Cancer Surgery 101

[0:00:00] Dr. Diane:  This week, surgery. Centuries ago, this intricate, profoundly complicated skill was in fact performed by barbers and butchers without anaesthesia. Today, it's a different picture. Surgeries, outcomes and patient experiences have significantly improved. In fact, some surgeries can be done with robots from thousands of miles away. But for some patients, especially cancer patients, it's still quite scary. Let's break it down.

Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center, and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have straightforward, evidence-based conversations. Our mission is to educate and empower you and your family members to make the right decisions and live happier, healthier lives. For more information about the topics discussed here or to send your questions, please visit us at mskcc.org/podcast. Today we have the honor to talk with Dr. Martin Weiser. Dr. Weiser is a world renowned colorectal surgeon at Memorial Sloan Kettering and my dear friend and colleague, Dr. Weiser welcome to the show.

[0:01:14] Dr. Weiser:  Oh, it's a pleasure to be here.

[0:01:16] Dr. Diane:  So Marty, I'd like to start to talk a little bit about your journey, I'm sure you have a pretty fascinating story to tell about how you got into surgery and particularly in colorectal surgery. So how did that journey start?

[0:01:29] Dr. Weiser:  I was always drawn actually to cardiology I thought I would be a medicine doctor. But during those rotations in your third and fourth year of medical school, I was really drawn to the surgeons, I think it was the fact that we would see a problem, take it to the operating room and try to fix it. So, the results were pretty obvious. Either you were successful or not, but it happened pretty quickly. And I think that's what drew me into surgery.

[0:01:51] Dr. Diane:  But that came a huge commitment you know.

[0:01:53] Dr. Weiser:   It did. And I wasn't necessarily a morning person, but I had to be-

[0:01:57] Dr. Diane:  Ouch.

[0:01:57] Dr. Weiser:   Yeah, for surgery. Yeah, you just sort of get drawn into it. And I started out like all surgeons in general surgery. And then, while rotating on all the surgical specialties, I was really drawn to oncology. And it was really perfect for me because I thought it was a mix of medicine and surgery where you would follow patients long term and help them make some very difficult decisions.

[0:02:20] Dr. Diane:  Wow, and then you also focused on the research too, which we'll talk about a little while later, but that research also was part of the decision or that came later in terms of your decision for oncology?

[0:02:31] Dr. Weiser:  Well, I was always interested in research and took part in research throughout my education in residency as well in fellowship, so I always knew I would -- research would be an important part. Oncology of course research is fascinating and many possibilities, so it made it quite easy.

[0:02:48] Dr. Diane:  Surgery is challenging, surgery and oncologic surgery, as you said is sort of another level of that and really amplified because when you're taking any patient to the operating room I can imagine the anxieties and fears are sky high. But now you've given this diagnosis of a life threatening disease like cancer. What do you tell patients when they get this dreaded diagnosis and they're in your office for the first time in terms of what to prepare for what to expect for and what are the sort of ABCs if there are of what might be important for a patient who is about to undergo some sort of surgery as it relates to cancer?

[0:03:19] Dr. Weiser:  They often come into the office with a diagnosis they've had time to think about it they have a lot of questions and a lot of fears. So, we – I start from the beginning and talk about what we're going to do and how we're going to do it. And you know, the obvious things, how long they'll be in the hospital, what the limitations are, what are the goals and what will be the next steps afterward. And then I really try to get them psyched up for the operation they should come into the operation ready for it, excited for it, we're about to possibly cure them or relieve their suffering and you know, I want them to be in the right mind space for it.

[0:03:53] Dr. Diane:  Patients have a fear of the time you know they wanted out yesterday. Being in a place like Memorial Sloan Kettering Cancer Center, we know that outcomes and where you get that first surgery really does matter. Is there anything in that respect that you would offer to share with patients that are about to undergo these types of techniques, whether it be, breast surgery or colorectal surgery or liver surgery?

[0:04:17] Dr. Weiser:  Diane, I think this is a critical point because patients come in panicked and some local physicians may not have alleviated these fears. Time there is generally no urgency in most of the operations that we do in trying to calm patients down and tell them about the disease and often tell them how it started and how long they've probably had it which is many, many months, maybe even years, and that picking the right treatment is critically important. So, we may want additional studies or imaging studies to determine if they need treatment before surgery and I really try to just reduce their anxiety level as much as possible.

[0:04:52] Dr. Diane:  I can't agree with you more in that way. So often patients I'm sorry, I just couldn't wait, I needed to go somewhere else for that, recognising the importance of just the confidence of the surgeon to know what they're doing and how they're going to do it, but also the sort of team approach and other things that often come into the decisions being made, particularly as it relates to cancer surgery, which is different than removing your gallbladder, for example, not to say that that's not important. But there's a lot more I think, decisions, right, you would say to in terms of how you make your decisions of what's going to happen, and when that should happen.

[0:05:24] Dr. Weiser:  Yeah, especially because there may be multiple surgeries and how you perform the first one will affect the second and the third one, and you really have to plan out and think of the whole picture. And that way, I think it's important to take some time and plan out well, so just spending time with the patient and discussing these issues. Often, they can reduce their anxiety and then make the best choice for themselves.

[0:05:49] Dr. Diane:  Well we say that nobody knows how to be a cancer patient, and that's probably equally important in our role of when we treat patients explaining what's expected and providing a plan is so critical. I often hear a couple of things that my patients will ask on just the sort of practicalities of what to do both pre-op and post-op. So, a couple of questions that patients often at least for me come up with that are recurring themes that often there may not be a consistent answer. So it allows, unfortunately for some uncertainty, so post-op, question one. How long can you be until you actually can get back on the treadmill, for example, to exercise?

[0:06:24] Dr. Weiser:  So I tell patients to stay away from any heavy lifting, pushing or pulling including exercise like the treadmill for about six day weeks to prevent hernia formation. I recommend that they go walking, they can go up and down stairs, lift nothing heavier than five pounds. And I urge them not to just sit on the couch that recovery is an active process.

[0:06:44] Dr. Diane:  Absolutely. So, for an abdominal surgery, six to eight weeks of cardiac and other things you can walk around and you should walk around, but really not doing anything strenuous because otherwise you're at risk for that hernia.

[0:06:55] Dr. Weiser:  Right. I really don't want them to engage with the core too much and if your significantly running, you are engaging your core. So, if they were to walk briskly or maybe do a light jog, that would be okay, but nothing more.

[0:07:06] Dr. Diane:  Great. Okay, that's super important. Question two, how do you prevent a scar or a keloid?

[0:07:11] Dr. Weiser:  Well, this does come up frequently. I worry about the topical maintenance because if your skin gets a reaction to it, then you make the scar worse. I often tell patients just to leave it alone, stay out of the sun because it can become hyperpigmented. And then down the road, it can be revised if they need to, scars take a full year to reach their final form. And I really urge them not to do anything for a year.

[0:07:34] Dr. Diane:  Okay, any diets to eat or not to eat either pre or post surgery?

[0:07:40] Dr. Weiser:  No, I don't think so. I would along the lines of trying to alleviate their fears. I tell them to have a normal life and do their normal activities, exercise if they want, go out and eat if they want. They have planned surgery, but they should continue their usual activity. So, I don't think they have to change anything in particular. Afterward, depending on the type of surgery, we may reduce the fiber in their diet for a while, but most of the time we go back on a regular diet.

[0:08:07] Dr. Diane:  Great. Yeah, we had a patient last week who came in who, unfortunately read on the internet that she should fast for two days before chemo [laughs] [0:08:15] she was an outside treatment and was then in the hospital for a week. So I couldn't agree with you more, for most things in the world of medicine, eating well is an important feature.

[0:08:25] Dr. Weiser:  We often get the question, should I reduce my sugar intake? The data isn't very strong on that. So I urge them to take everything in moderation.

[0:08:33] Dr. Diane:  Right, how quick do you have to get up post op?

[0:08:35] Dr. Weiser:   Immediately, almost all surgeries are associated with something called enhanced recovery and that includes getting up the day of surgery.

[0:08:43] Dr. Diane:  Day of surgery.

[0:08:44] Dr. Weiser:  Yeah.

[0:08:44] Dr. Diane:  So you just got out of a four hour surgery and you're going to get up out of bed to the chair or walking around.

[0:08:51] Dr. Weiser:  Definitely to the chair and if they can at least walk a bit.

[0:08:56] Dr. Diane:  Wow. And that helps.

[0:08:58] Dr. Weiser:  That helps. Yeah, I think you get deconditioned quite quickly in bed. And I think if you're up moving around, it's better for you.

[0:09:05] Dr. Diane:  Great, and last question anything else to do post up to increase your recovery time to get back to work? Because that's part of our privilege, right? It's not only about the cure, but you often say, you know, my greatest privilege is to get that patient back up to do the things that they're supposed to do and getting them back at work. So, is there any magic there?

[0:09:23] Dr. Weiser:  No, I mean, I tell patients, a lot of things. One, they should give themselves a break. So, don't be too hard on yourself, you're going to be tired, take a nap if you need to take a nap, take a rest. But otherwise you should be up and about but don't be hard on yourself. And then stay positive when patients get depressed or down which is very common after surgery or having the diagnosis of cancer really try to get help if you need it or rally and have the attitude that you're going to beat it and that requires you to get up and do things and do your usual activity.

[0:09:52] Dr. Diane:  So, just switch gears a little bit under the different techniques of surgery because there's so much out there and we talked a little bit about the sort of anxieties around. I got to get this out yesterday, and how finding the right surgeon is the right thing to do. But at the same time, there's so many messages out there on the right types of techniques. So, if we focus a little bit on colorectal surgery, for example, before, I would say probably early to mid in your career, you were still doing a lot of open types of surgeries. And that sort of changed a little bit to the whole laparoscopic. So could we talk about that transition first of what that meant both for the patient and for you as the clinician, and did it make that much of a difference. And then some of the more newer techniques we'll talk on about after them.

[0:10:35] Dr. Weiser:  Yeah, so there was a transformation in surgery. Moving to minimally invasive surgery. It started with gall bladders, appendix of course, the gynaecologist and the urologist were doing minimally invasive surgery for years and years and it's really an offshoot of techniques from endoscopy using small cameras with light. So, it's really all technology driven. So yeah, I was taught generally with open surgery and learned laparoscopy at the end of my training. The results were pretty dramatic. Reducing the incision size, reduces the trauma and the body's response to trauma and that's big. So, recovery is quicker, complications are generally less, including less hernia rates, and cosmetically it's more appealing for many patients. But I think I was drawn to minimally invasive surgery because the recovery was faster, and patients could return to usual activity sooner. Now, if you have to have open surgery, because you've had a lot of surgery before, your case is not amenable to a minimally invasive approach, I don't think you should worry about it, patients recover just fine with open surgery. But if you're able to have minimally invasive surgery by somebody who does it a lot. I think there's advantages.

[0:11:49] Dr. Diane:  People used to say that if you're open, you could actually get in there and feel it and you knew exactly where you were, you could get your hands around that monster of a tumor and remove it and that was the way to do it. Clearly with laparoscopy you have these kind of little handles that are that are doing it for you. These joysticks are, so how does that change the outcome of a patient who's undergoing this minimally invasive technique? Because I think for many it makes so much sense of less time to have to be on the bed less, you know, quicker to work. But does it affect the outcome?

[0:12:24] Dr. Weiser:  It's true, you don't necessarily have your hands in there, but you have your eyes in there and you have other senses that you can use other tactile senses. I would say in general without offending anyone, minimally invasive surgery forces you to be a more anatomic surgeon, a more gentle surgeon, a more exact surgeon, because you can't tolerate as much bleeding or tissue damage, and I think that may be related to the better outcomes. For some tumors clearly you need open surgery, but for many I think this surgery is actually done better minimally invasive.

[0:12:59] Dr. Diane:  Absolutely. For that technique to be done well, is this the Malcolm Gladwell 10,000 types of repeated episodes to do it well?

[0:13:08] Dr. Weiser:  Absolutely. This is all about repetition. So I think it's a very fair question to ask your surgeon, how many have they done and the number should be high? Exactly high we don't know. But the learning curve for let's just say, minimally invasive colectomy is, I think somewhere between 25 and 50. And if you've done 200, you're better than somebody who's done 100. It's just the way it is. And that's why you should see a specialist I think there's benefit to that.

[0:13:37] Dr. Diane:  We went from laparotomy open to laparoscopy, more minimally invasive. And then I guess around the time of the century, we got the robot, robot was a instrument that I imagined was supposed to be on the battlefield, right for if you were not there, we could take care of them. How did such a type of machinery actually get to the operating room. And does that make a difference in terms of laparoscopy versus robot? And I can imagine that is even more of a technique that has to be carefully learned before you do such a technique, and that's a newer one. So that makes people a little bit more nervous. Are they doing it right?

[0:14:17] Dr. Weiser:  So the robot allows you to do really ultra precise surgery as well as potentially remote surgery like you were alluding to for the battlefield. They've tested this, for instance, there was a famous case of a gallbladder performed in France, but the surgeon was in New York using the robot. And then it was originally developed for cardiac surgery because that's ultra fine surgery and that's what you can get but it then took off in other fields in GYN, urology, colorectal, general surgery, thoracic surgery, really all fields of surgery. It allows you I think, in the colorectal realm to do things that are very hard to do laparoscopically. So it allows you to expand what you can do minimally invasive, that's why we like to do it. It allows you to do those tougher cases that would be just too difficult to do lapper-laparoscopically.

[0:15:09] Dr. Diane:  So for example, in the rectum, there's a lot of important nerves down there in terms of your sexual function, your ability to move your bowels, etcetera. That's a tight area, makes a lot of sense that you want to have a precise ability to get to where you want to get to. What about though, for example, you've got a 20 centimeter tumor in your belly?

[0:15:28] Dr. Weiser:  If you have a very large tumor, you're going to need a large incision to get it out. So that may not make sense to do it minimally invasive. On the other hand, you always need a larger incision for open surgery than you would do for minimally invasive so, I think you take it a case by case. I think in tight spots for instance, I think this is why prostates are done robotically, because that's a very tight spot and you can see well, and you can manipulate your instruments in a very fine way in a very small space. The same for rectal cancer.

[0:16:01] Dr. Diane:  Right? But perhaps for example, breast surgery, where that tight space is not necessarily as clear, minimally invasive or another type of technique, and not necessarily a robot, it sounds like a robot is helping an unmet need. But it's not a one size fits all here in terms of who necessarily needs it, is that-

[0:16:20] Dr. Weiser:  Yes, and very true and as new technology comes out, it's often applied very broadly and then brought back and used in those situations that are really most beneficial. In some cases, there may not be any real benefit. And that's important to learn.

[0:16:35] Dr. Diane:  And what about outcomes there as compared to other types of surgical techniques, when you have the robot versus for example, laparoscopy?

[0:16:42] Dr. Weiser:  The data is hard to come by, those sort of studies are rare, there are some and when available, I think we should look at it. The problem is that it's an evolving field and the surgeon is often the most important variable and you can't really control for that.

[0:16:56] Dr. Diane:  I think that's the critical piece, right? So if you're a patient That has a cancer diagnosis and your patient is saying, “I would recommend the robot.” You can ask the questions as to why but one would expect that the surgeon would be comfortable. He or she knowing how to do that, presumably?

[0:17:13] Dr. Weiser:  Well, I think it's critically important when you're talking to your surgeon about the procedure, what they're going to do, I generally would recommend that you ask what they recommend. And you may make a suggestion like possibly minimally invasive or robotic, and I wouldn't want to push the surgeon into it to do something that they're not very comfortable or good at. It would be more important to get maybe another opinion and maybe search out another surgeon and get their idea of how to approach it.

[0:17:43] Dr. Diane:  Right. I think that's absolutely right. Anything else in terms of other questions that they may ask in terms of the techniques, outcomes, anything like that, besides the number of procedures, anything as it relates to the hospital and cancer sort of teams or ways to get to that. I mean, we are pretty privileged here that we have a team where we're meeting DMTs, or what we call our tumor boards, and there's oncologists and radiologists and surgeons to help make that decision. But often patients may not recognize how much again, effort goes into making those decisions about that. And I just wonder if there's any advice you may have for our listeners on how do you figure that kind of thing out.

[0:18:25] Dr. Weiser:  It can be quite tough because obviously diagnosed with cancer will be new to a patient and they may not know all the nuance, I think, asking questions that are important and realizing that most of cancer care currently is multidisciplinary. So, you should ask about that. Who else is going to be reviewing the case? Is it going to be reviewed at a conference to make sure that it's reviewed by a group?

[0:18:48] Dr. Diane:  Absolutely. Have you ever operated on a patient from afar with a robot?

[0:18:52] Dr. Weiser:  No, never. Not too interested in that.

[0:18:56] Dr. Diane:  Yes, I would gladly hope that you would not be. All right. Well thank you very much. Dr. Martin Weiser, colorectal surgeon and scientist. I really appreciate you being here. Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information or to send us any questions you may have, please visit mskcc.org/podcast. Help other people find this helpful resource by rating and reviewing this podcast at Apple podcasts or wherever you listen to your podcasts. These episodes are for you, but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Diane Reidy-Lagunes onward and upward.

[Audio Ends] [0:19:47]