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
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
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."