AAGL Meeting 2011 - Tamer Seckin

AAGL Meeting 2011 - Tamer Seckin

Tamer Seckin: I come from Big Apple, New York City. That's where I've been practicing for the last almost 26 years. I've been interested in endometriosis surgery more than two decades ago. For a long time, my practice is exclusively endometriosis surgery. I must admit, though, I started with fibroids. I mastered stitching, but fibroid gave me the courage to attack endometriosis.
I always say I'm so grateful to AAGL now giving me this opportunity to talk from early years on. It's through AAGL, I learned a lot of tricks from people who talk today. Bill Parker is in the back. Harry, who I work very closely for many, many years as a colleague, learned all the tricks. Let me just express to them, of course, I'd appreciate Linda Bradley and the rest of the team to giving this opportunity.

I did form a foundation and lately, we have also fellowship program at Lenox Hill Hospital. I'm a lucky man, not because Padma supports me, because I have administrators in the hospital who understand what I'm doing, department chief who I converted to a maternal/fetal guy. In New York City, most of the country's department chiefs are maternal/fetal guys. They really don't look at the surgery the way we combat surgery.
We started the foundation simply because many patients were not treated well. Many of the times, treatments were a fail. I never thought the women were crazy. As we looked onto these things, we saw endometriosis over and over again. But there was something, many of the treatments were failing, 20% to 40% of the time. No matter how good a surgeon who are at times, there are some failures. I mean, we really did not know much.

Awareness became an important issue. I thank again Dr. Oz and Susan Sarandon were always there to help us. We had social media over 300 million internet appearances. In many cases, we cannot even answer emails. On the side, we do conferences every year. We did two. We're going to do the third one.
The first one is about stem cells to excision surgery. We recognized the value of stem cells. We want to provoke understanding of endometriosis in the level of inflammation, what stem cells really means for endometriosis. We did a great conference. We honored Caroline Gargett from Monash University. She's the person who identified in endometrium stem cells. Together with Hugh Taylor, they do have almost tissue possible in human being from the stem cell that was derived from endometrium.
We also educated nurses. We just did this two weeks ago at Lenox Hill Hospital for nurses. Lunch & Learn program. We think education of nurses is very crucial, including school nurses to diagnose endometriosis early. I like to thank Mr. Heather Guidone who also helped me for this presentation to head our education department. She really does great job. This is what happens. In woman, there are periods. Endometriosis is thought to be ... You can really say it's the period that it started going wrong. What happens is they think among many periods, sometimes these periods as it leaves the uterus, it leaks backwards. Most of the time, the body cleans that. In some people, though, however, with endometriosis, these tissue cling to the surface of peritoneum. Peritoneum is a beautiful organ, transparent. But clings and stays there, survives there, and causes small bleeders. Usually, if we don't really do a close-up inspection of these periods, we miss many of these lesions. This time, we may easily say to the patient, "You look fine."

We know today, the recent understanding of endometriosis is endometriosis in every sense involves the nerves either directly or indirectly. Either increasing surface tension of peritoneum or attacking the nerve and circumscribing that. We came to a point that these people were not crazy. We can show these.
Here's a quick animation. My job is to introduce to you what endometriosis is. I'm sure ... How many hospital administrators are here? Most of them are doctors then, so anyway. This animation of what happens, retrograde period, that was the one. Let's see. These implantations can hide in the corners of the peritoneal cavity and really hide the visualization of the doctor easily. This is obviously animation, exaggerated pictures.
I cannot fast forward this, but that's okay I guess. These are small. But in the end, what happens is the peritoneum and all the organs close up and causes adhesions. This is in the end, in some cases, a bilateral endometrioma case. When these two endometriomas [inaudible 00:06:00] uterus, you cannot even see it. It's an advanced case. Many cases, many of my cases are extremely difficult cases as has been operated at least three times. I just operated a patient who was operated 21 times. This patient had endo and it was operated by two doctors. Patient go and went back, I mean, mind-boggling.
Out of hundreds, 30 to 50 cases, we do a year. 70% of these patients are all of the operative endometriosis. When these cysts rupture, it just looks like a Hershey chocolate. It's more than that. It's posterior, it's a retroperitoneal disease. If peritoneum thickens, the ureter is involved, and we really have no choice but complete the surgery completely. These cases do take time, four hours, six hours, eight hours. I'm a pretty fast surgeon. I don't really do repeat my moves. In the end, it's very, very tiresome.
These chocolate cysts in the end, one of the worst parts of endometriosis, this chocolate cyst, you can really ... It's like a hand grenade explodes inside with a jar of jelly breaks and stuff. What happens is, in the end, rectum closes and the whole rectum and posterior vagina fuses together. That's why these patients do have significant pain with sex, severe dysmenorrhea, and with bowel movement.
I cannot forward this much, but that's okay I guess. I don't have much to show. This is another video of showing why we don't propose cautery. Cautery contracts the peritoneum. You have really no way of knowing how much you destruct under the peritoneal cavity. It's not a method that, as a foundation, I will not promote cautery. I personally don't use laser ablation, because I'd failed to get any pathology and there's no feedback of my scissors. Uniformly, the tissue is destructed. I cannot see how deep I go. I don't use laser, too. Sorry for laser users.
What I do is simple, very inexpensive method with classic scissors. We just cut to the margin free as a possible. Through that, very well it goes. The disease could be in rectum or ureter because we can stitch them back. That's not a complication. That's part of the procedure. The patients all know that. They consent to it. They were shown video up in the office.

This is a disease that, as it was said, almost 180 million women is affected. The symptoms become most of the time, 70% of the time, all these women with colic pain are diagnosed with endometriosis as published by Yeung, our friend. We don't know what the cause is. As I said, stem cells is probably the missing puzzle of the piece. It really explained the [inaudible 00:09:22] of our friend, Dr. Bradley. I wish she also accepts the stem cell as part of it, or also the retrograde periods. Stem cells is the key. It's the third leading cause of hospitalization, leading cause of infertility, and major cause of hysterectomy. We know that there is 10-fold increase risk of endometriosis. Women with endometriosis have 10-fold increase risk of endometriosis and their first-degree relatives.

These women are, in general, diagnosed very late. They fall, when they are mistreated and misdiagnosed by many GI doctors, medical doctors, even gynecologists included as ... Awareness of endometriosis as a disease with substantial morbidity is vitally important. We think that early intervention, early diagnosis, together with the quality of surgery improving is the most important aspect in the care of these women.

It's tremendously costly according to an article that's coming by Simoens, substantial societal cause of endometriosis is between $70 and $100 billion. This is not an exaggeration because two-thirds of the cost are associated with loss of productivity compared with one-third of direct healthcare cost. Women with endometriosis have high hospital admissions and 63% higher than medical cost for the average woman in commercially insured group This is an important aspect. I have references for these results. For the women, there's significantly reduced quality of life and severely compromised academic and professional opportunities. These women lose their most productive years of life. They might experience the lateness in diagnosis even more. The correct treatment, surgical excision treatment, on the average, 14, 13 years late. Most of them are end-stage cases.

I see people with 10 years of stents bilaterally on each side. Nothing has been done and GYN oncologists refusing to take them. They see patients who have hysterectomies. Out of 150, 70% has had hysterectomy, mainly supracervical hysterectomy, but the disease is left behind. It's really unbelievable, because we get a lot of almost third-level referral cases.
We all know the benefits of laparoscopy. But I must say endometriosis surgery is the most difficult surgery ever. It was said 100 years ago, it's more difficult than [inaudible 00:12:11]. It still is, because it's fibrosis surgery, you really don't know how deep you're going to go, how it's going to end. There will be multiple bowel lesions. There could be multiple bowel resections in one case. Most of the time, hypogastric nerves are involved. It's below the ureters.
How am I doing with time?

Speaker 2: Two more minutes.

Tamer Seckin: Okay. I think it is important to understand the level of support from the hospital administration. It's good for the business, it's good for the society. The most important point is really getting these newly trained, fellowship trained, young doctors interested in this, develop a team in the hospital. What I have is, it's a multiple organ business. It's not the reproductive organ business. In fact, out of 1600 biopsy excisions I have in the last two years' period, on the average, eight excision per case. There are more lesions outside the tube and posterior uterus that are to rectum, side walls, appendix, and other places.
We have a team. It's a colorectal surgeon or urologist who knows endometriosis, and endometriosis surgeon is the chief of the team. It's not like [inaudible 00:13:40] to call somebody, "I have a problem. Please come in and help me." It's not like that. The patient sees them for surgery. The patient knows that their bowel will be fixed, their ureter will be fixed, or bladder will be fixed.
In short, endometriosis severely diminishes the physical and sexual and emotional health of those affected. Relationships, careers, academics, sexuality, fertility, and overall quality of life are negatively impacted. We need to work together. I think hospital administration's department chief's position is very, very important. I thank you and I will continue to create awareness. We'd like to come to our website, introduce yourself, be part of us. Every year, we have a meeting in New York. This year is going to be about the next generation of surgeons and the young patients who will have endometriosis in the future. We like to discuss how we will help them. Thank you for your attention.

Speaker 2: Thank you very, especially for all of your advocacy. Thank you for the advocacy work that you're also doing in bringing awareness. Lot of information today. Any questions for Tamer? I do have this one question because ACOG puts us on a delicate balancing being where the use of laparoscopy diagnostic is often relegated to one of the very last things that we do. Might you just comment about your first steps that you might take in terms of why. I know there are administrators here.
At what point, would you say, in terms of what variables, what make you initially upon seeing a patient who's never seen anybody before say, "I'm going to go straight to the OR" or "I'm going to try one of the medical therapies." I think the quandary for what's listed as a practice bulletin guideline through ACOG is very different. The types of patients you see when you're in a tertiary care center, for someone like yourself, it's a little bit different than the first patient that shows up never treated. We can't scope everybody with pain. But might you in one minute just give us an idea of that patient who will benefit from our hospital's services or cases or watch while waiting or something.

Tamer Seckin: We cannot scope everybody that's having pain, that's for sure. But there are patterns of symptoms. There are algorithms of it that you know from the patient history. The patient, you have to hear, to listen, to hear the patient very well, listen well. Patient is telling everything. Of course, our goal is not to operate. What options do we have? We have birth control pills. We have Lupron. Many times, we can try that. The rule of thumb is, if it doesn't work, we do surgery.
However, in my practice, if I feel rectovaginal tenderness, if I feel uterine tenderness on mobility, if I feel fullness, if I see endometrioma, if that woman is seriously very symptomatic, they have an option to ... The patient is the boss. The patient dictates to you what ... I am willing to do their surgeries. I don't delay their surgeries. That's my point.

Speaker 2: Thank you. Thank you guys all for being such attentive attendees. I hope you learned as much as we learned.