Karli Goldstein, DO - 10 years on lupron and 2 bowel resections later...
Endometriosis Foundation of America
Medical Conference 2019
From Biomarkers to Precision Surgery
March 8-9, 2019 - Lenox Hill Hospital, NYC
Thank you all for staying. I promise I'll be very quick. Dr. [inaudible 00:00:19] can actually introduced both of these cases in his morning, so I'm just going to expand a little bit and try not to be redundant. Just a second, let me ... Okay. 10 years of Lupron and two bower sections later. I'm actually going to present two cases both on hormone therapy for about 10 years. One with birth control pill and Depo-Provera, and another one with several rounds of Lupron and birth control pill and Aygestin.
The first case is a 45-year old female with a history of menarche age almost 16, who underwent emergency surgery at age 17 for an ex-lap with torsion, and what they said at the time was hemorrhagic cyst. However, it was likely endometrioma. She was started on birth control pills at the time and carried on them for years. At age 32 in 2005, she developed appendicitis and was diagnosed with endometriosis by the general surgeon at the time during laparoscopy. They did not do any excision at the time. They took out her appendix, offered her Lupron, and then tried continuous Nuva-ring for four years.
In 2009, a few years later, she had laparoscopic endometriosis ablation and was started on Lupron at the time and agreed to do it. She stopped it after developing a breast cyst a few years later. In 2016, age 42, she had an emergent small bowel obstruction and a resection of about 15 centimeters of small bowel, cecum, and ascending colon due to adhesions and structure. She was placed back on Lupron again, Aygestin, and took this for 18 months.
In 2018, age 45, she was one year off all of the medications. She had planned to go off of them at 44 due to her sister going through menopause at 44 and she felt that if she went off of everything because the symptoms side effects were lousy, maybe she would be okay since her sister went through menopause at 44. At, 45 one year after all of the medications wear off, she started having severe bowel symptoms, severe pain with her cycles, which were still there and irregular, but disabling.
In November, she started back on Lupron and Aygestin again, and in February, she saw us at age 45 and underwent laparoscopic deep excision surgery with a total hysterectomy, bilateral salpingectomy and preservation of both of her ovaries. We removed over 20 different endometriomas, and she required sigmoidectomy at the time, and we'll show you why. Hopefully this is going to come up. This is her pelvis when we went in, and again this is 10 years with aggressive Lupron and Aygestin, deep nodules, deeply infiltrating fibrosis, nodules. She had bilateral ureter nodules that were quite invasive.
Here's the sigmoid nodule that had an associated kink, which isn't portrayed well in this picture. Sorry about that, but I'll show you. And this is our friendly urology team places stands for us in cases like this, and we utilize ICG green throughout the case. This is an example of the left ureter nodule that's entrapment. You can see the chocolate cyst fluid on the side. This is after doing quite a bit of excision on the left side prior to the hysterectomy, and this is just more pictures. And you can see both sides really required extensive [inaudible 00:04:05] and pelvic sidewall dissection to free them of the nodules. This is the sigmoid after resection, and you can see that the nodule is full thickness, and I just have a very quick 13-second video about how deep this nodule is. This is Dr. [inaudible 00:04:31] incising outside of laparoscopy, a rare occurrence. Here we go.
Case two is a 34-year old who was on/off of birth control and Depo Provera for about 10 years. She had two prior ablation surgeries and presented to us after two failed IVF cycles, and a failed IUI. The IUI, she had five follicles actually, and failed the IUI. She also failed IVF. She had right sided ovulatory pain, leg pain, sharp intestinal pain before her bowel movements and rectal bleeding during her cycle for three months. MRI showed possible sigmoid intramural involvement. She underwent a colonoscopy preoperatively with colorectal, which was negative for through and through bowel involvement.
And in September, she had surgery with us for a deep excision of endometriosis. Her goal at this time was really fertility and the bowel. Those were her priorities. She had 42 out of 46 specimens positive, and on this laparoscopy we'd noticed several lesions on the diaphragm, and we actually decided [inaudible 00:05:43], as Dr. Oman mentioned earlier, we didn't want her to wake up with a chest tube when she was asymptomatic and had no real pulmonary complaints with her cycles. We left these guys in here, even though it was painful to do so. And this is her picture of the pelvis, and you can see the extensive dissemination of disease and remember 10 years of treatment, two ablation surgeries. The bladder is littered with lesions. The pelvis is littered with lesions.
And this is an anterior rectum nodule, which we were able to shave. The appendix was involved. Everything almost came back positive. This is just suturing of the rectum and the state we left it in at the end. She then returned to the office a few months later for her postop visits. Her pelvis was doing excellent. She had great bowel function. She no longer had any rectal pain, no pelvic pain. She was very happy. However, she now stated that she's noticing on her first two cycles postop that she has shortness of breath and chest pain, very intense on the right side and is noticing with each cycle difficulty climbing, even the stairs up for her apartment during her period.
This became progressive, and she was actually admitted through the ER in February with very intense chest pain and shortness of breath, and the studies preoperatively, chest CT, and imaging were negative. She didn't have any lung collapse or anything like this at the time of surgery. In conjunction with cardiothoracic surgery, who we reviewed all of our previous images with. She was consented and taken for a laparoscopic diaphragm resection with repair, and she was kept in-patient three days with a chest tube, which was [inaudible 00:07:33] postop day two.
Dr. [inaudible 00:07:36] can show images of earlier, and these are those starting lesions, which we took out at about 6:00 PM and thought we were doing great, and we were going to finish at a reasonable time and then this is the initial diaphragm. Then we realized after doing this further down, when you press the liver bed, there was about a four centimeter endometriomas at the Hemi diaphragm. And this is the excision. And then later repair with Ethibond, which was tied extra corporately. I shortened this to a minute, but I'll fast forward up. Well, I fast forward it all the way. Never mind. Thank you so much.