No instruments? Then your doctor will just have to make some | Theo Ruers in the FD

By cleverly combining affordable technologies, creative Dutch physicians are developing their own tools to treat cancer, cerebral infarctions, and kidney disease. “It surprises even me. None of this would have been possible a decade ago.”

“Take a good look, this is the abdominal cavity of one of our patients during surgery. At the center is the malignant tissue. Can you see it?” Theo Ruers looks up expectantly from his screen, but does not wait for an answer. “Me neither, and I have been operating n patients like these for my entire life.”

Ruers is a surgical oncologist. He has been operating on cancer patients at the Netherlands Cancer Institute in Amsterdam since 2007. But he kept running into the same issue: there’s a type of tumors that is incredibly hard to remove. “Imagine that your body is like a sponge,” he explains. “If there’s a hard tumor in the sponge, it will feel like a marble. You can easily feel and remove it. But there are tumors that feel exactly like a sponge.”

These kinds of tumors won’t show up on pictures, he explains. Only on MRI scans. The scan can tell you where you have to be, approximately, but you still face many decisions during the surgery. “Do I go to the left or right? How far can my scalpel go? If the area you cut out is too small, you risk leaving tumor tissue behind which means that your patient will have to come in for more intense treatment. But if you cut out too much, you cause too much damage. You’re always trying to find that balance as a surgeon.”

Special pen

Ruers struggled with this issue for a long time, until he realized that only surgeons hold the answer. They surrounded themselves with modern technology but still used their fingers and eyes for surgery, just like they did a century ago. “I realized that that’s where the restrictions lie. And then I started working on a solution: the Logiknife.”

That was five years ago. Now, in 2020, the Logiknife technique is amply used at the hospital. Ruers again gestures towards his screen, on which a 3D model of the lower body has appeared. A three dimensional “road map” of the area receiving the surgery and the tumor. Bones and blood vessels appear in white, red and blue. Small, green dots show the tumor. “In order to remove those green dots, surgeons use a special pen during the surgery, which can communicate through an electromagnetic mat on the operating table.” The pen ventures through the 3D model and shows malignant and benign tissue. Ruers: “Whenever you’re facing a tough decision during surgery, you can use your pen to check, and you know exactly what to do.”

And the system works, he says. “Very well, even. We have applied the technique in treatment of advanced rectal tumors. When using regular surgical techniques, tumor tissue remains in 50% of patients. Using the Logiknife can reduce this total to 20% of patients. We have treated over 75 patients with this new instrument. And the outcome is clear: this is our new normal in our surgeries. Even I can’t always believe it. This wouldn’t even have been possible last decade.”

Knowing that Ruers was the man who has found the solution shouldn’t be a big surprise. He is professor in oncology and biomedical imaging at the University of Twente, and as a result has a large network. “That’s a huge benefit. It can be hard to connect the medical world with the world of technology because clinicians and technicians speak entirely different languages. We have bought all the components as a hospital, and wrote our own software, hired technicians, people from the gaming industry for 3D visualization, and we have collaborated with the TU Twente. That’s a large operation that you can’t just start on a whim.”

Willem Kolff

Hard or not, the invention of advanced medical instruments by physicians is a beautiful Dutch tradition. The most famous example would be Willem Kolff (1911-2009), who had to watch a patient die of kidney failure in the 1930s without any way to intervene, which led to the development of the artificial kidney. Kolff also founded the first blood bank in Den Haag during the second world war, and implanted the first artificial hearts in people and dogs in the 50s. 

A team of physicians and technicians at the UMC Utrecht is still developing Kolff's initial work into dialysis by developing a portable dialysis machine that can improve the quality of life of patients with kidney disorders. The same UMC has developed a method to increase precision in the delivery of radiation to cancer cells. The development of this MR Linac method has been taken almost a decade, which proves how hard it can be to bring highly technical innovation to medical instrumentation: it’s expensive and requires a lot of organization. Kolff found these conditions for the development of his artificial heart in the United States in the 50s. In the Netherlands, these grand ideas are usually developed in the larger (university) hospitals.

Cerebral infarction

One such hospital is the Amsterdam UMC, location AMC. Barely 11 kilometers away from Theo Ruers, neurologist Jonathan Coutinho is working on an instrument that can recognize cerebral infarctions at an early stage. A cerebral infarction is when a blood clot in the vein blocks oxygen from flowing to the brain. “Treatment requires haste,” Coutinho explains. “The longer the clot remains, the more brain tissue will die. One minute can make the difference between total paralysis and someone reading the newspaper on the very next day.”

There are two types of cerebral infarctions: a version you can treat with relative ease in approximately 80 hospitals in the Netherlands, and a more complex variety that can only be treated at 19 of the larger hospitals equipped with angio rooms. “We can only diagnose patients when they arrive at the first aid department,” Coutinho explains. “If the patient cannot be treated at the hospital, they will need to get back into the ambulance and end up at a hospital like ours. I occasionally see people come in and wonder why it took them so long? That was frustrating. I thought, isn’t there something we can do?” 

Coutinho found a solution in a technique that had been readily available but that hadn’t been portable for quite as long: the EEG. This brain monitoring system could only be used in the controlled environment found at a hospital. But for a couple of years now, there’s a simplified version available using electrodes in something that looks like a shower cap. These are less accurate than a standard EEG, but you can put it on your head at home to start the process. 

Two years ago and together with his colleague Wouter Potters, technical medicine specialist, Coutinho started working on this cap, financed by a small subsidy of the Dutch Cardiovascular Society (Hartstichting). They made some kind of mobile brain scan using new parts and software. This cap, which is currently still in development, will be able to do two things: check whether a patient is having a cerebral infarction, and if yes, which kind? This will help ambulance drivers pick the right hospital to take the patient to. Coutinho: “That’s all it is. We have put six prototypes in ambulances in Amsterdam. Because the proof of the pudding is in the eating. We have also gathered plenty of data on patients to train artificial intelligence to diagnose the patient. We will have to collect this data over the coming years.” ‘When using regular surgical techniques, tumor tissue remains in 50% of patients. Using the Logiknife can reduce this total to 20% of patients. And the outcome is clear: this is our new normal in our surgeries.’

Valorization

Just like their colleagues at the UMC Utrecht, Ruers and Coutinho  expect that it may take years until their findings will be used at a larger scale. Ruers: “The system was developed at the Netherlands Cancer Institute and we are now able to use the Logiknife in our surgeries. But we can’t yet offer it to other hospitals before going through the process of getting it certified. It can be beneficial to start a company outside of the hospital. This is an option we are currently looking into.”

The same goes for Coutinho’s shower cap: “The valorization, as they call it, is a consideration. Should we start our own company or will we team up to sell an existing one? It is clear that we have to come up with something - hospitals don’t sell these kinds of products themselves. I don’t really care how the product will reach other people, as long as it does. Because that will save lives, and that’s what started it all.”

Read the full article in Dutch at FD.nl