July 03--John Ayers kicked cancer, but was left with an uncomfortable souvenir:
After six weeks of chemo and radiation therapy, so much scar tissue had built up
in his throat he couldn't swallow and, on occasion, struggled to breathe.
Ayers, 70, suffered through two tracheotomies and countless awkward dinner
parties. A feeding tube inserted into his stomach provided Ayers his own
provisions, leaving him the odd dinner guest with an empty plate.
Then, after more than three years of waiting for his scar tissue to break down
on its own, a doctor at Stanford offered a solution. He could use a surgical
robot to enter Ayers' throat through his mouth and attempt to remove the scar
The Portola Valley resident had two other options: endure an intense, 18-hour
surgery that would reconstruct his throat using a portion of his intestine and
remove his voice box -- allowing him to swallow but rendering him speechless --
or he could do nothing and possibly spend a lifetime staring at the steak on his
wife's dinner plate, tantalized.
To Ayers, the robot seemed like the way to go.
In an initial operation, Dr. Edward J. Damrose, a head and neck surgeon at
Stanford, used the robot -- known as the da Vinci -- to open up Ayers' throat,
exposing the airway and the esophagus.
The da Vinci looks a little like something out of science fiction -- a giant
surgical spider hovers over a patient, its arms crawling around inside the
cavities of the patient's body (or in this case, his mouth) as a surgeon plays
pilot from a cockpit of sorts.
It hit the market in 1999 and was cleared by the Food and Drug Administration
for general laparoscopic surgeries in 2000. It is only in recent years, that the
robot has been used for head and neck procedures, what has been dubbed transoral
robotic surgery, or TORS.
There are more than 2,500 da Vinci units in more than 2,000 hospitals worldwide,
according to Intuitive Surgical, the Sunnyvale company that makes the robot.
Stanford and UCSF are among the few medical institutions, though, that use the
da Vinci for head and neck procedures such as Ayers'. More commonly, it is used
as a minimally invasive alternative in procedures elsewhere in the body, such as
hysterectomies or gastric bypass.
Less complex procedure
The da Vinci's most frequent use in transoral procedures is in head and neck
cancers. By operating through the mouth, surgeons can remove tumors in places
that previously might have required much more complex procedures, such as
breaking the jaw to get a good enough look.
The robot has four arms -- three that can hold typical surgical tools, and a
fourth that holds an endoscopic camera, giving a surgeon a full view of the
"You get an almost panoramic view," said Damrose. "It's as if you were
miniaturized and in someone's throat looking around."
The da Vinci was first used on a human for a head and neck procedure in 2005 at
the University of Pennsylvania. An update to the robot made the experiment
possible, when slimmer tools were developed for the robot that might more easily
fit inside the mouth. (Even with the smaller tools, working inside someone's
throat can be a tight squeeze, depending on the patient.)
Stanford and UCSF both began performing the operations in 2011, and have done
upward of 30 procedures each since then.
For Ayers' surgery, the da Vinci was used to essentially chip away at the tough
scar tissue lining his throat after cancer on his tongue. The opening was
already small, but a common cold had caused a slight swelling in Ayers' airway,
making it nearly impossible for him to breathe. The initial robotic surgery
successfully opened up the airway and the hole into his esophagus. Subsequent
surgeries widened the esophagus, allowing Ayers to drink and eat some soft
foods. In January, he was finally able to ditch the feeding tube, subbing in
smoothies, soups, ice cream and the occasional bite of something like mashed
Aside from being uncomfortable, the feeding tube had become a serious annoyance:
He stopped flying after an airport security agent spent hours examining his tube
before letting him onto his flight, and he quit riding BART to work, for fear
someone would accidentally yank the tube out of his stomach -- as he did three
times, accidentally, himself.
He recalled before the surgeries attending his 9-year-old grandson's birthday,
during which he spent the family meal watching TV in a bedroom while his family
dined, emerging only for cake and presents. The tempting smell of his wife's
homemade tacos was unbearable.
No residual pain
Ayers said he missed only two days of work as a computer systems manager for
each procedure. There was no residual pain, and after some of the surgeries he
was able to leave the hospital the same day as the procedure.
The da Vinci's safety has been called into question recently after complications
in other procedures, but surgeons underscore its positive effects in head and
"If we're able to operate through the mouth, we can avoid a lot of downsides to
different approaches," Damrose said, pointing to surgeries that involve breaking
"Patients recover faster. They look better. They can swallow better," he said.
"It's helping us a lot to accomplish procedures endoscopically where a few years
ago these things would likely not have been possible."
Since Stanford started its robotic surgery program, three more surgeons have
been added to the program, and three fellows have been trained in the technique.
With the da Vinci, Damrose said, it might have been possible to avoid doing the
chemo and radiation therapy on Ayers that wound up causing his post-cancer
condition in the first place.
"We can really apply the same principles of surgery, but do it in a way that's
much less invasive," said Dr. Steven Wang, an associate professor at UCSF in the
Department of Otolaryngology.
Ayers had one last surgery on Friday, a surgery he hoped would finally open up
his throat enough to eat whatever he wanted. He was so excited for the prospect,
he cooked up a meal of spaghetti Bolognese for his family, anticipating it would
be one of the final times he would watch them eat without joining in.
"After this Friday, I figure I am going to be eating," Ayers said before the
On Monday, he recounted the good news: The opening in his throat had been opened
to double its previous size, meaning that once the swelling goes down in a week
or two he will probably be "back to normal."
He already had his first meal picked out: an In-N-Out burger.
Kristen V. Brown is a San Francisco Chronicle staff writer. E-mail:
email@example.com Twitter: @kristenvbrown
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