John Ayers didn't hesitate to pursue the chemotherapy and radiation recommended to treat his Stage 4 tongue cancer. But something happened after that treatment that typically didn't happen—and Ayers ended up in a situation that called for an extraordinary solution: slender robotic fingers directed by a master surgeon at Stanford Hospital & Clinics.
Ayers turns out to be someone whose tissues were more than usually scarred by the effects of radiation; when he developed a cold that made his throat swell closed, the effect was so overwhelming that he couldn't breathe. That act became an on-and-off again possibility, with trips to the emergency room for tracheotomy insertion a regular thing.
Nor could he eat. "The doctors told me, 'You have to eat' and I said, 'You can say that all you want, but physically I cannot do this.'" That left Ayers just one option—a feeding tube implanted in his stomach. He tolerated that, as well as anyone does, for three years until another problem emerged.
An Unexpected Challenge
He was diagnosed with thyroid cancer. The obstruction of his throat made surgery to remove that new cancer quite problematic. By now, he'd been in conversation with Stanford's Edward Damrose, MD, associate professor of otolaryngology and chief of the hospital's Division of Laryngeal Surgery. Damrose is also a physician who is interested in new transoral robotic surgery approaches to patient care. In Ayers' situation, he saw a person in a classic medical conundrum.
You could tell me all you want about the robot, but what's going to make it run is the person. I said to myself, 'This is the man I want to go to because he knows what he's talking about.'
-John Ayers, patient, Stanford Hospital & Clinics
"We had cured his first cancer," said Damrose, "but we had left him with a set of problems that were quite serious. This new cancer forced our hand." Damrose and his team would have to find a way to rid Ayers' throat of enough scar tissue to allow surgery to protect his life from the thyroid cancer—and, beyond that, to restore the reliability of his ability to breathe and eat.
Damrose turned to the latest developments in transoral robotic surgery. This broad avenue to treatment was first crossed a century ago but its tools have advanced greatly in the last five years with robotic devices that are significantly smaller, nimbler and optically superior. The robotic arms are also steadier than the human hand. With the addition of a robotic-supported fiber optic laser and harmonic scalpel, surgeons can minimize the amount of heat required to manipulate and remove tissue to such a degree that more healthy tissue is protected and more function preserved.
"Advances in transoral robotic surgery allow us to do things through the mouth that previously required extensive incisions, splitting the mandible, splitting the lip, approaching tumors through the neck and through the jaw," Damrose said. "Now we can approach these lesions entirely through the mouth with no incisions. Blood loss is minimized. Hospitalization is shorter. Complications are lower. Swallowing and speaking is quicker. It's truly a win-win for the patient."
To expedite Ayers' care, Damrose and the Stanford team devised a plan: To insert a tracheotomy tube for the thyroid surgery, move on to the dilation and removal of the scar tissue in his esophagus and then to use stretchers to return it to a normal size from the less than 10 percent of normal it had shrunk to. Ayers "healed beautifully," Damrose said.
When Damrose first mentioned the robot, "it made sense," Ayers said. "I knew it was a new thing. And I'm used to new technology, but my faith was not in the robot—it was in the doctor. You could tell me all you want about the robot, but what's going to make it run is the person. I said to myself, 'This is the man I want to go to because he knows what he's talking about.'"
A Brighter Future
"Working with John through these problems gave us new transoral robotic surgery ideas about how we could apply this technology to others," Damrose said. "As we use this to discover what we can do, this is prompting people to investigate new ways to use the device. The traditional answer for John would have been radical surgery—and that just wasn't a palatable option, especially when you take into account the added risks of operating in a previously radiated field. And I don't know how much longer he would have been able to go on the way he was."
Damrose has since conducted a second surgery to widen Ayers' throat again and it's only a question of a few days before he'll have complete freedom to eat. He has in mind a certain brand of hamburger for his first meal. "The most important message I'd like to get out there is that you don't give up," he said. "No matter what anybody says—you don't give up."