Endofound Medical Conference 2017
"Breast, Ovary and Endometriosis"
October 28, 2017 - Lotte New York Palace Hotel
Endometriosis: hormonal or surgical? My reality!
Harry Reich, MD, FACOG, FACS
Thank you very much for that introduction and I've a lot to say. This is quite a meeting, very ingenious topic, which I'm used to from Tamer; but let's see if I'll go.
Yeah, there. Yeah, I think I have it. Yeah, that's good. Go back.
I remember starting out in 1976 and my first cancer case was a patient who swore that she had a hysterectomy by a dot or line technique or whatever it was. It was an awful case and final pathology, they found that she probably did have a hysterectomy.
This was a big tumor from endometriosis of the vagina, so that's back in 1976, so that's going back a long time ago. During my residency, we did breast cancer in Boston at Boston Hospital for Women. It was part of our curriculum and the doctor who was right ahead of me had no interest in it.
I got my full of breast cancer surgery of all sorts. When I started private practice, general surgeons were doing the breast cancer.
They said, "No, no. Gynecologists can't do that." But there's no surgeon, at that time, in my small area in Northeastern Pennsylvania. There was no surgeon who was doing augmentation mammoplasties, so that was my form of breast surgery I did until we got a plastic surgeon around 1980.
A plastic surgeon came to town, that was the end of that; but, anyway, I'm fortunate. I started my residency program. My co-resident was Bob Kurman, who is the man behind finding out that most of the ovarian cancer comes from the fallopian tube.
I'm not gonna get into that much detail. Tamir has me here mainly to talk about endometriosis, so that's what I'll do with further ado, mainly, about endometriosis and, again, I have to give credit to Tamir, that's Tamir and my family at a meeting.
As you could see, Tamir's been around a long time.
If any of you recognize the guy who's there with him, that's Kurt Semm. He's considered the father of laparoscopy and that's Tamir back in, this has to be, early '90s. He's really into this stuff very early on.
Now, my topic is very interesting today, hormonal or surgical?
It's really a bad topic for me because I don't believe in hormonal at all, pretty much, because it never works.
I know of no single case that worked, so there we go; but, again, as you see later on in the title it says, "My reality" and that's my reality. What did reality ever do for me?
As Woody Allen said, he said it never did anything for him, not bad living in an unreal world, especially as we're finding out in the last year or so in our country. What did reality ever do for me? I am entitled to my own facts and my own beliefs and, as you could see, I state it fair and square.
I do not believe that retrograde menstruation is a cause of endometriosis. I never have, I'll get into what I do believe in a few minutes; but it doesn't make sense. Most possible retrograde endometriosis, you could take a good suction irrigator without the little holes at the distal tip and just move it, scrape it away, that goes away, that's not endometriosis.
Endometriosis is always, always, always surrounded by fibrosis. It's a chronic inflammatory reaction, so there's always some white fibrosis somewhere if it's causing any symptoms in the patient.
If it's not, forget about it. It will go away or the body will take care of it on it's own, so, anyway, continuing, as you could see, as we get older, we develop a specific philosophy in life.
A very simple graph, I think everybody will take that home for them; but, in the United States, bottom line is that we are now ruled by people who are completely alienated, not just by the scientific community, but from scientific idea completely.
We're living with it, we're a year into it, we're living with it. In the United States, the high-quality endometriosis surgery is dwindling.
I think this is very unfortunate. We presented this to ACOG. Tamir and I and another doctor or two, we went down to ACOG Building in Washington, DC. It's a beautiful building. Everything's perfect in there, everything. You could see a lot of money's been put into this building.
It's in the same block as the Oriental Hotel, it's like nothing's out of place in the building. We sat there and we had a meeting with these people there and, at the meeting, I don't think they were listening to us very much at all; but, at the end, I said, "Why are we here?"
A little lady in the end of the aisle said, "Because one of the consumers, celebrity consumer, had called and complained about no interest in endometriosis in the United States." There we were. What did we get out of the meeting? Nothing. In the United States, high-quality endometriosis surgery is dwindling with few recognized experts with bowel privileges.
Our ACOG has expressed little interest in surgery for this disease. We must learn to do better for our patients, we're here to help our patients. We have an organization in which I have my doubts about ever wanting to help patients with endometriosis. They do wanna help their doctors, as I'll get to in a few minutes.
They do wanna help big pharma, but, as far as endometriosis patients, forget it. We met with them. This was June 2016. I said, "Look at it. All we like is for you to explain to patients, to the people who are members of your organization, that they have to examine. If they're gonna do a pelvic pain exam without a rectal exam, it doesn't work because with a rectal exam, you can lift the cervix up and feel the hollow post here, part of the pelvis."
You can't feel that with a pelvic exam and, now, as we see all the time, they're trying to get us not even to do pelvic exams. It's just the computer and your medical record. What ridiculous ideas. Okay, but they seem more concerned about the income of their members who do many mediocre and probably worthless procedures for endometriosis than women who suffer for this condition.
This must stop. I would like it to stop, anyway; but, anyway, this disease has been around a long time.
We've known about it for a long time and, over a hundred years ago, Cullen reported that this is a most difficult problem that gynecologists face today. It's difficult surgery, it's harder than cancer surgery to do extensive endometriosis surgery. It's not like we didn't know about it, it just popped out of the blue.
Okay. Anyway, so I'm thinking what's this all about.
I'm trying to think, but then, all of a sudden, our president declares national emergency to combat opioid epidemic next week. Well, he said that a couple weeks ago. Well, I don't know. There's no money behind it; but, anyway, he's singling that. But what I found interesting is that the drugs are, did anybody see 60 Minutes last week?
The drugs are, the new drugs are, the United States was supposed to be our representative from Northeastern Pennsylvania, Tom Marino. He was instrumental in getting the DEA to let big pharma alone, so that they could pump out more and more and more opioid type prescriptions to places all over the United States.
Anyway, so Marino, that's our boy, chief advocate of the bill introduced to try to do this.
I got to thinking about this.
As you could see in the bottom, Marino reportedly received $100,000 from these committees.
I said, "Boy, they're putting a lot of money into trying to get their cause."
This is what big pharma does, as we know, so I started thinking about this with regard to endometriosis.
We have our enemies that we know about, we've always worried about our lawyers and our hospitals giving us privileges and OR time doing long cases.
Insurance company reimbursement's always been bad for endometriosis surgery. It's the same to do a 10-minute diagnostic laparoscopy in most parts of the United States as it is to do for our extensive endometriosis excision surgery, but the real bad guys you'd say are big pharma.
But also, our OB-GYNs just doing diagnostic laparoscopy, telling the patient that they solved the problem and then, usually, falling back on medical treatment, then doing a cashectomy a year or two later where they extract cash from the patient for another laparoscopy.
Who is behind all this? American College of OB-GYN. Our system is very different from other countries.
It's much worse. The reason is simple. Most nations focus on keeping people as healthy as possible. We don't, we concern ourselves and device systems to keep big pharma as healthy as possible.
They make a lot of profit and that governs the way we practice medicine. It's a shame, but our health insurers and drug manufacturers are very hard to deal with today.
Behind all of it, of course, is our American College of OB-GYN.
They have a serious conflict or interest because they wanna protect the fees generated from worthless operations by its members and to protect big pharma.
What about the women with endometriosis? Well, they'll probably continue to be ignored. I hate to say this, but this is the facts and we've been fighting this for 50 years.
Anyway, I'm gonna get onto my lecture now and endometriosis is a challenge. It's a challenge that we've been at for a long time.
I don't believe in retrograde menstruation as a cause, I never have. I am disease-orientated, I'm looking for, like I said, the white lesions of fibrosis to remove.
Endometriosis, then, is debulked, like Tamir said, sometimes, it has many specimens. My pathologist used to complain when I'd run the alphabet. He said there's 26 letters that we have to, now, sub-letter these different letters for the endometriosis lesions. I don't do that anymore.
When I went to Columbia, they would only let me take five specimens because that's all they got paid for. Anyway, when I started laparoscopy in 1976, there's nobody to learn from.
No books, journals. No teachers. There was harassment every step of the way. Anyway, continuing, going back in my training, I trained at Boston Hospital for Women with Dr. Robert Kistner, who was a very, very well-known endometriosis surgeon who saw 48 patients every afternoon.
He was on roller skates in his office, he had four offices and he had a nurse practitioner assigned to each one. He had the nurse practitioner doing the history and most of the physical. He would do rectal/vaginal exam on his patients, he'd see 48 patients between one and four every afternoon.
Impossible, but it happened. There were people like that in the old days, but his operation is operation that we learned, was diagnostic laparoscopy through Pfannenstiel's incision or Pfannenstiel incision laparotomy, that laparotomy did a uterine suspension. He did ovarian endometrioma, a beautiful surgery, on the ovaries, took out the endometrioma.
What about the cul-de-sac? He did nothing in the cul-de-sac. It was like it wasn't even there. They just did a presacral neurectomy on all the patients, so we did presacral. You say, "Where was Cullen from a hundred years ago?" Evidently, he was totally forgotten, so Kistner and then, Robert Franklin used to really push this whole concept.
I believe it wasn't until we, at laparoscopy, started attacking the cul-de-sac that we really got to be able to do some good work on endometriosis surgery.
Anyway, I like to emphasize, a video camera wasn't really invented until 1986. When I started in 1976, I did every operation with my eye and even when the videos came in fashion, we still used a beam splitter and a video.
We talked about hysterectomy or I did my own rectal work in urological work. We talked about rectal resection. I did them with my eye, the same with hysterectomy and other operations, until around 1990. I felt much more comfortable with a beam splitter, so everybody else in the OR could see what was going on; but I like to use my eye.
We used simple instruments, bipolar for hemostasis when needed.
I would cut and if it bled, then we would coagulate. I would not coagulate before it bled most of the time, so you didn't really need very expensive manipulators for inside the uterus because you could do just with a simple curette. You could elevate the uterus, but the most important innovation that I started back in the '70s was putting a probe in the rectum and a sponge behind the cervix for all of our endometriosis cases.
Sometimes, in the early days when you're working it out, the main part of the operation is to dissect or find the sponge, bisect that sponge is behind the cervix because a rectum, very frequently, will be stuck to the cervix overlying it. If you free the whole cervix, so, all of a sudden, it's mobile and usually you have a very happy patient.
The end of these operations, I put one to 2,000 CCs of Ringer's lactate in the peritoneal cavity, even for tubal ligations, I'd do it; but this lecture, I don't wanna get into the reasons. But there's many different reasons that make a lot of sense when I get into it. But my solution to pollution is dilution, so it works, so, like I mentioned, I didn't believe in retrograde.
I think endometriosis is present from birth, I do not believe it's acquired from menstrual fluid passing through the fallopian tube. It's much more probable that these tiny little cells are trying to make it to the inside of the uterus. The whole, it's amazing how you're formed; but these little cells that don't make it are scattered.
Usually, the most commonplace is in the rectum on the anterior rectum, sometimes, posterior vagina; but I certainly believe that's the way endometriosis forms. Again, I believe the most important instrument, much more important than all this MRIs or Cts, which I ordered, maybe in 30 years of practice, less than five; but the rectovaginal exam's the most important tool you have because you could feel.
You could feel and know where the patient hurts and you could excise that area when you do your surgeries. It's not brain science and, again, like I keep saying, if our myth in college would teach more and more surgeons how to do these operations, then it's possible.
Most of us aren't totally gifted surgeons, so we have seen one or two; but very few of us are. But we're just not being trained in the right way. Endometriosis treatment, medical treatment, like I said, never works. Hysterectomy by supracervical hysterectomy is public enemy number one because the endometriosis is left behind, so many people go in.
They see bad endometriosis, bad disease in the pelvis, instead of doing the right operation that's causing the pain and so, lop off the top of half of the uterus and call it a hysterectomy, make the same amount of money as if they took the whole operation out in a long time after excising the endometriosis to get to it.
Anyway, that's our life. Quickly, the concept of cure, I think that is important.
Well, if you can't cure the disease or almost cure the disease, a patient's gonna come back and have many, many recurrent operations, I would think; but if you can do a pretty good job, I believe it will not inevitably recur.
I think pessimistic perspectives have a devastating consequence on treatments for chronic pelvic pain.
I think if we teach people to excise the endometriosis, in my experience, isn't the only one. The French and the Italians have had the similar experiences where it's very rare to see a patient twice if you do a really good job the first time around. We did get published years ago for cul-de-sac obliteration dissection.
After many years of trying, we presented this and it got rejected for a five-year period of time before a journal finally picked it up. Our operation was first directed to complete dissection of the anterior rectum throughout its area of involvement until the loose areolar tissue of the rectovaginal septum was reached.
The endometriosis that we found, then, was always fibrotic and it was excised. I like to emphasize that, in our paper, we had 33% of patients who we second-looked and found no endometriosis at all and that was, again, before bowel resection. I think, today, this paper, I started working on this.
I started presenting it in 1987, I think if you looked at it today, results would me much, much higher with the advent of our much more aggressive additory to the bowel. This is a pet peeve of mine.
What I did is I excised deep fibrotic endometriosis. I did not excise deep infiltrating endometriosis and I think that came out right after my paper.
They started trying to call this deep infiltrating endometriosis. Well, it's not infiltrating. It is not cancer, it is endometriosis, so I do not like the idea of calling it DIE.
DIE is not DFE, which is excision of fibrotic endometriosis, which is what we do when we do surgery. Endo is not a malignancy.
Now, if I have time here, I'm gonna show a video and, first of all, this is an examination of the vagina.
You can see that there's endometriosis there, you'll see that at the top of the video. You see the cervix, so this lady has the whole posterior vagina is infiltrated with endometriosis, as is the cervix, as is the rectum. Then, we look in with a laparoscope and let's see what we see.
Will this play?
Let's see. It should play.
There you go.
Oh, there it is. Okay, there it goes. Now, let's take a look in with the laparoscope. Look at it. There's no evidence of retrograde menstruation here. The ovaries are normal, the tubes are normal. All of her disease, and it is extensive, this lady came to me when she's 18 years old.
She had extensive endometriosis, but she had a long history of pelvic pain and many mobile laparoscopies. The doctors in New Jersey were afraid to even go near it, so she gets to me, 18 years old. This is all important when I tell you the end result, but, somehow, her mother found me.
This was in 1990 or 1992 was the exact date of the case, so you see that my basic technique has not changed much.
I use a simple scissors. As Tamir will tell you, this is the best way to go most of the time. The first part is to free the rectum, even though it looks pretty normal. Usually, it's not this normal; but I wanna free the rectum from the posterior vagina.
I wanna keep freeing it all the way down, a lot further than this, because I know I have to get into the vagina because I have to remove the extensive portion of the vagina and reconstruct the vagina. Here is using the carbon dioxide laser, deep. You can see it's deep fibrosis, that's not soft little tissue.
I compounded on it with my section irrigator and it's fibrotic.
Let's see if I can. It doesn't seem to move. You could see the little line. Okay, little further on. Yeah, you could finally see the cervix. Oops, no. Go back. What happened there? Now, it's gone. Oh, here it is.
You went back.
Let's see if we can get in the middle. Okay, okay. At this point, we're in the vagina. You could see the endometriosis, the big chunk of endometriosis that we're removing. It's quite a large, almost felt, I called it a hotdog. It was like the hotdog effect with a rectovaginal exam because you felt this big mass of fibrosis and inflammation.
We're able to take that out and then, we go a little further and we'll take that piece out. Now, I can see the vagina. You could see the vaginal retractor that's inside the vagina and, now, I'll use the spoon electrode cutting current. We don't use any coagulation current ever at laparoscopy, we use low-voltage cutting current; but, instead of using a pointed electrode, I use a spoon.
I get good hemostasis, I could come across and remove down to normal vagina. I removed the major portion of the mass and I saw up the vagina and then, go to work on the rectum. Again, you could see inside the vagina. I see no more sign of any vaginal endometriosis, so we go to work on the rectum. You'll see the work on the rectum over the rectal probe after the vagina's closed.
This lady, like I said, was 18 years old. My son lives in New Jersey and when he moved in his new home, his neighbor came and asked him who he was. She said, "Your dad operated on me about 20 years ago." It was the same person and, at this point, she's 45 years old. She has three very good-looking children, boys. They're all around 14, 13, and 11, I think it was, and, anyway, so she's never seen a doctor since.
I said, "Don't ever, don't go back to any gynecologist especially because they'll wanna take another look in. You won't have any disease, you won't have any endometriosis anymore." Anyway, here's the rectum and I want you to see and tell me when I get in, when I enter the rectum.
If you look really closely on the video, you'll see as we remove the thick fibrotic lesion from inside the rectum. Our OR staff is very happy when I get into the rectum. They know the operation's almost over because they know what I'm going to do. I'm going to fix the hole very quickly and that's the end of the operation.
It's very easy to fix the hole in the rectum. Anybody who has never seen a rectal probe, that's what it looks like.
Yeah, okay. Tamir, had a late start. I did it in 30 minutes in Naples, Italy, that is; but, anyway, this whole video's 12 minutes unfortunately.
I'm just gonna first show you how I closed the rectum.
Now, look at the circular stapler. You see. Look really quickly. You see a circular stapler goes in, you could see where the bowel looks normal.
Notice how I pull the bowel together and that's all over a circular staple.
Okay, let me move quickly here.
I wanna show you this, but it's the endometrioma. But I'm gonna move on ahead and show you the evolution.
Oops, here. Okay, this was an extensive endo case where I excised deep into the cul-de-sac.
Later in that year, this is 1986. You could see I re-laparoscope there and that's what it looked like. Okay, everything back again, so then, I re-laparoscope. Well, I fix her up there and if you look, you'll see, on the rectum, there's endometriosis. It's gonna come back again anytime you do all that work and you leave that disease on the rectum.
It's gonna come back again. Here, I'm not gonna show you the whole video; but I will show you that this was extensive cul-de-sac disease to the top of the uterus. Here she is, a year later, still having pain and she had a rectal nodule, that's why she had the pain. The rectal nodule was the first time rectal endometriosis was ever removed by a gynecologist through the laparoscope.
This was 1986 and you could see we just used the laser.
We were able to get around the lesion and remove it.
Now, I show you this, too, because I ran into the patient three years ago in a sushi restaurant. She did say she's never had pain and never had another operation since and never seen a gynecologist since, so that's pretty good.
This is a circular stapler. I insert the circular stapler into the holes in the rectum, so I could put a suture through the hole or through the lesion, dunk the mass into the circular stapler and excise it.
It's pretty easy.
You could see here, lesion, after we uncover it and dissect the cul-de-sac.
I put the circular stapler in, I brang it altogether. The line that it makes is pretty need and it takes a good-sized specimen out. We checked the area underwater at the end of the operation. You could see the specimen. It was a big chunk of endometriosis from inside the rectum.
Here's the pathology of the rectal wall. You could see the lesion even went right through the rectal wall. Now, I was gonna show you how we checked the rectum; but time is limited.
I do wanna say that when I was at Columbia, we looked at the endometriosis cases for a 20-month period of time. There were no laparotomies were done to excise endometriosis. All the endometriosis that was excised in the cul-de-sac was by a laparoscopy. It was by a single surgeon and one of the staff members who's there helped, too.
The future, let's face it, the bowel is, I didn't get a chance to really get into the bowel stuff; but we recently went to, of course, with Mario Malzoni in Naples, Italy.
The guy, when he wrote this paper, which I helped him with, he had done 240 bowel resections for endometriosis.
At the meeting, in three days, there were about seven or eight bowel resections. It's very common in that center with extensive disease here, very extensive disease, with a bowel, the bladder lesion, and the ureter.
It's very common for them to excise it all, so what are the future perspectives for endo?
Future's very difficult to predict. Now, we know that excision works best. Will rectal resection become part of the treatment? We're awaiting the answers. Rectal resection, I still, with all the failures you here about, believe that that may be our future and that endometriosis, although a complex disease, is a gynecological condition.
We have it. Let's not let it escape. Finally, last two words, thank you, ACOG. These are our endometriosis enemies, so I say, "Thank you, ACOG. Please disclose the contributions you receive from big pharma." I regret every cent of dues that I contribute, I do review for your journals.
I reviewed in the last, I haven't read the journal, I don't get the journal because if you retire, which I did 15 years ago, you're off the journal receiving list; but, every year, I get papers to review, not a single paper that I reviewed has been accepted.
I say, "Why send?" I'm just telling them, "Don't send me any more papers. You're not accepting them, even the good ones." It's a bit of ridiculous mess. I do believe that endometriosis surgeons, not all gynecologists, all OB-GYNs who deliver babies and do diagnostic, mediocre laparoscopy stay.
Stay, but I do believe endometriosis surgeons should resign in mass from this organization. The organization has increasingly been handed over to business interest at the expense of the common good of women. I do believe it's a totally worthless organization for the endometriosis surgeon.
I thank you.