21: Minimal Medicine

New treatments aim to be less traumatic, shorter, cheaper, and more effective

Here's one of your worst medical nightmares. On June 5, Dean Monahan, a 42-year-old steelworker in Reading, Pa., was scheduled for an angiogram, a common medical procedure used to determine if plaque is building up in a patient's arteries. Monahan had experienced some pain in his arm and neck while exercising, which could indicate a blocked artery. He checked into Reading Hospital & Medical Center at 7 a.m., the angiogram was performed at 11 a.m., his arteries were declared completely clear, and he checked out at 4.

By 6:30 that night, Monahan had a temperature of 103. He rushed back to the hospital, where the staff discovered that he had contracted pneumonia during his nine hours there. "I was out of work for a month and flat on my back for a good 10 days," says Monahan. "I see now how old people succumb to pneumonia. It really saps all your strength."

What's particularly scary is that Monahan's story is not all that unusual. The Centers for Disease Control & Prevention calculate that 90,000 deaths in 2000 were caused by hospital infections, making the microbes that swarm our medical centers the fourth-largest cause of death in the U.S. Then there are the medical errors committed in U.S. hospitals that kill anywhere from 44,000 to 98,000 people each year--more than die from highway accidents, breast cancer, or AIDS. Consequently, one of the goals of just about any new medical treatment under development today is to eliminate, or at least minimize, hospital stays.

Thus the watchwords in forward-looking medical circles are "minimally invasive therapies." These are diagnostic and treatment strategies aimed at reducing the trauma, cost, and duration of medical care while, hopefully, increasing efficacy. The phrase encompasses a wide range of technologies, including high-definition imaging, robotics, miniaturized sensors, high-intensity sound waves, tissue engineering, and stem-cell manipulation. Some techniques are already indispensable in today's operating theaters; some are still years in the future.

There are, however, potential dangers in this rush to minimize medicine. "Just switching to a less invasive therapy isn't enough," warns Dr. David W. Rattner, a surgeon who oversees minimally invasive therapies at Massachusetts General Hospital in Boston. "You need to prove that it's more effective." Finding companies to commercialize these technologies is also a challenge, he says.

To that end, the Center for Minimally Invasive Surgical Therapies was established in Boston in 1993 to coordinate clinical and industrial research. Its members are researching techniques for the treatment of heart disease, stroke, cancer, and trauma. A typical effort: Dr. Edward P. Ingenito of Brigham & Women's Hospital in Boston is developing a nonsurgical method for removing damaged lung tissue in emphysema patients. His plan is to inject a biopolymer that will collapse and scar over the target area of the lung, thus reducing its volume.

Some minimalist therapies have already proven their worth. Laparoscopy, in which surgeons insert tiny cameras and long narrow instruments through incisions in the body, has been used since the late 1980s to repair knees and other joints, but the technique is slowly being applied to internal organs as well. City of Hope Cancer Center in Los Angeles has led the way in using laparoscopy for one of the most dreaded operations, removal of a cancerous prostate gland. Surgeons make five small holes rather than the standard six-inch incision, cutting blood loss by 50% and greatly reducing recovery time and hospital stays. Although studies have not confirmed whether the operation causes fewer side effects than standard surgery, it is much more easily tolerated. Dr. Timothy Wilson, director of urologic oncology at City of Hope, predicts that this procedure will one day be performed on an outpatient basis.

The next generation of surgical tools may not break the skin at all. At Brigham & Women's, doctors are testing sound waves--a variation of the technology used to illuminate fetuses in the womb--to blast fibroid tumors and precancerous breast lesions without making a single incision. A beam of high-intensity ultrasound is focused on a patient lying inside a magnetic resonance imaging (MRI) scanner. The soundwaves penetrate the skin to eradicate the tumors. The hope is that the system, which was developed by an Israeli joint venture of GE Medical Systems and Elbit Medical Imaging Ltd., called InSightec, will replace hysterectomies and mastectomies and might be used for brain tumors. "If you think about surgery, it's sort of medieval," says Dr. Darrell Smith, a Harvard University radiologist who led a clinical study of the InSightec system. "We're trying to get more elegant in the way we do this. It's kind of like Star Trek."

Science fiction analogies are common in the minimally invasive field, where talk of nanotechnology and wireless sensors abounds. At a recent electronics symposium, University of Michigan professor Kensall D. Wise, a pioneer in the field of microelectromechanical systems (MEMS), described a future in which electronics implanted in the body could cure Parkinson's disease, deafness, and blindness. Wise described a microsystem, now in clinical trials, that uses intelligent implants to detect an epileptic seizure and deliver electronic stimulus and drugs to patients who may not know that an attack is under way. He also predicted the development of intelligent stents that, when placed in an artery, would tell doctors if the vessel had reclogged without the need for an angiogram--the procedure that caused Monahan so much trouble.

Hospital operating rooms themselves should also become safer. Doctors at Mass General, led by Dr. Rattner, hope to do their first procedure within a month in an "operating room of the future"--a surgical theater full of computers, radio sensors, and sophisticated imaging equipment. Every person and object that enters the room will carry a radio-frequency ID tag. If a nurse approaches the patient with the wrong medicine, a scanner will sound an alert. It will also raise an alarm if doctors start preparing the wrong site on the body--a common mistake in hospitals. The patient will be operated on remotely using robotic arms inside an advanced MRI machine that updates the image every second or less, allowing surgeons to view their progress in real time on a video monitor. Computers will provide the exact coordinates of the tissue to be repaired.

Rattner predicts that it will be several years, at least, before such an operating room becomes commonplace. In the meantime, just hope you'll stay out of the hospital.

By Catherine Arnst

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