Peritoneal Endometriosis - Tamer Seckin, MD

Today I am going to talk about peritoneal endometriosis and I dare to talk about peritoneal endometriosis. I dare and I will be as transparent and as detailed. Please forgive me if you have questions, you'll ask.

The peritoneal endometriosis is an interesting topic for me because I practice in New York City and I see half of my practice is in a way that because truly peritoneal endometriosis is the enigmatic part of endometriosis that is undervalued in general by scientific writers and talking heads and experts. So what gives endometriosis enigma and bad reputation is this part. There's no blood test, there is no imaging. It's the patient that brings herself willing to be diagnosed. She wants to be vindicated, she wants to be validated. And in places like New York, I cannot tell a patient I can't look inside you and I will, and this brings me to present some data. I'm not going to talk about these things. Bilateral hydronephrosis, multiple pins at the sacroiliac joint and others on sciatic multiple pins. Again, I've seen these patients and I operate these patients. If you look at this, look at this. What is that on the right hand side corner. Anybody can tell what this is? Right hand corner. Do you see this mesh? How about no, it's not a mesh. It is not mesh, but it is not a cardiac stent. It's a stent in rectum.

Unbelievable, isn't it? We are going to talk about these a little bit. So I'm going to focus on peritoneal endometrial, not these. So

Yesterday I want to finish my IVC injury. Yesterday you saw this, right? So this is where we left. Everybody asked me, are you going to share what you guys really did? This is a catastrophic, very mortal situation. By the time you go in IVC here, it's going to take some time. You have to do open laparotomy and you can lose the patient. The good part is there's only good part here with the robot. Robotic arm immediately put the pressure and he stayed there. Literally stayed there until we decide what to do and she didn't bleed after this point. Luckily the cardiothoracic surgeons come, came vascular, everybody is in the room. Bloods are being asked this. We waited like 10 minutes, 15 minutes, 20 minutes and this hepatic surgeon said, I have a solution. And solution was this. This is a fibro and we are applying still.

The leak is blocked. This is the patient who came from John Hopkins. I can tell you that she came with pneumothorax. She had a surgery that you see the incision up there. What happened was IVC was infer was tented up and the surgeon got trapped with that and he didn't realize it wouldn't be that close. So this is fibrin sealant patch. Ever rest. It's like a cement. I carry this in my room all the time. Now it's in my room. So I think it's nice to know because nobody knew about it. Only hepatic surgeons knew this. This is new. So it's the off-label use never described IV injuries, but they did describe in heart surgery for penetration wounds and stuff. So I am mesmerized with moon obviously as dealing with a disease associated with menstruation. Full moon is important in the evolution of female brain and cycles.

So in other words, what we see is really, again, this is again full moon almost, but this is the eclipse that I went to Lake Champlain and we see one part of one of the moon. We never see the other side of the moon. To be honest with you. I never liked the song, the song The Dark Side of the Moon. I really didn't like the song. It's not, I'm a Beatles fan so I don't care about the, but there's a reason I didn't like most like I think poetically Dark Side of the Moon represents endometriosis. So we can move from that. So two cartoons from New York Times very favorite cartoonist, Luca Lubo. She did these things just for us. For the foundation you see a woman trapped within her uterus, that's the dark side of the moon and it's fertility situation, how the time passes and some woman never gets pregnant and suffers while the others enjoy their babies.

Peritoneal endometriosis initially was introduced again by whom? Samsung, the man is there and he quoted peritoneal endometriosis in this writing 63 times. He was so obsessed with peritoneal endometriosis. He saw the disease really started from that in his 19 40, 15 years later he said this or 18 years have elapsed since the essential feature of this theory was published. Ever since that time I have continued to be greatly interested in the image of all types. He knows all types, especially the peritoneal type, not only because it occurs more frequently than all others, it's cling the most important. But also it's pathogenesis is so tantalizingly alluring and elusive. It couldn't be put into better words like this and it took a hundred years really donate group really identified three types of endometriosis. Why did it take three somebody to write about after a hundred years? Because the truth is the endometrial is difficult disease.

In my practical experience, rectovaginal culdesac closure due to endometrial in the absence of endometrioma is very rare. I have rarely seen in the absence of peritoneal pathology just isolated. I have seen them maybe, but I cannot count more than time in my life. Alright? In the absence of peritoneal endometrioma, in the absence of peritoneal lesions are less than rare, but in infrequently seen it's very difficult to see also endometrioma without peritoneal. But we do see them more often. Let's accept this. So what happens is obviously the closure of cul-de-sac. The endometrioma is a very dangerous thing for, and we have to be very careful because it could be silent. The patient may be admitted through emergency room and we treat in New York, they treat them on bit antibiotics. So this is my experience. I want to share this as transparent as I can.

These are just pure peritoneal patients. Excluded are the hysterectomies, deep endometriosis, endometrioma, chest cases and everything. So over this is last 10 years, almost almost a thousand cases I excised everything went to pathology. Lenox, department of pathology. There is more than 13,000 specimens are taken out and with all my honesty, one third of the specimens less than one third are normal histology. I could explain that to you later the way I could explain, but most importantly half of them for the last 10 years I'm trying to do this and I had multiple people worked on my numbers. It's hard to get more or less always though the positivity of my retrieval positive gland and stroma around 50 to 60%. When I started doing this blue dye technique, I started to remove more specimens but more fibrosis than normal tissue also came up. And you know what?

I went after very small lesions and pathologists did not bother to exhaust the specimen. That's very important. So when there's already endo diagnosis was made, pathology just said normal. As long as there is endo moved on. In some cases I fought with them. Some cases I forgot. But more importantly, this is important. Zone three, zone three on each side was most frequently involved. This is not known in the literature. Nobody talks about zone three. This is ovarian fossa. We even divide this fos as cliff right under arm of the ovary and the periurethral and hypogastric reflection. But zone three is very prominent. Nobody writes about it. We think that it is more pathologists write that more common on ovary because they see that that's what they see. They don't see what, and we think it's more in cul-de-sac or uterosacral ligament. Deep endo is more frequent than uterosacral ligament.

So very important part is the fibrosis and inflammation portion of this. This is how it is. Zone three is in this graphic. You see prominently these two sites are more common and when you look at the distribution, more prevalence of fibrosis and inflammation with endo. Positive lesions are more on zone three and very prominently there and between left and right again more prominently it's says left Samsung was right. The retro greatness of the period has a point We see more on the right diaphragm and things like that. So I just want to share this by the record, we can discuss this later and when we are really correlating this with the patient's symptoms also, and we're going to correlate more with the age groups and things like that. So it's a big job because we have a huge data there. Early detection and proper management and timely intervention is the best prevention.

I wrote here. Ending endometriosis starts at the beginning. Not for this patient. She is 62 years old, admitted through emergency room. She's on estrogen replacement treatment plus bioidentical creams, pills, vaginal supervisory everywhere. She came through the emergent with a hemoperitoneum acute abdomen. And when you look at the peritoneum on the left on the right, you see this is a normal peritoneum. It looks everyone, no to me it didn't. So I look under blue dye underwater and then retroperitoneal push off the blue dye. This is what I get. This is very old picture. I'm sorry I could have gotten better shot. But the bottom line is if you remove that peritoneum, this is true of that patient and you slices with this technique pin technique, you see that endometrial is over there, right? This is exactly from that patient. I appreciate my pathologist doing this for me.

Gland and stroma. What you don't see is obviously with triple tri chrom staining, you see more inflammation vessels. Regular pathologist can't do this. I'm not a scientist, I'm not a, but I operate at this level. Pathology is important. There is nerves, there is blood vessels, muscles and nerves are trapped there. So it's important for me to present this because peritoneal endometriosis, these are the estrogen receptor situation and more mesothelium. The reason I presented that is peritoneal admitted is not superficial endometriosis, it is more than that. There is more to see. There's more going on. There's stem cell action due to inflammation there.

Peritoneum is more than a membrane. It is like our skin. It's the skin of internal organs. It covers from diaphragm all the way up and the patient's symptoms correlate that the patient comes with not just painful period, 90%, 80%, there's GI symptoms. Those GI symptoms are peritoneum related gi, they're not uterine contractions or cramps. So Grey's anatomy, this is true, they really labeled peritoneum as an organ. There are written, there are books about it, organ in health and disease because other professionals see how important it is in other diseases. What we see is endo belly has a lot to do with peritoneal involvement in patient symptomatology. It's not peral, peritoneum, mesenteric, peritoneum. It covers everything. So I like to put your attention to this and also the circulation of the peritoneal fluid is people say, well it is this because of the bowel movement, it's the heart pericardial beats, every 60 beats every minute pushes the perone from the left. It's all physics and the peritoneum is drained to media, to the meenal cavity through the right side. That's why we see diaphragm endometriosis, 99% even more on the right side.

So you have to think of peritoneum as I look at peritoneum as a computer screen with pixels and every lesion in my mind is microcircuit it to the upper centers and brain reads it as pain. Every lesion is a microcircuit. You cannot deny it because even a small lesion, think about a mosquito bite or a pimple, you can't even see it's deep, but it bothers us so much. Nobody sees only you feel it. Imagine a patient like this multiple 80 lesions, but nothing is showing up in the x-rays and the test peritoneum is shiny, transparent, smooth, incredible organ. I'm in love with peritoneum.

Well I mean this is not superficial endo, it's so thin diaphragm central tendon is so thin actually. And most of the pneumothorax happen in the just above the liver dome. These don't on the muscle side don't cause any hemoperitoneum. So this is true. I have done so many of these. I sent it to patal, I begged them and they did it. They looked under this debris. We see glands there and these glands are live like Samsung. Finally argued with Noac and everybody and these glands most likely gets trapped into certain things I'm going to be mentioning. Now this is angiogenesis is the sole part of peritoneal pathology. I think you may have different pictures and I like to take these pictures. It gets me going. And you see how wonderful that angiogenesis represented there. And look how disseminated it is. True. These are going to be deep lesions later. This girl is 15 years old. And it's not only that because of the pressure, we don't appreciate the physical property of these popular things. They do float and you can get them, I'll show it later. Look at this picture. I'm sure experience surgeon will see some endo here or may not. Do you see anything? You can make a comment. It's cervix. Is there bowel cul-de-sac right side. Look what happens. We put the blue dye.

There is endo right here. But look at the destruction of that beautiful peritoneum. It was multiple holes, multiple holes, that's inflammation. And when you give this to pathologists, they won't see the holes. Only I see the holes and pathologists may write normal. And even in these areas that holes stro positivity comes, that could be discussed later. So these potholes, I call them potholes because I think it's like the blood gets trapped in these holes and become the original seeding like we plant our pots or they are pores and in diaphragm it becomes holes. Look at these wonderful lesion and up there with blood there, look at the thickening of the peritoneum here I'm going to show these pictures fast. Again, it's the same thing. You don't see distinct pathology, but when you put the blue, you block the underlying red and yellow hues because it's absorbed by blueness and it gives you, and I registered, I'm a Chelsea fan, blue is the colors. Okay, we are going to move these pop out as small lesions like this and these bleeds later. Look how interest, what you see is you see here the blood and then look underneath that, there's another small lesion there. And it goes, look at the vascularization underneath it's being fed.

This site went to obvious oxidative stress, this that most likely there's a lot. You guys are talking about it. And the scientists know this. Any experienced surgeons know this,

I'm going to move fast. So these are more of these lesions and it says I love this picture. It's like little grape pieces popping out with different colors. I can't see this if I don't do the blue. Look at these, look at this little, again, this is a previously excise size and this is a recurrence actually in a case that we did. But if you look here on the side, the borders have deeper and more fibrotic component there and under ouai underwater, look how these projectile buds are moving. They're moving, but you can't appreciate it if you don't examine this underwater. This is interesting because this is again a repeat surgery on a patient on the right hand. I have removed this area completely. Alright, so then I excise this. This is a floating. As you see these projectile floating like you see here. You see how they are flickering again. So I biopsy this with very fine three millimeter forceps. And this is how that floating thing look like under microscope. You know what? There's no gland there. It's all stroma. This is it. It's all stroma. No gland. That's the piece over there.

No gland CD 10 confirms. Guess what? When it sticks to the peritoneum other part in the same lesion, the glands are there. Look at this. Somebody has to explain this. Okay? And we stain this. This is it again more. It's like a mushroom nuclear bomb. Look at this. I mean just want you to be with me. So in the end, this is peritoneal endo. It doesn't show anywhere. Look at this. How extensive the explanation. And these are again, and they bleed different patients, but I am grabbing the moment. So it's all about inflammation and fibrosis. I think going after inflammation and fibrosis is part of excision surgery. This is an excise area. Look how fibrosis extend downward. It is like dent rights, right? And there is significant surface tension when you remove it. Maybe it's the pressure, but there is surface tension when you excise without any cautery, anything central part of the lesion contracts and the periphery goes like that. And I kind of animated that in my simple mind. But look at this. You see this tenting very tight. You don't want it to your wife or any kids of you. God bless.

Anyways, thickening. Look how the peritoneum gets thickened left versus right. And this is underneath how these holes look under peritoneum. I'm looking under the lesions. This used to be like this beautiful, wonderful connective tissue. This connective tissue is the target of deeper endo. This connective tissue turns into it like egg white being cooked and it's replaced by fibrosis. Diffuse fibrosis. Fibrosis is different than an adhesion. Fibrosis happens underneath the peritoneum. I call it like that. I differentiate anyways, but the holes are active. Look at this. You give pressure. They're like, this is important. Maybe the patient feels according to some. Bruce Lessi explained this very well. He says these holes, he did it on different setting, but he says these holes really get the necrotizing blood and everything. It stimulates the nerves more. That's the cause of, but these probably these pores, holes, potholes, whatever you want to call it, is the same thing that causes dia fragmented holes. Most likely. I believe that it's the same thing, but central tendon is so, so thin actually it doesn't cause anything there, but it causes when you do blue, you can appreciate this. So it's all inflammation. This is culdesac. It's again fibrosis. As you see, you have to, I mean it's horizontal fiber. It's not dip, my apologies,

Sorry,

I'm going to go fast. This is important. Pair two fibers involved throughout lifecycle and it starts with cardinal symptoms for men. And then later, this is a timeline of symptoms. Then later when they're sexually active, the bowel, then bowel symptoms really gets more serious. What does the discomfort becomes? Diarrhea, constipation, dysesthesia, Nabil obviously anxiety with. And then chronic component of the pain, constant out of menses. Pain continues. Then infertility obviously patient goes many misdiagnoses, mistreatments in the middle and late diagnose what is important. We don't know what happens in telar when that period of two years when the estrogen pump starts from the ovary, the uterine size changes. Fundus grows at the expense of cervix maybe and the atrium gets formulated. We don't know that, but many patients, I talk to pediatric gynecologists, they do complain abdominal discomfort before, way before periods really starts. And we don't know other things.

What happens with birth neonatal vaginal bleeding. We know that that happens. And also during gas station, the end doctrine disruptors are there. And obviously familial pre disclosures. I mean I was fascinated when I started in this foundation with my twin sister. They were 41, but they both came with advanced endometriosis. After that they got pregnant, they were lawyers. They become my major speakers and everything. But the other girls are 19, 20 again. But these girls on the right could been diagnosed much earlier. And it is obviously, this is the timeline of other endometrium pops out when they're 25, 30 in general. I mean in my observ, this is my estimated things and bowel disease later comes more pronounced. Patients on the average bowel disease are older, but more importantly chest cases. We have close to 70 chest cases with on the average their ages 35, 34. Why?

Because endo is progressive in some patients. In some patients they're healed. In some patient it takes off like a Mac truck. Big horsepower that says endo is progressive. Many of these patients, when you look chest cases, 90% of 75% of the time, there's very advanced endometriosis inside. So unexplored space and endo is, I think we have to really look at these. Newborn period is hard to make, but sometimes I think we all know clinic. There's something called decid cast. I personally think there may be some involvement, something like that we don't know about. Uterine electrophysiology have hyper persis and other thing, rectal sigmoid, redundant colon. I've been seeing this. I've been seeing this curves like caves in the pelvis. Also, there are folds when you have redundant end dose gets squeezed there and sets up this infiltrative. Things we have quite a bit. We have at least five, six cases.

I learned this later. And the patients, nobody wants to operate on this, but some patients we did operate, and this is a pilot from Alaska. She's a good speaker. So the bottom line is, I'm almost done. The bottom line is excision surgery, you have to excise completely. When you commit for excision, you have to be prepared to fix your rectum. At times we don't know how deep it is and the sono grounds are not going to show that three to four millimeter depthness where you get into trouble. So you have to be able to fix your rectum ureter. And this is a little animation of which I show patients, but it's important with no energy. I prefer you cut this and it goes. So this is how it happens. I do this. Typically I use and I try to excise. The idea is not use any energy and cut it without energy.

So your borders are not cooked and you don't have retained. I just do it to see how I left that tissue behind. So I'll go and fix that too. My time is almost over, but I call this fally targeted excision instead of peritoneal stripping, which has no respect to patient's pathology. Indiscriminate stripping is not normal. We also do some uterine suspension, temporary sometimes in these cases. In some cases with very low A MH. I have pregnancies like this too. We bypass bring omentum into the ovary. So my last slide, almost what we observe is not nature itself, but nature exposed to our method of questioning. Be open-minded. This is Hanberg. She's a Nobel Prize winner, physicist. But for endometriosis, we can say what we observe in endo is not endo, but the endo exposed to our method of questioning. Thank you. Always find time for things that make you feel happy. This is my gems in my life. Lara and Perry. Thank you very much.