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Innovative procedures, devices at area hospitals

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San Diego is home to several first-rate hospitals, many of which offer specialized procedures on the cutting edge of health care. Here we highlight a few procedures from the three largest hospital systems in the area, UC San Diego Health System, Scripps Health and Sharp HealthCare.

‘Scarless’ surgery

UC San Diego Health System includes the UCSD Medical Center, Thornton Hospital, the Moores Cancer Center and the Sulpizio Cardiovascular Center.

UC San Diego Health System is a pioneer in the field of “scarless” surgeries. In Natural Orifice Translumenal Endoscopic Surgery, or NOTES, surgical instruments and a tiny camera are passed through one of the body’s natural openings, such as the mouth, vagina or anus to perform surgery. Patients can have gallbladder or appendix removal or weight loss surgeries without an incision in the abdomen.

The health system has been doing NOTES for about four years, and has performed more than 150 such surgeries, said Santiago Horgan, chief of the division of minimally invasive surgery and director of UCSD’s Center for the Future of Surgery. UCSD was the first hospital in the nation to remove a gallbladder through the mouth and an appendix through the vagina.

“The goal is to minimize injury to the abdominal wall,” Horgan said. Using the procedure, surgeons can “minimize pain after surgery while improving cosmetic results. For patients, that’s a really important component.”

An incision is made on the inside of the body, such as in the esophagus or colon, where there are no pain receptors. Avoiding major incisions through skin, muscle and nerves means patients experience less pain and recover faster. Patients also minimize the risk of post-operative complications such as hernias and wound infections, and leave the operating room with no visible scars.

For example, Horgan said in the past, surgical treatment for achalasia -- a disorder that makes it difficult to swallow -- would involve making a large incision in the chest and five in the abdomen. With NOTES, the surgery is done through the mouth, and the incision is made in the esophagus.

“They don’t have any abdominal pain, and the next day they can return to normal activity,” he said. “With an incision through the muscles in the abdomen, you’re going to have pain, infection, and potentially a hernia. It’s a dramatic change.”

This type of procedure has the potential to revolutionize minimally invasive surgery, much as laparoscopic surgery did in the 1980s and 90s.

“That’s why we opened the Center for the Future of Surgery at UCSD,” Horgan said.

The training and research facility is designed to develop new surgical techniques and provide advanced surgical training. Horgan said the center is closely following the patients who have undergone NOTES surgery to gather long-term data about the safety and efficacy of the procedure compared with laparoscopy. In laparoscopic surgery, doctors make several small incisions rather than the larger, open incisions that were previously required.

So far, Horgan said, the results are “extremely good, solid and predictable,” and the data show marked improvement over laparoscopy.

Proton therapy

The Scripps Health system includes Scripps Green Hospital, Scripps Memorial Hospital Encinitas, Scripps Memorial Hospital La Jolla, Scripps Mercy Hospital, as well as number of outpatient facilities. This summer, construction was completed on the new Scripps Proton Therapy Center in Mira Mesa.

In July, Scripps began consulting with prostate cancer patients at the 102,000-square-foot center, and expects to begin treating a broad range of tumor types later this year. A commissioning process for the facility is currently under review with the U.S. Food and Drug Administration. Additional equipment testing and verification will be ongoing for the next several weeks, said Carl Rossi, the director of the new center.

Proton therapy uses a controlled beam of protons to target tumors with more precision than other types of radiation therapies. Whereas X-rays travel all the way through the body releasing energy, proton beams slow down as they encounter body tissue and can be set to release energy at a specific point in the body. Doctors can create a burst of radiation that exactly matches the shape and location of the tumor.

The precise delivery of proton energy limits damage to healthy surrounding tissue, resulting in minimal or no side effects to the patient, according to Rossi.

“It’s a very good tool from a clinical standpoint -- it allows me as an oncologist to protect normal tissue to a degree that we’re not able to do with x-ray therapy of any type,” Rossi said. “The patient benefits are reduced normal tissue injury. In some cases, this means we can give a higher total radiation dose to the bad stuff so we’re more likely to kill it. In many cases it means we can prevent or at least minimize the risk of long-term side effects.”

Proton therapy is most appropriate for treating potentially curable, localized tumors that haven’t spread throughout the body, Rossi said. It is especially useful for tumors in sensitive areas of the body or those found in children.

“One area where protons really shine is in the treatment of children. If you think about radiation side effects -- stunting growth, affecting intellect, affecting normal organs -- in kids, you multiply all those factors,” he said.

“We do a better job at curing childhood cancer than at curing adults. So then you have to think about … what’s going to happen for the rest of their life from this treatment? The more normal tissue you can protect, the less likely it is to cause a problem.”

Chris Van Gorder, president and CEO of Scripps Health, said Scripps plans to form a partnership with Rady Children’s Hospital to provide proton therapy to pediatric patients. Scripps is also in discussions with other health care systems in the county to make the center available to their adult patients.

“Scripps views the center as a regional resource to be operated in a spirit of collaboration,” Van Gorder said.

The Scripps Proton Therapy Center will be the 12th treatment center of its kind in the nation, and the second in California. It was built through a collaboration among Scripps Health, Scripps Clinic Medical Group and Advanced Particle Therapy.

When the center is fully operational by late 2014, Rossi anticipates it will employ approximately 150 physicists, clinicians and other staff. It will have five treatment rooms, 16 patient exam rooms, offices for 14 physicians and will be able to treat up to 2,400 patients each year.

Robotic arm

The Sharp HealthCare system includes the Sharp Chula Vista Medical Center, Sharp Grossmont Hospital, Sharp Coronado Hospital and Sharp Memorial Hospital, as well as four specialty hospitals.

Sharp Coronado is the only area hospital to offer MAKOplasty, a surgical procedure that uses robotic arm technology to treat early and mid-stage osteoarthritis of the knee and joint failure in the hip. The hospital performs about 1,500 knee and hip replacement surgeries each year -- more than any other San Diego hospital.

The procedure is the same as traditional partial knee and total hip replacement surgeries, but the MAKO computer guidance system and robotic arm allow doctors to be very precise when putting an implant in place, said Steven Allsing, M.D.

Based on a computed tomography, or CT, scan, the MAKO computer creates a three-dimensional image of the joint to be replaced. Surgeons create a pre-surgical plan that customizes the size, positioning and alignment of the implant for each patient. The computer then dictates all that information the robotic arm, which maps out exactly how much bone needs to be removed and where.

The system also provides visual, tactile and auditory feedback during the procedure to ensure only the arthritic parts of the knee joint are removed, and enable the ideal implant positioning.

“The robotic arm stops me if I’m making a mistake, and it won’t let me move outside certain parameters,” said Allsing. “The advantage of this precision is, if implants are inserted as optimally as possible, their function is expected to be better, and the long-term outcome is expected to be better.”

The hospital has offered MAKOplasty since the end of 2010, and has since performed 174 partial knee replacements and 16 hip replacements (the MAKO technology to do hips has only been available to Sharp for about a year). MAKO surgeries currently comprise about 7 percent of total knee and hip replacement surgeries at Sharp Coronado.

The hospital was able to obtain the technology through an estate gift from a Coronado resident and board member.

“The problem is the technology is very, very expensive. Sharp Coronado is the only one in San Diego that has it in the operating room. You have to have the computer guidance system, the optical system to view the arrays, and the robot itself. The whole package is very pricey,” Allsing said. Physicians performing the surgery must also complete specialized training, he added.

He said the technology will likely catch on with more surgeons as more data demonstrates that the implanted joints have improved function and longer life.

“So far, the data shows that we’ve improved the position of the implants, but not enough time has passed for us to know whether the implants have lasted longer,” Allsing said. “The implants typically last 15-20 years. It would be nice if by positioning them as precisely as possible, we can stretch the life of the implants to 20-30 years.”

-Klam is a San Diego-based freelance writer.

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