Endometriosis Foundation of America
Endometriosis 2013 / Challenges We Confront with Endometriosis Surgery
- Harry Reich, MD
This one introduces the concept of the American Perspective, which is what we are talking about today. I want to make this short and brief and we will get into other subjects later. The main reason for this talk is that about ten years ago the Italian parliament, this is in Rome, invited me to give an idea of how laparoscopic surgery for endometriosis should proceed and I wrote them a letter. That is all I am going to show you, the letter that I wrote to the Italian parliament. It said thank you for the opportunity to express my views about endometriosis. I hope a lot of these things are solved today as the course goes on. We need to develop proper guidelines for its diagnosis and treatment. Please realize that extensive endometriosis surgery often involving rectal lesions is the most difficult surgery a gynecologist encounters, it is more difficult than cancer surgery. I have been treating this condition for over 30 years. I am convinced, and I stress this today, I am convinced that what is excised does not come back and my results for over a 1,000 cases show that less than 20 percent of these patients require further treatment.
Endometriosis, again, consists of endometriosis glands and stroma surrounded by fibromuscular tissue as accumulated over many years in response to cyclic monthly activation of endometriosis. They represent longstanding chronic inflammatory responses. Symptomatic endometriosis glands are always surrounded by some degree of fibrosis caused by repetitive longstanding inflammation and are often missed at diagnostic laparoscopy if the surgeon looks for brown lesions instead of white fibrotic ones.
Okay, here is the gist of it all. The American Situation, now again, this is ten years ago and I hope there have been some changes since. Two distinct groups are doing laparoscopic surgery. Two distinct groups have evolved; a very large cluster doing it for diagnosis and minimal treatment, and a much smaller elitist segment are doing it for optimal treatment instead of open abdominal laparotomy. There is a very poor level of surgical training to deal with endometriosis in the United States. We who do this type of surgery have very few disciples. There is very poor reimbursement for complex endometriosis surgery despite its increased medical legal risk. There are no codes at all to be able to differentiate an easy case from a difficult case and actually practicing gynecologists are penalized financially for spending too much time in the operating room instead of the office. Office patient visits and procedures pay approximately 20 times what can be made operating. Therefore, very few gynecologists want to get stuck with a complex endometriosis surgical case involving rectum, ureters and frequently the small bowel. One may do 100 cases just to cover the malpractice insurance.
Many women who undergo multiple endometriosis laparoscopies have no disease. I think this is very important. Surgeons do diagnostic laparoscopy without biopsy followed by six months of GnRH agonist treatment, followed by another diagnostic laparoscopy. This is often what I call "cashectomy", extracting cash from the patient without any long term benefits as the disease remains. The concept that endometriosis comes back is just a good excuse for poor treatment. What is called recurrent disease is really persistent disease that was not treated the first time out.
If the above sounds depressing regarding the state of endometriosis diagnosis and treatment in the United States believe me it is. Our lawyers and our managed care insurance systems have contributed. Remember all this was written ten years ago to explain our situation to the Italians. I was able to surgically treat extensive endometriosis only because I did not participate within the managed care insurance system.
In most cases of severe endometriosis the endometriosis surrounded by scar tissue can be palpated in the office using a simple rectal vaginal exam, a technique that is rarely used in the United States. Gynecologists do not routinely do rectal exams. These areas are usually very tender to palpation and this tenderness is used to direct the surgeon to the area to be removed. Post operative exam three to six months after surgery should be pain free if the appropriate area was excised. Diagnosis of endometriosis should require a positive biopsy documenting the disease. Papers in the literature regarding visual documentation, of which I would say were most papers, to my understanding are worthless. Most women with a diagnosis of endometriosis without biopsy do not have endometriosis. Diagnosis is often made visually by a laparoscopic visualization without biopsy. If these areas that are seen were biopsied the result would come back hemosiderin ladened macrophages, which are white blood cells filled with iron, the normal product of the body getting rid of the products of retrograde menstruation. Again, I emphasize many times I do not believe in Sampson's theory.
Quickly, surgical approach is enterolysis because almost always small intestine adhesions are present followed by rectosigmoid adhesions to the pelvic structures. We separate all pelvic organs including the ovaries, uterus, cervix, upper vagina and rectum. The endometriosis is then excised. Symptomatic endometriosis is surrounded by fibrous scar tissue from the repetitive longstanding inflammatory response. This scar tissue contains the endometriosis glands and stroma and is excised from these organs that are involved.
I do not believe oophorectomy is a necessity for endometriosis surgery. If the surgeon removes the disease the ovaries can stay and we have done over 200 hysterectomies with endometriosis with ovarian preservation. We have seen only two of these patients come back for another procedure.
Rectal resection, if the endometriosis penetrates the rectum and rectal wall, is on occasion necessary. I use various agents to separate the operated upon organs during early healing, mainly Ringer's lactate, which is still the king of all anti-adhesion developments. I have no use for GnRH agonists. They have never been shown to destroy a single endometriosis gland.
I just wanted to get this out to give you an idea of the American Situation ten years ago when I wrote to the Italian parliament. Hopefully today we will find out if this has changed very much because we really have a great line up of speakers who will address many of the things I have talked about.
Thank you very much for your attention.