In most cases, I favor treating patients definitively (I will list the exceptions to this recommendation in following commentary).
This means that I recommend all endometriosis is completely excised from the body. Up to this point in time, the only way that I am aware of that this can be done is by surgical excision. While I favor doing this Laporoscopically (using small umbilical and accessory ports for instrument insertion), this treatment can also be done by laparotomy (open incision). The energy source used for excision is best left to the experience and confidence of the surgeon, but I use the carbon dioxide laser as my energy source (why will be the discussion of another blog; see also http://centerforendo.com/dr-albee-on-excision).
There is one critically important aspect of excising all disease that is often overlooked by surgeons. Subtle ‘endo’ can hide in peritoneum that looks atypical, but does not have one of the ‘classic’ appearances of ‘endo’. In order to have low recurrence rates, surgeons must not leave any disease behind. This means that the surgeon must be committed to removing abnormal/atypical peritoneum even when it does not have a ‘classical’ appearance. For more on this discussion, refer to one of my academic papers on the subject: https://www.ncbi.nlm.nih.gov/pubmed/18262141.
Definitive treatment in my experience is the most effective treatment because it:
– Results in the longest intervals of time before retreatment is required (our data continues to indicate that 80-85% of our patients are currently free from any clinical indication of recurrent ‘endo’);
– Results in a significant improvement in ‘quality of life’ and pain reduction scores on follow-up surveys; and
– Fertility rates improve in stage 2, stage 3,and stage 4 cases after excision
The emotional burden of being told that you have an incurable disease is enormous. I do not tell patients that I am going to cure them, but I do tell them that if they have any more ‘endo,’ they will be the exception and not the rule (understanding that not all pelvic pain is the result of endometriosis and there are often comorbidities which also need to be addressed). Please note my above figure on our percentage of clinically disease-free patients after excision.
In following blogs, I will discuss the current objections to definitive treatment, and the reasons that I feel it is not more commonly used. But up next, let’s talk about ‘when I do not recommend definitive treatment.’ Stay tuned!