea, this concept,

s katerimi smo želeli idejo oz. koncept

noninvasive surgery,

neinvazivnega kirurškega posega

from the research lab to routine clinical use.

prenesti iz raziskovalnih laboratorijev v klinično prakso.

And this is what I'll tell you about.

O tem vam bom danes pripovedoval.

13 years --

Trinajst let --

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

nekateri bi z mano sočustvovali.

For me, today, on this date,

Jaz pa danes, na ta dan,

it's like a second bar mitzvah experience.

praznujem nekakšno drugo bar micvo.

(Laughter)

(Smeh)

So this dream

Te sanje

is really enabled

smo uresničili

by the convergence

z združitvijo

of two known technologies.

dveh znanih tehnologij.

One is the focused ultrasound,

Ena je usmerjen ultrazvok,

and the other one is the

druga pa

vision-enabled magnetic resonance imaging.

magnetna resonanca z vizualnim predstavljanjem.

So let's first talk about focused ultrasound.

Začnimo z usmerjenim ultrazvokom.

And I hold in my hand

V roki držim model,

a tissue-mimicking phantom.

ki prikazuje tkivo,

It is made out of silicon.

narejen iz silikona.

It is transparent, made just for you.

Je prozoren in izdelan prav za vas.

So you see, it's all intact,

Kot vidite, je čist

completely transparent.

in popolnoma prozoren.

I'll take you now to the acoustic lab.

Sedaj vas bom popeljal v akustični laboratorij.

You see the phantom within the aquarium.

Tu vidite ta model v akvariju,

This is a setup I put in a physics lab.

gre pa za postavitev v fizikalnem laboratoriju.

On the right-hand side,

Na desni strani vidite

you see an ultrasonic transducer.

ultrazvočni prevodnik.

So the ultrasonic transducer

Ta ultrazvočni prevodnik

emits basically an ultrasonic beam

oddaja ultrazvočni signal,

that focuses inside the phantom.

ki se fokusira znotraj silikonskega modela.

Okay, when you hear the click,

Ko zaslišite klik,

this is when the energy starts to emit

se začne oddajati energija

and you see a little lesion form

in vidite majhno sled,

inside the phantom.

poškodbo znotraj modela.

Okay, so everything around it

Vse okrog nje

is whole and intact.

pa je ostalo celo in nedotaknjeno.

It's just a lesion formed inside.

Poškodba tkiva je nastala le v notranjosti.

So think about, this is in your brain.

Zamislite si, da so to vaši možgani

We need to reach a target inside the brain.

in mi moramo doseči točko znotraj njih.

We can do it without harming any tissue.

To lahko storimo ne da bi poškodovali ostalo tkivo.

So this is, I think,

To je torej po mojem mnenju

the first kosher Hippocratic surgical system.

prvi Hipokratov košer operacijski sistem.

(Laughter)

(Smeh)

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

Naj povem nekaj stvari o ultrazvoku,

the force of ultrasound.

o moči ultrazvoka.

You know all about imaging, right, ultrasound imaging.

Vsi poznate ultrazvočne posnetke, kajne?

And you know also about lithotripsy --

Poznate tudi litotripsijo,

breaking kidney stones.

metodo drobljenja ledvičnih kamnov.

But ultrasound can be shaped

A ultrazvok lahko predstavlja

to be anything in between,

še marsikaj drugega,

because it's a mechanical force.

saj gre za mehansko silo.

Basically, it's a force acting on a tissue

V osnovi ta sila vpliva na vlakno,

that it transverses.

na katerega je usmerjena.

So you can change the intensity, the frequency,

Spreminjamo lahko jakost, frekvenco,

the duration, the pulse shape of the ultrasound

trajanje, obliko ultrazvočnega signala

to create anything

in tako ustvarimo karkoli,

from an airbrush to a hammer.

od airbrusha do kladiva.

And I am going to show you

Pokazal vam bom

multiple applications in the medical field

različne možnosti uporabe v medicini,

that can be enabled

ki jih omogoča

just by focusing,

zgolj fokusiranje,

physically focusing.

fizično fokusiranje.

So this idea

Ta koncept uporabe usmerjenega ultrazvoka

of harnessing focused ultrasound to treat lesions in the brain

za zdravljenje možganskih okvar

is not new at all.

pa sploh ni nov.

When I was born, this idea was already conceived

Ko sem se rodil, so se s to idejo že ukvarjali

by pioneers such as the Fry brothers

pionirji, kot sta brata Fry

and Lars Leksell,

in Lars Leksell,

who is know actually

danes znan kot

as the inventor of the gammaknife.

izumitelj gama noža.

But you may not know

Morda pa niste vedeli,

that he tried to perform lobotomies in the brain,

da je v petdesetih letih poskušal izvajati

noninvasively,

možgansko lobotomijo na neinvaziven način

with focused ultrasound in the '50s.

z usmerjenim ultrazvokom.

He failed,

Ni mu uspelo,

so he then invented the gammaknife.

je pa kasneje izumil gama nož.

And it makes you ponder

To da človeku misliti,

why those pioneers failed.

zakaj tem pionirjem ni uspelo.

And there was something fundamental

Manjkalo jim je

that they were missing.

nekaj bistvenega.

They were missing the vision.

Manjkala jim je vizija.

It wasn't until the invention of the MR

Šele z odkritjem slikanja

and really the integration of MR

z magnetno resonanco (MRI)

with focused ultrasound

in njeno združitvijo z usmerjenim ultrazvokom

that we could get the feedback --

smo dobili odziv,

both the anatomical and the physiological

tako anatomski kot fiziološki,

in order to have a completely noninvasive, closed-loop

in tako ustvarili popolnoma neinvaziven,

surgical procedure.

zaprtozančni kirurški poseg.

So this is how it looks, you know,

Tako je torej danes videti

the operating room of the future today.

operacijska soba prihodnosti.

This is an MR suite with a focused ultrasound system.

To je prostor za MRI s sistemom usmerjenega ultrazvoka.

And I will give you several examples.

Dal vam bom nekaj primerov.

So the first one is in the brain.

Začnimo z možgani.

One of the neurological conditions

Ena od nevroloških okvar,

that can be treated with focused ultrasound

ki jo lahko na tak način zdravimo,

are movement disorders,

so motnje gibanja, kot sta

like Parkinson's or essential tremor.

Parkinsonova bolezen ali esencialni tremor (ET)

What is typical to those conditions,

Za take motnje, kot na primer

to essential tremor for example,

pri esencialnem tremorju, je značilno,

is inability

da bolnik ne zmore

to drink or eat cereal or soup

piti ali jesti juhe ali kosmičev,

without spilling everything all over you,

ne da bi se polil,

or write legibly so people can understand it,

ali pisati dovolj čitljivo, da bi lahko za njim brali,

and be really independent in your life

oz. biti v življenju neodvisen

without the help of others.

in živeti brez pomoči okolice.

So I'd like you to meet John.

Predstavljam vam Johna.

John is a retired professor of history

John je upokojeni profesor zgodovine

from Virginia.

iz Virginie.

So he suffered from essential tremor for many years.

Esencialni tremor ga je zaznamoval mnogo let,

And medication didn't help him anymore.

zdravila pa mu niso več pomagala.

And many of those patients refused to undergo surgery

Veliko takšnih bolnikov je zavrnilo operacijo,

to have people cut into their brain.

saj niso želeli posegov na možganih.

And about four or five months ago,

Pred štirimi ali petimi meseci

he underwent an experimental procedure.

pa je John sodeloval v poskusnem postopku.

It is approved under an FDAIDE

Uporabo postopka v raziskovalne namene

at the University of Virginia

je odobril odbor Ministrstva za zdravje

in Charlottesville

na virginijski univerzi v Charlottesvillu,

using focused ultrasound

in tako smo z usmerjenim ultrazvokom

to ablate a point in his thalamus.

uničili delček tkiva v njegovem talamusu.

And this is his handwriting.

To je njegova pisava.

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

"Dvajsetega junija," če lahko preberete,

"2011."

"leta 2011".

This is his handwriting

To je njegova pisava

on the morning of the treatment

na jutro posega,

before going into the MR

pred vstopom v prostor za MRI.

So now I'll take you through

Pokazal vam bom,

[what] a typical procedure like that looks like,

kako deluje tak tipičen postopek

[what] noninvasive surgery looks like.

oz. neinvazivni kirurški poseg.

So we put the patient on the MR table.

Pacient leži na mizi za slikanje z magnetno resonanco.

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

V tem primeru prevodnik usmerimo na možgane,

but if it will be a different organ,

če pa bi šlo za drug organ,

it will be a different transducer attached to the patient.

bi uporabili tudi drugačen prevodnik.

And the physician

Zdravnik nato opravi

will then take a regular MR scan.

običajno slikanje z magnetno resonanco.

And the objective of that?

Kaj je cilj tega?

I don't have a pointer here,

Ne morem pokazati na sliko,

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

a vseeno lahko vidite zelen trapezoidni okvir.

This is the sort of general area of the treatment.

To je nekakšno splošno območje posega.

It's a safety boundary

Predstavlja varnostno mejo

around the target.

okrog točke, ki jo ciljamo.

It's a target in the thalamus.

Ta točka je v talamusu.

So once those pictures are acquired

Ko te slike pridobimo

and the physician has drawn

in ko zdravnik označi

all the necessary safety limits and so on,

vse potrebne varnostne meje,

he selects basically a point --

izbere določeno točko --

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

okroglo točko v sredini, ki jo označuje puščica --

and he presses this blue button called "sonicate."

in pritisne na modro tipko "Soniciraj".

We call this instance of injecting the energy,

Ta način injiciranja energije

we call it sonication.

imenujemo ultrazvočna sonikacija.

The only handwork the physician does here

Edino delo zdravnikovih rok

is moving a mouse.

je pri tem premikanje miške.

This is the only device he needs in this treatment.

To je edina naprava, s katero upravlja.

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

Ko pritisne "Soniciraj", se zgodi sledeče.

You see the transducer, the light blue.

Prevodnik je svetlo modre barve.

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

Med njim in lobanjo je voda.

And it does this burst of energy.

Ustvari se izbruh energije,

It elevates the temperature.

s čimer temperatura naraste.

We first need to verify

Najprej se moramo prepričati,

that we are on target.

da imamo pravo točko.

So the first sonication

Prva sonikacija

is at lower energy.

poteka z nižjo energijo.

It doesn't do any damage,

Ne povzroči nobene škode,

but it elevates the temperature

pač pa dvigne temperaturo

by a few degrees.

za nekaj stopinj.

And one of the unique capabilities

Ena od enkratnih sposobnosti,

that we leverage with the MR

ki jih dosežemo z magnetno resonanco,

is the ability to measure temperature noninvasively.

je neinvazivno merjenje temperature.

This is really a unique capability of the MR.

To je enkratna sposobnost magnetne resonance,

It is not being used

ki pa se ne uporablja

in regular diagnostic imaging.

pri običajnem diagnostičnem slikanju.

But here we can get

V našem primeru pa pridobimo anatomsko sliko

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

in temperaturni profil v danem trenutku.

And you can see the points there on the graph.

Na grafu lahko vidite točke.

The temperature was raised

Temperatura se je dvignila

to 43 degrees C temporarily.

na začasnih 43°C.

This doesn't cause any damage.

To ne povzroči nobene škode.

But the point is we are right on target.

Pomembno pa je, da ciljamo na pravo točko.

So once the physician verifies

Ko torej zdravnik potrdi,

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

da je točka fokusiranja prava,

then we move to perform

se izvede

a full-energy ablation

uničenje delčka tkiva s polno močjo,

like you see here.

kot vidite tu.

And you see the temperature rises

Temperatura se povzpne

to like 55 to 60 degrees C.

med 55 in 60 stopinj Celzija.

If you do it for more than a second,

Če to traja več kot eno sekundo,

it's enough to basically destroy

je jakost dovolj močna, da uniči

the proteins of the cells.

celične beljakovine.

This is the outcome from a patient perspective --

In to je rezultat s pacientovega stališča

same day after the treatment.

še isti dan po posegu.

This is an immediate relief.

Gre za takojšnje izboljšanje.

(Applause)

(Aplavz)

Thank you.

Hvala.

John is one of [about] a dozen

John je en od okrog ducata

very heroic, courageous people

zelo pogumnih, herojskih ljudi,

who volunteered for the study.

ki so se javili za sodelovanje v raziskavi.

And you have to understand

Treba je razumeti,

what is in people's mind

o čem razmišljajo ljudje,

when they are willing to take the risk.

ki se odločijo tvegati.

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

John je, potem ko je znova napisal sporočilo,

He said, "Miraculous."

dejal, "Neverjetno."

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

Njegova žena je rekla, "To je najsrečnejši trenutek mojega življenja."

And you wonder why.

Vprašate se, zakaj.

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

Eno od sporočil, ki ga želim posredovati,

is, what about defending quality of life?

je pomen ohranjanja kakovosti življenja.

I mean, those people lose their independence.

Ti ljudje so namreč izgubili svojo samostojnost.

They are dependent on others.

Odvisni so od pomoči drugih.

And John today is fully independent.

John pa je danes v celoti samostojen

He returned to a normal life routine.

in nadaljuje z vsakodnevno rutino.

And he also plays golf,

Igra tudi golf,

like you do in Virginia

kot običajno počnejo

when you are retired.

upokojeni v Virginiji.

Okay, so you can see here the spot.

Tu lahko vidite točko.

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

Meri približno tri milimetre v središču možganov.

There's no damage outside.

Okrog nje ni poškodb.

He suffers from no neurodeficit.

Ni več okvar živčevja.

There's no recovery needed, no nothing.

Po posegu ne potrebuje niti okrevanja,

He's back to his normal life.

pač pa se vrne v običajno življenje.

Let's move now

Poglejmo si sedaj

to a more painful subject.

bolj občutljivo področje.

Pain is something

Bolečina je nekaj,

that can make your life miserable.

kar vam lahko zagreni življenje.

And people are suffering from all kinds of pain

Ljudje trpijo zaradi vseh vrst bolečine,

like neuropathic pain, lower-back pain

od nevropatske bolečine, bolečine v križu,

and cancer pain from bone metastases,

do onkološke bolečine

when the metastases get to your bones,

metastaz na kosteh,

sometimes they are very painful.

kjer lahko postanejo izjemno boleče.

All those I've indicated

Vsi ti tipi bolečin

have already been shown

so bili dokazano

to be successfully treated

uspešno zdravljeni

by focused ultrasound

z usmerjenim ultrazvokom,

relieving the pain, again, very fast.

ki je zelo hitro odpravil bolečino.

And I would like to tell you

Rad bi vam predstavil še

about PJ.

PJ-jev primer.

He's a 78 year-old farmer

PJ je 78-letni kmet,

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

ki je imel -- kako naj to povem? --

it's called pain in the butt.

bolečino v zadnjici.

He had metastases in his right buttock,

Imel je metastaze na desni strani,

and he couldn't sit

zaradi česar ni mogel sedeti

even with medication.

niti ob uporabi zdravil.

He had to forgo all the farm activities.

Moral se je odpovedati vsem dejavnostim na kmetiji.

He was treated with radiation therapy,

Zdravili so ga z obsevanjem,

state-of-the-art radiation therapy,

najsodobnejšim obsevanjem,

but it didn't help.

a mu ni pomagalo.

Many patients like that favor radiation therapy.

Veliko takih pacientov se odloči za obsevanje.

And again, he volunteered

Tudi on je prostovoljno sodeloval

to a pivotal study

v osrednji raziskavi,

that we ran worldwide,

ki je potekala po celem svetu,

also in the U.S.

tudi v ZDA.

And his wife actually took him.

Pripeljala ga je njegova žena.

They drove like three hours

Od kmetije do bolnišnice

from their farm to the hospital.

sta se vozila tri ure.

He had to sit on a cushion,

Moral je sedeti na blazini

stand still, not move,

in se ne premikati,

because it was very painful.

saj je bilo preveč boleče.

He took the treatment,

Po posegu

and on the way back,

je na poti na kmetijo

he drove the truck by himself.

sam vozil tovornjak.

So again, this is an immediate relief.

Še enkrat gre torej za takojšnje izboljšanje.

And you have to understand

Treba je upoštevati,

what those people feel

kako se ti ljudje počutijo

and what their family experiences

in kaj občutijo njihove družine,

when it happens.

ko poseg uspe.

He returned again

PJ se je vrnil

to his daily routine on the farm.

k svoji dnevni rutini na kmetiji.

He rides his tractor.

Sam vozi traktor,

He rides his horse to their mountain cabin regularly.

pogosto celo jaha na konju do svoje koče v hribih.

And he has been very happy.

Res je srečen.

But now, you ask me,

Sedaj pa vas zanima,

but what about war, the war on cancer?

ali lahko s tem napovemo vojno raku?

Show us some primary cancer.

Kaj lahko storimo

What can be done there?

v začetnem stadiju rakavih obolenj?

So I have good news and bad news.

Imam dobro in slabo novico.

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

Dobra je, da se lahko stori marsikaj.

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

To smo dokazali izven ZDA.

And doing that in the U.S.

V ZDA je namreč take posege

is very painful.

zelo težko opravljati.

I don't see, without this nation

Bojim se, da če ne bo ta narod

taking it as some collective will

tega sprejel kot skupno željo

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

ali kot cilj celega naroda, da bi to omogočil,

it will not happen.

bodo taki posegi nemogoči.

And it's not just because of regulation;

Razlog niso samo predpisi,

it's because of the amount of money needed

pač pa predvsem količina denarja, zahtevana

under the current evidence-based medicine

v današnjem zdravstvu, ki temelji na dokazih,

and the size of trials and so on

in za obsežne raziskave,

to make it happen.

ki to onemogoča.

So the first two applications

Najprej smo ta način uporabili

are breast cancer and prostate cancer.

pri raku dojk in raku prostate.

They were the first to be treated by focused ultrasound.

Na teh dveh vrstah raka smo najprej izvedli postopek.

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

Pri raku dojk so rezultati boljši kot pri operaciji.

But I have a message for the men here.

Imam pa tudi sporočilo za moške.

We heard here yesterday Quyen

Včeraj je tu Quyen govorila o

talking about the adverse event trait

neželenih dogodkih

in prostate cancer.

pri raku prostate.

There is a unique opportunity now

Tu imamo izjemno priložnost uporabe

with focused ultrasound guided by MR,

usmerjenega ultrazvoka, ki ga vodi MR,

because we can actually think about

saj si dejansko lahko zamislimo

prostate lumpectomy --

lumpektomijo prostate, s čimer bi

treating just the focal lesion

zdravili le glavno poškodbo

and not removing the whole gland,

brez ostranitve celotne žleze

and by that, avoiding all the issues

in se tako izognili vsem težavam

with potency and incontinence.

s potenco in inkontinenco.

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

Tu imamo še druge rakave tumorje v trebuhu,

quite lethal, very lethal actually --

ki jih je pravzaprav zelo malo --

pancreas, liver, kidney.

rak na trebušni slinavki, jetrih in ledvicah.

The challenge there

Izziv pri tem je --

with a breathing and awake patient --

ob pacientu, ki diha in je buden,

and in all our treatments,

in tako kot pri vseh

the patient is awake and conscious

naših posegih zavestno

and speaks with the physician --

govori z zdravnikom --

is you have to teach the MR some tricks

da naučimo napravo za magnetno resonanco,

how to do it in real time.

kako naj poseg izvede ob pravem času.

And this will take time.

To pa bo terjalo čas.

This will take two years.

Trajalo bo približno dve leti.

But I have now a message to the ladies.

Imam pa tudi sporočilo za dame.

And this is, in 2004,

Leta 2004 je Ministrstvo za zdravje odobrilo uporabo

the FDA has approved MR-guided focused ultrasounds

usmerjenega ultrazvoka z magnetno resonanco

for the treatment of symptomatic uterine fibroids.

za zdravljenje simptomatskih materničnih fibroidov.

Women suffer from that disease.

Ženske zbolijo za to boleznijo.

All those tumors

Za te tumorje je značilno

have heavy bleeding during periods,

močno krvavenje v času perila,

abdominal pressure, back pain,

hude bolečine v trebuhu in hrbtu

frequent urination.

ter pogosto uriniranje.

And sometimes, they cannot even conceive and become pregnant

Včasih celo ne morejo spočeti otroka in zanositi

because of the fibroid.

zaradi fibroidov.

This is Frances.

To je Frances.

She was diagnosed with a grapefruit-sized fibroid.

Odkrili so ji fibroid v velikosti grenivke.

This is a big fibroid.

Gre za velik fibroid.

She was offered a hysterectomy,

Ponudili so ji histerektomijo,

but this is an inconceivable proposition

kar pa je nesprejemljiv predlog

for someone who wants to keep her pregnancy option.

za nekoga, ki želi nekoč zanositi.

So she elected to undergo a focused ultrasound procedure

Zato se je leta 2008 odločila za poseg

in 2008.

z usmerjenim ultrazvokom.

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

Leta 2010 je postala mlada mamica zdravi dojenčici.

So new life was born.

Rodilo se je novo življenje.

(Applause)

(Aplavz)

So in conclusion,

Za konec imam za vas

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

štiri sporočila.

One is, think about the amount

Prvič, pomislite,

of suffering that is saved

koliko trpljenja prihranimo pacientom

from patients undergoing noninvasive surgery,

v postopku neinvazivnega posega,

and also the economical and emotional burden

in koliko finančnega in čustvenega bremena

removed from their families and communities

prihranimo njihovim družinam, skupnostim

and the society at large --

in družbi nasploh

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

ter nenazadnje tudi njihovim zdravnikom.

And the other thing I would like you to think about

Drugič, rad bi, da razmislite

is the new type of relationship

o novi vrsti odnosa

between physician and patients

med zdravniki in pacienti,

when you have a patient on the table

ko je pacient na mizi buden

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

in preko zaslona spremlja poseg.

In all our treatments,

Pri vseh naših posegih ima pacient

the patient holds a stop sonication button.

dostop do gumba, ki ustavi sonikacijo.

He can stop the surgery at any moment.

Poseg lahko prepreči, kadar želi.

And with that note,

S to mislijo

I would like to thank you for listening.

se vam zahvaljujem za pozornost.

(Applause)

(Aplavz)