Interview with Amjad Parvaiz
As a young man, Amjad Parvaiz, now 54, wanted to become a “big trauma surgeon”. So after graduating from university in his home city of Lahore, in Pakistan, he moved to South Africa to do his trauma surgery training there. While in South Africa, in 1995, he says, “one of my bosses took me aside and said to me: ‘if you want to do 21st century surgery, go and learn laparoscopy. People in civilised countries are more likely to have cancer or other diseases than to be shot in the street’.” He followed his boss’ advice and arrived in the UK in 1998, first to become a leading colorectal cancer laparoscopic surgeon, and later, starting in 2013, a leading colorectal cancer robotic surgeon. He was then invited to collaborate with the Champalimaud Foundation (CF) by British surgeon Bill Heald (who will be one of our interviewees next week), to train oncology surgeons in laparoscopy. Amjad Parvaiz arrived in Lisbon in 2014-2015 and when, in 2016, CF acquired its first robotic surgery system, he created the European Academy of Robotic Colorectal Surgery to train surgeons from all over Europe in robotic surgery. In this interview, he shared with us his vision on the future of cancer surgery.
Is surgery the main treatment for colorectal cancer?
If at the appropriate stage, surgery remains the only tool that allows you to get cured. For safely removing a cancer of the colon or rectum while it is still contained, surgery is the mainstay treatment that offers a long-term cure.
When you say “cure”, do you mean remission, or long periods of time when the patient remains free of cancer?
No. That’s why I said that it depended on the stage of the cancer. For example, if you have a Stage I disease, then you will almost certainly be cured by surgery. We use so-called “5-year survival” figures, which represent how many similar people we operate on will be alive in five years without disease, and for stage I, this figure is around 95 to 98%. This is the group that we would say is cured. And if you have Stage III disease [more advanced], the figures drop, but surgery will still have an impact: at least 70% of those patients will still be alive and well, and without a tumor, five years later.
Are some people not operable?
For 10 to 20% of patients, surgery will not be the first mode of treatment, because it is better for them to have other treatments first, such as chemotherapy or targeted radiation.
There are several ways to perform the surgery. What are they?
The oldest way, open surgery, is done by making a big cut in the middle of the abdomen; this has been done ever since surgery exists. (Even nowadays, most surgeries in the world are open surgeries.) And it has been shown for a number of years that you can get excellent outcomes for colorectal cancer using the open surgery technique. But because you are doing it with massive incisions, it does bring complications: big wounds, slow recovery, wound infections, wounds falling apart – all these things are known to be associated with large incisions. And people will have to stay in the hospital, on average, for about two weeks. Moreover, open rectal cancer surgery is particularly challenging and the risk for associated complications is higher.
In the last three decades or so, the surgical community has slowly moved to doing the surgery by laparoscopy [a minimally invasive technique, involving small incisions and miniature instruments]. The operation remains the same inside the body, but now we do it with small, centimetre-long incisions to insert the tools, and, on average, we use about five cm-long incisions to pull the tumor out.
Laparoscopy underwent a lot of scrutiny, because it brought about a change in the working culture, challenging the existing practice. I was party to that change at the time of my training, and this discussion went on for years. Today, we know that because it is done through a small incision, you will recover faster, you will go home sooner, you’ll require less morphine, you’ll be in less pain, and return earlier to your normal day-to-day activities.
Then in 2013, robotic surgery came in. Essentially, this still means using the minimally invasive approach, but the robotic system allows you a much better view of the operation site and access to better tools. And particularly for places in the body which are narrow and challenging, as is the case with rectal cancer, it started to show that there is a huge advantage for patients – if you can do it with precision.
In fact, the main advantage of the robotic approach is that the surgeon’s vision improves, with 4K, high-definition like in laparoscopy, plus a tenfold magnification of the views, 3D and angulation of the instruments [they can rotate 360º, whereas the rotation of our wrist is limited]. The gains can be huge for the patients; for example, one of the major morbidities with rectal cancer surgery is urogenital functional disability – men can become impotent, women have deficient bladder function, bowel control can become a problem after these surgeries. All these things have been shown to improve using robotics. And that is because surgeons can much better visualise the involved nerves and avoid damaging them.
Some people criticise robotic surgery by saying that there aren’t enough studies that show that robotic surgery’s results are better than laparoscopic surgery. Can you comment on this?
I think it’s quite appropriate that, whenever we try to bring something new in treating patients, we have to put it under a lot of scrutiny and self-critique, to see if it is a change for the sake of doing better or a change for the sake of change. As somebody who saw the evolution of laparoscopy, I can say that the same debate happened about 25 years ago, when the young trainees were asking if laparoscopy was better than open surgery. There was a lot of pressure on laparoscopists to demonstrate that it was better. As people began getting experienced and becoming good at it, the results began to show.
I think a similar phenomenon is happening with robotics. Let me tell you about my personal experience: when laparoscopy came along, people against laparoscopy were very good, established open surgery surgeons, who suddenly thought they could become less relevant because of laparoscopy. You fast-forward it 25 years and now people who are really against robotics are well-established, experienced laparoscopists, who believe they have just about managed to learn something and become good at it, and now the goalpost is moving. This is one way of looking at it.
But in nearly a decade, in Europe, we’re beginning to see the same thing that came about with laparoscopy: some centres produce excellent outcomes when they are doing robotics, others don’t, and people are acquiring skills and becoming more competent at doing it.
The Champalimaud Foundation played quite a role in this, did it not, in particular in training?
Training surgeons is something close to my heart, and the Champalimaud Foundation was central to this in Europe. We had a European Academy of Robotics Colorectal Surgery here at the Champalimaud Foundation, we trained more than 150 surgeons through this academy, and over 1,400 surgeries were performed under supervision through this school. People would come to the Champalimaud Foundation, observe the operations, learn in the courses, then the teachers would travel to the students’ hospitals in Europe, where the trainees would perform robotic surgeries on their patients under direct teacher supervision.
We at the Champalimaud Foundation were the central coordination office, we did the training and the assessment of the training. There were also faculty from other institutions in Europe who contributed, but we were the major contributors, so to speak. To give you a number, out of 670 training operations performed in Europe through the Academy, more than 400 were done under direct supervision of the faculty at the Champalimaud Foundation. All this data has been published in well-respected peer-reviewed journals and demonstrates that teaching improves results. People from all over the world, not only Europe, also started attending the Academy.
When did the Academy start its activities?
In 2015, the Champalimaud Foundation established the International Training Academy in Robotic Colorectal Surgery. Then came COVID and surgeons were no longer able to travel and therefore teaching was temporarily suspended.
Are you planning to reopen it?
Yes, this is something central in our leadership’s mind; the Champalimaud Foundation’s Board of Administrators is very keen to reestablish the Academy. Around May, June, we may have the first teaching course to relaunch the Academy.
Robotic surgery is still far from being a mainstream procedure.
Robotics is still not mainstream, but with each passing month, more and more robotic units are being sold in Europe and more and more people are being trained. I think that in the UK alone, there are now more than 100 robotic systems already in place and working. In Germany, the number is twice that size. Interestingly, there are now about five or six international companies that can manufacture surgical robots, so the price is going to come down, and that means that more and more people will have access to robotic surgery.
But this is just a tool, it’s just a platform; the most important thing, as I already said, is that the surgeons need to be trained, so they can do a better job with this very expensive tool.
The most well-known and historically the first surgical robot is the Da Vinci robot, one of which is installed at the Champalimaud Foundation. Exactly how does it perform colorectal cancer surgery?
First of all, from the public’s perspective, it is important to understand that this is not an autonomous robot that operates by itself. It works on a master-slave concept, which means you have a tool that is attached to the patients with instruments loaded in the robot’s arm that make incisions that are less than a centimetre long and insufflate the abdomen.
The surgeon sits at an operative console, away from the patient, looking down at a tridimensional view of the patient on a screen, and moves the instruments by moving the tips of his fingers. It’s not a wireless system yet, but it will become possible one day to do it remotely with 5G. Say you are a surgeon in Lisbon and the machine is attached to a patient in Southampton: 5G would allow just a hundredth of a millisecond delay between the surgeon’s and the instruments movement, making it a remote surgery. But this will take time.
Secondly, there is no such thing as the machine having “a mind of its own”, which could suddenly stop obeying the surgeon sitting at the console. But there is a lot of work being done on something called automation – which is a bit like an auto-pilot flying a plane while the pilots are sitting in the cockpit making sure the numbers on the dashboard look OK, so the plane is doing what it’s supposed to do. This automation is in the pipeline, and it may happen in 10 or 20 years – and I think this is where the robotic system’s advantage will show. But for now, it’s still a master-slave concept. And, during the surgery, there are also bedside assistants around the patient – maybe one or two trainee surgeons - so it’s not like the patient is alone. The assistants can adjust the robotic arm if needed.
For patients with colorectal cancer, the Champalimaud Foundation developed a multidisciplinary team, bringing together surgeons, medical oncologists, radiation oncologists, radiologists, pathologists, scientists, physiotherapists, psychologists and specialised nurses. Consequently, a high number of patients are being treated and monitored at the Foundation bringing forth results that are published in international scientific journals and that are cited among the best in the world.
Is robotic surgery also used for other cancers?
At the Champalimaud Foundation we are currently offering the robotic approach to most of our cancer patients undergoing surgery. Colorectal surgeons were the first to use the robot, but today urologists, gynaecologists, thoracic surgeons, and liver and pancreas surgeons are able to offer robotic surgery to an increasing number of patients.
By Ana Gerschenfeld, Health & Science Writer of the Champalimaud Foundation.
