Yoav Medan: Ultrasound surgery -- healing without cuts

Prevodilac: Jelena Nedjic Lektor: Ana Zivanovic-Nenadovic

Over the last 13 years --

Poslednjih trinaest godina,

one, three, 13 years --

jedna, tri, trinaest godina,

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

sam deo vanrednog tima u "InSightec"-u u Izraelu

and partners around the world

i partnera širom sveta, koji su posvećeni tome

for taking this idea, this concept,

da ideja, koncept

noninvasive surgery,

neinvazivne hirurgije,

from the research lab to routine clinical use.

pređe iz faze istraživanja u rutinsku, kliničku praksu.

And this is what I'll tell you about.

O tome ću vam pričati.

13 years --

Trinaest godina,

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

neki od vas možda saosećaju sa tim brojem.

For me, today, on this date,

Ja se danas osećam

it's like a second bar mitzvah experience.

kao da sam na svojoj drugoj Bar Micvi.

(Laughter)

(smeh)

So this dream

Spajanje

is really enabled

dve poznate tehnologije

by the convergence

je dovelo

of two known technologies.

do ostvarivanja ovog sna.

One is the focused ultrasound,

Jedna je usmereni ultrazvuk,

and the other one is the

a druga je

vision-enabled magnetic resonance imaging.

magnetna rezonanca sa vizuelnim predstavljanjem.

So let's first talk about focused ultrasound.

Prvo ćemo pričati o fokusiranom ultrazvuku.

And I hold in my hand

Držim u svojoj ruci fantoma,

a tissue-mimicking phantom.

nešto što imitira tkivo.

It is made out of silicon.

Napravljen je od silicijuma.

It is transparent, made just for you.

Providan je i napravljen samo za vas.

So you see, it's all intact,

Vidite, čitav je i

completely transparent.

potpuno providan.

I'll take you now to the acoustic lab.

Sada idemo na turu kroz akustičnu laboratoriju.

You see the phantom within the aquarium.

Uočićete fantoma u akvarijumu.

This is a setup I put in a physics lab.

Ovo je konstrukcija koju sam postavio u laboratoriji za fiziku.

On the right-hand side,

Sa desne strane

you see an ultrasonic transducer.

je provodnik ultrazvuka.

So the ultrasonic transducer

Provodnik ultrazvuka

emits basically an ultrasonic beam

odašilje ultrazvučni snop

that focuses inside the phantom.

koji se fokusira unutar fantoma.

Okay, when you hear the click,

Okej, kada čujete klik,

this is when the energy starts to emit

to je momenat kada počinje emitovanje energije

and you see a little lesion form

i uočićete malu leziju koja se formira

inside the phantom.

unutar fantoma.

Okay, so everything around it

Okej, sve oko njega je

is whole and intact.

čitavo i netaknuto.

It's just a lesion formed inside.

Samo je jedna lezija napravljena unutra.

So think about, this is in your brain.

Zamislite sada da je to u vašem mozgu.

We need to reach a target inside the brain.

Moramo dospeti do ciljne tačke u vašem mozgu.

We can do it without harming any tissue.

Možemo to uraditi bez povrede tkiva.

So this is, I think,

Smatram da je ovo

the first kosher Hippocratic surgical system.

prvi Hipokratov operacioni sistem košer tipa.

(Laughter)

(smeh)

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

Okej, sada ćemo pričati malo o ultrazvuku,

the force of ultrasound.

o snazi ultrazvuka.

You know all about imaging, right, ultrasound imaging.

Znate sve o uslikavanju, zar ne, ultrazvučnom slikanju.

And you know also about lithotripsy --

Čuli ste i za litotripsiju (med.)

breaking kidney stones.

to je razbijanje kamenja u bubregu.

But ultrasound can be shaped

Ultrazvuk se može podesiti da

to be anything in between,

bude bilo šta na toj skali

because it's a mechanical force.

jer je to mehanička sila.

Basically, it's a force acting on a tissue

U suštini, to je sila koja deluje na tkivo

that it transverses.

kroz koje prolazi.

So you can change the intensity, the frequency,

Možete menjati jačinu, učestalost,

the duration, the pulse shape of the ultrasound

trajanje, pulsni oblik ultrazvuka

to create anything

kako biste napravili bilo šta

from an airbrush to a hammer.

od aerosolne četkice do čekića.

And I am going to show you

Pokazaću vam višestruke

multiple applications in the medical field

primene toga u medicini

that can be enabled

koje su ostvarive

just by focusing,

uz pomoć usmerenosti,

physically focusing.

fizičke usmerenosti.

So this idea

Ova ideja o

of harnessing focused ultrasound to treat lesions in the brain

korišćenju usmerenog ultrazvuka pri lečenju lezija u mozgu

is not new at all.

uopšte nije nova.

When I was born, this idea was already conceived

Kada sam ja rođen, ideja je već sazrela

by pioneers such as the Fry brothers

u glavama pionira, npr. Fraj braće

and Lars Leksell,

ili Larsa Leksela,

who is know actually

koji je poznat

as the inventor of the gammaknife.

kao pronalazač gama-noža.

But you may not know

Možda ne znate da je

that he tried to perform lobotomies in the brain,

on pokušao da uradi neinvazivne

noninvasively,

lobotomije mozga,

with focused ultrasound in the '50s.

uz pomoć usmerenog ultrazvuka u 50-im.

He failed,

Nije uspeo,

so he then invented the gammaknife.

pa je potom izumeo gama-nož.

And it makes you ponder

To vas navodi da pažljivo razmislite

why those pioneers failed.

zašto ti pioniri nisu uspeli.

And there was something fundamental

Postoji nešto osnovno

that they were missing.

što im je nedostajalo.

They were missing the vision.

Nedostajala im je vizija.

It wasn't until the invention of the MR

Tek kada je otkrivena magnetna rezonanca (MR)

and really the integration of MR

i kada je došlo do integracije MR tehnologije

with focused ultrasound

i usmerenog ultrazvuka

that we could get the feedback --

dobili smo povratnu informaciju--

both the anatomical and the physiological

i o anatomiji i o fiziologiji

in order to have a completely noninvasive, closed-loop

što je omogućilo da dođemo do potpuno neinvazivne

surgical procedure.

hirurške metode po tipu zatvorenog kola.

So this is how it looks, you know,

Znate, ovako izgleda

the operating room of the future today.

operaciona sala budućnosti.

This is an MR suite with a focused ultrasound system.

Ovo je MR odeljenje sa sistemom fokusiranog ultrazvuka.

And I will give you several examples.

Navešću vam nekoliko primera.

So the first one is in the brain.

Prvo ću pričati o mozgu.

One of the neurological conditions

Jedni od neuroloških poremećaja

that can be treated with focused ultrasound

koji mogu biti lečeni fokusiranim ultrazvukom

are movement disorders,

su poremećaji pokreta,

like Parkinson's or essential tremor.

kao što je Parkinsonova bolest ili osnovni tremor.

What is typical to those conditions,

Ono što je karakteristično za ova stanja,

to essential tremor for example,

na primer za osnovni tremor,

is inability

jeste nesposobnost

to drink or eat cereal or soup

da pijete ili jedete pahuljice ili supu,

without spilling everything all over you,

a da ne prospete sve po sebi,

or write legibly so people can understand it,

ili da pišete čitko kako bi ljudi to mogli da pročitaju

and be really independent in your life

i da budete zaista nezavisni od pomoći drugih

without the help of others.

u svom životu.

So I'd like you to meet John.

Hoću da vas upoznam sa Džonom.

John is a retired professor of history

Džon je penzionisan profesor istorije

from Virginia.

iz Virdžinije.

So he suffered from essential tremor for many years.

Patio je od osnovnog tremora godinama.

And medication didn't help him anymore.

Lekovi mu više nisu pomagali.

And many of those patients refused to undergo surgery

Mnogi pacijenti odbijaju da se podvrgnu operaciji

to have people cut into their brain.

da ljudi ne bi seckali njihov mozak.

And about four or five months ago,

Pre četiri ili pet meseci

he underwent an experimental procedure.

se podvrgao eksperimentalnom tretmanu.

It is approved under an FDAIDE

Odobren je od strane "FADAIDE"

at the University of Virginia

na Univerzitetu u Virdžiniji

in Charlottesville

u Šarlotsvilu,

using focused ultrasound

a koristi se ultrazvukom

to ablate a point in his thalamus.

kojim se uklanja deo u talamusu.

And this is his handwriting.

Ovo je njegov rukopis.

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

"20. juna," ukoliko možete da pročitate,

"2011."

"2011."

This is his handwriting

Ovo je njegov rukopis

on the morning of the treatment

jutra pre same operacije,

before going into the MR

pre odlaska na MR.

So now I'll take you through

Sada ću vam pokazati kako

[what] a typical procedure like that looks like,

klasična procedura ovog tipa izgleda,

[what] noninvasive surgery looks like.

kako neinvazivna hirurgija izgleda.

So we put the patient on the MR table.

Postavili smo pacijenta na MR sto.

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

Potom zakačimo provodnik, u ovom slučaju za mozak,

but if it will be a different organ,

ali ukoliko bi se radilo o drugom organu,

it will be a different transducer attached to the patient.

drugi tip provodnika bismo zakačili za bolesnika.

And the physician

Potom će doktor uraditi

will then take a regular MR scan.

prvi uobičajeni snimak MR-om.

And the objective of that?

Cilj toga?

I don't have a pointer here,

Nemam pokazivač sa sobom,

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

ali da li vidite zeleno, nešto kao kvadrat ili trapezoid?

This is the sort of general area of the treatment.

Ovo je opšte operativno polje.

It's a safety boundary

To je sigurnosna zona

around the target.

oko samog ciljnog mesta.

It's a target in the thalamus.

Ovo je cilj u talamusu.

So once those pictures are acquired

U trenutku kada lekar

and the physician has drawn

dobije željenu sliku

all the necessary safety limits and so on,

o svim neophodnim granicama bezbednosti i tako dalje,

he selects basically a point --

on odabira, u principu, tačku,

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

vidite li ovu okruglu tačku u sredini gde se pokazivač nalazi,

and he presses this blue button called "sonicate."

i potom pritisne plavo dugme koje se zove "sonikacija".

We call this instance of injecting the energy,

Ovaj proces ubrizgavanja energije

we call it sonication.

nazivamo sonikacijom.

The only handwork the physician does here

Sve što lekar uradi rukama ovde

is moving a mouse.

je pomeranje miša.

This is the only device he needs in this treatment.

To je jedini instrument koji mu je neophodan za tretman.

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

Kada pritisne dugme za sonikaciju, desi se sledeće.

You see the transducer, the light blue.

Vidite provodnik, u svetlo plavoj boji.

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

Između provodnika i lobanje se nalazi voda.

And it does this burst of energy.

Dolazi do ove eksplozije energije.

It elevates the temperature.

To povišava temperaturu.

We first need to verify

Prvo moramo da proverimo

that we are on target.

da zaista gađamo ciljanu tačku.

So the first sonication

Prva sonikacija se izvodi

is at lower energy.

uz manju količinu energije.

It doesn't do any damage,

Ne čini nikakvu štetu,

but it elevates the temperature

ali povišava temperaturu

by a few degrees.

za nekoliko stepeni.

And one of the unique capabilities

Jedna od osobenosti

that we leverage with the MR

primene MR tehnologije

is the ability to measure temperature noninvasively.

jeste mogućnost neinvazivnog merenja temperature.

This is really a unique capability of the MR.

Ovo je zaista jedinstvena sposobnost MR tehnike.

It is not being used

Ne koristi se za

in regular diagnostic imaging.

uobičajeno dijagnostičko uslikavanje.

But here we can get

Uz pomoć ovoga možemo

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

doći do slika anatomije i mape temperatura u stvarnom vremenu.

And you can see the points there on the graph.

Možete uočiti te tačke na grafikonu.

The temperature was raised

Temperatura je privremeno

to 43 degrees C temporarily.

povišena na 43 stepena Celzijusa.

This doesn't cause any damage.

Ovo ne dovodi ni do kakvih oštećenja.

But the point is we are right on target.

Poenta je u tome da gađamo ciljano mesto.

So once the physician verifies

U trenutku kada lekar potvrdi

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

da je zadata tačka na cilju koji je izabrao,

then we move to perform

sledeći korak je

a full-energy ablation

amputacija punom energijom

like you see here.

kao što ovde možete videti.

And you see the temperature rises

Vidite porast temperature do

to like 55 to 60 degrees C.

od prilike 55 do 60 stepeni Celzijusa.

If you do it for more than a second,

Ukoliko to radite duže od sekunde,

it's enough to basically destroy

to je dovoljno da uništi

the proteins of the cells.

sve proteine u ćelijama.

This is the outcome from a patient perspective --

Ovako rezultat izgleda iz persepktive pacijenta,

same day after the treatment.

istog dana nakon tretmana.

This is an immediate relief.

Ovo je momentalno olakšanje.

(Applause)

(aplauz)

Thank you.

Hvala.

John is one of [about] a dozen

Džon je jedan od desetak

very heroic, courageous people

veoma hrabrih ljudi, heroja,

who volunteered for the study.

koji su volontirali za ovu studiju.

And you have to understand

Morate razumeti šta je

what is in people's mind

u glavi ovih ljudi kada

when they are willing to take the risk.

požele da preuzmu takav rizik.

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

Sada ću citirati Džona nakon što je ovo napisao.

He said, "Miraculous."

On je rekao: "Ovo je čudo."

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

Njegova žena je rekla: "Ovo je najsrećniji trenutak u mom životu."

And you wonder why.

Pitate se zašto.

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

Znate, jedna od poruka koju želim da prenesem jeste,

is, what about defending quality of life?

šta je sa zaštitom kvaliteta života?

I mean, those people lose their independence.

Znate, ovi ljudi izgube svoju nezavisnost.

They are dependent on others.

Oni zavise od drugih.

And John today is fully independent.

Džon je danas potpuno nezavistan.

He returned to a normal life routine.

Vratio se uobičajenom stilu života.

And he also plays golf,

On takođe igra golf,

like you do in Virginia

jer je to ono što radite u Virdžiniji

when you are retired.

kada se penzionišete.

Okay, so you can see here the spot.

Okej, ovde možete uočiti naznačeni region.

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

U sredini mozga, veličine oko tri mm.

There's no damage outside.

Spolja nema oštećenja.

He suffers from no neurodeficit.

Ne pati od neurodeficita.

There's no recovery needed, no nothing.

Oporavak nije potreban, ništa se ne zahteva.

He's back to his normal life.

Vratio se svom uobičajenom životu.

Let's move now

Sada ćemo pričati

to a more painful subject.

o bolnijem predmetu.

Pain is something

Bol je nešto

that can make your life miserable.

što može učiniti život nepodnošljivim.

And people are suffering from all kinds of pain

Ljudi pate od različith vrsta bola,

like neuropathic pain, lower-back pain

kao što je neuropatski bol, bol u donjem delu kičme,

and cancer pain from bone metastases,

bol nastao usled koštanih metastaza

when the metastases get to your bones,

što se dešava kada rak metastazira u kostima,

sometimes they are very painful.

sve to je ponekad neopisivo bolno.

All those I've indicated

Za sve ove vrste bola koje sam naveo

have already been shown

je već pokazano

to be successfully treated

da mogu biti uspešno lečene

by focused ultrasound

pomoću usmerenog ultrazvuka

relieving the pain, again, very fast.

koji olakšava osećaj bola veoma brzo.

And I would like to tell you

Voleo bih da vam pričam

about PJ.

o PiDžej.

He's a 78 year-old farmer

On je sedamdesetosmogodišnji poljoprivrednik

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

koji je bolovao od - kako bih to nazvao? -

it's called pain in the butt.

naziva se bol u guzici.

He had metastases in his right buttock,

Rak je kod njega metastazirao na desnom guzu,

and he couldn't sit

i nije mogao da sedi

even with medication.

čak ni uz pomoć lekova.

He had to forgo all the farm activities.

Morao je da ostavi sve poslove na imanju.

He was treated with radiation therapy,

Lečen je radio-terapijom,

state-of-the-art radiation therapy,

najsavremenijom radio-terapijom,

but it didn't help.

ali to nije pomoglo.

Many patients like that favor radiation therapy.

Mnogi takvi bolesnici glasaju za radio-terapiju.

And again, he volunteered

Ponovo, on je volontirao

to a pivotal study

za važnu studiju koju

that we ran worldwide,

sprovodimo širom sveta,

also in the U.S.

pa i u Sjedinjenim Državama.

And his wife actually took him.

Ustvari, njegova žena ga je dovezla.

They drove like three hours

Vozili su oko tri sata

from their farm to the hospital.

od njihovog imanja do bolnice.

He had to sit on a cushion,

Morao je da sedi na jastuku,

stand still, not move,

da mirno stoji, da se ne kreće,

because it was very painful.

jer je bilo previše bolno.

He took the treatment,

Podvrgao se operaciji,

and on the way back,

i pri povratku kući

he drove the truck by himself.

on je vozio kamion.

So again, this is an immediate relief.

Još jednom, ovo je momentalno olakšanje.

And you have to understand

Morate razumeti

what those people feel

kako se ti ljudi osećaju

and what their family experiences

i šta njihove porodice dožive

when it happens.

kada se to dogodi.

He returned again

On se ponovo vratio

to his daily routine on the farm.

svom svakodnevnom ritmu na imanju.

He rides his tractor.

Vozi svoj traktor.

He rides his horse to their mountain cabin regularly.

Redovno jaše konja do njihove brvnare na planini.

And he has been very happy.

Veoma je srećan.

But now, you ask me,

Sada ćete me pitati

but what about war, the war on cancer?

kakav to uticaj ima na borbu protiv raka?

Show us some primary cancer.

Pokaži nam rezultate na primarnom raku.

What can be done there?

Šta se tu može uraditi?

So I have good news and bad news.

Pa, imam dobre i loše vesti.

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

Dobre vesti su da se svašta može učiniti.

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

To je ustvari bilo pokazano van Sjedinjenih Država.

And doing that in the U.S.

Veoma je naporno to

is very painful.

uraditi u Sjedinjenim Državama.

I don't see, without this nation

Ne vidim da će se to desiti ovde,

taking it as some collective will

iako je ovo nacija kojoj je zajednički testament,

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

ili gde je nacionalni cilj baš taj

it will not happen.

da se pobedi rak.

And it's not just because of regulation;

To nije samo zbog regulacija.

it's because of the amount of money needed

Ulogu u ostvarenju ovog cilja ima

under the current evidence-based medicine

i količina novca koja je danas neophodna

and the size of trials and so on

za medicinske dokaze,

to make it happen.

i velike studije.

So the first two applications

Prve dve primene su u lečenju

are breast cancer and prostate cancer.

raka dojke i raka prostate.

They were the first to be treated by focused ultrasound.

To su prvi pokušaji lečenja usmerenim ultrazvukom.

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

Imamo bolje rezultate nego klasična hirurgija u slučaju raka dojki.

But I have a message for the men here.

Takođe imam i poruku za mušarce.

We heard here yesterday Quyen

Juče je Kvijen govorila

talking about the adverse event trait

o nepoželjnim, sporednim efektima

in prostate cancer.

pri lečenju raka prostate.

There is a unique opportunity now

Sada imamo jedinstvenu priliku da

with focused ultrasound guided by MR,

uz pomoć usmerenog ultrazvuka i MR tehnologije

because we can actually think about

razmišljamo o procesu

prostate lumpectomy --

lampektomije prostate (med.)

treating just the focal lesion

o odstranjivanju samo određenog dela

and not removing the whole gland,

a ne cele žlezde,

and by that, avoiding all the issues

i na taj način možemo zaobići probleme

with potency and incontinence.

potentnosti i inkontinencije (med.).

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

Postoje i drugi tipovi raka u stomaku-

quite lethal, very lethal actually --

koji su veoma mali, zaista veoma mali--

pancreas, liver, kidney.

rak gušterače, jetre, bubrega.

The challenge there

Izazov u ovoj proceduri je u tome

with a breathing and awake patient --

što pacijent diše i budan je-

and in all our treatments,

u svim našim tretmanima

the patient is awake and conscious

su pacijenti budni i svesni

and speaks with the physician --

i pričaju sa lekarom--

is you have to teach the MR some tricks

izazov je u tome da MR treba podučiti nekim trikovima

how to do it in real time.

kako sve to uraditi u stvarnom vremenu.

And this will take time.

Za ovo je neophodno vreme.

This will take two years.

Neophodne su dve godine.

But I have now a message to the ladies.

Sada imam poruku za dame.

And this is, in 2004,

Ovo se dešava u 2004.

the FDA has approved MR-guided focused ultrasounds

kada je FDA odobrio usmereni ultravuk, navođen MR tehnikom

for the treatment of symptomatic uterine fibroids.

za lečenje simptomatskih fibroida materice.

Women suffer from that disease.

Žene pate od te bolesti.

All those tumors

Ove tumore karakterišu

have heavy bleeding during periods,

obilna krvarenja u toku ciklusa,

abdominal pressure, back pain,

pritisak u stomaku, bol u leđima,

frequent urination.

česti nagoni za mokrenjem.

And sometimes, they cannot even conceive and become pregnant

Ponekada ne može doći do začeća i trudnoće

because of the fibroid.

usled fibroida.

This is Frances.

Ovo je Frensis.

She was diagnosed with a grapefruit-sized fibroid.

Uspostavljeno je da ima fibroid veličine grejpfruta.

This is a big fibroid.

To je veliki fibroid.

She was offered a hysterectomy,

Predložena joj je histerektomija,

but this is an inconceivable proposition

ali to je neprihvatljiv predlog

for someone who wants to keep her pregnancy option.

za nekoga ko želi i dalje da rađa.

So she elected to undergo a focused ultrasound procedure

Odlučila je da se podvrgne tretmanu usmerenim ultrazvukom

in 2008.

u 2008.

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

2010. je postala prvorotka i ima zdravu bebu.

So new life was born.

Novi život je rođen.

(Applause)

(aplauz)

So in conclusion,

Na kraju,

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

voleo bih da zaključim sa četiri poruke.

One is, think about the amount

Prva, razmislite o pacijentima

of suffering that is saved

koji su pošteđeni patnje

from patients undergoing noninvasive surgery,

uz pomoć neinvazivne hirurgije,

and also the economical and emotional burden

a i o značajnom ekonomskom i emocionalnom

removed from their families and communities

rasterećenju njihovih familija i zajednica

and the society at large --

kao i celog društva-

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

a čini mi se i njihovih lekara, uzgred budi rečeno.

And the other thing I would like you to think about

Često razmišljam i o drugoj stvari koja se tiče

is the new type of relationship

novog tipa odnosa

between physician and patients

između lekara i pacijenata,

when you have a patient on the table

kada je pacijent budan na operaciom stolu

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

i može čak da prati tretman.

In all our treatments,

U svim našim tretmanima,

the patient holds a stop sonication button.

pacijent ima u rukama dugme za prekid sonikacije.

He can stop the surgery at any moment.

Može da stopira operaciju u bilo kom trenutku.

And with that note,

Sa tim bih završio.

I would like to thank you for listening.

Hvala na pažnji.

(Applause)

(aplauz)