Medical Conference 2010 - Camran Nezhat MD

Medical Conference 2010 - Camran Nezhat MD

I would like first to thank Tamer for inviting me to be among you all. I would like to thank the distinguished audience and some of the speakers that I have known for many years. A good friend of mine used to say if you live long enough and be persistent enough, you can follow George Bernard Shaw who said there are people who follow the rules and adapt to society and there are people who are unreasonable, persist to change the rules and never adapt. If it was not for them the world would never change. I am happy to announce that perhaps we have been two of those unreasonable people and to some degree continue to be unreasonable.

I would like to share with you a couple of points because I have only 20 minutes, and Tamer, who has done a great job and good work to have a faculty of such magnificence for this program is really honorable. I wish there were more people present to hear such great speakers this morning. What I would like to share with you however, is a different story. I want to tell you how we really have to thank women with endometriosis. Because of them I am able to tell you why the world of surgery really has changed. A lot of this history you can see in my slide, please start my first slide, I have something to show you.

Can you start with the first slide for me? You can find this book on Google, it is for free. If you like it, it is on Google’s Books. Some of the presentation I have with my - usually my fellows put my talks together, so if there is anything wrong, it is because of them. I would like to tell you why you have to thank a patient with endometriosis for the revolution in surgery. It starts from the 18th century that the first successful laparotomy, open surgery, was reported. It was 100 years later that we went from the midline to Pfannenstiel transverse incision in the lower abdomen, a C-section incision for those of you who are not doctors. Around the same time it took about 100 years to prove that the complications of opening up the abdomen are more when you do it by vertical incision compared to when you do it with transverse incision. So, with the C-section, again for those of you who are not physicians, with the C-section incision the complications are significantly less than cutting in the middle. It took 100 years. Around the same time endoscopy started. Some people watched laparoscopic surgery and this is the technique that everybody was looking at through the scope. It does not take a genius to understand it is better to make a little hole in the wall here and put a scope or a roto-rooter in to look on the other side of the wall if you are looking for a piece of gold, rather than destroy the whole wall to go and get the gold out. This was exactly what was happening. For 100 years, 200 years we were doing major incisions in the abdomen of men and women to go after a little problem. We were breaking the whole door down to see a little bit of something behind the door. The laparoscopic idea was a good idea but it did not go further because it is very difficult for a surgeon to operate like this. A simple change. And this continued even until 1977 that they were publishing books. This doctor, Dr. George Bursey, is one of the pioneers and he is about 90 something years old. He enthusiastically promoted laparoscopic surgery and even developed videos to look but always looking through this. It was around this time when I was a resident intern that I became interested in endometriosis because I personally had friends who suffered, and being still the ultimate single bachelor, any girl that I dated for some reason ended up having endometriosis. So it felt like I had to do something about endometriosis. I still continue in this state. This video laparoscopy is how I started and of course, at the very beginning, everybody laughed. How could you operate like that? I borrowed this beer bottle, it looks almost like a beer bottle from another discipline, and I started some of my video laparoscopies that day. Practically that changed the whole world of surgery from one single man from a band of surgeons, or a musical band, of one person to an orchestra. When you operate like this everybody else could help you, everybody else could do it. Now this is interesting, when I sent the paper for publication, and I have it still from one of the famous Journal _____, it says you can kill the patient by advocating operating by the monitor. One out of 200 surgeons would be able to do that, and you should not do that.

It took me ten years but finally I was able to publish this paper. I had to change the name, and I called it The Laser Laparoscopy as Harry mentioned to you. It was in 1984 and 1985 that we published it in Infertility and Sterility in the Royal American Fertility Society and the Canadian Fertility Society, which was in 1984 in Canada. I presented it there. And, of course, it was published in 1985 in the journal that I referred to. And even at that time that this paper was published a year later, remember I had been doing this for about ten years, we kept going back and forth, and the editors of this journal had to come and some of them to really believe that you are able to treat stage IV endometriosis by laparoscopy. Nobody would believe it. It was not even possible to prove to people that you can do that much disease, and at that stage we even said that mild to extensive disease should be managed laparoscopically and that was in 1980. The paper was published in 1986. That is almost 26, 27 years ago. At that stage with the revolution, work started to a large degree with the works of people who were interested in endometriosis. So, we really owe women with endometriosis a lot because right after that we gradually proceeded not only in gynecology, but we treated endometriosis of the bowel, bladder, ureter, and even endometriosis of the bowel before the revolution of the cholecystectomy. We presented some papers in the American College of OB/GYN in 1989 for bowel resection. Of course this continued for bladder endometriosis and ureter endometriosis, so endometriosis of different disciplines working with urologists and working with general surgeons, and then patients with endometriosis somehow because endometriosis travels everywhere in the body. And somebody who is obsessed and unreasonable, who is interested to go after the disease, and we were always very persistent…I remember that I had to convince urologists and colorectal surgeons, one by one, to please let us do this, let us do that, and of course persistence would pay. They were able to transfer the endometriosis surgery from genital to urological, to colorectal surgeons, and this continued for different pathologies.

The history of endometriosis of the bowel is a very interesting story. I would tell you that because when we started doing laparoscopic treatment, endometriosis of the bowel, and bowel resection, the colorectal surgeons got very angry and they called it a barbaric procedure. How could you do this procedure like that? Some of you know that the problem became pretty ugly at one time. The issue was less the messenger than the message. To a large degree they wanted to kill the message and for that purpose they came after me, the messenger. For those of you who do not know what I am referring to, at one time I was accused of practically everything in the world from medical terrorism, stealing, killing and barbarism. The only thing that I was not accused of was cannibalism. It was interesting, all that because I said let us not cut people, let us do everything by laparoscope. That was all I said, nothing different, my message was very simple.  I was actually a reasonable citizen. I had done nothing bad. I thought I was a good person, I always paid my taxes, I worked very hard, I did not do anything, I did not gamble, and I always had one girlfriend. The problem is that nobody believed it, so much so that I was investigated by – and I am not exaggerating –the Justice Department, the Georgia Board, the California Board, the IRS Immigration Naturalization, and practically everything and all because I was saying do laparoscopic surgery and it is better for the patient. That is all.

There was nothing bad of course and this is not new. In the history of medicine this has been done before. There was a doctor, his name was Dr Semmelweiss.  He said that before surgery we should wash our hands, because if you do not wash your hands women die more when you deliver babies. And they were dying more. All he said was that but he was run out of Vienna and naturally he died in depression. Thank goodness I have a better history and a better outcome, so far.

So we followed the history of endometriosis of the diaphragm and that was when the chest people got involved, that was when I started working with thoracic surgeons. We did a coronary bypass in the chest and of course we had published this in 1992, even in animals. When I was at Stamford I worked, as Harry said, with other disciplines like thoracic surgeons, oncologists and radiologists. That was why they accused me of performing surgery in the brain, in the heart, wherever I am not supposed to. All I was doing was helping other surgeons to do some good and that is why the story ran that. And that is why patients with endometriosis are responsible for that revolution, because I was an experienced surgeon and endometriosis surgery is far more difficult than any cancer surgery because endometriosis creates severe fibrosis, like a stone. There are no planes for endometriosis. A good surgical endometriosis surgeon can practically do anything.

I am an Asperger’s person probably to a large degree, I just concentrate and zero in on surgery, I love to do surgery and that is my problem. I never get bored of it. I like to do it, I have been doing it for four to five days a week for the past 30 years, and I continue to do it because this is my religion. What I believe is that I can help society because I believe laparotomy really is unnecessary for women and men and children. If you are going to have a laparotomy it is you or your mother, or your sister, or your daughter or your uncle, so my mission is to contribute by decreasing the number of laparotomies and that is what I have been doing. And endometriosis has been part of it, and again you have published and presented this data. I am sorry, I have to say this, and I like Alan DeCherney very, very much, and Alan DeCherney was very kind, he wrote in one of our books, “Just like in Star Trek, Camran dared to go where no man went before.  By doing so he opened up the unimagined vistas to endoscopic surgeons all over the world”. I am very grateful that he has said that, and I say that there are some people like Alan DeCherney who see the future, but it is not always like that. For example, in the bible of our discipline, the American Journal of OB/GYN, it was actually Green Journal of Obstetrics and Gynecology when we started teaching these courses, I remember there was one in 1992 that actually made a joke of one of our teaching courses about operative laparoscopy. This continued when we published another paper that even cancer in gynecology could be done by laparoscopy with the benefit of minimal invasive surgery, and this paper took almost two to three years to get published. There was a paper published in the Green Journal a little bit later where they made a joke of our paper because they thought they do laparoscopic vaginal delivery. So that was what the atmosphere was like. But things changed. 

When did thing change?  When there was a paper published in the New England Journal of Medicine and they compared colon resection by laparoscopy versus laparotomy. For those of you who do not recognize bowel resection by laparoscope, especially large bowel, it is one of the most difficult procedures endoscopically.  If you can do that by laparoscopy, you can practically do anything laparoscopically. This is the same procedure that the colorectal surgeons, when we did it, called it barbaric, and they almost ran me out of town and put me in jail. The New England Journal of Medicine in 2004 published this paper and this paper showed that even colon resection, if you do it for cancer by laparoscope, benefits the patient and is beneficial for people. Thus, the editor of the New England Journal of Medicine in 2004 wrote that surgeons must progress beyond the traditional techniques of cutting and sewing, to a future in which minimal access to the abdominal cavity is only the beginning. So, what I will tell you is, “You ain’t seen nothing yet”.

The majority of our procedures in the U.S. and the rest of the world are done still by cutting open.  Almost all of them have to be converted to laparoscopic surgery for the benefit of the patients. The story is so good that even Dr. Picton, who I admire and whom I respect a lot more now, recently published, actually this issue this month, and retracted his two previous papers where he said laparoscopic surgeries were bad, and he admits that no, for the majority of the world, almost always laparoscopic surgery is good. If you persist, things can change.  All of you know, you are telling me so, if this is so good, why has it taken so long and why can we not do this by laparoscopy? In 1992, I think, Newsweek interviewed me and published an article at that time. I wrote that in 20 years laparotomy would be practically non-existent. Right now already it is 20 years and still the majority of procedures are done by laparotomy. So, why is that? By laparoscopic surgery there are small incisions, faster recovery, better results, less complication, less bleeding, and it is even cheaper, the only problems are the limiting factors of skill and experience of the surgeon, and availability of proper instrumentation. Not everybody is able and comfortable to operate laparoscopically and thus these are the limiting factors, skill and experience of the surgeon and the availability of proper instrumentation.  This is where progress exists, it is when we have to continue to advance and create instrumention which allows other surgeons to do minimally invasive laparoscopic surgery and perfect the procedures that way. Thus, less men, women, children suffer from laparotomy and its complications.

Obviously one of the other issues about endometriosis is that if you cannot see it, you cannot treat it. I have some good news for the patients with endometriosis; while this morning it was wonderful to see all the good and futuristic technology, at the present what we have in hand is the more we see the better we can treat the disease. If we see better we can do better. There are new technologies, even the definition of the high definition cameras and scopes are getting better, you can see endometriosis significantly better. The light sources, the cameras, the high definition and some of the 3Ds allow you even to detect the smallest spots of endometriosis that you could not see before by looking at it, and by instrumentation which allows less skilled surgeons to treat the disease properly, and you can probably get better results on infertility and pain patients.

I will show you these pictures because you can see the fibrotic tissue practically everywhere in the ureter, bowel, and bladder endometriosis. This could be done by the different methods. I can speak to you for hours, and I have many video presentations but I will choose to show you only one, the one that shows the chest, the heart, and the lungs. Could you help them find that presentation for me? So those of you who are here, I  always like to ask this as a joke, do you know which organ in the body endometriosis has not been found yet, anybody know that? Eye, okay. You do not say that, eye, anybody else? Spleen. Practically in everybody - how about the heart, anybody know if endometriosis has been reported in the heart? There is one case of endometriosis in the heart and the patient has died, and then for the rest of it, practically the only organ in the body where it is not reported is the spleen. I wanted to show you a video tape, why it is the chest and the lung, not the bladder. There is a lot of endometriosis, but look at this patient I operated on her less than a month ago, because of endometriosis. This is the liver, that is the diaphragm…and a young woman, and of course there are different products we can use. This is the diaphragm, so what would I like to show you…this is a plasma jet instrument I use, and right now this is what we are doing inside the diaphragm, inside her chest. This is the heart here, the diaphragm you can see, and all this is endometriosis, these are all endometriosis going a large degree, practically the whole right hemidiaphragm was involved with endometriosis. So, if we have only one hammer everything in the world would be a nail. We should not always say that is the only way. We have to give some leeway. You cannot, for example, go ahead and excise the whole, and take the diaphragm out. You have to take the whole diaphragm off and put in a new diaphragm, so you have to be innovative. I am requesting that we should look and eliminate commercialism in our approach to patients with endometriosis, to try to help people scientifically, to try to really do enough for people but not try to scare the patient for the benefit of advancing one thing and to say this is the only way today. There is not only one way of doing anything.  We have to have an open mind and do our best to have a mission. I will tell you something, if we really want to help our patients, do the right thing rather than only watch for our own interests.

I am very grateful that you invited me for this and thank you Tamer again. Thank you.

If you have some questions I will be happy to answer. Usually nobody wants to ask questions of me, I don’t know why.

We have time for two questions, anyone dare?

Yes you have a question? Not yet…somebody wants to, that is the first time.

Question:  This should not be seen as a disagreement with anything you said but I just wonder about your approach to third world countries right now where it is very difficult to support well functioning laparoscopic equipment.

Okay, when there is a marathon everybody runs. Do you follow me? Some people are at the very head of the game and some people are at the end. In third world countries they cut people don’t they, okay good. I was in a third world county a while back, of course now they are getting very, very ahead. China and India have gone ahead. Dr. Raja Saheed here has done a lot for India and I have been in China. I want to let you know they do better laparoscopies than here now. Do you know why? Because economically it is more useful for them, it is safer and is cheaper, and they do not have to keep their patients in the hospital. Actually, they are making significantly more progress in those countries than us. Do you know why we do not progress in the U.S.? A lot of women are still having laparotomies done because insurance companies pay more to cut people to do it endoscopically, that’s why.  Another question?

One more question over here. Can we make questions and answers really short please.

Question: Okay, when you do a laparoscopy do you believe in excision or laser, and if so do you use laser?

Unfortunately, this is what I was referring to. There are groups that are using the laser excision words as a promotion and marketing. It does not matter, you can excise very inadequately and very imperfectly, or you can laser a patient totally correctly, or inadequately. These are all instruments, somebody who does not know how to use a laser might knock it. If you want to go to somebody who uses laser, go to somebody who knows how to use laser properly. Let me tell you, with a CO2 laser and hydrodissection, you can treat endometriosis better than anything available, anything. But the problem is the surgeon should be very, very comfortable doing it, and you can excise a piece of it. I have a video for you where a surgeon wanted to excise and went right into the bladder. You have to excise or use the laser properly, you can use the CO2 laser and excise the whole endometrioses very, very carefully, so please do not fall for that. Go to a surgeon who knows what he is doing.

And on that note, thank you very much indeed. This was a fantastic lecture.