Amazing Advancements in Health Care

What once was considered inoperable and incurable is today the fodder of medical miracles, just as these local stories prove.

Dr. Ankit Bharat
Dr. Joshua Alpert

Most health care systems have a well-publicized mission to provide the best possible treatment to their patients. Sometimes that means pushing the limits to try new techniques to prevent pain, correct maladies and even save lives.

“We try to really focus on innovation and to bring new frontiers of the treatment paradigm – not just the easy problems, but the most difficult and potentially unsolvable problems,” says Dr. Ankit Bharat, chief of thoracic surgery and director of the Northwestern Medicine Canning Thoracic Institute.

It’s not unusual for doctors to see a case that appears “unsolvable.” Perhaps other treatments have failed and options are short. That’s not something physicians like to hear. In fact, their desire to fully aid a patient is one reason driving doctors to new technologies and advanced techniques.
“You want to be able to treat the patient from beginning to end,” says Dr. Joshua Alpert, an orthopedic surgeon and sports medicine specialist at Fox Valley Orthopedics.

When treatment options run out, innovation meets reality. And that’s when “medical miracles” can happen – sometimes right in our own backyard.

“As part of our mission, we want to, as best as we can, take that innovation and best care and take it to a patient’s doorstep, because we know there are logistical barriers to traveling far away … that’s the rationale,” says Bharat.

(Northwestern Medicine Canning Thoracic Institute photo)

‘Incurable’ Lung Tumor Removed

Of all cancers, lung cancer is the highest killer, and it’s a huge health concern in the U.S. right now, says Bharat. Contrary to general belief, it doesn’t just affect smokers.

“It can happen in both smokers or non-smokers, and it often causes no symptoms until it has spread,” Bharat says. “So, we are developing novel programs at Northwestern Medicine that will help patients at different stages of lung cancer.”

Kathie Schultz of Union was a longtime smoker, yet in May 2023 she just assumed she had an upper respiratory infection when she asked her doctor about an antibiotic. It was the first time in 40 years she had been to a doctor.

To her complete disbelief, it wasn’t an infection at all. She discovered she had aggressive Stage 3 lung cancer.

“I’d been a smoker most of my life, but still, you never think it’s going to happen to you,” she says. “Before all this, I was on the treadmill 4 miles a day, for the past 20 years.”

When Bharat first saw Schultz, the tumor on her left lung was so large it was not amenable to surgery.

“This was not considered by conventional means resectable. We could not have taken it out,” Bharat says. “It was also deemed potentially incurable. So, using a multidisciplinary approach, we outlined a plan where we would customize a treatment using chemotherapy and immunotherapy to shrink the tumor and then remove it.”

The “medical miracle” part is this: Once the therapies did their work and shrunk the tumor to a more manageable size, Bharat and his surgical team at Northwestern Medicine McHenry Hospital made a 2-inch incision in Schultz’s chest and used robotic assistance to help separate the tumor from nearby structures – including her aorta, into which the tumor had begun to grow.

Then, the team removed her entire left lung through that incision, without rib spreading, rib breaking or muscle cutting.

Schultz went home in three days.

“Normally, when patients have their whole lung taken out, it’s such an invasive situation they stay in the hospital for about a week, and they’re recovering three to four months because we spread the ribs,” Bharat says. “The recovery is so much delayed; it hinders the cancer treatment these people need to have.”

Schultz’s procedure, which took place last October, marked the first time a whole lung and such a large tumor were removed in a robotic-aided, minimally invasive procedure, after having first treated it with chemotherapy and immunotherapy.

Best of all, Schultz has been deemed cancer-free. This success has great implications for other patients.

“What it does for the future is it really allows us to take these innovative strategies and go in with a curative intent,” Bharat says. “Lung cancer, unlike many other cancers, presents at very advanced stages: over 70% of lung cancer, when presented, is in advanced stages. Through this approach of chemo and immunotherapy and using the most advanced robotic advances, we were able to cure her. And we were able to do all of that at Northwestern Medicine McHenry Hospital, which was closer to Kathie’s house. She had really good family support there, and that helped a lot because logistically it would have been much more difficult at our downtown Chicago hospital.”

Additionally, Bharat and Northwestern Medicine continue to build upon this minimally invasive robotic procedure to help patients with similar ailments.

For example, Bharat and his team soon will be able to extend this type of surgical treatment to patients with esophagus cancer at Northwestern Medicine McHenry Hospital. He’s currently performing the procedure at the Chicago campus.

Esophagus cancer, while more rare than lung cancer, is equally lethal, Bharat says. The entire esophagus often needs replacement, which typically is accomplished through big incisions, feeding tubes and weeks-long hospital stays.

“But we have developed this technique where the whole thing can be done with tiny cuts, the size of a fingertip, and they’re home on day two or three,” Bharat says. “The reason I explain all of this is because we are trying to bring this type of innovation related to all cancers in the chest cavity. We’ve developed this robotic approach, which is a complete paradigm shift in how that treatment is approached. We want to help our patients fight cancer and live better lives after the procedure and have better outcomes.”

Despite the success of Schultz’s surgery, Bharat – and Schultz – acknowledge that a simple lung cancer screening could have caught her tumor much earlier.

“Kathie, like many other patients who need to go through lung cancer screening, they’re not getting screened,” Bharat says. “Less than 6% of patients who should be getting screening are not getting screening. That plays a huge role in lung cancer being incurable when they present.”

And because of her late diagnosis, Schultz has found life to be a bit different post-surgery.

Unlike the removal of a kidney, in which patients often experience little difference in their daily lives, those who lose a lung do take a hit, Bharat says.

Think of the lungs as a car engine, he says. If you cut the engine capacity in half, you’re going to be a lot slower.

“The lungs are really your capacity for activity and performance – your engine,” Bharat says. “So, by losing a lung, Kathie has lost half her lung function. She will feel some shortness of breath … and she recognized that. If you’re climbing up a couple flights of stairs, you’re going to get more winded, and those things are expected.

“But it’s coming with the benefit of having a cure of cancer, which would have killed her,” he adds. “All things considered, to have had a really bad tumor and now be cancer-free and pay a little price to have a little more effort to do day-to-day things, I think it’s a really good outcome given the alternative.”

Schultz agrees.

“When I went in for my follow-up after two weeks, I asked, ‘Where am I at? I’m not letting you out of this room until I hear the words,’” she says. “And Dr. Bharat looked at me. And I said, ‘That I’m cancer-free.’ He looked at me and said, ‘You are cancer-free.’ And I just broke down. It’s a big deal. Your milestones become so different. When they took out my port, it was a big deal. So, yeah, life is definitely different. But good.”

Reimagining Rotator Cuff Repair

Shoulder pain is the second most common complaint in orthopedics after neck and back pain, says Alpert, who has practiced sports medicine in the area for the past 15 years.

Quite often, that shoulder pain is related to the rotator cuff.

If you look at Alpert’s personal patient load, he sees roughly 5,000 patients a year at Fox Valley Orthopedics, mostly at the organization’s Elgin and Barrington offices. At least half of his patients with shoulder problems have rotator cuff injuries. Of the 200 shoulder surgeries he performs every year, about 150 of those are for rotator cuff tears.

When somebody has torn their rotator cuff, surgeons typically use a camera to find the tendon and pull it back onto the bone, Alpert says.

“When you take a tendon that’s torn off the bone and reattach it to the ball and socket of the head, sometimes that tendon doesn’t heal or it tears again,” he says. “Or, if the tear is large, it is unable to be fixed. When the rotator cuff is large and unable to be fixed, the ball rises up on the socket, toward the head, increasing a patient’s chance of developing arthritis.”

Research indicates the success rate for rotator cuff surgery is somewhere between 75% and 95%, Alpert says.

“So, if I’m doing 150 rotator cuff surgeries per year, there will be failures for whatever reason,” he says. “Sometimes, the repair fails because the tear is too big and doesn’t heal; sometimes there is a retear of the tendon because there’s not an adequate blood supply going to the rotator cuff to help it heal. Unrepairable rotator cuff tears are a challenging problem we often have to treat.”

When a rotator cuff tendon is not repairable, the treatment for patients in their 70s and 80s is generally shoulder replacement surgery – a straightforward solution to the chronic shoulder pain and weakness of that patient population.

Unfortunately, for younger patients in their 40s and 50s, it isn’t that simple.

“For these younger patients, a shoulder replacement is not an option because they can wear out in 10 to 15 years; they generally don’t last as long as the knee and hip replacements we do,” Alpert says. “At times, doctors may advise younger patients with an irreparable rotator cuff that they may have to live with the pain. For a lack of a better term, they have to suck it up. That’s the biggest problem: What do you do when someone is young and the rotator cuff is unrepairable?”

Alpert’s chance to perform a “medical miracle” came late in 2021 when a patient in her 40s showed up after not one, but two failed arthroscopic rotator cuff repairs.

“She was miserable and in pain,” Alpert recalls.

Alpert performed a superior capsular reconstruction – a surgery often seen as the last resort before shoulder replacement surgery. The operation entails putting a piece of graft tissue on top of the shoulder with anchors on each side of the ball and socket, essentially creating a new rotator cuff.

“The goal is for that graft tissue to be attached to the ball and socket and hold the ball in place to function like a new rotator cuff, which would delay the need for a complete shoulder replacement in the future,” Alpert says.

Unfortunately, that superior capsular reconstructive surgery did not heal in Alpert’s young patient.
“She had no other options when that failed,” Alpert says.

However, Alpert was aware of a newer, minimally invasive procedure that had the potential to help his patient after her third failed surgery. That procedure is called an arthroscopic InSpace balloon implant.

And he was one of the first orthopedic surgeons in Illinois to perform the procedure, alongside sports medicine surgeon Dr. Vishal Mehta.

After making a tiny poke hole in his patient’s shoulder, Alpert inserted a flat balloon on top of the ball of the joint. Attached to the balloon was a syringe that injected water into the balloon, which acted as a spacer to help hold the head down in the socket.

“By doing that procedure, that balloon prevents a person from needing a shoulder replacement for 10 or 15 years,” Alpert says. “I think it’s definitely going to be the wave of the future for this complicated problem in younger patients.”

Currently, the InSpace balloon implant is considered a new, innovative procedure, which comes with complications.

“One challenge is that you have to find the right candidate; you have to explain to the patient that this is new and experimental, and that’s challenging for people to understand. Some people don’t want it,” Alpert says. “The biggest challenge right now has just really been insurance coverage. It’s an expensive device. Any type of new technology that’s expensive and insurance doesn’t cover, even though we have literature that says it’s helpful to certain people, it’s hard to put them in practice.”

In the past two months alone, Alpert has had two potential candidates for the InSpace balloon implant, but insurance has denied the procedure.

However, if it does eventually catch on, Alpert believes it would defer shoulder replacement surgery for many patients, thereby keeping down the overall cost of treatment.

Looking way ahead, the next logical step is to place the implant without any formal surgery. And that alone sounds like a miracle.

“Potentially in the future, we could do this in the office under ultrasound, like cortisone shots,” Alpert says.