The Medical Symposium 2022
Commemorating endometriosis awareness month in March, the Endometriosis Foundation of America (EndoFound) organized a series of events including Patient Days and the 13th Endometriosis Medical Symposium under the theme “Here, There, and Everywhere”. These events brought together researchers, clinicians, patients, and caregivers to discuss various aspects of managing endometriosis.
The 13th Endometriosis Medical Symposium
The 13th Endometriosis Medical Symposium saw experts discussing the etiology of endometriosis, particularly with respect to endometriosis beyond the pelvis.
The meeting, which brought together renowned obstetricians and gynecologists, was moderated by Dr. Tamer Seckin, Attending Physician at Lenox Hill Hospital and the Founder and President of EndoFound.
Dr. Frank Chervenak, Chair of Obstetrics and Gynecology at Lenox Hill Hospital introduced the symposium.
Here are highlights from each of the presentations.
Delicate microsurgery needed for effective endometriosis surgery
According to Dr. Victor Gomel a Professor Emeritus at the Department of Obstetrics and Gynecology, University of British Columbia surgery is the most effective way of treating endometriosis and a delicate microsurgery procedure is the need of the hour for endometriosis surgery to be effective.
Dr. Gomel advocates the delicate handling of tissues with judicious use of electrical and laser energy taking cues from cleavage planes to completely excise endometriosis lesions. According to Dr. Gomel, precision alignment and approximation of tissues are essential.
Dr. Harry Reich’s endometriosis journey
Dr. Harry Reich a known pioneer in the field of laparoscopic surgery spoke about his endometriosis journey and how he started working on endometriosis in the 1970s without much help from anyone. He soon discovered that he could separate the endometrioma cyst wall from the ovarian cortex.
In the early 80s, he started cul-de-sac dissections and realized that fibrous tissue had endometriosis in it, and removing it was essential. Dr. Reich’s technique focused on going around the endometriosis lesions and bordering healthy tissue. He reiterated that it is necessary for the surgeon to physically feel the tactility difference in this area and that this would not be possible with laser ablation or robotic assistance.
Theories of endometriosis origin
Dr. Dan Martin EndoFound’s scientific and medical director and a Professor Emeritus at the School of Medicine, University of Tennessee Health Science Center focused on the origin, activation, and development of endometriosis, which is key to understanding disease etiology.
Dr. Martin discussed the possible causes of endometriosis. His website details several aspects and theories of disease origin including “the first cell of origin”.
Relevance of John Sampson’s theories today
Dr. John Yovich from the Pivet Medical Center and a pioneer in the field of in vitro fertilization (IVF) and the doctor who delivered Western Australia’s first IVF baby in 1982 gave a broad picture of the history of endometriosis prior to Sampson’s discoveries. He also talked about the current understanding of disease etiology that still draws from his theories.
Unlike popular belief, Dr. Yovich said that retrograde menstruation is not the most likely cause of the disease. He suggested that the disruption of the protective sub-endometrial anemic zone is the primary cause of adenomyosis and severe forms of endometriosis such as deep-infiltrating endometriosis of the rectum (DIER) or Cullen’s disease.
Role of stem cells and epigenetics in endometriosis
The session further continued with Dr. Hugh Taylor, an Anita O’Keeffe Young Professor of Obstetrics, Gynecology, and Reproductive Sciences at the Yale School of Medicine. Dr. Taylor said that the transport of endometriosis lesions to locations outside the peritoneal cavity could possibly be linked to stem cells, which can potentially differentiate into the endometrium.
Dr. Taylor also spoke about the role of microRNAs in disease progression, particularly the Let-7 family of microRNAs. Researchers have shown using mouse models of endometriosis that stem cells, microRNAs, and inflammation contribute to systemic effects such as weight loss and changes in brain physiology. Screening for circulating microRNAs can also act as a potential biomarker test for endometriosis, Dr. Taylor suggested.
Clinical aspects of stem cells in endometriosis
Continuing from Dr. Hugh Taylor’s presentation, Dr. Ray Garry, Professor of OB/GYN from the University of Western Australia, Perth, talked about the clinical relevance of the stem cell approach in understanding endometriosis. Endometrial epithelial cells are shed during menstruation. So endometriosis lesions may likely originate from the differentiation of precursor stem cells, which may also be present in the bone marrow, Dr. Tayolor explained.
Extra-pelvic endometriosis pathophysiology
Dr. Togas Tulandi, Professor and Academic Vice Chairman of Obstetrics and Gynecology at McGill University, Canada spoke about the spread of endometriosis beyond the pelvis by elucidating differential diagnoses in several case studies. Current theories to explain endometriosis spread to extra-pelvic regions include retrograde menstruation, hematogenic spread, lymphatic spread, coelomic and metaplasia.
Dr. Tulandi said that the presence of extra-pelvic lesions and catamenial pneumothorax is an indication of pelvic endometriosis. He further went on to detail the pathophysiology of primary umbilical endometriosis, the relation between catamenial pneumothorax and endometriosis, diaphragmatic endometriosis, and endometriosis of the appendix.
Thoracic endometriosis is the next frontier
Dr. Tamer Seckin spoke about why thoracic endometriosis is important and how there’s little information about this critical form of endometriosis. Dr. Seckin shared findings from the literature that showed that up to 80% of women having thoracic endometriosis also had concomitant pelvic endometriosis along with diaphragmatic anomalies.
Dr. Seckin advocated the use of a dual-compartment approach to treat thoracic endometriosis. This would involve both video-assisted thoracoscopic surgery (VATS) and laparoscopic deep excision surgery to probe both the pelvis and the thorax simultaneously. This can allow the surgeons to study both visceral and pleural lesions in both regions and mark them for complete removal, Dr.Seckin said.
Reliable imaging in endometriosis
Dr. Alessandra Di Giovanni talked about how ultrasound and magnetic resonance imaging (MRI) have advanced enough to challenge the laparoscopic diagnosis of endometriosis, which is still considered to be a gold standard. Dr. Di Giovanni, who is a consultant for Endoscopica Malzoni – Center for Advanced Pelvic Surgery, Avellino, Italy, spoke about how imaging scans can guide therapeutic approaches and help set up a proper surgical strategy.
Dr. Di Giovanni showed experimental evidence for the effectiveness of transvaginal/transabdominal pelvic ultrasonography in accurately predicting deep infiltrating bowel endometriosis in 3 dimensions. She also advocated the use of both transabdominal and transvaginal scans to get complete information for accurate diagnosis. MRI, while useful in expert hands, should not be preferred over ultrasound, Dr. Di Giovanni said. Also, diagnostic laparoscopy should not be performed unless absolutely needed. The clinician should have proper knowledge of pelvic anatomy and specialized training in DIE in order to reach an accurate diagnosis.
Dr. Mario Malzoni receives the Dr. Harry Reich Award 2022
Dr. Mario Malzoni, the Director of the National Center for Endometriosis (Malzoni Group), Italy spoke about different approaches that his team uses to diagnose and treat endometriosis. Dr. Malzoni spoke about his approaches to scanning for deep endometriosis nodules and accurately identifying them. He said that the aim of surgery should be to improve symptoms, restore function and anatomy, preserve fertility, and minimize neurological damage. He described in detail parametrial endometriosis, particularly the skillful navigation around the ureter.
In view of his significant contributions to endometriosis research and surgery, Dr. Tamer Seckin announced that the Dr. Harry Reich Award for 2022 would be presented to Dr. Malzoni. Dr. Harry Reich recollected his association with Dr. Malzoni and said that he is honored to be presenting this eponymous award to him.
An evidence-based ethical approach to patient-centered endometriosis surgery
There is a need to base surgical decisions on evidence and ethics while adopting a patient-centered approach. This was according to Dr. Philippe Koninckx from the Latifa Women and Children Hospital Hospital in the United Arab Emirates. Dr. Koninckx spoke about the importance of understanding statistical measures and bias in data. He also touched upon how to make critical clinical judgments pertaining to diagnosis and treatment.
A patient-centric approach that includes informed consent about the surgical technique being used along with chances of procedures such as ovariectomy needs to be followed, Dr. Koninckx said. A genetic-epigenetic pathophysiology understanding is necessary to prevent the formation of new lesions and study patient responses.
Genetics in endometriosis treatment
Further on, Dr. Serdar Bulun from the Northwestern University Feinberg School of Medicine, Chicago, delved into how genetics can inform treatment choices.
Dr. Bulun presented work that demonstrated the accumulation of KRAS mutations in the endometriotic lesions further validating the epidemiological link between ovarian cancer and endometriosis. His group also found epigenetic abnormalities that can speed disease progression, particularly within the gene coding for aromatase. Thus, aromatase inhibitors can be particularly useful in endometriosis treatment, according to Dr. Bulun.
Sciatic endometriosis, the real, deep endometriosis
Dr. Marc Possover, Director at the Possover International Medical Center and a pioneer in the relatively new field of neuropelveology and minimally invasive surgery for pelvic gynecologic tumors talked about the relation between endometriosis and neuropathy, which is one of the common symptoms of endometriosis. He detailed how endometriosis can affect the sciatic nerve and the sacral plexus resulting in a typical sciatic pain radiating to the legs.
Dr. Possover also said that proper diagnosis is essential to confirm neuropelveological diagnosis. Sciatic nerve surgery has to be done in one shot, and requires a lot of expertise, Dr. Possover said. The surgeon should know which nerve to act on, he said. The nerve should be fully released from the endometriosis lesion and associated fibrosis as the pain is likely to persist otherwise, he added.
Colorectal endometriosis management
The session continued with Dr. Horace Roman‘s presentation on managing colorectal endometriosis. Dr. Roman is from the Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France, and specializes in minimally invasive endometriosis surgery. Dr. Roman talked about the different types of colorectal deep endometriosis nodules and the various approaches for treatment, particularly shaving, disk excision, and segmental resection techniques.
Shaving can be a good, first-line treatment option in elderly women or in conditions of post-operative amenorrhea. Dr. Roman said he prefers disc excision as it can help with complete excision while retaining bowel length and volume without denervation and can be easily sutured. Colorectal segmental resection, on the other hand, is a more radical management approach that requires the removal of a whole bowel segment. He also stressed that surgeons performing colorectal resection should be aware of low anterior rectal resection syndrome that results in constipation, frequent bowel movements, and rectosigmoid stenosis.
Endometriosis in adolescents
The last presentation of the day was delivered by Dr. Valerie Flores from the Yale School of Medicine on endometriosis in adolescents. Dr. Flores spoke about challenges in endometriosis diagnosis in these patients. In adolescents, nearly 20 to 40% of those diagnosed with endometriosis had chronic pelvic pain with 50 to 70% undergoing laparoscopic surgery. Risk factors for endometriosis in adolescents include family history, early menarche, shorter menstrual cycles, and menorrhagia, Dr. Flores explained.
She said that the complex and systemic nature of endometriosis makes diagnosis difficult. Aside from Sampson’s theory of retrograde menstruation, factors such as stem cells, aberrant expression of inflammatory cytokines, and microRNAs are responsible for some of the systemic effects of endometriosis. Medical therapies that can possibly delay symptoms at least until menopause include progestins, GnRH antagonists, bazedoxifene-CE for endometriosis-associated pain, and Let7 microRNA mimics. Ultimately, surgery is needed to minimize the risk of recurrence, Dr, Flores said.
The full session can be viewed here.