Endofound Medical Conference 2017
"Breast, Ovary and Endometriosis"
October 28, 2017 - Lotte New York Palace Hotel
Why is Endometriosis Foundation of America Doing this Conference?
Tamer Seckin, MD
Thank you. First, thank you all coming here, dear faculty and the participants. I think you may not realize, but in my opinion you're making the history, because this is the first time ever, a conference under this topic is going to be covered. We're going to investigate the sex hormones, and its role on endometriosis, more importantly breast and ovary. This is breast cancer awareness month, and I'm happy that our little cause in the radar of healthcare is reaching out to acknowledge for research alliance. Today, you're going to hear wonderful, brilliant speakers, who are scientists. They're not like me. I'm just a technician. Who are true scientists, who are going to look at the molecular, and all these things that we fail to understand, they are going to make us understand. At the end of this think tank meeting, maybe there will be something for our future.
I just want to start with, obviously, the foundation is almost 10 years old. We're getting there. We are here to promote education, awareness, and push for quality surgical care, and treatment, and medical care of endometriosis.
Historically, why are we doing this? Because we were doing this. We started this as medical conferences in 2010. This was our first conference. We touched the subject of stem cells to radical excision surgery. Stem cells and excision surgery is the key that really opens up the door of understanding endometriosis, because endometriosis is like, in many ways, surgically challenging disease that needs to be removed. We thought, with this meeting, we could emphasize that. What you see, that little thing, bubbles under bubbles moving, are new blood vessels popping out like flowers, like seeds. Most likely endometriosis lesion.
We have biopsies, that they show at least stroma. I promise you stroma is there. The top is my animation of ... I tried this 10 years ago. I still use it, but I'm not going to go through it, it's a long animation. Basically, what it does, is constant peritoneal irritation with the blood, finally opens up mesothelial cells, and activates chronic wound healing that is estrogen sensitive. We don't know, really, it's the implantation from above or from these new vessels, this endometriosis develops. Nobody was able to solve that problem. But more research supports, definitely there is retrograde bleeding that triggers the event. It's not everything, not at all. We don't understand why short-term lesions really go forward and become a massive disaster for the patient.
Then, we did very brave meeting. We said, "Let's talk about sex and endometriosis seriously." This was 2011. We want to really go over and run down the barriers, taboo barriers. We want to talk about why the deep disease is never appreciated. We covered a lot of deep disease that year. We talk about deep excision of recto-vaginal septum, bowel disease in the cul-de-sac.
Then we went, we said, "This disease starts at childhood." It's with menarche, maybe with telarche, and we covered the adolescent endometriosis in 2012. We got little bit politically focused in 2013. We covered politics, controversies. We pushed for endometriosis and other women's problems are all for human rights issue maybe, maybe civil rights issue. We're forgetting about human rights nowadays, but definitely in this country, it is a civil rights issue, as far as healthcare is concerned.
Then, we focused on, again back to early years, we said the [inaudible 00:05:26] percentage, what does it say there? It starts in the beginning. Treatment starts at [inaudible 00:05:31]. Again, we focused on the value of early diagnosis, early recognition, and removal of the disease. Again, finally last year we focused on the surgeon. How important to focus on precision, and how surgeons of this disease should be teamed up in order to get the best care for the patient. Every meeting we did have patient awareness day. We answered their questions in our capacity. We were grateful that some recognized faces were always behind us, really acknowledged their help throughout the years. They have been incredibly supportive for us.
Well I can't this pass this. Everything in life is a little personal. I lost two good friends of mine. They both died of breast cancer within the last year. One of them also had advanced stage endometriosis. Their confidential information is still alive in me, so we are going to move. It is my personal experience starts with Buffalo almost 40 years ago. I, kind of, dropped in Buffalo from nowhere and find the second-year surgical residency program. Having had some surgical experience back home, I started breast cancer clinic in Buffalo. That's how my introduction to breast was initiated. This was an incredible experience for me because this is where I saw radical mastectomies that most of you may not know, except maybe senior. There's one senior surgeon here. He may remember. Halstead procedure where they remove the bone and every little thing until the pericardium. In this case, the incision is on right side, but I've seen cases, I swear, where the incision was on the left side. You could see the heart pumping like on the chest wall. That was Halstead.
In Buffalo, I see fantastic things. I learned the term excision, what it really meant. I learned about scientists from Pittsburgh, Fisher Study, that really started the chemotherapy. Really at that time, I didn't know about Happy Rockefeller and Betty Ford. I learned about, when I was trying to promote my cause, I learned about them later. My issue with endometriosis, ladies and gentlemen, is more personal. It gets more personal, because my late father had male breast cancer and it's such a rare entity, and I did not know about it until he had the cancers late in life. It was very interesting. Then I learned his father has died, not from lung cancer, it was breast cancer he died of. Nobody wanted to say the word breast cancer for a man in Turkey, so they used the word ... And my father's ... In fact, it started as a lump on the breast. My grandmother has always mentioned about it, but they called it his chest. Taboos are not only for women, also for men.
What is endo? Endo is easy to recognize we think. This is a case that came from Alabama to us. She had robotic surgery. She came with bowel disease. What you see is obvious lesions around. We excised almost 15 specimens from this case. What was interesting on this case is after we did the bowel resection, it went to pathology and this case came back, as you see, the endo and the bowel, but these are not normal endo specimens. These came as positive for borderline neoplasm. I'm emphasizing the value of excision. The diagnosis has to be made under microscope, not to be confirmed by only visually and ablated. It has to go to a second opinion almost, somebody else has to read that. That also, not tissue diagnosis, but also it's the best treatment. We aim to remove as border free, and probably not only treat, eliminates the pain and gets the inflammatory tissues out. Potentially, it may get possible future cancer tissue out. We don't know that.
This article came out on May 11th, original article. My name is there and I was the one who supplied, out of 24 cases in this article 17 of them my own cases, and I promoted this article to be published. Unfortunately, I couldn't get anyone in New York to understand what I was doing, so I had to go to John Hopkins and they did it. They sent a pathologists to Lenox Hill and she laser dissected these specimens and worked on this mutation foci.
I just basically, what endometriosis is, really endometriosis we all think, we describe as gland, stroma, but most important aspect of endometriosis for surgeons is the inflammation, what inflammation does. The scarring and that irreversible damage it causes in the internal organs. It disfigures and finally causes dysfunction of the adjacent organ as well as immense pain. This scarring, this inflammation, is estrogen dependent and there are many theories how it really happens, but this is basically most likely displaced, regurgitated, refluxed endomyometrial junction cell complex, as well as, obviously, it goes with blood and lymph spread to other distant organs. Endometriosis is a difficult disease. It's not what we see, it really is difficult to understand. It infiltrates. It's not really invasive, but it does infiltrate. It goes into lungs, everywhere in the body.
This is a retrograde blood collection. We just do this all the time. I time my laparoscopies during period. Always you see blood, but at times, in some patients, you see this inflammation. All these white areas are endo, not only what you see as this black area. The rest are all endo. Those are non-pigmented lesions visually that we call them.
There's another case. You think you see this, but there's more to see here, obviously. For that reason, visual identification of endometriosis lesions is very important. The color of red, high-spectrum colors, really obliterates our visual acuity to differentiate the opaque, the peritoneal surface abnormalities. I started this. I'm the first one ever that did this because I have a patent on this. I do use diluted blue dye adjuvant to eliminate the retroperitoneal red and white and yellow and try to bring the irregularities of the peritoneum. This is a diseased peritoneum. You don't see any lesion there, but this completely peritoneal surface is destructed. There are holes, there are vessel formations, thickening, and you really can appreciate it when blue is in the background.
These are another vesicular form of endometriosis. Look at this. This is a complete deformed pelvis. Look at that sidewall. And look how it looks on the same patient. You can appreciate the amount of destruction this peritoneum goes. Endometriosis is primarily a disease of the peritoneum. Most of the pain. 99% of the endometriosis clinically is peritoneal endometriosis. Luckily, probably in the general population, advanced cases we don't see, but we end up operating on the advanced cases.
This is how the peritoneum looks. I want you to see this thickening here. Thickening, as well as there's glands here. You can appreciate. This is how it looks. The holes from retroperitoneum when you look underneath. This is how we do it. We just install the hydrodistention of the retroperitoneum. You see it, but then it doesn't stay there. It doesn't stop with the excision. You have to really dissect the pelvic sidewall. You see these obturator vessels here. We go all the way to the pelvic sidewall, the external iliac, obturator to umbilical artery, obturators. This is the uterine artery. The veins and the ureter is only here. That meticulousness would be needed in some cases of endometriosis. In many, actually, if you're really going for pain. Many patients come by with having had multiple surgeries with persisting pain.
Well, it's the disease of inflammation. Anybody call tell what this is. Hands up. Dr. Haymen.
Stent.
It's a stent. This is a rectal stent. This patient's endometriosis is so severe that finally the rectum has given up and the stent has to be put because surgical timing was not made and nobody dared to operate on this patient. This tells us this whole pelvis is frozen. Every organ is attacked by this disease. This is the same patient. Yes, both kidneys are shut up. Pelvic sidewalls and nerves are all, and vagina, everything is involved.
When you do endometrial surgery, it's impossible not to explore the mucosa and the lumen of adjacent organs. If you can't handle that, don't do it. Let others do it. Very often we are in bladder. Very often we are in rectum. Very often we have to ... Can you play this video? Very often you are in the ureter, you have to resect the endo, you have to put the ureter back. You have to do it. You can't just do it in a second time. Oops. Go back, please. We're almost done.
I want to give you a picture of how bad this can get. This not me. Anyway, so ... Yeah, thank you. Can we get going, please? You can see this is the right ovary with endometrioma and there's appendix sticking out underneath that and there's the bowel that coming there. I mean, it is endless and it's so challenging. I have to tell you, for a surgeon, it's almost addictive because you want the best outcome and you really stay, in these cases, in the OR for hours, all day, and you can't do these cases without other teams around you. I'm extremely lucky in my hospital. The culture, I believe has changed. There are people who believe in what we do, what we could accomplish with their help. These cases are handled very appropriately with multi-specialist team. Some of the general surgeons are here who assist me and help me. I assist them in these cases. Our results have been fantastic with bowel surgeries, with ureter surgeries, even thoracic surgeries.
This is the same patient. How the pelvis initially ... Oh, this is not the same. Okay. This is another patient you're going to see. This is the pelvis of another patient, but the disease has been really all the way on the diaphragm up there. You can see it's a dual-compartment surgery. Simultaneously, we remove the diaphragmatic endo by stapler. It is this right here. Then she had a bowel disease. We did an ileocecal removal of the IC junction with appendix. She had myomectomy. She had, actually, also pelvic sidewall dissection for endo. We put everything in that bag with the bowel and the patient really went home three days after her chest tube was removed.
What I'm trying to say is there's not a single case I can really do without the help of my co-specialists. In this case, you have to be really aggressive. You have to look beyond this liver. You can't just say, "Well, there's diaphragm." This patient had chest pain, had all sorts of symptoms suggestive of thoracic endo. This as we lysed this. This is what we saw. In this case, it was quick way out. We basically wanted to prove on future pneumothoraces from this patient.
Again, another chest case. You see the implants here. Again, it was done by stapler, thoracically dual-compartment. This is how it looked from the inside, the stapling of the total removal of the diaphragm. In some cases you are tempted when the patient is symptomatic on the diaphragm. You remove this. You end up with a hole. This is my case. You have to repair it. It's not that difficult. Two stitches, three stitches. It is fine.
Overall, we don't know what really causes endometriosis, but the role of obstructive [inaudible 00:22:21] anomalies are definite. This is a case of a rudimentary horn, where the patient came with bilateral endometrioma. I actually missed this. I did not, because of the intensiveness of the surgery with it, I did not really pay attention to the rudimentary horn.
This is a book chapter on hysteroscopy coming out. We have, two of my residents, we did this chapter. Our experience with laparoscopy proven endometriosis cases, when you do hysteroscopy, if you're very careful, you're going to see very prominently some midline prominence, corneal funneling, and some variation of arc [inaudible 00:23:13]. In our cases, we show this out of 260 cases, almost 38%. There's one other group also that did this kind of study from Connecticut. They called it a septic uterus, but there's terminology variation there.
I'm going to move a little bit faster here. Basically, you wonder if this patient, she is right now 43, but they had known about this anomaly and had it corrected, maybe one day we'll develop a protocol. If you understand endometriosis well, or we could be on top of some early anomalies. This patient came up with a spinal iliosacral pin and operated by neurosurgeons in my hospital, Lenox Hill, and what she had was basically huge nodule retroperitoneum at the iliac spine and she had stage IV endometriosis.
This is the last case I'm going to show. Interesting case. Emergency room admission at Lenox Hill with hemoperitoneum. You need to know that this patient is 62 years old, has been getting all sorts of bioidentical from all over. From skin, nose, you name it. She looked gorgeous, but her cervix was so stenotic. When I looked, there was literally blood all over. I was curious. This is the peritoneum. It doesn't look that bad, right? It really looks normal, right? This is what happens. Put the dye back, get that piece, send it to pathology. We pinned this like they do in stomach cancer cases. You see all these endo lesions with peripheral nerves and we stained this for estrogen positivity. Everything was there in this patient.
We have a great lineup today. This is a quote I love. What we observe is not nature itself, but nature exposed to our method of questioning.
