Yoav Medan: Ultrasound surgery -- healing without cuts

譯者: kane tan 審譯者: Kai Cheong Chan

Over the last 13 years --

過去 13 年中 --

one, three, 13 years --

1,3,13 年 --

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

我曾是以色列 InSightec 公司和其來自世界各地的伙伴

and partners around the world

的一個優秀小組的成員，

for taking this idea, this concept,

我們把非侵入式的手術

noninvasive surgery,

這個想法、這個概念，

from the research lab to routine clinical use.

從研究實驗室中推行到例行性的臨床使用上。

And this is what I'll tell you about.

而這就是我將要告訴大家的東西。

13 years --

13 年 --

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

對你們一些人而言，也許會有種同情的感覺。

For me, today, on this date,

對我而言，今天這個日子，

it's like a second bar mitzvah experience.

就像是第二次的成年禮一樣。

(Laughter)

(笑聲)

So this dream

而這個夢想

is really enabled

已經藉由

by the convergence

兩項技術的結合

of two known technologies.

而成真了。

One is the focused ultrasound,

其中一項是聚焦超音波，

and the other one is the

另一項則是

vision-enabled magnetic resonance imaging.

視覺化的磁振造影技術。

So let's first talk about focused ultrasound.

讓我們先談談聚焦超音波。

And I hold in my hand

我手中所拿著的是

a tissue-mimicking phantom.

一個組織模型。

It is made out of silicon.

它是用矽做成的。

It is transparent, made just for you.

它是透明的, 特別為大家製造的。

So you see, it's all intact,

如你所見，它是完好無缺，

completely transparent.

完全透明的。

I'll take you now to the acoustic lab.

我現在帶你來到聲效實驗室。

You see the phantom within the aquarium.

你可以看見模型被放在玻璃缸裡。

This is a setup I put in a physics lab.

這是我放在物理實驗室的一套設備。

On the right-hand side,

在右手邊，

you see an ultrasonic transducer.

你可以看見一台超音波轉換器。

So the ultrasonic transducer

當這個超音波轉換器

emits basically an ultrasonic beam

對著模型聚焦

that focuses inside the phantom.

發射出超音波束。

Okay, when you hear the click,

好,當你聽見「啪」一聲，

this is when the energy starts to emit

這表示能量開始被傳送出來，

and you see a little lesion form

然後你可以看見在模型裡面

inside the phantom.

出現小小的損傷。

Okay, so everything around it

而它周圍的其他位置

is whole and intact.

則都完好無缺。

It's just a lesion formed inside.

損傷只在內部形成。

So think about, this is in your brain.

想像一下，這東西在你的大腦內。

We need to reach a target inside the brain.

我們需要觸及大腦中的這個目標物。

We can do it without harming any tissue.

我們可以在不傷及任何組織的前提下做到。

So this is, I think,

所以，我想，

the first kosher Hippocratic surgical system.

這是第一個符合猶太戒律的希波克拉提斯手術系統。

(Laughter)

(笑聲)

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

接著我們來談談超音波，

the force of ultrasound.

超音波的力量。

You know all about imaging, right, ultrasound imaging.

大家都聽過造影,對,超音波的造影。

And you know also about lithotripsy --

也聽過震波碎石 --

breaking kidney stones.

震碎腎臟結石。

But ultrasound can be shaped

但超音波可以被塑造成

to be anything in between,

介於這兩者之間的東西，

because it's a mechanical force.

因為它是一種機械式的力量。

Basically, it's a force acting on a tissue

基本上，它的一種作用在

that it transverses.

它所橫越過的組織上的力量。

So you can change the intensity, the frequency,

所以你可以改變超音波的強度、頻率、

the duration, the pulse shape of the ultrasound

週期、波形等

to create anything

來創造出

from an airbrush to a hammer.

像噴鎗以至鎚頭的任何東西。

And I am going to show you

接下來我將會給你演示

multiple applications in the medical field

藉由聚焦，

that can be enabled

完全的聚焦，

just by focusing,

在醫療領域中

physically focusing.

所能做到的各種應用。

So this idea

使用控制聚焦超音波

of harnessing focused ultrasound to treat lesions in the brain

來治療大腦裡的患處

is not new at all.

並不是全新的想法。

When I was born, this idea was already conceived

這個想法在我出生時

by pioneers such as the Fry brothers

就已經被一些前輩提出，例如 Fry 兄弟們，

and Lars Leksell,

以及 Lars Leksell，

who is know actually

他實際上正是

as the inventor of the gammaknife.

加馬刀(利用放射線聚焦)的發明人。

But you may not know

不過你可能不知道

that he tried to perform lobotomies in the brain,

他曾經在1950年代，

noninvasively,

嘗試利用聚焦超音波

with focused ultrasound in the '50s.

進行非侵入式的前腦葉白質切除術。

He failed,

他失敗了，

so he then invented the gammaknife.

之後他就發明了加馬刀。

And it makes you ponder

這會讓你疑惑

why those pioneers failed.

為什麼這些前輩們會失敗。

And there was something fundamental

他們缺少了一些

that they were missing.

很基本的東西。

They were missing the vision.

他們缺少了視覺影像。

It wasn't until the invention of the MR

直到磁振造影被發明出來，

and really the integration of MR

並且真正將磁振造影

with focused ultrasound

結合聚焦超音波

that we could get the feedback --

使我們得到

both the anatomical and the physiological

解剖學和生理學上的回饋

in order to have a completely noninvasive, closed-loop

藉以達到完全非侵入式，封閉循環的

surgical procedure.

手術程序。

So this is how it looks, you know,

這就是在今天,我們所看到

the operating room of the future today.

未來的手術室的樣子。

This is an MR suite with a focused ultrasound system.

這是搭配了聚焦超音波系統的磁振造影設備。

And I will give you several examples.

我將會給大家看一些範例。

So the first one is in the brain.

第一個例子是在大腦之中。

One of the neurological conditions

一種神經系統的疾病

that can be treated with focused ultrasound

是可以用聚焦超音波來治療的

are movement disorders,

是運動障礙症,

like Parkinson's or essential tremor.

像帕金森氏症或是原發性顫抖症等。

What is typical to those conditions,

這些問題的典型症狀是，

to essential tremor for example,

以原發性顫抖症為例，

is inability

在喝湯或吃麥片時

to drink or eat cereal or soup

無法做到

without spilling everything all over you,

不把東西灑得到處都是，

or write legibly so people can understand it,

或是無法端正寫字讓大家看懂，

and be really independent in your life

以及無法不靠別人的幫助

without the help of others.

只靠自己過生活。

So I'd like you to meet John.

我想讓大家看看 John。

John is a retired professor of history

John 是退休的歷史教授，

from Virginia.

住在維吉尼亞。

So he suffered from essential tremor for many years.

他罹患原發性顫抖症許多年了。

And medication didn't help him anymore.

藥物治療無法再給他任何幫助。

And many of those patients refused to undergo surgery

許多患這種病的人拒絕接受

to have people cut into their brain.

讓人切割大腦的手術。

And about four or five months ago,

在 4~5 個月前，

he underwent an experimental procedure.

他接受了一次實驗性的療程。

It is approved under an FDAIDE

這獲得美國食品藥品管理局(FDA)的臨床試驗醫療器材豁免(IDE)批准，

at the University of Virginia

在夏洛特斯維爾的

in Charlottesville

維吉尼亞大學裡面進行，

using focused ultrasound

使用聚焦超音波

to ablate a point in his thalamus.

消融他視丘葉片中的一點。

And this is his handwriting.

這是他的筆跡。

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

「在 6 月 20 號」 如果你有看見的話，

"2011."

「2011年」

This is his handwriting

這是他在治療當天早上

on the morning of the treatment

進行磁振造影之前

before going into the MR

所留下的筆跡。

So now I'll take you through

接下來我要讓大家了解

[what] a typical procedure like that looks like,

像這種手術的典型流程是怎樣的，

[what] noninvasive surgery looks like.

無侵入式的手術是怎樣的。

So we put the patient on the MR table.

我們讓病人躺在磁振造影的檯子上。

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

在這個案例裡,我們把轉換器接到大腦上，

but if it will be a different organ,

如果是不同的器官，

it will be a different transducer attached to the patient.

就會把不同的轉換器接到病人身上。

And the physician

接著主治醫師

will then take a regular MR scan.

會進行常規的磁振造影掃描。

And the objective of that?

目的是什麼呢?

I don't have a pointer here,

我手邊沒有投影筆，

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

不過你可以看見這綠色、類似矩形或梯形的部份?

This is the sort of general area of the treatment.

這是進行治療的大概區域。

It's a safety boundary

這是目標物周圍的

around the target.

安全範圍。

It's a target in the thalamus.

它是在視丘內的一個目標。

So once those pictures are acquired

一旦取得了這些照片後，

and the physician has drawn

主治醫師畫出了

all the necessary safety limits and so on,

所有必要的安全限制範圍等等，

he selects basically a point --

他基本上選取一點 --

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

你看到在游標的位置,中間的一個圓點 --

and he presses this blue button called "sonicate."

然後他按下這個叫做「超音波降解」的藍色按鈕。

We call this instance of injecting the energy,

我們稱這注入能量的步驟，

we call it sonication.

我們稱它為超音波降解。

The only handwork the physician does here

主治醫師唯一需要動手的

is moving a mouse.

是移動這隻滑鼠。

This is the only device he needs in this treatment.

這是他在這項治療中唯一用到的器具。

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

他按下超音波降解，跟著就會出現以下的情況。

You see the transducer, the light blue.

你看看那個轉換器，淺藍色的地方。

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

在頭顱和轉換器之間注有水。

And it does this burst of energy.

然後它放出巨大能量。

It elevates the temperature.

它提升溫度。

We first need to verify

首先我們必須確認

that we are on target.

我們命中了目標。

So the first sonication

所以第一次超音波降解

is at lower energy.

是使用較低的能量。

It doesn't do any damage,

這不會造成任何傷害，

but it elevates the temperature

它只是讓溫度上升

by a few degrees.

幾度而已。

And one of the unique capabilities

使用磁振造影

that we leverage with the MR

其中一項獨特的能力就是

is the ability to measure temperature noninvasively.

可以進行非侵入式溫度量測。

This is really a unique capability of the MR.

這確實是磁振造影的獨特之處。

It is not being used

它並不是被用作

in regular diagnostic imaging.

常規的造影診斷。

But here we can get

但這裡我們可以取得

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

實時的解剖造影和溫度分佈圖。

And you can see the points there on the graph.

你可以看見圖中的這些點。

The temperature was raised

溫度暫時地

to 43 degrees C temporarily.

上升到攝氏 43 度。

This doesn't cause any damage.

這並不會造成任何傷害。

But the point is we are right on target.

但重點是，我們準確的命中目標。

So once the physician verifies

一旦主治醫師確認了

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

聚焦點是在他所選取的目標上，

then we move to perform

接著就會進行

a full-energy ablation

一次最高能量的消融治療，

like you see here.

就像你在這裡看到的一樣。

And you see the temperature rises

你看見溫度上升

to like 55 to 60 degrees C.

到達約攝氏 55 至 60 度。

If you do it for more than a second,

如果持續超過 1 秒鐘，

it's enough to basically destroy

基本上足以

the proteins of the cells.

消滅細胞中的蛋白質了。

This is the outcome from a patient perspective --

這是從病人角度看到的結果 --

same day after the treatment.

就在治療完成當天。

This is an immediate relief.

問題立刻就被解決了。

(Applause)

(掌聲)

Thank you.

謝謝大家。

John is one of [about] a dozen

John 是許多有膽量、

very heroic, courageous people

有勇氣自願接受這個研究的

who volunteered for the study.

約12個參加者中之一。

And you have to understand

你必須了解，

what is in people's mind

當這些人願意接受這個風險時，

when they are willing to take the risk.

他們的心裡在想些什麼。

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

這裡引用了 John 所寫下的內容。

He said, "Miraculous."

他說「太神奇了」。

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

他的妻子說「這是我這一生中最開心的時刻」。

And you wonder why.

你也許感到疑惑。

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

我想傳達給大家其中一個訊息是，

is, what about defending quality of life?

有沒有想過維護生活質素?

I mean, those people lose their independence.

我是說，這些人失去了獨立性。

They are dependent on others.

他們必須依靠其他人。

And John today is fully independent.

然而現在，John 完全不需要依靠別人了。

He returned to a normal life routine.

他回復到一個正常生活了。

And he also plays golf,

他也打打高爾夫球，

like you do in Virginia

就像你們在維吉尼亞

when you are retired.

退休後所做的一樣。

Okay, so you can see here the spot.

你可以看到這邊的班點處。

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

在大腦中約 3 mm 的東西。

There's no damage outside.

在外面並沒有任何的損傷。

He suffers from no neurodeficit.

他沒有受到任何神經損傷。

There's no recovery needed, no nothing.

不需要復健，什麼都不需要。

He's back to his normal life.

他已恢復正常生活。

Let's move now

接著我們繼續

to a more painful subject.

談談一個更痛苦的題目。

Pain is something

疼痛是一種

that can make your life miserable.

讓你的生命很不舒服的東西。

And people are suffering from all kinds of pain

而人們正承受著種種的疼痛，

like neuropathic pain, lower-back pain

例如神經痛、下背痛、

and cancer pain from bone metastases,

以及癌症骨擴散的疼痛，

when the metastases get to your bones,

當癌細胞擴散到你的骨頭時，

sometimes they are very painful.

有時候是會非常痛楚的。

All those I've indicated

我所指出的這些全部狀況

have already been shown

都已經被證實

to be successfully treated

可用聚焦超音波

by focused ultrasound

成功治療

relieving the pain, again, very fast.

很快速的解除疼痛。

And I would like to tell you

接著我想告訴大家

about PJ.

關於 PJ 的故事。

He's a 78 year-old farmer

他是一位 78 歲的農夫，

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

患上 -- 該怎麼說呢? --

it's called pain in the butt.

那被稱為臀部疼痛的病症。

He had metastases in his right buttock,

他的癌細胞擴散到了右臀，

and he couldn't sit

即使靠著藥物治療

even with medication.

他仍然沒辦法坐下來。

He had to forgo all the farm activities.

他必須放棄所有農田的工作。

He was treated with radiation therapy,

他接受了放射線治療，

state-of-the-art radiation therapy,

最先進的放射線治療，

but it didn't help.

不過沒用。

Many patients like that favor radiation therapy.

許多像他一樣的病人偏向使用放射線治療。

And again, he volunteered

不過，他自願參與

to a pivotal study

我們在世界各地進行的

that we ran worldwide,

也在美國進行的

also in the U.S.

一個關鍵性的研究，

And his wife actually took him.

事實上是由他妻子帶他來的。

They drove like three hours

他們從農場

from their farm to the hospital.

開了 3 個小時的車到醫院。

He had to sit on a cushion,

他必須坐在一個軟墊上，

stand still, not move,

完全不能移動，

because it was very painful.

因為動的話會很痛。

He took the treatment,

他接受了治療，

and on the way back,

在回家的時候，

he drove the truck by himself.

是由他自己開著卡車。

So again, this is an immediate relief.

再一次，問題立刻就被解決了。

And you have to understand

你必須明白

what those people feel

當事情發生時，

and what their family experiences

這些人的感覺

when it happens.

以及他們家人的感受。

He returned again

他再次回到

to his daily routine on the farm.

農場進行日常工作。

He rides his tractor.

他駕駛他的拖拉機。

He rides his horse to their mountain cabin regularly.

經常騎馬到山上小屋。

And he has been very happy.

他變得很開心。

But now, you ask me,

但你可能會問我，

but what about war, the war on cancer?

那對抗癌症的戰爭又怎樣呢?

Show us some primary cancer.

讓我們看看主要的癌症。

What can be done there?

又有甚麼可以做的呢?

So I have good news and bad news.

我有好消息，也有壞消息。

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

好消息是：我們有許多事情可以做。

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

在美國以外的國家實際上已經被證實了。

And doing that in the U.S.

但在美國進行這件事

is very painful.

是很痛苦的。

I don't see, without this nation

我想，除非這個國家

taking it as some collective will

將它視為某種集體意願

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

或是某種必須達成的國家目標，

it will not happen.

否則它不會發生。

And it's not just because of regulation;

它不單是監管上的問題；

it's because of the amount of money needed

而因為在現行的實證醫學體系下，

under the current evidence-based medicine

以及測試規模等問題下，

and the size of trials and so on

想要達成它

to make it happen.

必須花費很大量的金錢。

So the first two applications

最初的兩項應用

are breast cancer and prostate cancer.

是乳癌和前列腺癌。

They were the first to be treated by focused ultrasound.

這是最早使用聚焦超音波來治療的癌症。

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

對於乳癌，效果比開刀還好。

But I have a message for the men here.

不過我要告訴在場的男士們一個消息。

We heard here yesterday Quyen

我們昨天在這裡

talking about the adverse event trait

聽到 Quyen 談論治療前列腺癌

in prostate cancer.

不好的後遺症。

There is a unique opportunity now

而使用磁振造影引導進行聚焦超音波治療

with focused ultrasound guided by MR,

有著獨一無二的契機，

because we can actually think about

因為我們可以改良原有的

prostate lumpectomy --

前列腺腫瘤切除術 --

treating just the focal lesion

只針對聚焦點進行治療，

and not removing the whole gland,

而不是將整個腺體移除，

and by that, avoiding all the issues

藉此，避開所有

with potency and incontinence.

性能力或尿失禁的問題。

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

此外,腹腔內還有其他的癌症腫瘤 --

quite lethal, very lethal actually --

很小的，事實上非常細小的 --

pancreas, liver, kidney.

在胰臟、肝臟和腎臟裡。

The challenge there

這裡的挑戰是，

with a breathing and awake patient --

對於有意識而且清醒的病人 --

and in all our treatments,

在我們所有的治療中，

the patient is awake and conscious

病人都是清醒的，有意識的，

and speaks with the physician --

並且和主治醫師交談的 --

is you have to teach the MR some tricks

你必須教導磁振造影一些訣竅，

how to do it in real time.

如何實進行。

And this will take time.

這要花一些時間。

This will take two years.

這要花兩年的時間。

But I have now a message to the ladies.

現在我要給現場的女士一個消息。

And this is, in 2004,

那就是，在 2004 年，

the FDA has approved MR-guided focused ultrasounds

美國食品藥品管理局(FDA)已批准了磁振造影引導聚焦超音波

for the treatment of symptomatic uterine fibroids.

用來治療子宮肌瘤。

Women suffer from that disease.

女人常被這個病所苦。

All those tumors

那些腫瘤會導致

have heavy bleeding during periods,

經期大量出血、

abdominal pressure, back pain,

腹部漲痛、背痛、

frequent urination.

頻尿等問題。

And sometimes, they cannot even conceive and become pregnant

有時候,子宮肌瘤甚至會造成

because of the fibroid.

無法受孕或無法懷孕等問題。

This is Frances.

這是Frances。

She was diagnosed with a grapefruit-sized fibroid.

她被診斷出有葡萄柚大小的子宮肌瘤。

This is a big fibroid.

這是一個很大的子宮肌瘤。

She was offered a hysterectomy,

醫生建議她進行子宮切除手術，

but this is an inconceivable proposition

但對於一位還想懷孕的女士而言

for someone who wants to keep her pregnancy option.

這是一個無法接受的建議。

So she elected to undergo a focused ultrasound procedure

所以在 2008 年，

in 2008.

她選擇了接受聚焦超音波的治療。

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

而在 2010 年，她成為了一個健康寶寶的新手媽媽。

So new life was born.

就這樣，一個新生命誕生了。

(Applause)

(掌聲)

So in conclusion,

所以，在最後，

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

我要給大家四項消息。

One is, think about the amount

首先，請想想看

of suffering that is saved

病人接受無侵入式手術，

from patients undergoing noninvasive surgery,

可以免受多少的苦痛，

and also the economical and emotional burden

還有，可以讓他們的家人、居住的社區、

removed from their families and communities

以及社會都可以解除那巨大的

and the society at large --

經濟以及情感上的負擔，

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

另外,我想也解除他的主治醫師的負擔。

And the other thing I would like you to think about

另一件我想大家思考的事情

is the new type of relationship

是主治醫師和病人之間

between physician and patients

所出現的全新型態的關係，

when you have a patient on the table

病人躺在手術台上時，

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

是清醒的,甚至還可監視著治療的進行。

In all our treatments,

在我們所有的治療中，

the patient holds a stop sonication button.

病患都握著一個停止超音波降解的按鈕。

He can stop the surgery at any moment.

他可隨時停止手術的進行。

And with that note,

以此按語

I would like to thank you for listening.

我想感謝大家的聆聽。

(Applause)

(掌聲)