OncChats: Mapping Progress Made in Pancreatic Cancer Surgery

, Horacio J. Asbun, MD, and Domenech Asbun, MD, explain how augmented reality or artificial intelligence may be utilized to improve outcomes for patients with pancreatic cancer who are undergoing surgical procedures.

But tell me a little bit more. An area that I see we still operate blindly is the liver, right? What do you think is going to happen with augmented reality or artificial intelligence [AI]? Improved imaging reconstruction? Are we going to be planning the surgery before[hand]? Do you see that field evolving quickly? I think, yes, but you have more experience with that. What do you think about that?

I think it is already expanding. As you’re aware, 3D reconstructions of anatomy are already commonplace in places that do high-volume liver surgery. The ability to use those 3D reconstructions for surgical planning is moving far beyond just looking at a CT scan or an MRI, and helping surgeons understand how to access the tumor, what vessels to look out for, etc

And yeah, you’re completely right. I think the 2 biggest areas in which we will see these changes is in augmented reality—so, the ability for the surgeon to superimpose previously obtained anatomical images on the surgical field, which will help with identifying some of these infrastructures—as well as the role of AI. Now, this is very early field, and it will take a long time for the technology to get [the job done] well enough that it will actually be helpful, but there’s a big interest in seeing how a surgeon’s perspective can be supplemented by AI feedback during the operation of certain structures, certain anatomical situations, etc. That might make the surgeon’s life a little bit easier in these inherently very complex operations.

It’s exciting; no question about it. I think that the changes we have witnessed over the past decades, and what we’re witnessing now, is all very exciting. We are fortunate to be surgeons. We’re fortunate to be able to help patients in the way that we do, and I feel so much more pleasure interacting with our colleagues now, in oncology, interventional radiology, gastroenterology, interventional gastroenterology, etc., because it feels that we are a real team treating patients. I think that you have been able to experience that, [too]. It’s fantastic to work together.

I don’t know whether you want to make any closing comments, but I think that we have [covered quite a bit]. I don’t want to bore anyone; I know for a fact that you and I can continue talking about all of this for several hours. I think we will need to stop at some point.

I think we’ll stop. I’ll just echo your comments that it’s an exciting time to be a surgeon. It’s going to be somewhat crazy to look back at this conversation 5 to 10 years [from now] and see how far we’ve come, but I’m very happy to have the best job in the world and to share it with you.

 for hosting us on [this] OncChats [series]. We’re very appreciative of the opportunity.

Videos

In this last episode of OncChats: Mapping Progress Made in Pancreatic Cancer Surgery, Horacio J. Asbun, MD, and Domenech Asbun, MD, explain how augmented reality or artificial intelligence may be utilized to improve outcomes for patients with pancreatic cancer who are undergoing surgical procedures.

Mapping Progress in Pancreatic Cancer Surgery: Leveraging New Technology

, Horacio J. Asbun, MD, and Domenech Asbun, MD, project where the pancreatic cancer treatment paradigm is headed, from a surgical perspective and beyond.

 Before we close, Domenech, we have been talking about what has happened in the past, and maybe even gloating a little bit. The reason for that is because, at least in my case, I have to say that [with the advances made these] past few years, I feel very optimistic that [we are] finally [seeing] a change in the survival of [patients with] pancreatic cancer; it’s happening.We’re still far from saying that this is the case [for everyone], scientifically, but we have observed [advances] that [have left us in awe].

We’re now able to give hope to those patients. In the past, it was very difficult to give hope. Now, we have tangible [progress]. For [example,] we have the type of radiation that we do on the MRI-LINAC, or percutaneous irreversible electroporation, new chemotherapeutic agents, and some of the trials that we have [are examining administering] chemotherapy intraarterially, directly into the area of the tumor. All those things have helped us give some hope to the patients.

That said, what do you foresee for the future? What is going to be coming [down the pike]? I’m not talking about [what you expect] in 20 years from now; we don’t need to [emanate] Star Trek here. But what do you think is going to happen next 5 years? Are we going to continue at this pace [in terms] of improvement? What are your thoughts on this?

It’s a good question. I think that first, we will see the continued importance of therapies that are not surgical, so systemic therapies and particularly immunotherapy. This is a huge field right now and the advances are very exciting. I hate to say this, and I say it somewhat quietly, but I think we’re going to get to a point where we’re operating less because our other therapies are going to be more useful and more effective in the long term. Obviously, we’re not there yet and I don’t see a world in which surgery is completely out of the picture at all. However, we are seeing very big advances [beyond that area].

From a surgical standpoint, we’re always looking to see how we can improve things, how we can make the operations better and faster, and [easier] for the patients. That’s one of the joys of surgery; you get a little bit of creative freedom to see what you can do that will make an established surgery even better, even these very complex operations. I see the changes [on] that [front] continuing. Through the minimally invasive approaches, we’re now seeing an ongoing revolution that continues to pick up momentum. I think that’s what we have to look forward to. Maybe it’ll take a little more [time beyond 5 years] to see really significant changes, but that’s where we're going.

One other area that is also starting to get a lot more attention are the modalities for screening for some of these very aggressive cancers, such as pancreatic cancer, cholangiocarcinoma, [and others]. These [efforts are] still in [their] infancy, but we are looking for ways to be able to screen patients that will not be a massive burden on the overall healthcare system. [We want] something that is feasible to do in patients on a yearly basis that is, ideally, not very invasive, maybe [in the form of] a blood test, urine analysis, or salivary analysis, etc. That’s another field that we’re going to see continue to blossom, and that will help us help patients.

[I think] you're right, [for the most part]. I am not sure that we’re going to be operating less. In fact, maybe we’ll operate less from the point of view that we [will] learn [more about] the biology of the disease and realize that for some patients it is not even worth it to try to attempt surgery. However, I think that with all these other therapies, at least up to now—the neoadjuvant [approaches], the new chemotherapies, and radiation—we’re operating more. We’re operating on patients who, in the past, we wouldn’t operate on. Hopefully, that trend is going to continue, or really, whatever trend [that will allow us] to cure more patients.

I might have been looking at the Star Trek future. You’re right.

Yeah, you were looking at the Star Trek future. That’s why I prompted you to that.

Check back on Wednesday for the final episode in the series.

In this fourth episode of OncChats: Mapping Progress Made in Pancreatic Cancer Surgery, Horacio J. Asbun, MD, and Domenech Asbun, MD, project where the pancreatic cancer treatment paradigm is headed, from a surgical perspective and beyond. 

Mapping Progress in Pancreatic Cancer Surgery: Looking to the Future

, Horacio J. Asbun, MD, and Domenech Asbun, MD, both of Baptist Health South Florida, underscore the need for utilizing a multidisciplinary approach to determine the optimal care plan for each patient with pancreatic cancer.

The other aspect that I think has become much more the standard of care, which is something we interact with on a weekly basis here at Miami Cancer Institute, is the multidisciplinary approach to patients [with cancer]. Treatment decisions are no longer made by a single person on an island; they are made by a team of experts. Can you talk to how that has affected patient care?

Yes. We’re surgeons, right? We think we should be the ones deciding everything. Traditionally, [the decision of whether] a patient was going to have surgery or not had been [made by] the surgeon, because if you were not capable of deciding, you were [considered to be] “weak;” that [was] the perception. All of that has gone out the window. If you’re working at a true multidisciplinary integrated care facility that’s [caring for] patients with pancreatic cancer or liver cancer, all those [cases] have to be prospectively presented on tumor boards. Basically, now you have a second or third or fourth or fifth opinion regarding what a patient [will need] to have done, and those opinions are given by different specialists.

Now, there are plenty of places that say, “Yeah, we present patient [cases on] tumor boards [and we use a] multidisciplinary approach” because those are the catchphrases. But the reality is, you definitely have to [do this.] When you joined us, [Domenech,] you came from finishing your fellowship at Mayo Clinic, where I had spent 10 years, as you know very well. At facilities like Mayo Clinic [and] Miami Cancer Institute, [these] things are real; it’s integrated care under one roof. Here, we enjoy the presence of people who are world renowned and who have helped us. This is not [an attempt] to advertise; I’m trying to say that there’s no justification today, unless there’s an access issue, [for treating] those patients in an isolated manner. You need to make the decisions of when to operate or not to operate and [whether they should receive] neoadjuvant [treatment] first, with a group of colleagues that you respect. In that way, you can [ensure that you] offer the best option for [each] patient.

With molecular studies, this is going to become much, much more important, and we have seen that [with regard to] the cysts, [for example]. We know now that aspirating the fluid of some of these cysts [may be beneficial;] in the past, we would just blindly observe [these patients]. Now, with the molecular analysis, we can detect with a much better sense whether those cysts may eventually become [cancerous] and [accordingly,] we [can] act on them a little earlier. As more mutations are discovered, it’s going to be more and more important to delegate that part of input into the decision-making process to other colleagues because we cannot do it all.

Check back on Wednesday for the next episode in this series.

In this third episode of OncChats: Mapping Progress Made in Pancreatic Cancer Surgery, Horacio J. Asbun, MD, and Domenech Asbun, MD, underscore the need for utilizing a multidisciplinary approach to determine the optimal care plan for each patient with pancreatic cancer.

Mapping Progress in Pancreatic Cancer Surgery: Multidisciplinary Approach to Care 

, Horacio J. Asbun, MD, and Domenech Asbun, MD, both of Baptist Health South Florida, share examples of efforts that have moved the needle forward in pancreatic cancer surgery, and note potential areas of opportunity.

There is no question that pancreas surgery today is very different than [what it was] before, but I do agree with you. Despite [the fact] that the surgery has improved, the outcomes of the procedure, in terms of overall prognosis, have not. You still need surgery [to achieve] curative results; without surgery, patients are not cured. But [for] those [in whom] we do surgery, the overall prognosis has not changed for several years. That’s when, as you said, chemotherapy and other modalities play a significant role.

Absolutely. I want to also add that it’s nice to see that a lot of these changes have [improved] outcomes after surgery, [in terms of] morbidity and mortality; some of [these changes] have actually increased survival. But there’s also an increase in quality of life [QOL]. When a patient has a very serious diagnosis, even one that may be terminal, QOL is even more important in some ways because it has a very big impact on that patient’s life. As such, it’s nice to see those [kinds of] advances.

Absolutely. You’re absolutely right. We have seen that, for example, with distal pancreatectomy, meaning left-side pancreatectomy and non-Whipple [procedures]. I cannot say this officially, of course, [but] it’s almost like, why don’t we do palliative surgery for those patients? Because they’re not going to have the infiltration of the celiac trunk, they’re not going to have the amount of pain, and yes, they may succumb to the disease anyway, but [with] the distal pancreatectomies, when done by experienced people through a minimal access approach, the results are so good that palliation may play a role. Who knows?

Right, and [for] those surgeries [that] we do with 4 ports and no drains people are usually home in a few days. So, it’s a different approach to treating cancers [compared with] knowing that they would be in the hospital for 2 weeks as almost a mandatory prescription.

Check back next Wednesday for the next episode in this series.

In this second episode of OncChats: Mapping Progress Made in Pancreatic Cancer Surgery, Horacio J. Asbun, MD, and Domenech Asbun, MD, share examples of efforts that have moved the needle forward in pancreatic cancer surgery, and note potential areas of opportunity.

Mapping Progress in Pancreatic Cancer Surgery: Continuing to Move the Needle

, Horacio J. Asbun, MD, and Domenech Asbun, MD, both of Baptist Health South Florida, discuss recent advances made in the surgical field and beyond for pancreatic cancer, including the benefits of minimally invasive approaches.

 Good afternoon. Thank you for having us. It is a pleasure for me to be here. My name is Horacio Asbun. I’m the chief of hepatobiliary and pancreas surgery at Miami Cancer Institute. It is particularly my pleasure because I’m having a conversation with someone who I [have] known for several years. I have witnessed him grow and become a phenomenal surgeon, which is not that common. I feel fortunate to have Domenech Asbun [here with me today]. Domenech?

Thank you very much for the very kind introduction. My name is Domenech Asbun. I am also a hepatobiliary and pancreatic surgeon at Miami Cancer Institute. I specialize primarily in cancers of the hepatobiliary tract, pancreas, and the upper gastrointestinal tract. I’m excited to be speaking with you today about some of the more recent updates in these fields.

Thanks, Domenech. Starting off today, tell us a little bit about how we have evolved over the past few years in the treatment of cancer of the liver and pancreas.

That’s a good question, and a loaded question. You and I are surgeons; we both love to operate, but I think we both have to admit that a lot of the changes that we have seen have come from outside of the operating room. The advances in chemotherapy—not just the agents that are used, but the timing; molecular profiling and subsequent actionable treatment plans based on those results; immune therapy; [and] other adjunctive treatments, such as radiation, electroporation, or other modalities, have all given patients in this somewhat varied class of cancers, a lot more hope than they may have had a few decades ago.

One of the other improvements we’ve also seen, inside the operating room, are advances in how we approach the operation, particularly [with] minimally invasive surgery. You are a pioneer in this field. You’ve been doing this for over 2 decades, back when most people had no idea that it was even a possibility to do some of these procedures in a minimally invasive fashion. And so, from your perspective, how is it that we’ve progressed, and what changes are you happy to look back on right now?

Well, the big change came even a little bit before that time, when the mortality and morbidity of the major pancreatic procedure, the Whipple procedure, had decreased significantly. Prior to my time, the mortality was [around] 40%, and that has changed little by little by doing more hemostasis, meaning less blood loss, and trying to do a little bit more delicate surgery. Around 20 years ago—if we talk about all pancreas surgery, it’s probably 27 or 28 years—we started doing the Whipple laparoscopically. At the beginning, it was not widely accepted. It took, I would say, over a decade for other people to really be open to the idea that this was something that could be done and could be [more widespread]—especially now, with the introduction of [robotic surgery].Currently, we have a significant number of surgeons doing it.

But what is the attraction? As you understand, Domenech, when we’re doing a complex procedure such as this, trying to shorten the hospital stay by a day or trying to [give] the patient a smaller incision is not as important as when you’re talking about cholecystectomy or when you’re talking about adrenalectomy because the patient will stay in the hospital for 5 days anyway because of the complexity of the procedure. I think the important part is that we have learned a lot more about anatomy. We have seen the area in different angles, we have been able to understand that minimally invasive surgery [leads to] less blood loss, because if not, the view gets fogged. If that’s the case, then we realize, why is it that in open surgery, we lose more blood than laparoscopic? I feel that the minimally invasive access approach for pancreas surgery has helped us become much better surgeons.

In terms of the perioperative experience for the patient, that’s [where there is a need for] a smaller incision; patients can get out of bed sooner. We also added the Enhanced Recovery [After Surgery] protocols. For colleagues who are not familiar with those terms, we all know that traditionally, people couldn't eat or drink past midnight prior to surgery, and that's all gone now. In fact, we realize that patients arrive to the operating room dehydrated if you do that. We give them high carbohydrate drinks up to 4 hours before the surgery, as long as they are clear liquids. We get them out of bed and walking the same day of surgery. We don't use nasogastric [NG] tubes, or I should say, we use NG tubes sparingly. Besides that, we give all the other medications that you are familiar with, Domenech, in terms of anti-inflammatories and prokinetic agents prophylactically before the surgery. All that has translated to a much better, much more enhanced experience for the patient who is undergoing these very complex procedures.

In this first episode of OncChats: Mapping Progress Made in Pancreatic Cancer Surgery, Horacio J. Asbun, MD, and Domenech Asbun, MD, discuss recent advances made in the surgical field and beyond for pancreatic cancer, including the benefits of minimally invasive approaches.

Domenech Asbun, MD

Articles

Mapping Progress in Pancreatic Cancer Surgery: Leveraging New Technology

Mapping Progress in Pancreatic Cancer Surgery: Looking to the Future

Mapping Progress in Pancreatic Cancer Surgery: Multidisciplinary Approach to Care

Mapping Progress in Pancreatic Cancer Surgery: Continuing to Move the Needle

Mapping Progress in Pancreatic Cancer Surgery: Minimally Invasive Approaches