Our next speaker is a friend, true scientist, and surgeon from Brazil. He happens to be in the only department in the world who has endometriosis division in the OBGYN Department. Mauricio is well known with his bowel work and he has some groundbreaking publications. He is a new start in the international arena for his work. This is Mauricio Abrao.
Mauricio S. Abrao
Thank you very much, Tamer. It is a great honor and a great pleasure to be with you here. Okay, so thank you again and congratulation for this excellent organization and this excellent job in terms of the endometriosis foundation. So I will show you some spectacular aspects related mainly to our country to prove how we did in terms of the creativity to improve the diagnosis of endometriosis mainly because we know that even being minimally invasive method the laparoscopy, it is not easy to do it for many, many patients that have this kind of disease. So, the first thing that I would like to show you is that things changed a lot in terms of the study of endometriosis, since description in '89 and '90s of the deeply infiltrating endometriosis that we consider now the deep endometriosis. Deep endometriosis has lesions with more than 5 mm in terms of depth and it is related off to more intense pelvic and clinical complaints like pelvic pain and symptoms like this. When we analyze more than 700 cases of endometriosis in our division, we can see that 40% of our cases used to have deep endometriosis and one interesting data is that half of them may have the bowel compromised by endometriosis or 20% of all cases of endometriosis. And as everybody knows endometriosis depends on the laparoscopy for us to do the diagnosis of the disease and we try to study in the last 15 to 20 years the clinical data that should be considered for us to do the diagnosis of the disease, the laboratory criteria, and the emerging method for us not only to think about the disease but nowadays we know that it is very useful for us to decide what to do when we do a proper treatment for patients with endometriosis.
Talking about clinical data, we know that there are six main group of symptoms related to endometriosis many of them related to pain, like menorrhea, a cyclic pain, bowel symptoms, urinary symptoms, and dyspareunia and also we need to consider infertility as another group of symptoms that need to be considered when we talk about endometriosis. When we look for the patients with deep endometriosis, we can see in our experience that the pain is much more frequent and also the asymptomatic patients are less common in terms when the deep endometriosis occurs in this group of patients.
Looking for some markers that can be related to the disease, we studied some years ago, the possibility to use markers like CA-125 and other markers CA-99 and other possible markers and the conclusion of these studies was that the main marker even today, still to date this is the main marker for us to analyze to use for the disease is that CA-125 and it must be measured on the first, second, or the third day of menstrual cycle but the problem is that there is a low accuracy in terms of the early stages of the disease and when we find levels of CA-125 higher than 100 unit is per ml, we think about the possibility of the patient may have advanced stages of endometriosis and then we try to look for the imaging methods to diagnose endometriosis for this purpose. So, we started with the transrectal ultrasound that is also called rectal endoscopic ultrasound and we published some studies showing that it is a feasible method but with a great problem, because it is much more expensive method. It depends on sedation and it is impossible to do it in terms of public health mainly because if more than 10-15% of women have endometriosis, it is not possible to do it for this group of patients, trying to find endometriosis and mainly deep endometriosis. So, we came back to the regular exams and we started to study the transvaginal ultrasound and MRI for this purpose. And cases like this one, when we used the laparoscopy and we see that only the tip of the iceberg, we tried to show that it is possible to use the combination between the clinical exam and the transvaginal ultrasound for this purpose for us to think about the disease and to use this information to decide how to treat properly the patient with endometriosis.
MRI also can be a good method for this purpose. As you can see here, it is possible to see a image of endometriosis compromising the rectum or other types of deep endometriosis, but the problem is that nowadays the MRI is not as precise as the ultrasound to indicate which layer of the bowel is compromising by endometriosis because there is a confusion between the fibrotic tissue and the normal layers of the rectum in this situation, but it is possible to think about deep endometriosis compromising the bladder, the rectum, the sigmoid, and other sides of endometriosis. The ureter as you can see here, so it is feasible to use this method.
So, we compared this method in this publication, showing that their sensitivity and specificity of the transvaginal ultrasound for us to see the rectal lesions is higher, is a good accuracy in terms, in general aspects. As you can see here we found 98% of sensitivity with transvaginal ultrasound and 83% with MRI and also for the other sides of disease like retrocervical lesion, we can use also this methods for this purpose.
With this information our presurgical workup is to use a good clinical exam perhaps a marker during the menstrual cycle, the first, second or third day and then the transvaginal ultrasound for this purpose. If this exam is normal, we think that this patient doesn’t have endometriosis, or has a disease in the early stages and obviously the treatment can be more conservative or the strategy maybe not as invasive as if we find deep endometriosis compromising direct on the ligaments and so on. And if we have doubt in terms of the ovary, we indicate MRI; doubt in terms of the rectovaginal septum or deep endometriosis, in these cases we indicate transrectal ultrasound; and doubts about the urinary tract, we indicate urography or MRI and the purpose is to look for the disease and to try to remove the endometriosis nodules and not only to treat the tip of the iceberg, trying to do a one shot surgery, trying to solve the problem of the patient without doing a lot of surgeries when we do not treat properly this kind of endometriosis.
And the other thing that we think that it is very, very important nowadays is to define what to do if we have deep endometriosis compromising the bowel and we think nowadays that if we know the deep layers of the rectum is compromised by endometriosis and the distance between the lesion and the anal verge and also if there is one or more lesions we can define properly if we do a bowel resection, if you do non-resection or even if we only develop clinical treatment to observe the symptoms and the development of the disease. For this reason, we describe it that it is possible to analyze the layers of the rectum with this exam. It is important to tell you that this transvaginal ultrasound is done for very well-trained specialists and with a simple bowel preparation with an enema one hour before of the exam to remove the gas and to allow this exam to show the layers and the deep endometriosis and we can look properly for the lesion, you can see the lesion direct in here, and the lesion compromising the muscularis of the rectum and the big lesion and even the circumference of the rectum compromising by endometriosis for this purpose and also both methods MRI or transvaginal ultrasound can allow us to know the distance between the lesion and the anal verge and of course to the lower lesions, the risk of the treatment is higher in comparison to the lesions that are higher in term of distance to the anal verge, so it is possible to use this information to treat properly this kind of patients.
And we also showed that when lesions compromise the rectum deeper than the inner muscularis, the circumference of the bowel compromises, it used to be more than 40% and of course with this information we can plan the treatment removing or not the segment of the bowel or only the nodule as you can see here with this information about the main circumference when the outer layer is the deepest layer compromised are the inner muscularis or the submucosa or the mucosa analyzed at the circumference of the rectum in the situation. And using this information we recently published this study showing that it is possible to look for the layer, to analyze the deepest layer of the rectum with regular method with transvaginal ultrasound with bowel preparation, and this study showed that we have a good accuracy predicting the depth of the lesion and of course predicting that the circumference of the layer compromised by endometriosis.
So nowadays we decide when to perform bowel resection in terms of the analysis of the deepest layer and of course if the lesion is multifocal or unifocal deciding for disc resection or even a segmental resection, if we have a deeper lesion or a multifocal lesion for this purpose. So there are many questions that can be answered before the surgery for us to define the surgical strategy, one them the real symptoms of the patient maybe because we only indicate the advanced surgery, if the patient has pain and the infertility that is not the conclusion and till to-date if it is better to remove lesion compromising the bowel for example for patient without pain, but we think that the pain is the main criteria for us to decide about this and which surgery should be indicated if bowel or segmental resection, it depends on the size of the lesion, the multifocality, the depth and also about the clinical treatment. If we can indicate clinical treatment and we think nowadays that sometimes if we decide to not do the surgery for many reasons, if the patient does not have symptoms or even if the patient does not want to be submitted to surgery we think that we can use some clinical treatment only to follow the patient with imaging methods and perhaps decide if the symptom appear if we will do or not the procedure and sometimes we indicate after the surgery, the clinical treatment mainly using oral contraceptives or for example, intrauterine devices with progestogens and before IVF we think that it is a good indication two months before IVF, after the surgery to use for example GnRH Analogs for this purpose.
So, to define this strategy, it is absolutely necessary for us to know the clinical information to use good imaging method and for us this is the best one nowadays the transvaginal ultrasound with bowel preparation, for us to define the multidisciplinary team and bowel preparation for the surgery and looking for a one-shot surgery and allowing us to have a global approach to treat the patient with other specialists looking for the pain and other symptoms for this purpose.
So, this is a summary of our work in terms of the diagnosis and the treatment and I would like again to thank you very much Tamer for this invitation. Thank you.