Mauricio Abrao, MD
The need to improve the therapeutic strategy of endometriosis treatment
Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 18-19, 2016
The Union Club, New York
The goal of this presentation is just to bring forth some concepts that we are talking about for a long time and that is how important it is to improve therapy strategies of endometriosis treatment even because nowadays we do not think that it is acceptable for us to go for surgery without knowing what we can have right even for many things that I am trying to discuss here.
This is an example of what we are talking about. This is a laparoscopic surgery for a patient with endometriosis compromising the bowel, the left ureter with adhesions. The issue is in 2015 and 2016 we do not think that we can discover, we can decide about what is going to be done during the procedure. We must think about before, we must discuss with the patients, we must consider the implication about possible complications and how to prepare the team. In other words, it is a very important issue that contributes a lot for us to reduce the complication rates and to improve a lot of things related to the surgery for endometriosis.
I am going to talk about a few concepts and the prevalence of the different types of endometriosis, the clinical and imaging considerations that we have nowadays in our hands and why the preoperative information is so important and some perspectives for us.
We know that when we talk about endometriosis we are talking about three different diseases and the most important disease for us to predict to find a strategy for sure is the deep disease that was described after this publication of 1990 from the Belgian group from Cornellie and co-authors. We know that when we look for our experience in the Sao Paulo University considering more than 1,200 cases you can see that in 40 percent of our cases we have deep endometriosis and what is very relevant is that in half of these 40 percentile, 20 percent of all cases, we may have endometriosis compromised in the bowel.
This is something that we need to think about before the surgery. Of course we need to think about the symptoms and we need to do a clinical exam. This is a study that we published a few years ago just to reinforce that deep endometriosis is more related to pain in terms of dysmenorrhea, non-cyclic pelvic pain, dyschezia or even deep dyspareunia. And it is also more related to infertility. We are sure now that after many, many studies there is also a connection.
But also, in addition to a good clinical evaluation we can use now good imaging methods. We started using trans rectal ultrasound, which is something that we do not use anymore, then we defined studies looking for which method would be the best one for us to find a strategy for the procedure. The trans rectal ultrasound was a publication that we made in 2004 showing that as a feasible method but because it was more expensive method it needs sedation. For public health purposes it is not easy for us to do trans-rectal ultrasound for ten to 15 percent of women at reproductive ages. And, of course, it cannot define other sites of the disease.
Because of this we started working a lot with transvaginal ultrasound with a simple bowel prep, it was a simple protocol first to look for situations like this when even the laparoscopy sometimes we only see the tip of the iceberg as you can see here. When we do a clinical exam and a good transvaginal ultrasound is possible for us to identify a nodule to be resected, and of course to prepare a good strategy for us to treat the patient properly.
This is a publication that we made in 2007 in Human Reproduction that shows we have a very nice sensitivity with transvaginal ultrasound for rectal endometriosis, endometriosis compromising the rectum with a sensitivity of 98 percent. That is much better than MRI. MRI you can see here that it was 84 percent. Even for other sites like the retrocervical endometriosis the sensitivity of the ultrasound is better than an MRI as you can see here.
Just to see that we can associate an imaging method, a simple one with a good clinical exam and we can look for more information to find a strategy.
This is another very simple paper that we published in 2008. We had the award of the best endometriosis paper of the AAGL that year. It shows that endometriosis lesions that compromise the rectum deeper than the inner muscularis layer may have more than 40 percent of the circumference of the rectum affected by the disease. This was the conclusion of this study. But just to show you that it is even possible to use imaging methods for us to predict the deepest layer compromised by the disease, the distance between the lesion and the anal verge and even the circumference of the bowel that is affected by endometriosis.
In this study we evaluated morphologically 40 patients with bowel disease and we tried to correlate the depth of the lesion with the circumference of the bowel affected by endometriosis and this is what we found. When the deepest layer compromises what the ultra muscularis layer we had a mean circumference of 29 percent, 51 when the inner muscularis was affected, 60 when the submucosa was affected and 81 when the mucosa was affected. Just to reinforce that for sure we are trying to think about what procedure needs to be done. For situations where we have more than 50 percent or more than 40 percent of the circumference affected it is not possible to remove a disc it is imperative for us to propose segmental resection.
Again, we can use imaging methods to find, to give us information like this – this is the publication from 2009, also in Human Reproduction, just showing that we can have this additional information as you can see here.
We know that in situations where we use the ultrasound for this purpose we can also look for the endometriosis compromising the ileum, the appendix and other sites of the disease. Of course we have important information like the distance between the lesion and anal verge using MRI or ultrasound and finding with a reasonable sensitivity this information according to the strategy that we are going to plan to treat this patient.
This is an ultrasound showing that there is an ileum compromised by the disease and this is very relevant for us because we know that the chance for the patient to have a bowel obstruction is higher when the disease compromises the ileum and then when the disease compromises the rectum. We can also look for information like this; endometriosis compromising the diaphragm. For this purpose when the patient has pain in her right shoulder during her period the MRI is the best method to provide us this information and we are looking more and more nowadays for more specific information like this because we know that to know when the lesion infiltrates the nerves, not only the hypogastric nerves, but the sciatic nerve as well as other nerves of the pelvis, it is important for us to think about this before the surgery to plan the procedure, to discuss with the patient or even to think twice before going ahead and indicating the procedure.
Why is the pre-op information so important? We know that no surprises, we can organize the scene and we can organize the bowel prep. The other important issue is that we for sure can reduce the risk. I am sure that we have nowadays less than 1 percent of fistula in our many, many bowel cases in Sao Paul and we truly have less complications. Not only because of the surgical technique but because of how we planned the procedure, so this is very relevant. To optimize the results for the patient that is of course essential for this purpose and also to reduce legal problems, that is for sure in this country, mainly in this country but all over the world. This is a very relevant statement for us to pursue. To look for one shot surgery because we know that in many situations when we talk about recurrence of the disease we are not talking about the recurrence of the disease, we are talking about the persistence of the disease because there was a non-appropriate plan for the surgery.
Another situation is for research purposes. We can do much better research when we have in Sao Paula a very strong tissue bank collaborating with many, many groups all over the world and for sure, using this background of the pre-op information.
This is another study from the group of Chapron showing that the pre-op work-up for patients with deep endometriosis have in the transvaginal ultrasound the first line imaging examination for this proposal this is something that is not an idea from our service in Brazil. We know that in many, many other services, even in this country, we already have strong people doing a good job. We have, for example, people from the Mayo Clinic, people from Chicago coming to train with us for this proposal, this is essential for us to predict and even what Juan showed before it is feasible. It shows that it is feasible for us to provide a map, right, not only for the surgeons but also for the patient for her to have very precise information before the procedure for us to have a good strategy.
What do we do? We start with a good clinical examination. We do a transvaginal ultrasound. If it is normal we think that the patient does not have disease or she has disease in the early stages. We may be more conservative for this purpose. If this is conclusive we can plan the treatment in a very appropriate mode. If we have questions about the ovary here we can do the MRI, questions about the bowel or the rectovaginal septum, here we can indicate transrectal ultrasound. I think that the last time I did it was more than five years ago because we do not need transrectal ultrasound nowadays, and questions about the urinary tract, the urinary MRI or urography may be considered.
And for perspective, we are finalizing an important study showing that we can even use imaging methods to try to stage the disease before the procedure. This is something that is feasible and we are planning to publish it soon. We have other techniques coming like the elastosonography for this purpose or even the ultrasound navigation with 4D reconstruction, as a perspective for us just to try more and more to discuss. And having this goal here – that is the image fusion for us to think about the disease in a more appropriate mode before the surgery.
Thanks a lot it is a big pleasure to be here.