Endometriosis Foundation of America
Endometriosis 2013 / The American Perspective
Fertility Conscious Endometriosis Surgery
- Tamer Seckin, MD
I have also added the surgeon's side of the story. There is a sub-field of medicine right now called The Translation of Medicine. Trust me, many of these presentations that you saw as a surgeon they are French to me too.
We get so specialized in our fields we do not know what the other guy is really doing. I get so excited when I see that little chromatin DNA material being sucked up and prepared for another world. Many of the times patients really do not know what surgeons do, what affects their results and what are the little things that they are into and how crazy they can get to achieve something. Having said that, there are really nice people in the crowd and I would like to acknowledge my colleague who also does similar work that I really respect, Ceana from Atlanta is here. He is an excision surgeon. And Dr. C.Y. Liu who is an incredible reparative reconstructive pelvis surgeon, and he pioneered as well this year and I would like to acknowledge them because we are going to talk about surgery.
Whatever it is everybody has their own...but there is 75 percent failure rate, in general, despite all the money, efforts and hopes. We believe in that 75 percent endometriosis plays a significant role and we know that because the disease starts very early and it is 70 percent to menarche. One type is probably a more dangerous form of endometriosis, it is endometrioma. It starts around 23 years of age when the first symptom pops up and those women really get inflicted with a bad outcome.
I think in many ways if we diagnose endometriosis early, if we treat them right, I think many of these patients will also be preventatively treated against infertility problems. It makes sense doesn't it? If we come up with tests with us diagnosing endometriosis patients early, we will also find the markers for possible fertility issues. And I think that is something to be explored. You see the endometriosis subject is so vast. It is slow motion it is a slow movie that really explains every theory in medicine in many aspects. It also tells cancer, tells fertility. I think it is an important subject. We know that it affects the quality of eggs, transportation, conception and pregnancy. Jane will talk about that.
In the last four years I had two statistics come out and in the last two years of that my wife, who is an MBA chemical engineer, if it is wrong it is all her fault, but this is my personal load of cases in the last four years; I have done over 400 cases and I have excised close to 3,500 specimens. Per case this is...at one case the most I excised was 34. That case took 11 hours. This is not an easy surgery. It is not that you are going inside and shooting the laser or burning things. Excision surgery means really going in and removing all the disease without leaving anything in there, any disease behind. I leave very naturally healing, tendency to heal, natural background, healthy background without any burn - that is the ideal.
This is a small animation of what we do. It is basically classic surgery, you cut but you make sure you remove all the disease. You saw how the peritoneum really gets relaxed and you can see underlying tissue, what it is, where the bowel is, ureter and everything. It really comes into play with many of the patients I see, 75 percent are repeat surgeries, and trust me many of them are not treated well. The quality of the surgery is bad, very, very bad. Taking a biopsy and getting off and doing a mess does not treat the patient. Again, 90 percent of my patients are pain patients. They come with recurrent pain and significant symptoms of debilitating life stories.
I decided to give you a couple of case stories. And these are cases that I looked at just recently. This patient just walked to my office last week. And I want to prove it. I was so excited, these are my messy notes. I saw this patient the first time when she was in an internet group from Philadelphia, 22 years old with stage 4 endometriosis. She was operated on by a gyn oncologist and there was significant leg pain to both sides. After the operation she has obviously constipation and painful bowel movements, this is really stage 4 endometriosis in patients. Really, these stages should not get mixed up in your mind because it is really irrelevant what fertility sees as stage 4 and what the gyn surgeon sees as stage 4 is, a little bit different from me. Maybe this patient is stage 5 because she has infiltrative disease causing neuropathy. The interesting thing with this patient is that we did both sidewalls and the appendix was involved, a total of 16 specimens, seven and a half hours, peripheral nerves or ganglia were involved. I really went deep on her because that was where the disease was. Everything was positive. She came about, I guess, five months later, 23 years old and positive pregnancy. She was crying in my office. I said, "Why cry, I thought you would be happy". She said, "Well, you know you never told me I could get pregnant". I said, "Okay, sorry, I'm sorry". She said, "But you know the reason is my gyn oncologist told me I would never get pregnant. I would have done a hysterectomy....you are twenty-five years old". So, a 22 year old with advanced endometriosis and the thing is she got pregnant, of course by accident. By accident, but also the disease had been removed. Not everybody with disease this advanced will get pregnant. I never thought she would. I did not think she would get pregnant to be honest with you. I told her what I did was this; I preserved the ovaries and tubes as much as I can. The ovaries were so destroyed that even the tissue I saved helped. It is very interesting, in even the most advanced endometriosis the tubes are taken, they are taken. Even the most advanced endometriosis with such deep endometriosis the tubes are taken. In my 201st case we removed...and we looked at the pathologies, which we were working on hoping my wife will knock you out. The least portion of the pelvis that was affected was the tube actually, a tube and an ovary, excluding the endometriomas. Most of the pathologies were in the pelvis, pelvic sidewall, rectum, everywhere. That is why the endometriosis symptoms are very elusive. It does involve every part of the pelvis and vagina all the way to the diaphragm.
This is a small animation - I did it for a patient to understand. Also for me, sometimes I need reminding. There are 400 periods. There are always 400, in some cases with endometriosis there are 400 episodes of retrograde reflux coming up. But not everybody gets endometriosis. This is something I animated - actually behind as you are going to see the peritoneum lesion but somehow I do not...what you see is with every period the accumulation of the inflammation stops above the mesothelial causing mesothelial damage. Stem cells below and above - it is very interesting. There is definitely some degree of stem cell action coming from and changing to vascularity. These two things are talking to each other, signaling each other and the body is kind of fooled with this foreign material. And it is like graph versus false reaction. It says, "Finally, hey you're mine, I'll save you". And exactly, he is like a little mouse there, this is early...catch out every time. That little thing survives and anchors. The body makes it, owns that gland and becomes part of that peritoneum. But that gland will work against the body, against the peritoneum, against every organ it is adjacent to.
This is the micro menses, it will pop up capillary and it is how your period, how you get photographs of it, and this is another version of it - you see it is bleeding on the side. I really get crazy for that - my residents know that. I do not know what they talk about behind my back but I am into photographs in the OR.
As you see this is the way I, obviously this is not the same patient, but I take many, many thousands of photographs. This micro bleeding, as you see it is more organized and is an inflammatory reaction for absorption of that bleeding. You see that yellow should be marking those white patches where there is fibrosis, micro fibrosis developed. But in the big picture this is the pelvic sidewall and you see that white, usually these lesions are missed, generally missed or mistreated with a laser or a burn. You cannot treat it you do not know how deep this is. It is just the tip of the iceberg. As you see the vascularity that lesion was like that and it has been covered on topic. It is covered like this and then it gets deeper and better. But this is my perception. It may be false but this is the way I have been seeing this movie. Thousands and thousands of times these pictures. In the end it comes like a little vesicular thing popping out from there.
For the sake of this presentation - I do not know how much time I have. [From audience, "Seven more minutes".] Oh really, okay time flies.
What you need to see here though, I look at these pelvises underwater, under blue water; you see those lesions are popping up. They are positives, CD10 positives stroma patients. Underwater you see things that you really do not see. You see things that vegetative lesions pop out from the peritoneum. You do not see this with positive pressure of the gaps. You put water, you put blue dye, look inside. You get rid of your yellow and red, then contrast. You get excited. How did... These lesions do not pop out from nothing. This is the preparation, tendering of that peritoneum. It is like sauce. In the end we can...five rows affects everything.
I guess I may just present this case, this could be it, but this is an interesting case. These are her words, "For the past ten years I have had excruciating pain with Stage IV endometriosis. By the age of 37, I was consulting with a fertility specialist, urologist, neurologist and gastroenterologist. Over the years endometriosis blocked my right ureter, resulting in right hydronephrosis. I have had over ten outpatient surgeries to have stents inserted..." Ten years she has stents due to this disease. "More recently, the endometriosis attached to my rectum, which caused frequent and painful bowel movements. A nerve was also affected, resulting in numbness... I have had four laparoscopies to address the endometriosis but the pain would recur after a few months. A hysterectomy was recommended" along with nephrectomy.
At this time the surgery, both sides you look at it, are not bad. You see a normal pelvis, you see the laser effect and the stent is there but, I just want to give you an image of laser, how laser works. Laser, beautiful instrument, evenly burns, ablates tissue but leaves an even surface, like makes you believe that everything is fine but you cannot control the depth of it, you do not know what is behind. You may misleadingly believe that you removed the lesion.
This is a great case to explain this because these are the lesions, by his own words the surgeon has dictated, "...superficial endometriosis over the right ureter was evaporated". There was a chocolate cyst here. Guess what, this is the chocolate cyst. I opened this area, chocolate cyst right there popping out, right next to the ureter. Opening up more, the ureter actually right there that is a graphics of how the ureter obstructed. It is a parametrial lesion and you will see later it is extended all the way to the obturators. Her pain is real. Her neuropathy is real. These are some shots from the case. Ureter and...parametrial removal on part of the discoid resection on her, part of her rectum was removed. This was a very long surgery. These are the obturator nodes and the vessels on the right, the ureter and bladder. This is the same movie on the.... This is exactly how it happened. This is the ureter, as you see all these constrictor rings around it, top is removed these are the obturator structures. I will be honest with you there was still endometriosis when I left the case but this patient has done so fabulous with the amount of procedure.
She has given birth. I received a letter from her and she called us when she was pregnant. In the end this patient got pregnant and she had a baby.
Do I have one more case? Okay, this is a simple case. Why you say? She is 41 years old and trying to get pregnant for three and a half years. She has painful periods, ovulation, painful sex, you name it. She is into Maya massage, I did not know what it was, I want to share with you. Anybody know about Maya massage? (Audience interruption)...sorry, you will have your turn. We typically look at their bladders, hysteroscopy check, every endometriosis surgeon starts with it. Then you look inside, you do not see anything, normal, more or less nothing. You put the blue water in, you look under you see abnormal peritoneum here and there, and you excise them. Look at this, you do not see anything much here. And when we are under the water you do not see anything either. I also put retroperitoneal blue dye in this. When I put the blue dye in the back whatever I do not see there, it is the same picture, the same lesions you see, look at the right side, look at how fibrotic it is. These are all CD10 positive. Stroma positive, no glands, complete stromas, like an artistic paint brush of the stromal tissue; evidence from the Department of Pathology, Lenox Hill Hospital, 12th floor.
This is how your tissue looks. To me this is fantastic. There are little burns you see that are micro bipolar backup, still some fibrosis. I have also biopsied these fibrotic areas. Some of them also still stain CD10. So there is depth to it. A month ago, 2/6/2013 she came to the office. She is pregnant, naturally, no IVF, nothing.
This will be my last item. This is another excision. Let me get to the next case. One more case, she also got pregnant. But I want to show you how it looks underwater. You see this? This is underwater. How the red and yellow are out of the picture how those lesions pop out. That is underwater.
This is another patient, PhD. I remember her because she so impressed me with her work. I remember her severe dyspareunia and dysmenorrhea, three IVFs. This is an animation of it and you can see how puckered the posterior side is bilateral endometrioma. You see how the posterior cervix releases itself (??) and these patients do exceptionally well symptomatically. This is the pocket of window between the ureter and uterosacral. You need to excise that, you cannot laser this, it will never be well. You are going to injure the patient. This is how it looks in the end, we suspend the ovaries and I...the suspension six hours later, three hours if I...the suspension. As long as that posterior peritoneum is somewhat sealed.
Let this be the last one. I just want to show you how the endometrioma - this is because it is endometrioma - this is the anti ovarian side, okay? Look at this video again, one more. On top the endometrioma - everybody knows every doctor treats endometriomas whether it is...good ones they peel it and obsessive ones like you, like myself, put the ovaries together. I never burn, I never apply to the entrance to the ovary. I finally put them to be constructed...I take the suspension off. But the trick in endometriosis surgery is this pelvic sidewall. It does chronic inflammation, distortion of the underlying tissue, pain and everything. As a pain person who promises patients to do their surgery I have an obligation to get to all those inflammatory tissues of retroperitoneum and I will leave that ureter intact and clean. These patients do exceptionally well. This patient was seen again November 2012 bilateral endometrioma, leakage, cleaning up. This is the inside of the endometrioma. This is the cyst we removed and she became pregnant in February 2013.
This is the end of my talk.