BLOG #5 QUESTION: IF ‘COMPLETE EXCISION’ IS THE GOLD STANDARD FOR ENDOMETRIOSIS TREATMENT, WHY IS IT SO UNCOMMONLY OFFERED?

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Following is a list of factors that negatively impact the use of ‘complete excision’ to treat endometriosis.

Most Gynecology (gyn) training programs continue to teach that ‘endo’ is a chronically recurring disease regardless of any form of treatment. Of course, my own experience using complete excision – LAPEX – is that after a carefully performed LAPEX, less than 10% of patients have a subsequent surgery during which endo is diagnosed and pathologically confirmed.

This teaching that endo is a chronically progressive disease in spite of treatment mistakenly leads gynecologists to believe that any surgical treatment short of removing all pelvic organs (ie. hysterectomy, tube and ovary removal) is a waste of time, energy, and resources, and that conservative surgery (like LAPEX) requires a surgical risk that does not have a long term benefit.

Gynecology resident doctors have only limited opportunities to treat endo during residency training programs. Furthermore, exposure to surgical treatment is often limited to patients with stages 3 and 4 disease who are requiring removal of uterus, tubes or ovaries. To my knowledge, there are no gyn residency programs teaching their residents the LAPEX surgical procedure. If a gyn surgeon wants to learn to excise the disease Laparoscopically, he/she must seek out post residency training, usually as a Fellow at a center of expertise like ours (Center For Endometriosis Care). This additional training needs to include delicate dissections of endo and scar tissue around bladder, ureter, intestines and beyond.

Even when these skills have been mastered, surgeons may face invasive endo in organs and need to remove segments of intestine, portions of the bladder wall, or a section of ureter. If specialists are not immediately available to assist the gyn surgeon, the case may need to be prematurely interrupted in order to assemble a team of appropriate specialists to complete the necessary surgery.

Therefore, if a gyn surgeon is encouraged to see for him/herself if results (like the ones I can attest to after decades of experience) can be achieved in their hands, it is not a simple substitution of an alternate surgical procedure – special training is necessary.

The lowest rates of recurrent endo are reported when the surgeon removes all abnormal/atypical peritoneum. If the surgeon relies on his/her visual expertise in recognizing endo, some of the disease is likely to be left behind resulting in incomplete excision. Obviously, recurrence rates will be higher in this situation, and this leads to underestimating the value of complete excision. In one of our own published studies, we found that complete excision required removing all atypical peritoneum, because atypical peritoneum frequently contained microscopic endo (I will also discuss this further in a future blog).

In endo cases with extensive disease, there is a valid concern that LAPEX will create adhesions in the internal excision sites as the patient heals. However, adhesions also form when the disease is left untreated or simply suppressed by drug therapies.

In Blog #3 I discussed circumstances that I feel allow for delaying definitive surgery. If quality of life, infertility or pelvic masses do not require disease excision, it may be reasonable to suppress endo using simple ovulation inhibition, and follow the patient closely. However, in my experience, it is best to remove all disease via LAPEX and then if necessary treat the adhesions as required subsequently. Using this plan, follow-up surgeries were significantly less complicated because there was no more disease. When adhesion treatment is not complicated by endo, I found success rates to be significantly higher. The important thing to remember is that adhesions may be a problem in endo patients with or without surgical treatment. Avoiding LAPEX offers no guarantees that adhesions will not progress.

Misleading information is being provided to gynecologists regarding the effectiveness and safety of strong drugs that are bringing in literally millions and millions of dollars to the manufacturers. If the information that the manufacturers provide is not read very carefully, the reader may conclude that a drug generally controls endo, that it can be used for an indefinite amount of time, and that the side effects are easily tolerated by the majority of patients. In my experience, these are inaccurate conclusions for all except oral contraceptives.

Finally, there is no financial incentive to learn excisional skills or to perform long surgeries painstakingly excising every bit of endo and all atypical peritoneum. In the majority of cases, insurance companies/government programs pay the same amount for a simple Laparoscopy (such as a diagnostic Laparoscopy with removal of an ectopic pregnancy) as they do for a 4-6hr meticulous, complex LAPEX. Additionally, if the surgeon takes 15-30 minutes to remove an appendix because it contains endo, he/she is paid nothing because “most appendectomies are incidental.”

When each of the above factors is taken into consideration, I think it is easy to understand why the ‘gold standard’ of treatment is the exception and not the rule. Only in highly motivated surgeons do we find this treatment available today. The good news is that we are making progress in the training of more surgeons qualified and motivated to treat endo definitively.

Stay tuned!