March 9: Tamer Seckin, MD - Symptoms of Many Systems Leading to Multiorgan Surgery
Endometriosis Foundation of America
Medical Conference 2019
From Biomarkers to Precision Surgery
March 8-9, 2019 - Lenox Hill Hospital, NYC
There's something about the original photograph that has this sort of energy or aura of the original person that I think is being transferred into the painting itself. We're always trying to understand someone else as a way of understanding ourselves. I think that even though these family photographs are not our own family photographs, there's still this sort of universal aspect.
Anthropologists and Michael Tosic talk about sacred objects being shocked back into being when they're being defaced. I think of a family photograph in that context where it is an object.
This is Daisy Patten speaking from Colorado. She's an incredible artist. Understood behind the story, there is an incredible meaning that I kind of attached to this meeting. It's about what she does. She basically collects the black and white photographs of yesteryears. People who have passed away and brings life to those photographs by coloring them, adding photographs, and putting a [inaudible 00:01:32] to patient faces.
I thought it was so close to the meeting of this with respect to what we make out of stem cells. Stem cells, the ultimate symbol of life that doesn't die. That genetically transfer through the sperm and the egg combination to the next generation. In other words, these patients never die. The sentiment and the overall keyword of this meeting is inflammation and inflammation is due to stem cell quarterbacking. Everything that's happening there. I thought these patterns work was so meaningful. She loaned those beautiful paintings just for this meeting. They're transferred from Colorado here. I appreciate her kindness and generosity.
Yesterday, as we were closing, it was about patients. I said, no one understands the patients except the patients themselves. We doctors, surgeons can only see what we see with them. Even among doctors, there's so many differences or opinion what is right, what is wrong. Between scientists and doctors and surgeons there are so many different opinions and how to deal with endometriosis patient. In that sense, this whole meeting is about developing a common language to advance the science and surgery of endometriosis for the betterment of lives for the patients and for the future generation.
So, the keyword, the magic word is inflammation and it's the stem cells. Yesterday, it was very exciting to see ideas clash and good things really come from ideas of clashing each other and disagreements. Disagreements are the best thing ever happened. If we agree on everything, there is no progress, right? We've got to start with the first light. Red wine is right. We can never show where the attachment, but red wine also says there is no need for detachment. How to approach this? It's about we cannot detach each other because the treatment is the main treatment. A gold treatment is excision. Whether this lesion pops out from here or whether it is implanted. I mean, I cannot show anything more than this as a surgeon because I don't have tissue diagnosis. That's why tissue diagnosis is important.
For us, this is a slide I used in open endoscopy format at Linda Griffith, event at MIT. Really, we doctors are in bed with the beast. Endometriosis is best defined as a disease of the beast, itself is a beast. It's very troublesome for the doctors, for the surgeons, for the patients. I'm sure it is understood very well. This is the way I see it when I look back, my history with endometriosis for more than 30 years. These slides that the angiogenesis becomes the main culprit of the event, which brings neurogenesis. Even with the simplest form of peritoneal implant, there is incredible pain, which we cannot correlate with the amount of disease physically we see inside.
These are forms of endo. Maybe I showed these yesterday, but in laparoscopy, the lesions are flattened because of the pressure. If you put water, blue water, the lesions, you can see vegetative lesion starts to fly. Like in this, you can see all these buddy buds flipping around. This is the earliest form I can detect. Believe it or not, as much as they say, endometriosis when you exercise and it never comes back and these lesions do bleed, they do bleed. I can show this like in this beautiful under blue water it is dripping. Is that vegetative lesion bleeding?
This is a patient that I operated five years prior. Paraplectic excision. You see the excision site. I'm not sure if it's clear, but you see these flattened lesions, there are lesions there. Alright. This is this exact excision area. I suspect there's something happening there. I get close, I put water, underwater. There are two types of things I'm seeing here. One is floating lesions like this look like a butterfly. Another lesion on top you're going to see flattened, smashed, part of the peritoneum now. I excise these separately and I begged my pathologist, please, please examine this for me.
This is the floating lesion. I have to put my glass and this is the floating lesion, which we see up there. Only Stroma, only stroma. This is the floating lesion up there and down here the same lesion under a microscope. Just pure stroma. These vascular beds stromal and no gland is seen here and CD 10. Okay.
How about the flattened vascular buds show the one that you saw smashed to the peritoneum has shown glands in it. Whether this means anything, it's up to you to decide and think. Whatever is happening in endometriosis is happening right here, I believe. Everything we should really look science, science-wise, whatever, all the things we heard yesterday. It was a great presenter. I think yesterday was the best start we ever had for the meeting. I was very excited and this is the area I think we should really also focus. When does the gland comes and why Stroma is so important. Stroma is the cement that really gets endometriosis. Why is it in some patients it goes all the way to an end-stage case where a pelvis gets frozen all the way to the bone.
You see how angiogenesis and it's fibrotic elements here. When you look at this picture, you can write 10,000 of pages on this page, on this one single inflammatory happening here. It's like when I was in high school, my chemistry teacher told me, this is a flame and my professor wrote 10,000 pages of a book about this one single flame. I think this inflammation also will be written more and more. I'm glad we are united under this team this weekend here. The peritoneum is a pristine, shiny, beautiful organ. I may say organ for us. It is a very thin vendor telium and basement membrane. It's like silk. What happens with endometriosis? This is what happens within endometriosis. You don't see any lesion here, but trust me there is in that little bit area. More importantly, there are peritoneal holes. These peritoneal holes really represent this secretive and occultness of endometriosis.
How it really gives symptoms of yesterday. Dr. Mark Passover explained beautifully even how these sympathetic, parasympathetic have leads to the sent brain where the pain is really recognized. All discomfort has nothing to do with a lot of things we know about. Secret retroperitoneal, parasympathetic and sympathetic nerves that are giving signals and side kicking other nerves. This is exactly what's happening. These holes make the interfering with the hemodynamics of the peritoneum and the way the patients feel bloated and everything. Whatever it is, the insult goes all the way to retroperitoneum directly inner waste the nerves. I put this a diluted methylene blue. We push it with pressure. It's a hydrodistention and you see how this peritoneum looks here. This is another one. Look, this is a pure inflammation. The same area, look at how it looks.
Let's go back. Let's go here. There are defects. There is thickening of the peritoneum. It becomes like leather in some cases and microvascular sprouting is there. Look at the thickening here. Look at the vessels spiraling underneath. On the right side with [inaudible 00:10:47] without burning. You see the borders, how it's not clean cut and underneath peritoneum when the hydro dystonic detaches from the underlying is this the shield tissue. There are holes you can see like this. A case like this. This is previously excised by another surgeon. I think he did a great job. You see excision surfaces. When it's very well controlled, microvascular bleeding is well controlled. Really, there is no adhesion.
In this case, even there is endometriosis. We removed like eight 10, 12, I do not remember. On the left side these fibrotic areas ... I have to put my glasses on. These are not my glasses. I borrowed. I forgot my glasses at home. My wife is bringing my glasses, but this is a loan. It's not exact. So, it's a rectovaginal area as endo and ovarian fossa on the right side. That whitened area has endo, but you can see this is the occult endo that you cannot really recognize. Even by laparoscopy, you have to excise everything that's abnormal. What brings us today is the symptoms of endometriosis that leads to moving to an organ. Thank you very much. My wife is here apparently. Thank you.
I really took this with the liberty of Doctor Masani presented his case. I said, this was a great way of presenting, so I changed the slide to this. I don't do this, but from now on I learned from him. I'll get his permission. I'll utilize this excel format. This is beautiful. I think we should really listen. The Patient will tell you everything. Just listen to patient patiently and write down everything with her own words. They use such pristine words to describe. Everyone, like every endometriosis, is different. Every patient describes that there endometriosis in different words. I'm astonished to hear and write them down.
The most important symptom is the symptom that's associated with the menorrhagia, with the menstruation. Many of these patients, maybe 80% even more, have significant bleeding. They bleed more than others. There's no doubt about it. It starts from the menage. You ask them, 80 to 90% their symptoms are very back to manage. They are associated with other organs. Most of them have the same way, have GI symptoms, whether it is bloatedness, whether it is gas, whether it's the right side, left constipation, painful bowel movements, diarrhea. They all tell the story. In the end, they'll tell you, my bowel wounds are pencil thin. They will tell you. They'll describe in different ways.
Bowels we cannot ignore. The bowel is the most neglected part of inpatient who claims, who have undergone even the most advanced show called endometriosis surgery. Most of the repeat surgeries are done for lesions that are missed in the bowel. We are joined by Doctor Horace Roman today. He came last night. Thank you. He's here in the front seat. He will be honoring us to present the beautiful work that he has championed over the years with his bowel battles. Okay. Alright.
The symptoms, the patient will tell you. You have to ask and we have to ask every symptom. Chest pain, whether it is the most magic word is whether it is associated with menstruation. There is more to chest pain. Obviously, these patients will go many chest surgery for this is and everything, but no one will ask whether it's associated with menstruation. Leg pain, anterior, posterior, growing pain, hip pain. These are specific questions we cannot ignore.
The treatment has to be adjusted accordingly. When we'll go into the procedure, we have to really look into every organ that patients pain could be associated with. We cannot let go because that's the sacred opportunity for us as surgeons. The patient has trusted us. She's undergone anesthesia. She has nothing but trusting our observation and final execution of what we have to do. I think we cannot forget their history during the case. I go with my partners, my memory, sometimes labs. We are three in the room. Make sure everything is in the room. Their x-ray's, MRI's and their histories.
Well, let me start with this case. A couple of cases I will present and I want to finish on time. Patient's mother approaches me. I don't know if she's here today, but yesterday. Are you going to present my daughter's case, she said. It was really on the last sheet of my presentation, but I thought we could start with that case because it is important. Mother is a doctor, a very famous doctor in Manhattan. She knows everyone in Manhattan, except me. Well, she's not from my hospital. That's understandable.
The bottom line is the patient is 29 years old, beautiful young lady. The first complaint is right, upper abdominal pain, bloating, history of dyspareunia symptoms, everything you can imagine. Her pain goes back to manage. She's been on birth control pill for almost on and off for many years. She had two previous laparoscopic surgeries. Ablation, one is excision. It did prove there was endometriosis.
Father's a brain surgeon who passed away from Astrocytomata at the age of 44. I may say a mother has a colectomy for ulcerative colitis and grandmother died of colon cancer. Well, to the bottom line is it was nothing but regular endometriosis. I was very happy. We removed. I'm not sure how many I removed, but probably around 24, 25 lesions. I excise everything and sent to the pathology. The pathologist hate me. They don't like me because I insist every specimen should be looked at separately. This is not rare what we found in this patient. This patient had borderline serous carcinoma, low grade.
Well, every year I have one or two out of more than 200 cases I perform. For this patient, it may be it's a coincidental good treatment, but it shows the value of excision. Excision leads to treatment, not only for pain and good results with pain but also coincidental other pathologies. We don't know what it means for this patient. I personally believe it is what it is. This is the correct diagnosis. It's been verified by multiple cancer pathologists. Maybe this is the prevention of further progress of this lesion to another thing. We do not know. We have nothing by optimistic, this is it for this patient and it should be devised accordingly.
This is some more pictures from this patient. She stopped her birth control pill three weeks ago. She was bleeding at the time. This is unfortunately, I believe that's retrograde bleeding, but I leave it to you. This is what the pathology showed. A noninvasive implant serves line, a borderline low grade. You see the cells here.
Let's go to another case. This is a patient and nurse, 23 years old. Had been on nonstop birth control pills. You know we use rectal probe like Harry uses and rectum is Val delineated, par erectile, peritoneal space, peritoneum, cool perirectal col de sac. We see multiple lesions, each lesion excised. The reason I show this to you is how aggressive peritoneal endo is. It's not only one, two lesions, it's all. We removed 62 lesions from this patient. Every one of them was endo. There's all format of endo was here with projectiles, vegetative lesions, everything you can imagine. I showed this probably yesterday. I show it's because there's this vegetation. I liked the way it floats around. It's good to show people so they understand better. There is a six to two lesions. I'm just verifying.
It's important for the patient also to see how many are. That validates their complaints of years of suffering because nobody believes that. When the number is each and each lesion proves that they have the disease, they are exonerated. They have a way of showing how and they kind of were right. Everybody was wrong.
This is another patient who we operated in the past. I removed many lesions. I thought I treated her. I removed her diaphragm lesions, but we were just leaving the case. In the end, we said, this patient is complaining so much. This diaphragm cannot be everything that explains her. We'll look at the other part of the dome. There was a huge lesion that this way. I mean, flattened like a cake there. As we did it, obviously we were in the thoracic cavity. I probably presented this case yesterday to a degree.
We approach these cases like a dual compartment. In this case, we were in the chest cavity. We sutured basically from below and the thoracic surgeon is there. Right now, with laparoscopy, you can go dual cavity and examine the other part too from the chest because many times there is like an R glass involvement of the pathology in these cases. You see that we go into the chest in this case. There are many cases that we've done like this.
This is another patient that came. These are all recent cases of last month. This patient came from a physician herself. Her husband is an orthopedic surgeon. She had multiple bowel surgeries. She has been on Lupron for 10 years. 10 years on and off, on and off. Recently, she had bowel obstruction in November. Her shot was given. When she came we did too many rectal and we thought we could avoid, but she had a high sigmoid lesion. She ended up in [inaudible 00:22:33] and hysterectomy.
I'm telling you this because we have to differentiate between treatment and management. The pills, the Lupron are fine. I mean, it's up to the physician who uses them, but they are not treatment. They do not get rid of the lesions who are fibrotically already settled there. I don't care what, who says what. This is the reality we face. I only believe what I see for my patient. I'm sure a lot of the surgeons would agree. These medications are not treatment. They are management. Stopping periods, stopping ovulation. Wonderful. Their pain that is associated with those symptoms will go away. However, no one knows and these cases are a testimony to that. The lesions maybe even progress to do the worst part, it may. I don't believe these patients diseases stay stagnant and stopped. I think that they progressed even on the birth control pills.
Another one. This is again, last three weeks case. She came from Florida. She had a hysterectomy. Her right kidney has a stent. We double stented. Neurologists are here. I see them in the background. This is the patient who had bilateral pinning of the sacral iliac joint, double pinning. Following that, she had four revisions of the same surgery. Back and forth they thought. They did not do a good job because the patient pain was continuing. This is the patient. Hysterectomy with the right-sided stent.
When you look at it, the rectum is pulled in. The urator is way up. She had bilateral oophorosalpingectomy and hysterectomy. The masses there is pinching all the way to the Coccyx, sacrospinous ligament and everything. We do ICG green with them, I'm not sure you guys use this in Europe, but it's been standard with us here because we use Stryker sets in the hospital. Stryker has a camera. It's really helpful. In one click, you see, you assure yourself and you move fast. This is where the urator was. Again, the rectum is separated there.
Oops. Oh. I'm sorry. I have to go forward.
As rectum separate, she got locked away. It lucky because she didn't have to have another bowel. This was just a nodule. In the end, we repair this. Her rectum was repaired, but what happens to the rest? You see the cyst is emptied. The ureters up here, how deep it is really going to her vagina, all the way down to the Endopelvic Fascia and all the levator anti components including Sciatica origins here. This is the cyst wall. This is the internal iliac artery. You see on the bottom, this is the ureter. You see the hydro ureter. We did internally, the arc artery ligation. Everyone eventually of these kinds of cases needs one as long as it's not bilateral, right?
As we control the valve, this is a preventive approach so you don't get into deep trouble, some bleeding, which I had just a few. The internal iliac arteries ligated. This is the cyst wall sitting right there. It's so difficult to strip this over the years. It has basically cemented if it is difficult to separate from the others. This is just with sharp scissor we can do this. I'm sure doctor Mark Passover will tell more about these cases. This is sacra spines ligament and its attachment to the sacrum. It's very difficult, but the way the tissues are running, some of them has to be nerves. I dare not to touch them. I'm glad I didn't. This patient is doing fine except for some of her pain is back. I will see her next week sometime.
Overall, I think I want to cut my presentation here because we have a great program today. Most importantly, we have conservative surgery. We have definitive surgery. Even conservative surgery is radical. If you're doing excision surgery, it is not a simple surgery because with excision you are going, you can dive into ureter, bladder and you will, for the most part. You have to have a team. You have to have all the equipment and the experience to repair it. So, it's about restoration, it's about reconstruction. There is stitching going on. You cannot get staples all the time. It is a single haul. You have to do your fine work.
Conservative surgery may be radical deep and everything. At the heart of the definitive surgery, there is hysterectomy, unfortunately. Somehow, the central power of where the nuclear power of pain does come from probably the uterus. So, when patients are done with their childbearing and when their pain is continuing especially associated with menorrhagia, there's Adenomyosis. I think central part hysterectomy should be given an option and it's unavoidable. As much as colectomy and ureter attachments, implants, multiple chest procedures are part of the all definitive treatment and not a single of them is the complete treatment. It should be complemented with the excision and removal of lesions.
Before I close, I want to thank you again for coming here. It's a beautiful sunny day. I want to thank our board members for supporting me. I want to thank some individuals who without their efforts this could have never happened. Is Sarper here? I want you to recognize Sarper. He is my computer guy who really did everything by himself. For many years he has been helping me. I want to thank Jeanne who personally is the heart of this whole activity. My junior associates, Laurie, and Dr. Goldstein are here. I want to thank Dennis and Channel for everything they did.