Доктор Клавель / Dr. Pablo Clavel – потомственный врач. Его отец тоже нейрохирург, медицине посвятили свою жизнь его дед и прадед. Пабло Клавель чтит семейные ценности, но признается, что занимается этой специальностью не под давлением, а по призванию, продолжая начатое старшим поколением дело с целеустремленностью и обновленным духом.

Профессиональная обеспокоенность и забота о пациентах привели к тому, что его в 2008 году он нашел способ изменить текущую технику операций на спине и запатентовать метод, который назвал «поясничным передним доступом/ anterior lumbar approaches». Такой подход представляет собой не что иное, как оперирование дегенеративных поражений межпозвоночного диска через живот, а не со стороны спины, как это делается до сих пор.

«Поначалу мало кто верил в новую практику, но это сработало! И не только потому, что такая операция снижает риски для пациента и оптимизирует результаты, но и из-за того, что наш центр уже является международным эталоном, и нам доверяют», – говорит нейрохирург Пабло Клавель.

ЧТО ТАКОЕ ПЕРЕДНИЙ ПОЯСНИЧНЫЙ ДОСТУП

Передний поясничный доступ – метод, когда при дегенеративных поражениях межпозвоночных дисков операция проводится спереди, а не сзади. Цель та же, как при традиционной операции: заменить поврежденный диск искусственным, но с этой техникой риск намного меньше, так как для достижения диска не придется обходить нервы и мышцы, с которыми хирург сталкивается при операциях со спины. Работать с промежуточными нервами и мышцами сложно, так как это может привести к их повреждению, в то время как вмешательство спереди исключает подобные риски. Потребуется обойти кишечник, артерии и вены, идущие к ногам, но доступ будет более прямым и менее рискованным. Кроме того, восстановление в послеоперационный период сокращается с шести месяцев, необходимых в классической хирургии, примерно до двух месяцев.

КАК ОСУЩЕСТВЛЯЕТСЯ ОБХОД КИШЕЧНИКА

Сначала пациенту делают небольшой разрез в нижней части пупка, а затем с помощью малоинвазивной хирургии окружают брюшину и достигают поясничной области, в которой нужно произвести вмешательство. Оказавшись там, врачи помещают сепаратор для обхода артерий и вен, что позволяет провести операцию с меньшими трудностями и более высокой гарантией положительного результата.

ПОЧЕМУ ТАК МАЛО ЦЕНТРОВ, ГДЕ ЭТО ДЕЛАЮТ

На сегодняшний день эта методика не получила широкого распространения, но единственной причиной является недостаток специалистов, имеющих должную специализацию.
Институт Клавель обладает штатом хирургов высокой квалификации и является международным справочным центром в этой области. Когда тут только начали использовать новую технику, то в год проводилось около тридцати операций. В 2017 году было выполнено 250, а в 2018 году уже 300 таких операций, и с каждым годом их число растет. Вот почему сюда обращаются не только граждане страны, но и много иностранцев.

СТВОЛОВЫЕ КЛЕТКИ ВЫТЕСНЯТ ОПЕРАЦИИ НА СПИНЕ?

Ответ на этот вопрос – нет. Прежде всего, важно помнить, что на уровне межпозвоночного диска регенерация стволовых клеток не доказана. Есть несколько исследований, но использование этих клеток для восстановления травм межпозвоночного диска все еще находится в начальной фазе, на уровне эксперимента. При их введении было замечено, что не все клетки выживают. Количества крови в зоне имплантации недостаточно для регенерации, требуется создание дополнительных условий, чтобы стволовые клетки смогли активно регенерировать. Когда-нибудь эту проблему удастся решить, но это не значит, что обычные операции на спине прекратятся. «Мы не сможем отказаться от них, по крайней мере, в ближайшие 50 лет», – отметил Пабло Клавель.

Unlike its predecessors, includes an integrated optical camera that allows the robot to acquire images in real time and perform a volumetric evaluation of the surgical field to auto-detect its location and avoid collisions with other system components.

WHAT SURGERIES IS IT USED FOR?

• Surgery to correct scoliosis
• Arthrodesis of the dorsal spine (degenerative, traumatic or tumor pathology)
• Arthrodesis of the lumbar spine (degenerative, traumatic or tumor pathology)
• Vertebral interbody fusion
• Vertebral biopsy (tumor pathology)
• Kyphoplasty (vertebal fractures)

WHAT ARE THE BENEFITS FOR THE PATIENT?

Robotic surgery systems have shown obvious advantages in comparison with conventional surgery of the spine:

• Improved precision in the placement of implants. Recent studies have confirmed that the system has a 98.7% precision rate of correct placement of screws (without deviation).
• Minimizes exposure to ionizing radiation, both for the patient and for all the operating room personnel. The average time required to insert a screw is 3.6 minutes, which reduces both the duration of the surgery and the risk of infection, as well as reduced exposure to radiation.
• Facilitates minimally invasive surgeries, which means a smaller surgical incision, and reduced loss of blood.
• Reduced postoperative pain thanks to the use of the robotic arm that less muscle retraction needed to operate in deep tissue.
• Contributes to a lower risk of infection thanks to a shorter time in surgery.
• Reduced risk of infection in the adjacent segment according to recent studies.

HOW DOES IT WORK?

The Mazor X robotic surgery system works as follows:

• The surgeon plans the surgical path of the implants using the patient’s images (CT scan taken before or during surgery) at the Mazor X Stealth Edition work station.
• The patient is placed on the operating table.
• The robot is anchored to the table and to the patient.
• The robotic arm records images of the patient. Mazor X features an innovative cross-modality image recording process, each vertebral body is independently registered. The robotic guidance system analyzes and pairs images from different modalities, such as matching a preoperative CT scan with intraoperative fluoroscopy or 3D surgical images, including images captured at different times and in different anatomical planes.
• The software guides the robotic arm according the the plan established by the surgeon for the surgical field.
• Placement of implants by the surgeon aided by the real-time neuronavigation system and guided by the robotic arm.

A REVIEW OF THE STELLA-2 TRIAL OF EVALUATION OF THE EXTRAPERITONEAL APPROACH

This study consisted of a retrospective review of the STELLA-2 trial, which sought to assess whether an extraperitoneal approach or without violating the peritoneal cavity would be safer for patients undergoing staging procedures in ovarian and endometrial cancers in early stage. The results of this review have served to conclude that the extraperioteneal robot-assisted approach for lymphadenectomy or dissection of the lymph nodes arranged around the abdominal aorta, also known by its acronym PALND, was associated with fewer surgical complications. The results of this study have been published in The Journal of Minimally Invasive Gynecology.

The results of this recent study have served to conclude that the extraperioteneal robot-assisted approach to lymphadenectomy is associated with fewer surgical complications

A COMPARISON OF FOUR DIFFERENT SURGICAL APPROACHES

Data from 203 patients from the STELLA-2 trial were included in this outcome review and served to compare four different approaches. Thus, the results of two laparoscopic approaches were evaluated, one transperitoneal and the other extraperitoneal with another two robot-assisted, also transperitoneal and extraperitoneal. “In all cases it was observed that variables such as age, body mass index and waist-hip ratio independently increased the risk of complications in PALND, while the extraperitoneal robotic approach was an independent protective factor for the appearance of these complications”, explains Dr. Berta Díaz-Feijoo, gynecologist oncologist at the Instituto Clínic de Ginecología, Obstetricia y Neonatología (ICGON) of the Hospital Clínic de Barcelona and gynecologist oncologist of barnaclínic+.

Dra. Berta Diaz-Feijoo
“In all cases it was observed that variables such as age, body mass index and waist-hip ratio independently increased the risk of complications in PALND, while the extraperitoneal robotic approach was an independent protective factor for the appearance of these complications”

ADVANTAGES OF THE EXTRAPERITONEAL ROBOTIC APPROACH

The results of the published review also demonstrates that this extraperitoneal robotic approach does not compromise lymph node recovery or increase operative time or hospital stay. “Improved 3D robotic visualization, surgeon ergonomics, or hemostatic precision could explain these results”, adds Dr. Berta Díaz-Feijoo. In addition, it highlights how little data is available so far on the benefit of robot-assisted surgery in reducing intraoperative and postoperative complications and that, thanks to this publication, it has been possible to advance in defining a better approach to the many options that now exist.

Dra. Berta Diaz-Feijoo
“The improved robotic 3D visualization, the ergonomics of the surgeon or the hemostatic precision could explain these results”
Dr. Berta Díaz-Feijoo, gynecologic oncologist of the Hospital Clínic de Barcelona and barnaclínic+

Thus, and according to the data obtained, whenever lymphadenectomy is necessary for the surgical staging of high-risk ovarian or endometrial carcinoma, the extraperitoneal robotic approach could lead to better patient management, regardless of their baseline characteristics (that is, previous surgeries, age or obesity).

It involves complete resection of a tumoral lesion located in the intraocular space. The advantage is that it completely removes the tumour and, in addition, it allows us to analyse its cell pattern in the laboratory, unlike other destructive techniques such as radiotherapy. These surgical procedures are highly specialised.

WHAT ARE ITS INDICATIONS?

Currently, due to the use of other treatment techniques like episcleral barchytherapy, the surgical procedure has been limited to the treatment of different types of very specific tumours located in the iris or the ciliary body.

Surgical techniques are also used for ab externo or ab interno removal of tumours of the back part of the eyeball.

HOW IS IT PERFORMED?

The ab externo surgical approach is performed on the white layer of the eye (the sclera) and the tumour is removed in one single piece with very specialist microsurgery techniques.

In the ab interno technique, the tumour is destroyed and aspirated inside the eyeball itself. It is a technique that basically uses certain melanomas of the posterior uvea and it is always combined with an episcleral brachytherapy to irradiate possible cellular remains at the base of the tumour.

RESULTS

The results are good in the sense that this technique eliminates the tumour completely and the eye still has a varying degree of vision.

The postoperative period is usually tedious due to the inflammation caused by the surgery and, in general, the patient will reach their final level of vision after a few months.

POSSIBLE RISKS

Depending on the location of the lesion and the technique used, an induced astigmatism, displacement of the pupil, cataracts, postoperative haemorrhaging, hypotonia or ocular hypertension or visual sequelae may occur. In these cases, you must undergo a very close clinical follow-up to identify and treat any complications.

PROFESSIONALS WHO PERFORM THIS TREATMENT

Dr. Javier Elizalde

A macular hole is the name for the formation of a break in the centre of the retina, the area which call the macula. It usually occurs in people over the age of 50 and it is more common among women. It can be bilateral in 15% of individuals.

Its diagnosis is clinical, i.e., viewing the back of the eye after dilating the pupils and using magnifying lenses. However, in all cases, we will perform a scan of the macula (OCT or optical coherence tomography) to measure the size and thickness of the macular hole, upon which will depend the prognosis and potential treatment.

SYMPTOMS

The clinical signs of a macular hole can vary: from patients who are completely asymptomatic at the start to a severe loss of vision and the appearance of a blind spot in the centre of the eye (scotoma).

Metamorphopsia (perception of distorted images and straight lines with undulations) is also very common as is macropsia and/or micropsia (seeing objects as larger or smaller than they are in reality).

A very characteristic symptom of this condition is seeing broken lines, known as the “Watzke-Allen sign”.

CAUSES AND RISK FACTORS

It is believed that its cause lies in the traction that the vitreous humour (transparent gelatinous liquid filling the eyeball) exercises over the macula when it contracts, because of a physiological ageing process. Under normal conditions, when we get older, the vitreous detaches, i.e., the intraocular gel recedes and moves away from the macula without causing any damage thereto or having any consequences on the eyesight. However, in some people, the vitreous cortex has strong adherence to the macula and a sharp focal contraction thereof leads to a break in the macular tissue and the formation of a macular hole.

We can also experience a macular hole after a blunt eye trauma, in the context of a high degree of myopia or a chronic macular oedema complication.

TYPES

Macular holes can be classified in different ways:

— According to their cause: Idiopathic or senile (associated with ageing), myopic (those that occur to patients with a high degree of myopia) and traumatic (the consequence of previous trauma).

— According to the thickness of the damaged retina: Full-thickness (when the hole affects the full thickness of the retina) and lamellar (when they partially affect the thickness of the retina) associated, in general, with the epiretinal membrane.

— According to the OCT findings: A complex classification that we do not mention herein.

PREVENTION

There is no way of preventing a macular hole from forming. What is important, however, is diagnosing it at a very early stage when surgery is very effective. Therefore, regular eye check-ups, above all in patients who have had the same condition in the contralateral eye, are advised.

TREATMENT

Macular hole treatment is eminently surgical.

The surgery is called a vitrectomy . It is an outpatients procedure and performed under local anaesthesia. It’s a microincision technique, i.e., it uses microscopic incisions that do not require stitches. It involves removing all the structures that cause traction on the macula, be it the vitreous humour, the epiretinal membrane or the internal limiting membrane of the retina (the outermost layer of the retina).

At the end of surgery, a gas bubble is injected into the vitreous cavity (intraocular tamponade), which helps the macular hole to close. For the days following surgery, patients will have to stay in quite a strict position (generally seated or with the mouth facing downwards), depending on the type of duration of the gas.

The surgical outcomes are more promising the less the disease has evolved and the smaller the size of the hole. In early cases, there is a high percentage of anatomical closure and a considerable improvement in visual acuity compared to more advanced cases or macular holes in myopic eyes.

PROFESSIONALS WHO TREAT THIS PATHOLOGY

• Dr. Santiago Abengoechea
• Dr. Mª José Capella Elizalde
• Dr. Javier Elizalde
• Dr. Jeroni Nadal
• Dr. Sònia Viver

The word brachytherapy comes from the Greek (“brachys”) which means “near”, and it is a type of local radiotherapy which allows the tumour to be treated with radiation from a source that is in contact with or even inside the affected organ. The most commonly used radioactive isotope is Iodine-125. In ophthalmology, the radioactive source is placed above the sclera (episcleral), which is the white part of the eye.

WHAT ARE ITS INDICATIONS?

The first indication of episcleral brachytherapy is uveal melanoma, although it can also be used to treat intraocular tumours (retinoblastoma, metastasis and vascular tumours of the retina and choroid).

• Choroidal hemangioma
• Uveal melanoma
• Vascular tumours of the retina

HOW IS IT PERFORMED?

It is a surgical procedure that involves attaching a gold plaque charged with radioactive isotopes to the eyeball in the location of the tumour. The size of the plaque and dose is determined on an individual basis, depending on the type of tumour and its size.

A well-coordinated team including an expert ophthalmologist and radiation oncologist who decides how long the plaque should be in situ is essential. After this period (usually 3 to 5 days) the plate is removed.

RESULTS

In a high percentage of cases, healing of the tumour is acheived, but not immediately. The patient should have clinical checks and regular ultrasound scans to check that the tumour has not returned. The final resolution of the tumour usually occurs after a few months.

POSSIBLE RISKS

The radiation emitted by the episcleral brachytherapy does not affect other organs or people in the vicinity, since it is very localised radiotherapy. In general, it’s a treatment with very few undesired effects.

When the tumour is located on the inner part of the eye there is a risk of developing a radiogenic cataract and in cases where a lesion close to the central retina or optic nerve is being treated with radiation, radiation retinopathy or radiation neuropathy may appear along with reduced vision.

PROFESSIONALS WHO PERFORM THIS TREATMENT

Dr. Javier Elizalde

The retina is a sensitive tissue of the eye containing a multitude of blood vessels. These vessels may grow and proliferate anomalously, be it from birth or acquired, leading to different vascular tumours of the retina.

TYPES

There are four types:

1. Capillary hemangioblastoma (which is occasionally associated with Von Hippel-Lindau syndrome).
2. Cavernous hemangioma.
3. Vasoproliferative proliferal tumours.
4. Racemose hemangioma (congenital arteriovenous communications of the retina).

SYMPTOMS

The symptoms depend on the type of tumour and its location. Hemangioblastoma of the retina and vasoproliferative tumours can exudate (lose liquid), leading to exudative retinal detachment or it may generate proliferations that exert pressure on the retina.

In these cases, the patient show signs of gradually worsening vision. Cavernous and racemose hemangioma are congenital and if they are located near the centre of the retina, they can lead to underdeveloped eyesight (amblyopia).

TREATMENT

There are multiple treatment alternatives depending on the type of tumour, its location and the associated complications. The most used treatments are intravitreal drug injections that can reduce vascular permeability, laser, cryotherpay and vitreous surgery to treat tractional complications or retinal detachment, episcleral brachytherapy and external radiotherapy. In many cases, combined treatments are required. It is a complex pathology that should be treated in a centre of reference.

• Episcleral brachytherapy
• External radiotherapy
• Laser photocoagulation

PROFESSIONALS WHO TREAT THIS PATHOLOGY

Dr. Javier Elizalde

«Мы гордимся тем, что разработали эту технику еще в 2009 году и первыми во всем мире применили ее на практике. Уже через десять месяцев всем пациентам с опухолями прямой кишки, которые проходили у нас лечение в то время, были сделаны операции этим методом», – рассказал доктор Антонио де Ласи. Он подчеркнул, то Hospital Clínic Group всегда поддерживает развитие исследований и внедрение различных инноваций, таких как TaTME.

МИРОВОЙ СПРАВОЧНЫЙ ЦЕНТР ПО МИНИМАЛЬНО ИНВАЗИВНОМУ ПОДХОДУ

Команда доктора Антонио де Ласи провела более 500 вмешательств, выполненных с помощью минимально инвазивной техники TaTME, и на сегодняшний день стала мировым лидером в данном подходе.
Это комбинированная техника, включающая:
лапароскопическую резекцию – метод малоинвазивной хирургии, при которой используется тонкая трубка, вводящаяся в брюшную полость через небольшой разрез
трансанальную резекцию, то есть проникновение через задний проход пациента

ТРАНСАНАЛЬНЫЙ ПОДХОД – ПРЕИМУЩЕСТВА ДЛЯ ПАЦИЕНТОВ

TaTME предоставляет пациентам целый ряд преимуществ, влияющих как на результаты лечения, так и на качество их дальнейшей жизни. Пожалуй, одним из основных плюсов, является снижение частоты колостомий. Таким образом, если после операции возникает необходимость носить с собой мешочек с экскрементами, то более чем в 99% случаев от него можно отказаться через 3 или 6 месяцев.

«Благодаря этой методике сокращается время проведения операции и пребывания в больнице, появляется возможность ослабить послеоперационную боль. За счет уменьшения повреждения соединений снижается травматичность процедуры, а послеоперационные осложнения, такие как инфекции, расхождение или спонтанное вскрытие ран встречаются в 2 раза реже», – делится доктор Антонио де Ласи.

С онкологической точки зрения, Тотальное трансанальное мезоректальное иссечение (TaTME) позволяет удалить рак прямой и толстой кишки более безопасным способом и повышает шансы выживания пациентов.

«Чтобы убедиться в том, что этот метод, действительно, способствует получению хороших онкологических прогнозов, мы инициируем исследования. Ведь мы не только удаляем злокачественную опухоль, но и снижаем вероятность метастазирования и осложнений после лечения», – добавляет Антонио де Ласи.

БОЛЬШИЕ ВОЗМОЖНОСТИ ДЛЯ ТАТМЭ

Рак толстой и прямой кишки – тип опухоли, которая занимает третье место по частоте среди онкологических заболеваний – после рака груди у женщин и рака простаты и легких у мужчин. Так как эта опухоль на протяжении многих лет представляет собой полип, который при раннем обнаружении немедленно удаляется, рак можно предотвратить и вылечить. Тотальное трансанальное мезоректальное иссечение (TaTME) – наиболее предпочтительный метод при удалении, как доброкачественных полипов, так и тех, которые уже перешли в злокачественную стадию.

Хотя, изначально TaTME применялось для пациентов с опухолями прямой кишки, сегодня метод распространился на многие другие патологии. Помимо рака прямой и толстой кишки или доброкачественных опухолей, его можно рекомендовать для лечения воспалительных заболеваний кишечника, стриктур прямой кишки, сложных свищей, недержания кала, при семейном аденоматозном полипозе, лучевом проктите, при необходимости удаления культей или реконструкции прямой кишки после операции Хартмана, а также при послеоперационных осложнениях и рецидивах.

Факторы, определяющие выбор метода Тотального трансанального мезоректального иссечения (TaTME) для лечения рака толстой и прямой кишки: мужской пол, расстояние от опухоли менее 12 см от анального края, узкий и / или глубокий таз, висцеральное ожирение, ИМТ более 30, гипертрофия предстательной железы, диаметр опухоли более 4 см, искажение плоскости из-за неоадъювантной лучевой терапии или очень низкое расположение опухоли, требующее очень точного дистального края резекции.

Современная тенденция – использовать эту технику во всех случаях патологии прямой кишки.

Статьи по интересам:

Институт хирургии доктора Ласи (IQL) в клинике «Кирон Салюд»

Доктор Антонио де Ласи Фортуни 

It’s a surgical procedure for the treatment of glaucoma that involves inserting a tube to connect the intraocular tube with a device (that may or may not have a valve) located below the conjunctiva to drain the aqueous humour from the eye.

WHEN IS THIS TREATMENT INDICATED?

Generally, it is used for glaucoma where other types of filtration surgery have failed, for types of glaucoma where the result is better than other techniques like for neovascular glaucoma, or when the state of the conjunctiva would prevent the use of surgical techniques.

HOW IS IT PERFORMED?

It is perfomed under local anaesthetic and sedation, so that the patient is completely calm. The majority of the device is placed on the outside of the eye, below the conjunctiva.

A small tube is place in the anterior chamber of the eye. The liquid drains through the tube to the posterior part of the implant where it builds up and is reabsorbed.

RESULTS

The results of drainage devices may vary depending on the type of glaucoma, the age of the patient, the state of the conjunctiva and the number of previous surgeries. They normally control the intraocular pressure in the majority of cases, although over time topical treatment should be added to control it.

POSSIBLE RISKS

There is the possibility that the pressure is too low. This is known as “hypotony”. The implant may also interfere with the external muscles that move the eye causing double vision.

If there is excessive scarring around the device, it may block the fluid from being reasborbed, which, once again, leads to an increase in the pressure. To treat this, hypotensive eyedrops or new procedures may be required.

Other complications may include corneal lesions, which may be due to the mechanical contact between the tube on the inside of the eye and the inner part of the cornea.

PROFESSIONALS WHO PERFORM THIS TREATMENT

Dr. Maria Isabel Canut
Dr. Francisco Ruiz Tolosa
Dr. Federico Trejos

Within the scope of glaucoma, we should be aware that the thickness of the cornea is related to the measurement of intraocular pressure, in that corneas that are thicker or less thick than average may give flawed readings on pressure measurement devices which should be corrected.

Concerning refractive surgery, a pachymetry is one of the most important examinations for determining whether a person should undergo laser treatment for their myopia, hypermetropia or astigmatism, since the surgery modifies the shape of the cornea, extracting a certain amount of tissue which will directly affect the thickness of the cornea. Therefore, the cornea should be thick enough to correct a given number of dioptres.

It is also a diagnostic tool for some pathologies that cause a thinning of the cornea as per the case with keratoconus or even those that cause thickness as per the case with corneal oedema.