Quyen Nguyen: Color-coded surgery

翻译人员: Yingzhi Vera Gu 校对人员: Ting Huang

I want to talk to you

我今天想和你们谈谈

about one of the biggest myths in medicine,

医学上最大的误区之一。

and that is the idea

这个误区认为

that all we need are more medical breakthroughs

只要有更多的医学突破，

and then all of our problems will be solved.

一切问题都会迎刃而解。

Our society loves to romanticize

我们的社会热衷于

the idea of the single, solo inventor

把单枪匹马的发明者浪漫化：

who, working late in the lab one night,

想象他某一天在实验室工作到深夜，

makes an earthshaking discovery,

有了惊天动地的发现，

and voila, overnight everything's changed.

于是， 一夜之间一切都改变了。

That's a very appealing picture,

这的确是很吸引人的画面

however, it's just not true.

但是，却不真实。

In fact, medicine today is a team sport.

实际上，今天的医学是一个团队项目。

And in many ways,

从很多方面看，

it always has been.

它总是这样。

I'd like to share with you a story

我想告诉你

about how I've experienced this very dramatically

我是怎样在我的工作中

in my own work.

深深体会到这点的。

I'm a surgeon,

我是一名外科医生

and we surgeons have always had

我们外科医生总是

this special relationship with light.

和灯光关系很特别。

When I make an incision inside a patient's body, it's dark.

给病人体内动手术时，体内是黑暗的

We need to shine light to see what we're doing.

所以需要灯光帮助照明。

And this is why, traditionally,

所以，一直以来，

surgeries have always started so early in the morning --

手术总是在凌晨开始

to take advantage of daylight hours.

因为可以利用日光

And if you look at historical pictures

如果你看早期手术室的

of the early operating rooms,

老照片，

they have been on top of buildings.

手术室都建在房子的顶部。

For example, this is the oldest operating room in the Western world,

例如，这是西方世界最古老的一个手术室，

in London,

建于伦敦。

where the operating room

这个手术室

is actually on top of a church

实际上是建在一个教堂的顶部，

with a skylight coming in.

带有一个天窗。

And then this is a picture

看看这幅画吧，

of one of the most famous hospitals in America.

这是美国最著名的医院之一，

This is Mass General in Boston.

波士顿的麻省总医院。

And do you know where the operating room is?

你知道手术室建在哪里吗？

Here it is

在这里

on the top of the building

房子的顶上，

with plenty of windows to let light in.

窗够多，阳光可以泄入。

So nowadays in the operating room,

现在的手术室

we no longer need to use sunlight.

不再用自然光了，

And because we no longer need to use sunlight,

因为我们不需要自然光。

we have very specialized lights

我们有专为手术室制造

that are made for the operating room.

的非常特别的灯。

We have an opportunity

我们有机会

to bring in other kinds of lights --

引入其它类型的灯--

lights that can allow us to see

那种灯可以让我们看见

what we currently don't see.

我们目前看不见的东西。

And this is what I think

这就是我觉得荧光的

is the magic of fluorescence.

神奇之处。

So let me back up a little bit.

我想再解释一下。

When we are in medical school,

我们在医学院学习的时候，

we learn our anatomy from illustrations such as this

从人体图解上学习解剖学，

where everything's color-coded.

图解上全都标上颜色

Nerves are yellow, arteries are red,

黄色的是神经，红色的是动脉，

veins are blue.

蓝色是静脉。

That's so easy anybody could become a surgeon, right?

那太容易了，那样的话每个人都可以做外科医生了，是吧？

However, when we have a real patient on the table,

但是，当我们有真的病人躺在手术台上时，

this is the same neck dissection --

同样的颈部解剖，

not so easy to tell the difference

却不太容易分辨

between different structures.

不同的结构。

We heard over the last couple days

最近，我们听说

what an urgent problem

现在癌症

cancer still is in our society,

还是我们社会中的一个紧迫问题。

what a pressing need it is

我们迫切的希望，

for us to not have

不会

one person die every minute.

每分钟都有人死于癌症。

Well if cancer can be caught early,

但是如果癌症可以被及早发现

enough such that someone can have their cancer taken out,

早到可以用手术将

excised with surgery,

肿瘤切除，

I don't care if it has this gene or that gene,

我就不在乎肿瘤是否有这个基因、那个基因。

or if it has this protein or that protein,

或者有这个蛋白、那个蛋白的，

it's in the jar.

它已经在罐子了。

It's done, it's out, you're cured of cancer.

动了手术，取出来，癌症被治好了。

This is how we excise cancers.

这就是我们治疗癌症的方法。

We do our best, based upon our training

我们尽力，根据我们受到的训练，

and the way the cancer looks and the way it feels

根据肿瘤的外观和感觉，

and its relationship to other structures and all of our experience,

根据它与其它身体结构的关系，根据我们所有的经验，

we say, you know what, the cancer's gone.

我们说，你知道吗？你的癌症已经没有了。

We've made a good job. We've taken it out.

很好，我们把肿瘤取出来了。

That's what the surgeon is saying in the operating room

这是手术医生在手术室

when the patient's on the table.

对手术台上的病人说的话。

But then we actually don't know that it's all out.

但是我们实际上并不知道肿瘤是否已被完全切除。

We actually have to take samples from the surgical bed,

我们需要从手术台上拿样本

what's left behind in the patient,

把从病人身上切除的样本

and then send those bits to the pathology lab.

送到病理实验室

In the meanwhile, the patient's on the operating room table.

同时，病人还躺在手术台上。

The nurses, anesthesiologist, the surgeon,

护士、麻醉师、手术医生

all the assistants are waiting around.

还有所有的助手都等在一边。

And we wait.

等啊等。

The pathologist takes that sample,

病理学家拿到样本，

freezes it, cuts it, looks in the microscope one by one

冷冻、切割、拿着显微镜一个一个看，

and then calls back into the room.

然后给手术室打电话。

And that may be 20 minutes later per piece.

每个样本检查要20分钟

So if you've sent three specimens,

因此如果送去三个样本

it's an hour later.

就要等一个小时。

And very often they say,

经常他们会说：

"You know what, points A and B are okay,

“你知道吗？A点和B 点还行，

but point C, you still have some residual cancer there.

但是C点，还有些残留肿瘤在上面。

Please go cut that piece out."

请把那块切掉。”

So we go back and we do that again, and again.

所以我们回头再干，一次又一次。

And this whole process:

这就是整个过程。

"Okay you're done.

“好了，完成了。

We think the entire tumor is out."

我们认为整个肿瘤都切除了。‘

But very often several days later,

但是，经常是几天后，

the patient's gone home,

病人已经回家了，

we get a phone call:

我们接到电话说：“

"I'm sorry,

对不起

once we looked at the final pathology,

我们看了最后的病理报告

once we looked at the final specimen,

我们看了最后的抽样，

we actually found that there's a couple other spots

我们发现有几个地方，

where the margins are positive.

边缘呈阳性。

There's still cancer in your patient."

你的病人身上还有肿瘤。”

So now you're faced with telling your patient, first of all,

所以我们就不得不首先告诉病人他们

that they may need another surgery,

可能还要进行另一次手术，

or that they need additional therapy

或者需要其它的治疗

such as radiation or chemotherapy.

比如放射疗法和化疗。

So wouldn't it be better

所以最好就是

if we could really tell,

我们，

if the surgeon could really tell,

手术医生在动手术时，

whether or not there's still cancer on the surgical field?

就知道肿瘤是否都切除了。

I mean, in many ways, the way that we're doing it,

我的意思是，从很多方面说，我们现在的操作方式，

we're still operating in the dark.

还是在黑暗中摸索。

So in 2004, during my surgical residency,

因此在2004年，在我担任外科住院医生期间，

I had the great fortune

我有幸

to meet Dr. Roger Tsien,

遇到了Roger 陈医生，

who went on to win the Nobel Prize for chemistry

他后来获得了诺贝尔化学奖，

in 2008.

是在2008年。

Roger and his team

那时Roger和他的团队

were working on a way to detect cancer,

正在寻找发现肿瘤的方法。

and they had a very clever molecule

他们发明了一种

that they had come up with.

非常聪明的分子，

The molecule they had developed

这种分子

had three parts.

有三个部分。

The main part of it is the blue part, polycation,

主要部分是这个蓝色的部分，叫聚阳离子，

and it's basically very sticky

它是很黏的物质

to every tissue in your body.

能粘住身体里的每个组织。

So imagine that you make a solution

所以想象我们制作一个

full of this sticky material

充满这种粘稠物体的溶液

and inject it into the veins of someone who has cancer,

并将其注入癌症病人的静脉中，

everything's going to get lit up.

一切都被照亮了，

Nothing will be specific.

每个部位，无一例外

There's no specificity there.

没有特殊性。

So they added two additional components.

之后他们又加了两个附加组件

The first one is a polyanionic segment,

第一个是聚阴离子部分

which basically acts as a non-stick backing

它就像是黏胶纸的背面

like the back of a sticker.

执行不粘的功能

So when those two are together, the molecule is neutral

所以当这两者在一起时，分子是中性的，

and nothing gets stuck down.

不会粘任何东西。

And the two pieces are then linked

这两个部分又通过其它部分相连，

by something that can only be cut

只有用合适的分子剪刀，

if you have the right molecular scissors --

才能剪掉这个部分。

for example, the kind of protease enzymes

譬如说，这种肿瘤制造的

that tumors make.

蛋白酶

So here in this situation,

在这种情况下，

if you make a solution full of this three-part molecule

如果用这三种分子制作溶液，

along with the dye, which is shown in green,

加上染料，就显出绿色。

and you inject it into the vein

把液体注入癌症病人的

of someone who has cancer,

静脉

normal tissue can't cut it.

一般的组织是不能剪断它的。

The molecule passes through and gets excreted.

分子经过它，排泄。

However, in the presence of the tumor,

但是，有肿瘤的地方，

now there are molecular scissors

我们有分子剪刀，

that can break this molecule apart

可以把这种分子剪开

right there at the cleavable site.

就在这个分裂的地方。

And now, boom,

现在，嘭，

the tumor labels itself

肿瘤自己挂上了标签

and it gets fluorescent.

发出荧光。

So here's an example of a nerve

这是一根神经，

that has tumor surrounding it.

周围有肿瘤

Can you tell where the tumor is?

你知道肿瘤在哪里吗?

I couldn't when I was working on this.

我以前也不知道

But here it is. It's fluorescent.

但是，现在，你看，在这里，就是闪荧光的地方。

Now it's green.

是绿色的。

See, so every single one in the audience

所以，每一位观众，

now can tell where the cancer is.

现在都知道肿瘤在哪里了。

We can tell in the operating room, in the field,

我们在手术室里，当场就知道了。

at a molecular level,

在有分子的地方，

where is the cancer and what the surgeon needs to do

肿瘤在哪里，手术医生需要做什么，

and how much more work they need to do

他们还需要做多少工作

to cut that out.

把肿瘤切除。

And the cool thing about fluorescence

荧光的好处在于

is that it's not only bright,

它不仅发光

it actually can shine through tissue.

实际上它可以使组织发光。

The light that the fluorescence emits

荧光发出的亮光

can go through tissue.

可以穿透组织。

So even if the tumor is not right on the surface,

因此即使肿瘤表面不亮，

you'll still be able to see it.

我们仍然可以看到它。

In this movie, you can see

在这个影片中，你可以看到，

that the tumor is green.

肿瘤是绿色的，

There's actually normal muscle on top of it. See that?

实际上它的表面是正常的肌肉，看到了吗？

And I'm peeling that muscle away.

我正在把那层肌肉剥离。

But even before I peel that muscle away,

但即使就在我剥离那层肌肉之前

you saw that there was a tumor underneath.

你仍可以看到有肿瘤在下面。

So that's the beauty of having a tumor

这就是用荧光分子标记肿瘤的

that's labeled with fluorescent molecules.

美妙之处。

That you can, not only see the margins

你不仅可以看到

right there on a molecular level,

在荧光分子处看到肿瘤的边缘

but you can see it even if it's not right on the top --

即使它不是在正上方

even if it's beyond your field of view.

超越你视野所及的范围。

And this works for metastatic lymph nodes also.

这种方法也用于治疗淋巴结转移癌。

Sentinel lymph node dissection

前哨淋巴结解剖

has really changed the way that we manage breast cancer, melanoma.

已经改变了我们治疗乳腺癌和黑素瘤的方式。

Women used to get

以前妇女要

really debilitating surgeries

做大伤元气的手术，

to excise all of the axillary lymph nodes.

来切除全部的腋淋巴结。

But when sentinel lymph node

但是按照我们治疗

came into our treatment protocol,

前哨淋巴结的方案，

the surgeon basically looks for the single node

手术医生会首先寻找单个的，

that is the first draining lymph node of the cancer.

肿瘤首先损害的淋巴结。

And then if that node has cancer,

如果那个淋巴结有肿瘤

the woman would go on to get

妇女才会继续

the axillary lymph node dissection.

进行腋淋巴结切除手术。

So what that means

这就是说

is if the lymph node did not have cancer,

如果那个淋巴结没有肿瘤，

the woman would be saved

这位妇女就不需要

from having unnecessary surgery.

进行不必要的手术。

But sentinel lymph node, the way that we do it today,

但是我们今天做前哨淋巴结手术的方式

is kind of like having a road map

有点像拿着一张地图

just to know where to go.

就能知道往哪里走。

So if you're driving on the freeway

就像你在高速公路上开车

and you want to know where's the next gas station,

你想知道下一个加油站在哪

you have a map to tell you that that gas station is down the road.

你的地图会显示前面有一个加油站。

It doesn't tell you whether or not

但是地图不会告诉你

the gas station has gas.

加油站里是否有油。

You have to cut it out, bring it back home,

你必须把油管拔下来，带回家，

cut it up, look inside

打开看里面，

and say, "Oh yes, it does have gas."

才知道: "哦，是的，里面有油。”

So that takes more time.

但是这样要花很多时间。

Patients are still on the operating room table.

病人还躺在手术台上。

Anesthesiologists, surgeons are waiting around.

麻醉医师，手术医生都等在周围。

That takes time.

上述做法要花不少时间。

So with our technology, we can tell right away.

但是用我们的技术立即就可以知道。

You see a lot of little, roundish bumps there.

你看这里有许多小小圆圆的肿块。

Some of these are swollen lymph nodes

这其中的一些是肿胀的淋巴结

that look a little larger than others.

看起来比其他的要大些。

Who amongst us hasn't had swollen lymph nodes with a cold?

我们中间有谁在感冒时淋巴结不肿胀呢？

That doesn't mean that there's cancer inside.

这并不说明其中有癌症。

Well with our technology,

但是用我们的技术

the surgeon is able to tell immediately

医生可以立即知道

which nodes have cancer.

哪个淋巴结有肿瘤。

I won't go into this very much,

我不想再继续深入阐述，

but our technology, besides being able

但是我们的技术，除了可以

to tag tumor and metastatic lymph nodes with fluorescence,

用荧光标记肿瘤和转移性淋巴结，

we can also use the same smart three-part molecule

我们还可以用同样的智能三元分子

to tag gadolinium onto the system

在系统上标注轧元素

so you can do this noninvasively.

这样做是无创的。

The patient has cancer,

病人患有癌症，

you want to know if the lymph nodes have cancer

我们想在动手术前

even before you go in.

就知道他的淋巴结是否有肿瘤

Well you can see this on an MRI.

这可以从核磁共振上看。

So in surgery,

在手术中

it's important to know what to cut out.

重要的是要知道切割什么

But equally important

同样重要的是

is to preserve things

保留什么。

that are important for function.

这对于病人的恢复很重要。

So it's very important to avoid inadvertent injury.

因此要小心，不要因为疏忽使病人受伤。

And what I'm talking about

我指的是

are nerves.

神经。

Nerves, if they are injured,

如果伤害了神经

can cause paralysis,

可能导致瘫痪，

can cause pain.

可能导致疼痛。

In the setting of prostate cancer,

拿前列腺癌来举例，

up to 60 percent of men

百分之六十的病人

after prostate cancer surgery

在手术后

may have urinary incontinence

会出现小便失禁

and erectile disfunction.

以及勃起功能障碍。

That's a lot of people to have a lot of problems --

很多人出现很多的问题--

and this is even in

这种情况甚至出现在

so-called nerve-sparing surgery,

所谓的神经保留手术中。

which means that the surgeon is aware of the problem,

这说明外科医生已经意识到了问题，

and they are trying to avoid the nerves.

并且努力避免伤害神经。

But you know what, these little nerves are so small,

但是，你知道吗？这些神经在

in the context of prostate cancer,

前列腺癌中太小

that they are actually never seen.

基本看不到。

They are traced

只能根据

just by their known anatomical path

已知的解剖路径

along vasculature.

沿着脉管系统找到它们。

And they're known because somebody has decided to study them,

因为有人对此进行研究，我们才得以了解。

which means that we're still learning

但是我们还在研究

about where they are.

这些神经的位置。

Crazy to think that we're having surgery,

如果我们要动手术，

we're trying to excise cancer, we don't know where the cancer is.

切除肿瘤，但是却不知道肿瘤在哪里，那简直是疯了。

We're trying to preserve nerves; we can't see where they are.

我们努力保护神经，但是不知道神经在哪里。

So I said, wouldn't it be great

所以我说，

if we could find a way

如果我们能找到一种方法

to see nerves with fluorescence?

用荧光看到神经，不是很好吗？

And at first this didn't get a lot of support.

刚开始，没有很多人支持我。

People said, "We've been doing it this way for all these years.

有人说：“我们这样做已经很多年了。

What's the problem?

有什么问题呢？

We haven't had that many complications."

我们没有那么多的并发症嘛。“

But I went ahead anyway.

但是我还是继续研究。

And Roger helped me.

Roger 帮助了我。

And he brought his whole team with him.

他把他的整个队伍带来了。

So there's that teamwork thing again.

所以我们又是进行团队研究，

And we eventually discovered molecules

并且最终发现了

that were specifically labeling nerves.

可以明确标记神经的分子。

And when we made a solution of this,

当我们做好

tagged with the fluorescence

这样的溶液，标记上荧光

and injected in the body of a mouse,

注射进老鼠身体的时候，

their nerves literally glowed.

它们的神经真的发光了。

You can see where they are.

你可以看到神经在哪里。

Here you're looking at a sciatic nerve of a mouse,

这里你看一只老鼠的坐骨神经，

and you can see that that big, fat portion you can see very easily.

这个部分大大肥肥的，很容易看到。

But in fact, at the tip of that where I'm dissecting now,

可是实际上，从我现在解剖的顶部看，

there's actually very fine arborizations

那只是非常精细的神经分支，

that can't really be seen.

用肉眼根本看不到。

You see what looks like little Medusa heads coming out.

你看，这个看起来就像小美杜莎的头伸在外面。

We have been able to see nerves

我们可以看到神经--

for facial expression, for facial movement, for breathing --

面部表情、面部运动和呼吸的

every single nerve --

每一根神经--

nerves for urinary function around the prostate.

前列腺周围排尿功能的神经。

We've been able to see every single nerve.

我们可以看到每一根神经，

When we put these two probes together ...

当我们把两根探针放到一起时。。。

So here's a tumor.

所以这是一个肿瘤，

Do you guys know where the margins of this tumor is?

你知道肿瘤的边缘在哪儿吗？

Now you do.

现在你知道了。

What about the nerve that's going into this tumor?

那么这个肿瘤里的神经呢？

That white portion there is easy to see.

那个白色的部分很容易看到

But what about the part that goes into the tumor?

但是肿瘤里面的部分呢？

Do you know where it's going?

你知道在哪儿么？

Now you do.

现在知道了。

Basically, we've come up with a way

实际上，我们找到了一种

to stain tissue

将组织染色的方法，

and color-code the surgical field.

也就是色码手术。

This was a bit of a breakthrough.

这比以前有些突破。

I think that it'll change the way that we do surgery.

我想这会改变我们现在动手术的方式。

We published our results

我们的研究结果刊登在

in the proceedings of the National Academy of Sciences

国家科学院期刊

and in Nature Biotechnology.

和自然生物技术期刊上。

We received commentary in Discover magazine,

探索杂志

in The Economist.

和经济学家杂志也作了评论。

And we showed it to a lot of my surgical colleagues.

我们把研究结果给很多外科医生同行看

They said, "Wow!

他们说：“哇！”

I have patients

我的病人

who would benefit from this.

将会从中受益。

I think that this will result in my surgeries

我想这会为我的手术

with a better outcome

带来更好的效果和

and fewer complications."

更少的并发症。

What needs to happen now

现在我们需要的是

is further development of our technology

进一步的技术

along with development

和医疗器械

of the instrumentation

的发展。

that allows us to see

这可以让我们在手术室

this sort of fluorescence in the operating room.

看到这种荧光。

The eventual goal

最终的目标是

is that we'll get this into patients.

我们可以将此用于病人。

However, we've discovered

但是我们发现

that there's actually no straightforward mechanism

实际上没有一个简单的机制

to develop a molecule

可以发展一次性使用的

for one-time use.

分子。

Understandably, the majority of the medical industry

我们了解到，医疗行业

is focused on multiple-use drugs,

主要是集中在开发用途广泛的药物

such as long-term daily medications.

如可每日长期服用的药物。

We are focused on making this technology better.

我们专注于改进技术、

We're focused on adding drugs,

提高药效、

adding growth factors,

添加生长因子、

killing nerves that are causing problems

杀死招致麻烦的神经

and not the surrounding tissue.

而不是周边组织。

We know that this can be done and we're committed to doing it.

我们知道这可以做到，我们也在尽全力去做。

I'd like to leave you with this final thought.

最后，我想和大家分享的是

Successful innovation

成功的创新

is not a single breakthrough.

不是来自某一次的突破，

It is not a sprint.

或某一次的冲刺。

It is not an event for the solo runner.

创新不来自个人。

Successful innovation

成功的创新

is a team sport, it's a relay race.

是一个团队项目，是接力赛跑。

It requires one team for the breakthrough

它要求一支队伍合作突破

and another team

接着另一支队伍

to get the breakthrough accepted and adopted.

使这项突破被接受并采用。

And this takes the long-term steady courage

这需要长期坚韧不拔的勇气

of the day-in day-out struggle

每天与困难作斗争

to educate, to persuade

去教育、说服人们

and to win acceptance.

接受新技术。

And that is the light that I want to shine

这就是我想和大家分享的

on health and medicine today.

当今健康和医疗的新发展。

Thank you very much.

谢谢。

(Applause)

（掌声）