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Check out the show notes for the application link. All applications are due April 20th. Again, all applications are due on April 20th. Dominate the day. Welcome back to another episode of Colorectal Surgery Journal Review with Drs. Glandiak, Cavalukas, Bolshinsky, and Simon. We have a special guest with us, a world leader and pioneer in the management and treatment of endometriosis. focusing on bowel endometriosis today.
Yes, we're very thrilled to have Dr. Farh Nizad joining us today. Dr. Nizad is a clinical professor of obstetrics and gynecology at Weill Cornell Medical College. of Cornell University. He's director of a division and fellowship of minimally invasive gynecologic surgery and robotics. at NYU Lugone Hospital at Long Island.
He's an internationally known expert on endometriosis and has been a prolific contributor to the medical literature. He's a member of many respected professional societies, including SGO. and he's actually at the SGO meeting right now, ACOG, ASCO, the American Society of Reproductive Surgeons, the Society of Laparal Endoscopic Surgeons, the Society of Pelvic Surgeons, and many others.
He frequently serves as a director of postgraduate courses and is regularly invited faculty member at many professional society meetings. Thank you very much for joining us today, Dr. Nezat. My pleasure. Thank you very much for asking me to participate. So Dr. Azat and his research team recently published a review in the Journal of Clinical Medicine just last month. and it was titled Comprehensive Management of Bowel Endometriosis, Surgical Techniques, Outcomes, and Best Practices.
which we'll discuss first today to provide a structured framework to the listeners for the evaluation of bowel endometriosis as we dive into the surgical options. Additionally, we'll briefly review an article published in 2020 from the Journal of Minimally Invasive Gynecology titled, Surgical Outcomes After Colorectal Surgery for Endometriosis, a Systematic Review and Meta-Analysis by Roman et al., to compare and contrast some of the complications reported.
And that article in regard to the discussion generated from Dr. Nazat's work.
To expand the discussion to rectal-specific endometriosis and to link the colorectal surgeon's involvement, we'll review an article published in the Diseases of the Colon and Rectum titled, Functional Outcomes After Rectal Resection for Deep Infiltrating Pelvic Endometriosis Long-Term Results by Warnie et al. and a brief article recently published in Colorectal Disease titled The Impact of Surgeon's Specialty on Surgical Outcomes Following Colorectal Resection for Endometriosis by Meyer et al.
But before we begin, in reviewing the other authors on your paper, endometriosis seems to be a family passion. What sparked interest in pioneering endometriosis treatment in your family? So I give you a little background. My older brother Kamran Nijan. He is an inventor of the video laparoscopy. He was the person that started the video laparoscopy that we are using these days in laparoscopy.
He is a reproductive endocrinology and infertility, and he was trained in Buffalo, New York by his professor, Ron Bath, that God bless his soul. He was endometriosis. expert. And he was doing the aporoscopy to find the endometriosis, and then he was doing the aporotomy to take care of an even smaller stage of endometriosis.
When my brother Cameron did his fellowship in Augusta, Georgia, and he had interest in the endometriosis and laparoscopy, so instead of looking, he started treating the endometriosis laparoscopy. and then he used to paint over the scope. It was difficult to do it, and he borrowed the scope from the other discipline, connected it to the scope, and he developed a video laparoscopy. And then he published his first series of treated endometriosis laparoscopy in early 80s. And then he published that.
video laparoscopy, the pregnancy rate and the pain relief is significantly higher than laparoscopy. And then that was the beginning of everything. And then I joined him in 1987. After I did my residency, I had done fellowship in REI before. I joined him. And then, actually, we presented the first abstract in laparoscopic treatment of the bowel endometriosis in 1988 in American fertility society.
And then later on, my youngest brother, Sinan Najad, he joined us in the early 90s. And then later on, my niece, Auzan Najad, she joined us. So that is the history. And well, you're all experts. Family empire. Yeah. All right. So I think Dr. Bolshinsky will kind of start us off in regards to starting the conversation specifically centered on your recent publication.
Yes, thanks for giving us the opportunity to talk to you. Look, so the paper we're focusing on initially is called Comprehensive Management of Bowel Endometriosis, Surgical Techniques, Outcomes and Best Practice. Now, this paper or your work sort of begins by telling the readers about four scenarios specific to endometriosis, and then that expands into sort of more technical components.
And I found the case is very interesting. The first case is a study you mentioned that the patient had a frozen pelvis. And so from a clinical perspective, I just want to know, there's a term called blamishelf. I'm not sure if it's used in the US or rectal shelf.
And so for the benefit of the audience, this is a palpable finding of an extrinsic mass, typically metastatic via rectal exam, which lies in the deep sort of pouch of Douglas. Is this something that you can detect when doing an exam for endometriosis? Good point. I am very familiar with Blum and Shell that we use it for OIA and cancer when we do a retrovisual examination. Frozen pelvis, what we mean is only laparoscopic findings. This is when most of these patients even they have had.
bad endometriosis, stage 4 endometriosis, or have had surgeries before, and now they have developed adhesions. And for this purpose, it means that the rectal sigma colon is pulled up. severely attached to the back of the uterus and adenexa. and that way you don't see anything. deep pelvis, we call it frozen pelvis. And it is very difficult to separate the rectosignal colon and adenexo from each other because of the inflammatory process of endometriosis and adhesion.
However, as you mentioned, One of the most common areas of endometriosis is posterior coltus. And when you do rectivision examination and we feel a nodularity, we call it nodularity, you feel a nodularity between the rectum and the vagina. It is a sign that there is endometriosis in the part of Douglas between the rectum and the vagina and uterus sacral digam.
Thank you. Sort of following up on this, I share a monthly list with a gynecology colleague and I can't actually wait to show her this video. But that aside, I review the patients that we share prior to surgery. And I noticed that most of the patients on digital rectal exam have a sort of a hypertrophied and tender levator ani muscle.
And I guess my other question to you is, is endometriosis directly associated with levator anispasm or is there any direct association due to pain? What is your view on this? both of them because they are in the posterior corner side. even if it is mild disease, could cause pain. And this patient, because it's a chronic disease, they have this long duration of the spasm in their pelvis. All endometriosis could affect the nerve.
in the pelvic, in different branches of the inferior apogastric plexus nerve and pudendal nerve that goes towards the deep pelvic. So, that is the reason that when we take care of the endometriosis, we all, and the patient has this type of pelvic pain, we always let them know that, don't expect that the pain goes away right away. And a lot of time, we have to send these patients to pelvic physiotherapy to take care of this long duration of the pelvic patient.
Right. Yeah, actually, I wanted to ask about pelvic physiotherapy, but I guess you've just answered that, which is handy. So in case study four, I think you describe a patient with an obliterated pouch of Douglas. And you talk about doing a shave. Now, in the body of the article, there's a discussion between the difference between a shave excision, a disc resection, and a segmental resection. And so my question is...
How do you approach a shave and at what point would you decide that a shave needs to be converted to a disc? Is it something that you have a predetermined view on or is it that, you know, you try to shave and... Remember, when you want to treat endometriosis, you have to keep in mind two goals. you eradicate the disease as much as possible.
and causing the least possible complications, because endometriosis has two specific characteristics. It's estrogen-dependent and inflammatory disease, and causes inflammation and scars. And when you resect them, you want to be sure you have completely eliminated it, but at the same time, because sitting with the vital organs, you have to be sure you don't cause damage. When it comes to the bowel,
Fortunately, most of them are involved in serosa and mastillitis in the two layers of mastillitis. You guys know that. Rarely gets to the mucosus. That is the reason a lot of this patient rarely you see a rectal bleeding. but they have bowel symptoms. Or you do colonoscopy and rarely you see lesion in the mucosa of the rectum or transverse colon or ascending colon. But the patient has bowel endometriosis. So what we do, when you want to eliminate a disease, as I said, you want to use the least
damaging surgical technique. So if you could, with the tip of your scissors or lateral surgery or sometimes you use a laser, you eliminate, eradicate the disease. and without getting to the lumen of the bowel is the best way. That is called shaving technique. So shaving technique, you could use it anywhere. Any part of the body, most of the time, you could use shaving technique, which is called ablation or resection. You could use a high energy, but plasma just...
CO2 laser, even high power, tele-surgery, and ablating. Or you could excise it. But when you excise it, you have to be sure you have not gone too deep. If you think you have removed a big portion of mastodonis of the bone, then we suture it. so that is called shaving
you have to go deeper. You have to go deeper, as I said, rarely gets to the mucosa, but the big depth of the macellaris and the bar is involved, and you want to be sure to get a good margin, you excise a piece of the... take your lateral rectal bulb and then you repair it and usually we do just those ones if the lesion is less than five cents. that the average is three centimeters are very good size that you excise them completely you know you have got a very good margin and you
any type of energy you want to use, and then you repair the bowel. So either you repair the bowel with the sutures. Or sometimes you could use a stapler, either you could use the circular stapler. to put in the rectum, mobilize the bowel. and push the segment of the power between your anvil and the stapler, push it down, and you close it and you resect it, or you fire across the endo-GIA, and you remove it without causing a stricture of the cord.
Can I ask, intraoperatively, is there anything you can do to assess how deep the endometriosis goes? Do you ever use ultrasound probes or anything of that sort to tell how deep the lesion goes? A lot of work is done peer-operatively to see how you could find. Some people are very good with ultrasound, transvaginal ultrasound, if it is in the lower portion, not higher portion of the sigmoid colon, and MRI.
could be good. Sometimes you have to let the radiologist know that they put some KY jelly in the rectum to identify. However, still, unfortunately, there is false negative and false positive. So the best one, Susan, at the end is a poroscopy to find out how big the lesion is and how deep the lesion. Back-perioperative imaging is also used.
When I review a topic, I sometimes go back to a trusted textbook of mine. Unfortunately, the textbook is now starting to get dated. Dr. Fazio was the head author who's passed away, obviously. But in the endometriosis chapter... they stress about the importance of tactile feedback. Is that still relevant these days with the progress, particularly with robotic surgery and increased visualization? That is a very good point.
Again, experience plays a role. Most of these patients, the lesion is in the lower portion, so rectoviginal examination is helpful. And especially with the robotic, the tactile feedback, you don't have it. You have to be very careful. Rarely I have had patients that have missed it. And then, when we exteriorized the bowel and we palpated it, and we have felt it. But most of these patients, they have some sort of... signs, either the bow has discoloration or it is tethered.
or there is a little bit narrowing of the areas that you could feel that there is something underneath. Thank you. Sorry for attacking you with all these questions. Two more things from your paper, which I did find very interesting. One is a discussion in the etiology section. And you've mentioned about the relationship of endometriosis and intestinal microbiome, which of course is a very topical thing in colorectal surgery at the moment. Sort of to extrapolate from this.
For example, there's a link between bacterial infections, say Streptococcus bovis, and the association with colorectal cancer. Are there any associations with a particular bacterial, either, you know, systemic or an infection that you can culture via either the bowel or swabs in the vagina and endometriosis? In short answer, no, it is not. At present time, it is not. And going back, I mentioned before, endometriosis is an inflammatory estrogen-dependent disease.
Anything that increases inflammation and also the estrogen could contribute to progression. of this disease. It is not necessarily to start the progression of the disease. the disruption of the micrograms of the rectum. This has been suggested that when this balance of the bacteria in the rectum is being altered, then there is disruption of the immune response. and then some bacteria, maybe, or the antigens could penetrate outside and could cause inflammation.
And also, we know that the patient that they are taking the estrogen. the risk of the rectal cancer is less. Now, this alteration of the estrogen, because of disruption of these macroboms, could have some effect. on endometriosis. So, that is the reason that sometimes
Our patients, they have chronic pelvic pain, we took care of endometriosis, and still they have symptoms. We give them one course of antibiotics, and we have seen it. We have seen that it has helped them not only for pain, but also has helped them for infertility. Right. At the present time, there's no specific bacteria that we could culture in the rectum.
Thank you. And now the other thing that jumped out at me was the comment about liquid biopsies. Now, can you please explain a little bit of this to us? Sure. As you know, right now, the only way to be 100% sure a patient has endometriosis is lulacrosis. And we know endometriosis, it is a benign proliferation of the tumors. As I mentioned, the endometriosis could become malignant.
As for any other type of cancer, and now people are looking at the molecular alterations and trying to find out a special alteration of the molecules and check that alteration in the blood. the same way that right now they use the blood test for the trisomies or the Down syndrome and they do the blood test. and several companies are working on it to find out a test.
So far, it has not been successful, but I am sure the next few years, we will come up with some sort of blood test to check it, or even with saliva, or even the urine test. So far, there's nothing in the market. There is one test that we do in the endometrium. It is called BCL-6. that has been shown to be very accurate for diagnosis of endometriosis, but no blood tests yet. Thank you.
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So I guess we've got another paper to kind of juxtapose this topic to. The paper is called Surgical Outcomes After Colorectal Surgery for Endometriosis, Systematic Review and Meta-Analysis. This paper comes from France, published in 2020 with, I think, Dr. Horace Ramon. being the senior author. In brief, this group performed a systematic review and meta-analysis to compare surgical outcomes and complications of colorectal surgery.
particularly looking at rectal shaving, disc excision and segmental resection. The group identified 1,191 studies, of which 60 were included in the review. And for the meta-analysis, the data available was as follows. So the incidence of rectovaginal fistulae was discussed in 17 studies. Anastomotic leaks were seen in 10 studies. Anastomotic stenosis was in five studies. And voiding dysfunction was in nine studies.
The authors do state that the technique was unique to each team, and I think Dr. Nazard mentioned his approach to that, which was great. Disc excision techniques were divided into two groups, being stapler and scissor. freehand which again dr nazad has already mentioned In terms of the overall complications, the complications with shave was the lowest at 2.2%. Disc was 9.7% and segmental resection was 9.9%.
The thing that I found most interesting and I wanted to get the group's opinion was the incidence of... Anastomotic stenosis was 5.2% in the segmental resection group. And to me, this seemed quite high because the incidence of anastomotic stenosis in colorectal cancer surgery, I mean, it varies in...
in my experience, is far less. And so I wonder, and I suspect it's related to limited mobilization and therefore probably tension and perhaps ischemia. So I just want to know what everyone else thinks about that. I think it also depends on stapler size as well, what stapler size they've chosen. But I mean, it's hard. I don't know what doctrine is, what stapler size would. gynecologists be using for this.
That's an excellent point. I think in my career, I have had only one rectal stenosis. And that patient had... long history of the accused actually had colostomy for 15 years, and finally she came to us and we did this, our resection, and we did anastomosis, but the anastomosis didn't work, unfortunately. So she had to go back to the colostomy. I think... The reason for the structure is two things. First of all, This is an inflammatory disease that I told you.
and disease. For some area, maybe the margins are negative, but still. people have done studies that they have gone beyond the anastomosis and they resected the bowel and still there was macroscopic endometriosis in that area. And also, because this is a very fibrotic disease, and when you mobilize the bowel, you may have compromised the vascularity of the bowel. So although it looks good by looking, but already the bowel has been compromised. and cause the...
And I think when looking at studies like this, When you're looking at the forest plots, you have to also look at the heterogeneity.
reported. I mean, for a lot of these analyses, they have incredibly high heterogeneity, especially if you're looking at the anastomotic stenosis thing. So I think you have to... take some of these with a grain of salt plus for all of these there's no risk of bias assessment for any of these studies so There are a lot of numbers to talk about, but I think it really does go back to kind of your expertise and level of volume when it comes to.
operating on endometrial bowel disease. But if you look at the study sizes, they go from 28 to 2000. But overall, I think I took away from your article the best practice recommendation of... Generally, consider shave biopsy on most lesions, at least distal to the sigmoid. unless they're very large or infiltrating through all the layers or, you know, into the muscularis, like you said. And then, you know, obviously consider bowel resection for sigmoid or any proximal bowel that may be involved.
You know, overall, like Dr. Bolshinsky said, the overall major complication rates in this article that we're taking with kind of a grain of salt is low for shave biopsy, but they put... disc and segmental resection, kind of similar overall complications. you know, kind of contradicts some of that. I think it's table two in your article that that's always disc excision is the next alternative option. Like you talked about, if shave biopsy is not the case.
Now, do you have any more kind of pearls of wisdom when it comes to disc excision outside of maybe those lesion sizes that you mentioned before? As I said earlier, you have to realize that these people, most likely, are young. and you want to do the least possible problem, and if they have leak, and then you have period infection, it will affect their fertility. It will affect the fallopian tube and the ovaries. So, even if you...
leave a small amount of disease. For example, you have taken 80% of the disease. Especially you have taken excise and taken to biopsy to be sure there is no pill malignant disease because some of these patients' lesions could be malignant or pill malignant. As long as you have taken care of maybe 80%. and you leave the rest of them behind. This is a benign condition. and the patient tries to get pregnant, it is better to not be very aggressive.
especially anything below the seven or eight centimeters from the anal verse. You don't want to distract the nerve because if you want to do, even if you want to do this excision and be sure the repair is tension free, you have to mobilize the bar. And when the lower you go... you are affecting the inferior hypodastic places now.
and then you could create constipation or urinary retention and even sometimes vaginal dryness and some of the patients could have complained about the lack of the orgasm. So you have to try to keep in mind all of those things. So the best way, as I said, is to individualize the case. and also work with the colorectal people and the urine and see what the patient's symptoms are.
The patient's infertility, you find the lesion, and then you remove the lesion as much as possible. For shaving technique, as you saw, all of the studies have shown, shaving has the least complication. the higher chance of recurrence because you leave some disease maybe behind and the next one is Right now, in our practices, we do segmental resection, anything below the letter sigma ecolumn, only if there is a strict check.
Above the sigmoid colon, that the nerves will not be adapted, that's no problem. If we cannot do this excision, we do segmental dissection.
I've been motivated to say they can be done very well. Iliocicum the same way, you could do segmental section, but below the deep pelvis, we try to avoid segmental section and do shaving. The next one is this excision again as a machine because you don't want to alter the the blood vessels and also the bleeding over there you know deep pelvis hemorrhoidal artery sometimes very vascular and it is very difficult to control them especially obese patients
and then even if you use electrosurgery you could cause more damage to the nerve and to the bowel and that is the reason that they could develop fistula. A lot of the articles that I reviewed for preparing for this podcast. I found it interesting that not many people use bowel prep as a factor to even, you know, consider when looking into these. outcomes. Can you comment about your practice and using a bowel prep preoperatively? But that's a good point. I gave the Chirindabao the day before.
And they use the ERAS protocol. We ask them to eat a carbohydrate. We give them, but they ask them to clean their mouth. We give them some sort of laxative and interoperatively. Again, we give stefanosperine, but if we get to the bowel, we give flat G2. So we have modified our technique and it has worked very well for us. A full colonoscopic kind of quality bowel prep? Exactly.
Now that we've reviewed now endometriosis and surgical framework based on the location of the lesion, infiltration, and other patient factors, let's move to our third selected article, Functional Outcomes After Rectal Resection. deep infiltrating pelvic endometriosis, long-term results published in DCR. This is a paper from Switzerland with the lead author being Matthias Warnie.
It's a single center retrospective study which aimed to assess late post-operative patient reported outcomes on bowel function, which is incontinence and evacuation, after rectal resection for deep infiltrating endometriosis. These cases all were performed in a combined fashion with gynecologists and colorectal surgeon team. And the study had an average seven-year follow-up.
Just over 50 women underwent bowel resection for rectal endo in their study, a period of nine years. The average age of the patient was 32. 75% of them had had a prior surgery for endometriosis. 94% underwent resection laparoscopically, and a little more than half of the patients had a colorectal anastomosis below 7 centimeters from the anal verge, so low. They dichotomized it to low or high from 7 centimeters.
They reported a 2% leak rate in this study with one rectal vaginal fistula, and 70% of patients reported no long-term menstrual-related pelvic. The authors assessed patient reported outcomes using a 21-point questionnaire. They go into kind of the details in the article more, but zero being good and 21 points being the worst score you could have to assess the stool evacuation and incontinence before and after surgery.
The composite evacuation score increased after surgery from 0 to 2, but again, the range preoperatively was 0 to 11 and a range postoperatively 0 to 15. And the incontinence score increased also from zero to two with similar range. These increases in the paper were noted to be statistically significant, however, in the discussion, not necessarily clinically significant from 0 to 2.
There was also a subgroup analysis of the anastomotic height, less than 7 or greater than 7 centimeters, and of those, the greater than 7 centimeter anastomosis. reported a significant increase in incontinence scores, but not evacuation issues here with these 50 women. Overall, the authors concluded that the results of rectal resection for endo have acceptable clinical impairment. However, acceptable is defined here.
I believe this article hits on two important points that we've really discussed thus far, just outcomes related to nerve injury during bowel resection. And the importance of recording and documenting patient reporting symptoms before and after surgery to ensure that the interoperative decision-making can be based also on the long-term quality of life measures.
In your practice, do you keep a common questionnaire before and after these types of surgeries to assess these types of patient-reported outcomes? Right now I don't do any more this question. And as I said, we published our self-use of the segmental resection, and we had some chronic constipation. But unfortunately, we didn't have the retention as we have seen. We have seen from other people that do a lot of sedimentary section. We see.
did this be isolated the articles so they are they are new to this technology to this to this procedure so as you said acceptable it is how much how much the patient, all these patients do well regarding the pain. More than 75% of these patients regarding their pain relief, they do well. Regarding the pregnancy rate, also, if you go have their own, as long as the fallopian tooth, and you always are fine, or you have the IVF, a lot of them, they get pregnant.
As I said, you have to be careful that you don't cause any harm. And it is good that they have seven years of follow-up, although the numbers are small, not too many patients. It is good that still they have had some... worsening of the bowel function, constipation, and also urinary issues. So that is the reason I said we try not to do segmental restriction as much as possible.
One thing that was interesting in the article that if the lesion is more than seven centimeters higher up, they have more problems. Actually, to us, it is reversed. I would assume too. Yeah, that's what we see. Exactly. I just said, these are, as you mentioned, these are how you define it. And this is the first maybe series. I am sure these people continue later on, five, six years from now. they will again go towards a more conservative approach.
It sounded like this was about a quarter of their patients. overall that they were doing this on. But what they describe is basically what we in colorectal surgery called low anterior resection syndrome. And that's just, and with us, it's the lower you go, the more reservoir. the more reservoir function of the rectum you resect.
the worse it is in terms of, and that's what they asked for on their questionnaire in terms of returning to evacuate, difficulties emptying, you know, that's basically all the things that they asked about. And then kind of the resounding conclusion was a team-focused approach with MIGs and gastrointestinal surgeons to provide that interdisciplinary approach. And, you know, I just learned even reading a little bit more to prepare for this, I think.
As colorectal surgeons and as consultants, where most folks are worked up initially by, you know, a minimally invasive gynecologic surgeon, and then kind of referred to us to have that potential bowel resection discussion risks and benefits. you know, in our clinic beforehand, or at least that's how it works here in our practice.
we're very comfortable doing bowel resections. And so I think at least personally, it's been easy to say, oh yeah, we'll resect this. But now I'm kind of in my head thinking as the colorectal surgeon that walked into the room to maybe... take a step back and say, maybe we can do a shave biopsy or a disc excision. We're just not as familiar with those techniques.
And maybe that needs to be something that is incorporated more into a colorectal fellowship or something because, you know, we can resect now. But when it comes to being asked to maybe do those other techniques, we say, oh, why don't we resect instead? Maybe. So do you have any thoughts about that particular comment? Yes, I'm glad you brought it up. So it started by saying that endometriosis is a very common disease. This is what we believe.
the colorectal surgeon or urologist don't know about endometriosis, the gynecologist. they are not surgeons, and they leave the disease behind, so this group has to work together. And, as I said, because it's a very common disease. And the best method of diagnosis right now is the operoscopy and minimally invasive surgery. And you all know minimally invasive surgery is less morbidity compared to the operatomy.
Not only you could see better and diagnose the disease better, of course you have less morbidity. for you, for young people, all of you, that definitely you should get involved in dermatiosis.
But that actually leads us into this last article that we reviewed, which was the impact of surgeons' specialty on outcomes following resection for endometriosis. And in the interest of time, without taking a deep dive into the exact takeaways of the article... I think the thing that was surprising to me most and I can't
necessarily tell about their study methods, but it sounds like they found quite a bit of general surgeons who were acting alone on endometriosis, which I personally would never do in this day and age. I would always call my gynecology. colleagues, but I think, you know, in certain techniques such as resection, some of the odds ratios kind of went more towards the complications for gynecologic surgeons.
versus others. And then I think the big take home was that, you know, considering a multidisciplinary or dual surgical team, I think is... Probably the best. That's certainly what we try to do. It sounds like what you try to do as well. But we were just, you know. trying to highlight the importance of having, you know, people, the more viewpoints you have in an operating room, usually the better outcome for a patient. But we were just trying to get your thoughts on that in your daily practice.
and you said exactly the ultimate goal is the patient's care and as i said this is not only the issue of the pain. There are other issues. These are the young patients. You have to be careful about infertility a lot of times. If they call me, the operating room, they'll call me, oh, Ford, come here, see what you think you want to do. I say, hold on, hold on. How old is she? How am I paying them? How am I? Good job.
This practice ovary has endometrioma or not. Is endometrioma going to be removed or not? should she go to have egg freezing first? Because when you remove the endometrioma, the Hawaiian reserve may come down. So the beauty of laparoscopy is that you could stop. Stop and evaluate the patient. Then you get the MRI to see if she had deep infected endometriosis.
So, our practice, I was interested when I read this article that says the complication rate of the general gynecology and colorectal, and it's the same. Not too many general gynecologists have even privileges. Even if they have a smart intratomy, they have to call a general surgeon to repair it. So who were these people? Did the VG1 oncologists that they had there?
the privileges to do bowel resection. I am a juvenile oncologist myself and I am working in Manhattan. My colleague from Sloan Kettering, when they have bad endometriosis, they sent it to me. and there are oncologists, but they know that endometriosis is a different disease. okay so i was surprised to see the data
Yeah, you do bar resection and you talk about, maybe they are talking about the leak or fistula, maybe it's the same. No matter what you do, you have some leak and some fistula, especially if you do hysterectomy.
But that is not the issue. The issue is outcome. And a lot of these articles, they never mention about the pain relief or pregnancy rate. So... that again that is the reason that we in my practice when they refer the patient it is not unusual that before i take them to the operating room send them for their consultation with rei if they want to freeze the eggs A lot of these people, you put them in suppressive therapy, hormonal suppressive therapy.
Because, as I said, it's an estrogen-dependent disease. the more you suppress the estrogen, you put more anti-estrogen, not to generate agonists or antagonists or progesterone. There's less inflammation, less bleeding, and less damage to surrounding stress. Yeah. And I think, you know, we've been called into the operating room many times sort of on the fly. And my first go-to is let's go get the flexible sigmoidoscope and, you know, kind of help me.
you know let me look and see how deep your shave went maybe it was deeper than you think maybe there's some micro perforation or air bubbles and i think that you know just having another set of tools to evaluate the the area can be helpful Exactly. You see what I was saying? Because, you know, surgery is surgery. No matter what you do, the patient would have complications. So it is better to cover all the bases. We always do the sigmoidoscopy, do bubble tests.
And to be sure, I have any doubt, you put suture on the area. So, again, people, every day are there. We are not. We are GYN. And even towards our experience, still, we are not as good as you guys. So that is the reason working together definitely helps you and also be asleep better at night. Okay, Farr, thank you so much for taking time out of your meeting. We really appreciate it. This has been wonderful. Yeah, so nice to have you.
Just listen to your expertise. And I think that the behind the knife listeners will thoroughly enjoy this. So we can let you go and then we will do our five quick hits. For number one, remember, endometriosis can affect any organ and cause dysfunction. Number two, patients can have symptoms for 7 to 10 years before being diagnosed. Three, always consider the impact of fertility and therefore do the minimum intervention. Four, shave excision whenever possible. And five, resective stenosis.
And with that, a big thanks to all the Behind the Knife listeners for a great last two years. And for the last time, dominate. Be sure to check out our website at www.behindthenife.org. Download our free app available for Apple iOS and Android. Simply search for Behind the Knife in the App Store or Google Play to download the app. In the app, you can listen to our episode.
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