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Endometriosis Treatment: When Surgery Works & When it Does Not! - Ted Lee, MD

Endometriosis Treatment: When Surgery Works & When it Does Not! - Ted Lee, MD
Tamer Seckin, MD (00:09):

Dr. Ted Lee, who is a renowned surgeon, an endometriosis specialist among our field. He needs no further introduction, but for you, he's a new face in New York. He's the director of innovation and minimally invasive surgery at New York University and YI feel very privileged to have a friend in New York who understands our language and he will be helping so many New Yorkers. He was the president of a GL at a young age. He proved his skills and gift and end surgery is a very special surgery. If you don't have special manual dexterity, you cannot move forward. It's like a fighter pilot situation. So Dr. Lee is one of those fantastic surgeons that I know and I respect very much. It's a great pleasure. I'm honored to invite them to the podium. Thank you.

Ted Lee, MD (01:18):

Thank you Dr. Sashka. And it's an honor and privilege to have this opportunity to present to the patient about this topic. Most of my talks usually are directly to other surgeons, so this is one of those rare opportunities I have been able to talk directly to the patients. So Dr Session gave me a very good topic and it's something that's in my wheelhouse and material treatment, when surgery works and when it does not. And I think this is something that everybody talk to me about, discuss with the patients, discuss it with other surgeons. And here I think I try to break it down to make it very simple and straightforward. Very common sensical.

So when come to endometriosis surgery, if you look on the right side when surgery works, so in order for surgery to work that whole thing on the right side has worked. You need to have the right diagnosis, the right surgery, the right surgeon at the right time, okay? And it's very, very easy for that to go wrong. So on the left side, when it does not is you can have wrong diagnosis, you can have the wrong surgery, the wrong surgeon at the wrong time. Any of those can happen, one of those can happen. Then you're not going to have good outcome. So it's actually quite difficult to have everything aligned, the right diagnosis, the right surgery, the right surgery at the right time. Everything has to align.

In terms of diagnosis and I, many of this has been addressed earlier is a lot of times we go back to the basic, a good history and a good exam. The history, obviously they're very, very common. The three Ds, the dysmenorrhea, dyspareunia, dys, geia and so on. Any kind of GI or GU symptoms associated with periods. Lateralized pain, left sided pain, right Sided pain during periods are very, very common. Symptoms that patient may have. It doesn't take very long to get those history and most people nowadays kind of forget about the exam. Most people just forget how to do the pelvic exams. So when I do my exam for the patients with pelvic pain, I do what I call very compartmentalized exam, very systematic. I palpate anterior vaginal wall where bladder sits on top of that in the patient with indu cystitis. When you palpate anterior vaginal wall, they go through the roof.

I palpate the elevated muscles and up sure the muscles, some patient who have the anti muscle spasms, myofascial pain in that area, I can list that and I do rectal vaginal exam on every patient's pelvic pain. A lot of times patient really appreciated that I'm the first person to reproduce their pain because I validated experience that nobody ever be able to find that pain for me. And I was able to reproduce that. The word classical visceral reaction I come up with that term is that when you touch different parts of the pelvis, everything seems fine and then you touch that area where endometriosis is, their reactions is instantaneous. You cannot fake it. They don't even stay. It hurts. They just react with their facial expression with a song or something and then sometime they end up in cold sweats. Lots of classic visceral reactions. If I have patient with that exam with a classic visceral reactions, I feel super confident that surgery is like to help our patients.

A lot of people use imaging nowadays to help them diagnose endometriosis imaging. As DR was earlier mentioned, that imaging you can miss a lot of stage one and stage two disease is completely missed. So what is obvious on imaging, the ovarian cyst, endometrioma and fibroid, it just may not even be the reason for your pain. A lot of patients who go to fibroid center fibroid is very easy to diagnose, but that's frequently not the reason for their pain. Fibroid rarely cause severe pain. A lot of times in emergency room patient go in the emergency room and they've been told the reason you have pain is ovarian cyst. It's ovarian system, not reason for your pain. You just have a normal al root cyst like atory cyst. That's normal. But the reason for your pain is not cyst. And when it comes to endometrial has been shown by others during this conference is that endometrioma is a sign of severe endometriosis.

By the time you have endometrial mod, that means you have stage four endometriosis. That means you have five times the risk of oblation of the culdesac, which means that your bowel is stuck to the back of the uterus stuck to your vagina. That's what endometrial means. And also endometriosis pretty much everywhere as Dr. S can already mentioned. So remove the cyst. Removing the endometrium by itself is not sufficient to help with the pain. So you have to remove all the osis, the pelvic sidewall in the rectal vaginal septum, the area behind the cervix, the vagina in patient with endometrium. Those areas are also affected as well. So if you've just removed the cyst and do nothing else, patient will still be in pain. And also keep in mind that endometrium, although it is a very common cause of pain, but now all pelvic pain is caused by endometriosis as well. So as an endometriosis surgeon, you must be very, very good at be able to triage patients appropriately. You must have knowledge of other pathologies and pathophysiologies of other conditions such as in the cystitis i, bowel syndrome, pelvic floor, muscle dysfunctions and so on.

But at the same time, I have patients come in to my office with all this diagnosis of IBSI bullshit in cystitis, PID, lator spasm, fibromyalgia, PID. It's unfortunately in a lot of emergency room, especially given to patients with African descent or Latino descent, when they come in with pelvic pain caused osis, they'll be given the diagnosis of PID. Even though have no fever, the high blood cell comes normal. So a lot of times in the effort to give patient a diagnosis, patient are given the wrong diagnosis. So at times endometriosis can be also coincidental and not a source of the patient's pain. For example, there are patients who have multiple prior C-sections and then she has pelvic pain and their gynecologist did a diagnostic laparoscopy. So there's couple of small blebs endometriosis and effect that her pain started after she had babies making less likely for endometriosis to be the cause of her pain. Just because of the endometriosis there doesn't always means that it's cause of the pain. It could be just coincidental. We also have to keep in mind sometimes patients do have pain coming from the uterus. If you have endo, myosis, endo myoma and you can also have osis at the same time, but removing the miosis lung, you may not have the relief you're looking for. So you have to do both. So this is very important to be aware of that possibility.

Now everything come from the right diagnosis, an early diagnosis, right? Surgery is based on right diagnosis, right diagnosis is the right surgery. And so if I find a patch of endometriosis, I excise that patient will do well, especially if that's the area where I touch, they jump off the roof and I have the classic visceral reaction. Everything matches every single lines. Lots of patients that I feel so confident that surgeon is going to help. And also at times if a right diagnosis, you can even avoid surgeries altogether. Surgery may not be the answer for every pelvic pain. So that's why it's very super important for the endometriosis surgeon to be well-versed in all different sources of pelvic pain.

The problem is sometimes wrong. Diagnosis is wrong surgery and potentially leads to even more surgeries. And there's a vicious cycle that keep on happening to patient over and over again. The patient may have 10 20 laparoscopy or whatever other surgeries that she had by the time they come see me, let see DR session. So the right surgeon, assuming that you have the right diagnosis and the right surgery is chosen, surgery may not work. If you don't have the right surgeon, it's so difficult to have good surgery, to have the surgery to help you because everything has to line up. And what is the right surgeon? The right surgeon is a person with a necessary skill to perform the surgery and able to em a team of competent surgeons in other disciplines. That's the right surgeon for you. But for the patients you are in the dark.

You have no idea who the right surgeon is because there's no test, there's no objective assessment of skills for endometriosis surgeons. Everybody can proclaim to be the endometriosis experts. The one that you pay lots of money to have surgery may or may not be the surgeon for you. The one with the big title is professor of big University Hospital may not be the right surgeon for you. That person may not be any good. Someone who write a textbook, you think that the person is going to be the person for you. They may not be the person for you. So that's why it's very, very important for us to have a more objective measure and that doesn't exist and we should have that.

So the lesson from the colorectal cancer, the colorectal surgeons. So there were multiple studies and this is why particularly it's very important. This study is particularly is very important. So basically they were looking and throughout the years the general surgeons are much much ahead of us when it comes to this type of studies. We actually had no study like this in gynecology, none endometriosis surgery, but in colorectal cancer, they decided to em like 60 plus experts from all over the world, from different countries who are experts in the field and they achieve consensus in terms of the elements of the techniques, the completeness, the different required steps of the surgery, and then put a scoring on that.

And then it subsequently do a validation studies where they were able to find the scoring on the video review. If we review the videos of the surgery being performed, the scoring correlate with the short-term and long-term outcome of those patients. So I think the ultimate goal for us is to be able to come up with something similar for endometriosis surgery, use some Delphi methods wherever we achieve a consensus. Okay? That's our goal is to have that, to have consensus on the techniques, the completeness of the surgery, the steps of the dissections for stage four endometriosis with obligation of cul-de-sac, as also as for modified radical hysterectomy for the same pathology. These are two the very, very common conditions, but very distinct conditions that require exceptional skill to achieve good result. So if we can come up with that, that's really the future for our field because right now everybody's in the dark. I'm in the dark, you're in the dark. You don't have the privilege of seeing the surgeons doing operation. I mean, obviously I see other people operate, so people I know what they can do. Other people see me do surgery, I do live surgery in different parts of the world. I do that, but not many times you'd be able to see your surgeon do surgery.

Having said that, it's super important to have early diagnosis, the right diagnosis at the right surgery, at the right time. When your diagnosis delay, when your surgeries delay, that leads to centralized pain. And centralized pain is a condition where even if the disease remove your head, your mind still remember that pain. It doesn't go away completely. And then the later you do the surgery, the worst stage of disease, who leads to more incomplete surgery, more difficult surgery. And after multiple failed surgery, you need centralized pain and all the dissection plan has been destroyed by the previous surgery. It makes surgery even more difficult at times. Patient will give up. Actually a lot of times patient may have 20 surgery. Actually a lot of those times, most of the surgery are what I call foreseeable surgeries. They didn't do much. Let's go in and burn a few spots and call that surgery.

By this time I examine the patients this. You have the classic visceral reactions. I know I can help the patients. Guess what they come to see and say, Dr. Lee, I have so many surgery, I want a hysterectomy. Now the patients deal in their twenties and thirties and in my mind I say, I think I can help you. It don't need to have hysterectomy. By that time, they're so fed up, they just want to be done. So a lot of times all this previous surgery can lead to bad decisions on the patient's part. So that's why it is actually incredibly difficult to be able to have the right diagnosis, the right surgery by the right surgeons at the right time. Thank you. And I'm here to answer many questions because I think I still have a little bit more time. Go ahead. You have mic for the audience.

Ted Lee, MD (16:10):

Thank you.

Member of the Audience (16:13):

Thank you so much for speaking, doctor. I had my incision surgery in 2021. I was diagnosed with late stage four, early stage five endometriosis. And although the symptoms are better, I do feel the endo growing back. When I use a super plus tampon, I bleed through it in half an hour. I still feel loss of symptoms. Even now, my current gyno prescribed me orisa, but even then I'm still getting my period every two weeks with heavy clotting. I'm still experiencing pain during sex pain while peeing. I'm just curious what next steps you recommend if you recommend another surgery going on, a blood diluter as my gyno recommended. I'm just at a loss right now as to what next steps to take. Thank you.

Ted Lee, MD (17:09):

Yeah, thank you for that question. Obviously, without taking your complete history and exam, it's difficult to determine what the next step would be. So a lot of things could go wrong. As you can see that it's not easy to have the right surgery, the right diagnosis, surgery, and the right surgeon at the right time. Especially for stage four endometriosis. For stage four endometriosis, it require the surgeon to have ability to do radical dissections. Not much different from doing a radical hysterectomy. Not saying the hysterectomy is in your case, but I'm just saying it require your surgeon to know the techniques. So the worse the disease, the more likely the disease is going to be left behind. Okay? That's why it's crucial. We don't want to be operating on the stage for endometriosis if we could. We like to, we'd like to work on peritoneal endometriosis like Dr. Sesh going to mentioned. So that's really the goal. And I think your goal right now is to find the right surgeon, which is obviously extremely difficult because there's no objective assessment that we currently have. But I think there's still hope, and I dunno where you live, but if you are happy to be in New York, I'm happy to assess you. So yeah,

Thank you.