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In Image-Guided Operating Suites, Surgeons See Real-Time MRI, CT Scans

Imaging during surgery reduces risk, gives more visual cues from inside in the body

Surgeons sometimes fly blind when operating on hard-to-reach anatomical parts or hard-to-see conditions. For visual references inside the brain or body, they often rely on images and scans taken before an operation.

A growing number of hospitals are equipping operating suites with magnetic resonance imaging, CT scanners and other technology that enables surgeons to scan a patient in real time, without having to move them from the operating table.

The resulting real-time 3D visuals—known as “intraoperative imaging”—help surgeons excise tumors and tissue with greater accuracy, reducing risks, such as nicked nerves from an errant knife, and the potential need for repeat surgery. The images also help surgeons spot bleeding, blood clots or other unexpected complications outside their field of vision.

Intraoperative imaging allows surgeons to perform “significantly better” than conventional surgery, says Sohail Mirza, medical director of the Center for Surgical Innovation and chairman of orthopedics at the Dartmouth-Hitchcock health system in Lebanon, N.H., affiliated with Dartmouth College’s medical school.

“We still need a surgeon’s training and judgment,” Dr. Mirza says, “but we can use three-dimensional deep imaging to get past the limitations of human error and hand-eye coordination.” Dartmouth-Hitchcock opened the $20 million center last year with financing from a National Institutes of Health grant and its own funds. MRI and CT scanners mounted on ceiling rails slide in and out of four sterile operating and procedure rooms.

The technology, first developed for use in complex brain surgeries, now is expanding for use in spinal cord surgery, biopsies and removal of tumors and lesions in the breast, lung, prostate, liver, pancreas and kidneys. Researchers are studying other ways the technology can help diagnose and treat cancer and other diseases.

Doctors used real-time MRI and CT scan images to remove a complicated tumor last year from the spine of Jack Deliso, 9, center. With him are his parents, Lisa and Michael, and sisters Chloe, left, and Rigney.
Doctors used real-time MRI and CT scan images to remove a complicated tumor last year from the spine of Jack Deliso, 9, center. With him are his parents, Lisa and Michael, and sisters Chloe, left, and Rigney. Photo: Michael Deliso

The real-time scans can show surgeons whether tissue or organs have shifted during an operation, and where the border of a lesion ends and healthy tissue begins. In radiation treatment, doctors using the scans can see when a tumor shifts and pause to spare healthy tissue. The images can also provide better visualization of masses that are completely out of sight. Studies have found that in 40% of cases, brain surgeons will modify what they are doing based on an intraoperative MRI scan.

“This is precision medicine at its best, using an individual patient’s images to guide their procedure,” says Clare Tempany, co-director of the Advanced Multimodality Image-Guided Operating Suite program (known as Amigo) at Brigham and Women’s Hospital in Boston. The program is part of the hospital’s federally-funded National Center for Image-Guided Therapy, which is researching the use of intraoperative imaging in a variety of procedures and treatments including its cost-effectiveness. Since Amigo opened in 2011, 700 patients have undergone surgery including lung biopsies and breast-conserving tumor removal.

The need for more accuracy is real. As many as 40% of women who have breast-conserving surgery known as lumpectomy followed by radiation need a second operation because positive cells remain. At Brigham and Women’s researchers are looking at how to improve surgeons’ ability to determine the exact margins of tumors using intraoperative MRI followed by chemical analysis to decrease the need for re-operations.

Dr. Mirza says in the past, during spine surgeries, if he became concerned about whether screws or implants were perfectly placed, he would close up an incision and wheel his patient two floors down for a scan. In some cases, he would bring the patient back to revise the surgery, or in other cases accept “slightly imperfect” results to avoid more cutting. Revisions, in addition to adding to the patient’s risks, use up costly operating room and staff time, he says.

Last fall, Jack Deliso, then 8, needed surgery to remove a painful mass wrapped around his lower spine that made it increasingly hard for him to walk. An initial biopsy to test for malignancy had been inconclusive. Dr. Mirza and a pediatric neurosurgeon, David Bauer, proposed cutting out the entire tumor in one procedure.

Jack’s parents, Michael and Lisa Deliso, were fearful that if nerves were damaged during surgery, his ability to walk as well as his bladder and bowel function could be impaired.

The technology was reassuring. “They explained to us that they were able to take the pictures with the MRI while they were operating to make sure they got everything, without having to damage nerves or disturb the tumor,” Mr. Deliso says.

Jack says he was calm going into surgery “because it just had to be done and there was no use being scared of it.” He was tired of lying awake at night, when he says he felt “excruciating pain.”

During the 12-hour procedure, surgeons could see only the back of Jack’s spine. Because they didn’t know if the tumor was malignant, they were determined to avoid cutting into it, which could spread potentially cancerous cells elsewhere in the body. As they drilled into bones to detach and remove the tumor, they used a CT scan of the spine to help navigate accurately and avoid removing bone that wasn’t directly involved.

Next, they performed an MRI to make sure the nerve roots were unscathed and they hadn’t missed any part of the mass. Toward the end of the procedure, they did a second CT scan, which showed there was enough bone left so Jack wouldn’t need reconstruction with rods, screws and bone grafts. They finished up and closed the incision.

Jack was in the for three nights. A week later, pathology tests came back showing the tumor had been benign and the surgeons had gotten all of it. Now 9 years old, Jack says he would like to play soccer or football—and be an orthopedic surgeon when he grows up.

Intraoperative scanning is costly for hospitals. For example, Imris Inc. of Canada makes Visius Surgical Theatre systems found in 87 operating rooms world-wide including at Brigham and Women’s and at Dartmouth. Each system consists of a two- or three-room suite with MRI units costing from about $3 million to $7 million, and CT scanners ranging from about $1.5 million to $3.5 million.

Jay Miller, president and chief executive, says over 17,000 procedures have been performed to date with Imris systems.

Intraoperative imaging has its own risks, says Bernadette Henrichs, director of the nurse anesthesia program at Barnes-Jewish College and nurse anesthesia research and education at Washington University School of Medicine, both in St. Louis.

Because of the strong magnetic force used in MRI, ferrous metal objects and tools must be kept out of the operating room, along with pagers, cellphones, jewelry and hair pins. Anesthesia teams stay with patients during scans and use equipment such as aluminum oxygen tanks and instruments made from plastic, titanium and other materials compatible with MRI.

At Barnes-Jewish Hospital, OR teams get training before they can work with live MRI imaging. They do annual safety drills including emergency procedures in the event a patient has a cardiac arrest while undergoing a scan.

“These are exciting advances, but we have to be vigilant in making sure patients and health-care workers aren’t harmed and take necessary safety precautions,” Ms. Hendrichs says.

Photo and caption:

At Dartmouth-Hitchcock health system in Lebanon, N.H., David Bauer, left, a pediatric neurosurgeon, and Sohail Mirza, right, an orthopaedic surgeon, perform a procedure with help from real-time 3-D images in an operating room equipped with MRI, CT scans and X-ray equipment.
At Dartmouth-Hitchcock health system in Lebanon, N.H., David Bauer, left, a pediatric neurosurgeon, and Sohail Mirza, right, an orthopaedic surgeon, perform a procedure with help from real-time 3-D images in an operating room equipped with MRI, CT scans and X-ray equipment. Photo: Mark Washburn/Dartmouth-Hitchcock

Rating

2 Star

In Image-Guided Operating Suites, Surgeons See Real-Time MRI, CT Scans

Our Review Summary

The story provides an overview of techniques that incorporate computerized tomography (CT) scans and/or magnetic resonance imaging (MRI) into surgeries, giving surgeons “real-time” images of the patient and what is happening during the procedure. The idea is that such real-time imaging makes the surgeries more accurate and reduces the likelihood of repeated surgeries or complications. Though it quotes an expert who says the new technology allows surgeons to perform “significantly better” than with conventional surgery, the story never backs up that assertion. It offers very little information on whether these techniques are actually resulting in better health outcomes for patients or how far these techniques are from widespread adoption.

 

Why This Matters

The story notes that these real-time imaging techniques are primarily being considered for use in brain and spinal surgeries and for a number of surgeries related to biopsy and tumor removal. These are surgeries that often pose considerable risks for patients. Even small mistakes can have significant long-term effects on a patient’s quality of life. Patients and doctors who are dealing with these kinds of surgical decisions are likely to be very interested in new techniques that could improve surgical outcomes. However, the story does not offer much quantifiable information that can be used to help guide decision making.

Criteria

Does the story adequately discuss the costs of the intervention?

Satisfactory

The story notes that the technology needed to implement these real-time imaging techniques is costly for hospitals, and lists examples of technologies that range in price from $1.5 million to $7 million. The story could have done even better if it had placed those numbers in context. How much does it normally cost to outfit a surgical suite? And what do these costs mean for patients? It would have been hugely helpful to compare costs for the same surgery with or without the new technology. On a related note: are insurers covering the costs of these real-time imaging procedures?

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Not Satisfactory

The story focuses on how these new techniques and technologies can address perceived shortcomings in conventional surgery. And it uses compelling language to describe these potential benefits: “The resulting real-time 3D visuals—known as ‘intraoperative imaging’—help surgeons excise tumors and tissue with greater accuracy, reducing risks, such as nicked nerves from an errant knife, and the potential need for repeat surgery. The images also help surgeons spot bleeding, blood clots or other unexpected complications outside their field of vision.”

However, the story doesn’t offer any numbers to demonstrate whether that potential is being fulfilled. For example, the story notes that the Advanced Multimodality Image-Guided Operating Suite program at Brigham and Women’s Hospital, which focuses on these real-time imaging techniques, has conducted 700 surgeries since 2011. Did those surgeries have better outcomes than comparable surgeries that didn’t use these imaging technique? The story doesn’t say.

Does the story adequately explain/quantify the harms of the intervention?

Not Satisfactory

This one’s a close call that we ultimately ruled unsatisfactory. The story is enamored with the greater accuracy that “real-time” imaging should provide for surgeons, but it doesn’t acknowledge that the scalpel cuts both ways. With increased visibility, there’s a greater chance that these scans will turn up so-called “incidental findings” — problems that no one was looking for and that could well be meaningless to the patient (for example, a slow-growing tumor that would never pose a real risk to the patient). Cutting based on such findings may, in fact, increase morbidity and mortality.

The story does get credit for thoroughly explaining the potential risks associated with MRIs. However, the story does not address the risks associated with CT scans at all. CT scans require exposure to a significant amount of radiation, and patients can suffer allergic allergic reactions to the contrast dyes.

Does the story seem to grasp the quality of the evidence?

Not Satisfactory

The only quantifiable evidence the story presents is that “in 40% of cases, brain surgeons will modify what they are doing based on an intraoperative MRI scan.” However, it’s not clear where that number comes from, making it difficult to assess the quality of the evidence. Moreover, surgeons modifying what they are doing does not mean that the patient’s outcome is necessarily going to be better. Otherwise, the story relies on one lengthy anecdote and qualitative discussions of why these real-time imaging techniques make sense. Some analysis of the existing literature on these techniques would have been valuable.

Does the story commit disease-mongering?

Satisfactory

We’ll rate this satisfactory for a lack of any obvious disease mongering. But as noted above under “Harms,” there is a presumption in this story that increased access to imaging can only be a good thing. The story doesn’t entertain the possibility that these scans will turn up meaningless — but potentially worrisome — findings that could cause anxiety for patients and lead to overtreatment.

Does the story use independent sources and identify conflicts of interest?

Not Satisfactory

The two doctors quoted in the story on the value of these real-time imaging surgical techniques are both leaders of high-profile programs that are dedicated to, well, advancing these real-time imaging surgical techniques. The story would have benefited from the input of an independent source.

Does the story compare the new approach with existing alternatives?

Not Satisfactory

The story explains how, in theory, real-time imaging could significantly improve surgical outcomes. But the story does not actually offer any comparison of the outcomes of surgical procedures that use real-time imaging techniques versus surgical procedures that do not.

Does the story establish the availability of the treatment/test/product/procedure?

Not Satisfactory

The story discusses the relatively new Center for Surgical Innovation in New Hampshire and the program at Brigham and Women’s Hospital in Boston. But it’s not clear from the story whether these real-time imaging surgical techniques are being implemented elsewhere. Is it widespread? Do we expect it to become widespread? If so, when? And at what cost?

Does the story establish the true novelty of the approach?

Satisfactory

The story clearly notes that these techniques were originally developed for use in brain surgeries, but are now being considered for use in a variety of other procedures — and have been since at least 2011.

Does the story appear to rely solely or largely on a news release?

Satisfactory

The story does not appear to draw from a news release.

Total Score: 4 of 10 Satisfactory

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