Journal Review in Colorectal Surgery: Bowel Endometriosis

Welcome back to another episode of Colorectal Surgery Journal Review with Drs. Glandiak, Kavalukas, Bolszynski, 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. Fahr Nazat joining us today. Dr. Nazat is a Clinical Professor of Obstetrics and Gynecology at Weill Cornell Medical College of Cornell University. He's Director of the Division of and Fellowship of Minimally Invasive Gynecologic Surgery and Robotics at NYU Lugon 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 Lap Endoscopic Surgeons, the Society of Pelvic Surgeons and many others. He frequently serves, 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. Naza. My pleasure. Thank you very much for asking me to participate. So Dr. Dezant 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, that article in 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 and Long Term Results by Warney et al. And a brief article recently published in colorectal disease titled the impact of surgeon 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'll give you a little bit of background.

My older brother, Kamran Nejat, he is the inventor of the video laparoscopy. He was the person that started the video laparoscopy. That we are all using these days in laparoscopy. He is a reproductive endocrinologist in 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 laparoscopy to find endometriosis, and then he was doing laparotomy to take care of it, even a small 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 laparoscopically. And then he

used to bend over the scope. It was difficult to do it. And he borrowed the scope from the other discipline, connected it to a scope, and he developed a video laparoscopy. And then he published. his first series of treating endometriosis laparoscopically 80s. And then And he published that with the video laparoscopy, the pregnancy rate and the pain relief is significantly higher than laparotomy. And then that was the beginning of everything. And then I I joined him in 1987, after I did my residency. I had done fellowship in REI before. I joined him, and then actually he probably presented the first abstract in laparoscopic treatment of the bowel endometriosis in 1988 in

American Fertility Society. And then later on my The youngest brother, Sinan Nejad, he joined us in the early 90s, and then later on my niece, Azadeh Nejad, she joined us. So that is the history. And now 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, 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 cases very

interesting. The first case in 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 Blummer's shelf. I'm not sure if it's used in the U. S. 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 blue on the shelf that we use it for ovarian cancer when we do a rectal vaginal examination. Frozen pelvis, what we mean is only laparoscopic findings. This is when most of these patients, even they have had Bad endometriosis, a stage four endometriosis, or they have had surgeries before, and now they have developed adhesions, and frozen

pelvis, it means that the rectosigmoid colon is being pulled up, severely attached to back of the uterus, and adenexa, and that way we don't see anything deep pelvis. We call it frozen pelvis, and it is very difficult to separate the Colon an each other because of the inflammatory process of endometriosis and a visions. However, as you mentioned, when the, one of the most common area of endometriosis is posterior culdesac and when you do rec examination and we feel a nodularity, we call it nodularity, and you feel a no between the rectum and the vagina. It is a sign that there is endometriosis in the pouch of Douglas between the rectum and the vagina and uterus sacral decamps. 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, 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 muscles. And I guess my other question to you is, is endometriosis directly associated with levator ani spasm? Or is there any direct association due to pain? What is your view on this? Oh, both of them, because endometriosis is a posterior cul de sac. Even if it is a mild disease, it could cause pain, and this patient, because it is a chronic disease, they have this long duration of the spasm in their pelvic. All endometriosis could affect the nerves. in the pelvic, in different branches of the inferior apogastric plexus

nerve and pudendal nerves that goes towards the deep pelvis. So that is the reason that when we take care of the endometriosis, we all, and the patient has this type of the 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 a pelvic physiotherapy to take care of this long duration of the 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 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 It's too deep or whatnot, and then you convert. So, if, if, when you, 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 scarring. And when you resect them, you want to be sure you have completely eliminated it, but at the same time, because it's sitting in 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

cirrhosis and macularis, the two layers of macularis, you guys know that, rarely gets to the mucosa. Rarely. That is the reason a lot of this patient rarely you see a rectal bleeding, that they have bowel symptoms, or you do colonoscopy and rarely you see lesion in the mucosa of the, of the rectum or transverse colon or ascending colon. That the patient has bowel endometriosis. So, what we do, we, when you want to eliminate a disease, as I said, you want to use the least damaging surgical technique. So if you could be the tip of your scissors or electro surgery or sometimes 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. Either you could use a high energy, like plasma chest, CO2 laser, and even high power telesurgery, and ablating. Or you could excise it. But when you excise it, you have to be sure you are not going too deep. If you think you have removed a peak, portion of mastodonus of the bowel, and then we suture it. So that is called shaving. Now, sometimes You have to go deeper. You have to go deeper. As I said, it rarely gets to the mucosa, but the big depth of the macularis of the bowel is involved, and you want to be sure to get a good margin, you excise a piece of the anterior or lateral rectal wall, and then you repair it, and usually we do just those ones if the lesion is less than five centimeters. The average is

three centimeters, a very good size, that you excise them completely, you know you have got a very good margin, and you, any type of the energy you want to use, and then you repair the bow. So, either you repair the bow with the sutures, Or sometimes you could use a stapler, either you could use the circular stapler, you put in the rectum, mobilize the bowel, and push the segment of the bowel between your anvil and the the stapler, push it down, And you close it and you resect it, or you fire across it endo GIA and you remove it without causing a stricture of the colon. Can I, Farah, 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 preoperatively to see you could, how you could find some people are very good with the ultrasound, transversional ultrasound, if it is in the lower portion, not the 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 it. However, still, unfortunately, there is false negative and false positive. So, the best way chosen at the end is laparoscopy to find out how big the lesion is and how deep the lesion is. Back peer operated imaging also is useful. 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 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 with 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 rectovascular 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 patients that have missed it, and then When we externalize the, the bowel and we palpated it, and we have felt it. But most of these patients, they have some sort of signs. Either the the bowel has discoloration,

or it is tethered, or there is a little bit narrowing of the areas that you could feel that there is something under it. Thank you. Sorry for attacking you with all these questions. Two more, 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 infection, say streptococcus bovis and the association with colorectal cancer. Are there any associations with the particular bacterial, either, you know, systemic or a or an infection that you can culture via the, either the bowel or swabs in the vagina and endometriosis? The short answer is no, it is not. At the present time, it is not. And going back, I

mentioned before, endometriosis is an inflammatory estrogen dependent disease. So, anything that increases inflammation and also the estrogen could contribute to progression of this disease. It is not necessarily to start it, to progression of the disease. Now, the disruption of the macrograms of the, of the, of the rectum, this had been suggested that When this balance of the bacteria of in the rectum is being altered, then there is disruption of the, of the immune response. And then some bacteria may be, or the an antibody, yeah, the antigen could penetrate outside and could cause inflammation. And also we know that a 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 the, this macrobooms 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 has helped them not only for pain, also has helped them for infertility. At the present time, there is no specific bacteria that you could culture in the rectum of the vagina. Thank you. 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 percent sure a patient has endometriosis is do laparoscopy. And we know endometriosis, it is a benign

proliferation of the, of the, of the tumors. As I mentioned the endometriosis could become malignant. As for any other type of the 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 blood tests. And there are several companies are working on it to find out. A test so far has not been successful, but I'm 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. That so far there's nothing either in the market. There is one test that we do

on endometrium. It is called PCL six, that has been shown to be very accurate for diagnosis of endometriosis, but no, no blood tests yet. Thank you. So I guess we've got another paper to kind of juxtapose this topic to the paper was, 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 and asthmatic stenosis was in five studies and voiding dysfunction was in nine studies. Of note when analyzing rectal shaving the authors do state that the technique was unique to each team. And I think Dr. Nassar mentioned his approach to that, which was great. Disc excision techniques were divided into two groups, being stapler and scissor at freehand, which again, Dr Nazat has already mentioned. In terms of the overall complications, the complications with shave was the lowest at 2. 2%. Disc was 9. 7 percent 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 percent in the segmental resection group. And to me, this, this seemed quite high because the incidence of anastomotic

stenosis in colorectal cancer surgery I mean, it varies in, in the publications, but certainly in my experience is far less. And, 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, but stapler size they've chosen. But I mean, it's hard. I don't know what Dr. Nuzat, what stapler size would gynecologists be using for this? That's an excellent point. I think in my in my career, I have had only one rectal stenosis, and that patient had a long history of the endometriosis. Actually, she 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 she had to go back to the colostomy. I think the reason for the stereotype is two things. First of all, This is a inflammatory disease, as I told you, and fibrotic disease. So some area, maybe the margins are negative, but still, people have done studies that they have gone beyond, beyond the anastomosis and they resected the bowel, and still there was macroscopical endometriosis in that area. And also, because this is a very fibrotic disease, 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 caused the anastomosis stricture. And I think when looking at

studies like this, you when you're looking at the forest plots, I mean, you have to also look at that 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 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 2, 000. Yeah. 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, that may be involved. And, you know, Overall, like Dr. Bolszynski said, the overall major complication rates in, in this article, when we're taking with kind of a grain of salt is low for shaved biopsy, but they put disc and segmental resection, kind of similar overall complications which 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 shaved 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, you mentioned before? They say alien.

You have to realize that these people are, most of them are young, and you want to do the least possible problems, and if they have leak, and then they have perineal infection, it could affect the fertility, affect the fallopian tube and the ovaries. So. Even if you leave a small amount of disease, for example, you have taken 80 percent of the disease, especially you have taken excise and taken to biopsy to be sure there is no premalignant disease, because some of these patients lesions could be malignant or premalignant. As long as you have taken care of maybe 80 percent of it. And You leave the rest of them behind, but it 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 centimeter from the anal verge. You don't

want to disrupt the nerve because if you want to do. So, even if you want to do this excision and be sure the repair is tension free, you have to mobilize the bowel, and when the lower you go, you are affecting the inferior epigastric flexor's nerve, and then you could create constipation or urinary retention, and even sometimes vaginal dryness, and some of the patients will have complaint about the lack of the orgasm. So, you have to try to keep in mind all of those things. So you the best way, as I said, best to individualize the case and also work with the, the colorectal people and the joann and see what the patient's symptoms are. The patient's infertility. You find a lesion and then you are remove the lesion att as possible or shaving technique that as you, you, you saw all of the studies have shown shaving has the least. complication, a higher chance of

recurrence because you leave some disease maybe behind, and the next one is desection. Right now, in our practices, we do segmental resection, anything below the rate of sigma E colon, only if there is a stricture above sigma E colon that the nerves are not be interrupted. That's no problem. If we cannot do this excision, we do segmental resection, and minimally invasive surgery can be done very well. Iliocycline, the same way, you could do segmental resection, but below the Deep pelvis, we try to avoid segmental resection and do shaving. The next one is this excision. Again, as I mentioned, because you don't want to alter the The blood vessels and also the bleeding over there, you know, deep pelvis, hemorrhagic artery, sometimes very vascular and it's very difficult to control them, especially obese patient. 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. 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, your practice and, and using a bowel prep? Preoperatively, but that's a good point. I give the killing about the day before and the use a ERAS protocol. You ask them to eat a carbohydrate, give them by the awesome to clean about giving the some some sort of laxative and interoperatively. Again, we use the cephalospirin, but if we get to the bow, we give phylagis to. So we have modified. Our technique, and it has worked very well for us. Do you do an osmotic bowel

prep? Yeah, either we give the fillets enema, or one of these laxatives to drink it the night before. A full, like, colonoscopic kind of quality bowel prep. Exactly. Exactly. Okay. All right. 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 3rd selected article functional outcomes after rectal resection and deep infiltrating pelvic endometriosis long term results published in DCR in 2018. This is a paper from Switzerland with the lead author being Mateus Warny. It's a single center retrospective study which aimed to assess late postoperative 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 period of nine years. The average age of the patient was 32. 75 percent of them had had a prior surgery for endometriosis, 94 percent underwent resection laparoscopically, and a little more than half of the patients had a colorectal anastomosis below seven centimeters from the anal verge, so low. They, they dichotomized it to lower high from seven centimeters. They reported a 2 percent leak rate in this study with one rectal vaginal fistula, and 70 percent of patients reported no long term menstrual related pelvic pain. 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 zero to two, but again, the range preoperatively was zero to 11 and a range postoperatively, zero to 15, and the incontinence score increased also from. Zero to two with similar ranges. These increases in the paper were noted to be statistically significant. However, in the discussion not necessarily clinically significant from zero to two. There was also a subgroup analysis of the anastomotic height less than seven or greater than seven centimeters. And of those, the greater than seven 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, but I believe this article hits on two important points that we've all, 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 as well. 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. These questionnaires. And as I said, we publish ourselves using the segmental resection, and we had some chronic constipation, but unfortunately we didn't have unit retention, as we have seen. We have seen from other people that do a lot of segmental resection. We see it. So, this is the article, 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, yes, all these patients do well regarding the pain. More than 75 percent of these patients, regarding their pain relief, they do well. Regarding the pregnancy rate, Also, if you go have their own, as long as you follow beyond tools and you always are fine or you have the IVF, a lot of them may 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. Also, the numbers are small, not too many, not too many patients. It is good that still they have had some. Worsening of the bowel function, constipation, and also urinary issue. So, and 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 high enough, they have more problem. Actually, to us, it is reversed. If it is lower, I would assume too. Yeah, that's what we say. Yeah. Exactly. So, as I said, these are, as you mentioned, these are the, how you define it, and this is the first, maybe, series. I am sure these people continue later on, in five, six years from now, they will again go towards a more advanced 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 that, 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, minimally invasive, I call it 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, we'll resect this. But now I, 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 bow, 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 I think it started by saying that endometriosis is a very common disease. This is what we believe. that the colorectal surgeon or urologist don't know about endometriosis. The gynecologist, they are not surgeon and they are, they, they leave the disease behind and they, so this, 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 laparoscopy and minimally invasive

surgery. And you all know minimally invasive surgery is less morbidity compared to laparotomy. Not only you could see better and diagnose the disease better, of course you have less morbidity. So, For, for, for you, for young people, all of you that definitely you should get involved in endometriosis. But that actually leads us into this last article that we reviewed, which was the impact of surgeon specialty on outcomes following resection for endometriosis. And you know, 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 over my gynecology colleagues, but I think, you know, a certain. techniques such as resection.

Some of the odds ratios kind of went more towards the complications for for gynecologic surgeons versus others. And then I think the big take home what was that, you know, considering a multidisciplinary or dual surgical team, I think is probably the best. That's certainly, you know, what we try to do and 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 the infertility. A lot of times, if they call me, the operating room, some colleagues, they have called me, come here and see what

you think you want to do. I say, hold on, hold on. How old is she? How many kids does she have? Let's look at this 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 ovarian reserve may come down. So the beauty of laparoscopy is that you could stop. Stop, evaluate the patient. You get the MI to see if she had deep infected endometriosis. So, our practice, I was, was interested when I read this article that say, oh, the, the complication rate of the general gynecologist and colorectal and the same, not too many general gynecologists have even privileges. to do bowel resection. Even if they have a small introtomy, they have to call a general surgeon to repair it. So who are these people? Do they have GYN oncologists that they

had the privileges to do bowel resection? I am a GYN oncologist myself, and I am working in Manhattan. My colleague from Sloan Kettering, when they have bad endometriosis, they send it to me, and they're oncologists, but they know endometriosis is a different disease. Okay, so I was surprised to see the data. Yeah, you do bowel resection and you talk of the, maybe the 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. 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. Again, that is the reason that we, in my practice, when I refer the patient, it is not unusual that before I take them to the operating

room, send them for their consultation with the REI, if they want to freeze the eggs, but 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 them on anti estrogen, like GnRH, agonist or antagonist or progesterone. There's less inflammation, less bleeding, and less damage to surrounding structures. 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 when 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 area can be helpful. Exactly. You see what I'm 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, any doubt, you put suture on the on the area. So, again., you are Colorado people. Every day you are there. We are not. We are GYN. And even to all of our experience, still we are not as good as you guys. So that is the reason, working together. Definitely helps you and also we are still better at night. So far. Thank you so much for taking time out of your meeting. We really appreciate it. This has been wonderful. Yeah, so so nice to have you and 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 seven to ten years before being diagnosed. Three, always consider the impact of fertility and therefore do the minimum intervention. Four, shave excision whenever possible. And five, refective stenosis present. With that, a big thanks to all the Behind the Knife listeners for a great last two years, and for the last time, dominate the