Well aloha once again,
Last week I took a vacation and went back to my old stomping grounds in Hawaii. (don't tell anybody or they'll think I'm slacking!) It was great to see my house there, and my old friends. The highlight of the trip was seeing all the whales! It was truly whale season, and we must have seen 100 whales, more than I've ever seen. We were fishing one day on a boat, and this huge humpback breached right in front of the boat, then rested at the surface just off the bow for several minutes before diving back into the deep. That was cool.
So what's new in the realm of Endo???
Well, there was a new paper published this month that identified genes in the peritoneum of women with endometriosis that are not active in women without endometriosis. These genes are thought to promote the development of endometriosis lesions via the same pathways that were used during embryogenesis (the formation of organ systems in the first 10 weeks after conception). The genes were found in highest concentration within endometriosis lesions, then slightly less in normal appearing peritoneal cells of women with endometriosis, and almost none in the peritoneal cells of women without endometriosis. These same genes are important in the formation of a normal uterus and normal endometrial tissue. Their conclusion was the same as Dr. Redwine has spent his life trying to prove: that endometriosis forms by a metaplastic (change) process where normal peritoneal cells (cells lining the abdominal cavity) change tissue types such that they become cells that resemble the endometrium (endometriosis). This means that it is NOT formed by retrograde menstruation (Sampson's theory) and does NOT continue to repopulate the pelvis and regrow after excision, therefore it is NOT futile to remove endometriosis instead of giving Lupron. Gee, sounds familiar, eh????
When I was in Hawaii last week I told my old neighbors about what I was doing here in Bend, and about what endometriosis surgery was like. I told him that endo was like a weed that had really deep roots that wrapped around all the important structures in the pelvis like the ureters, bowel, blood vessels, etc. He said, "why not use Roundup?" I just laughed, because the analogy of Roundup to Lupron was so obvious. The endo weeds are resistant to Lupron roundup, so we have to be able to get in there and dig it out. I think it's a great analogy, so I thought I'd share it with you all.
So, I'm still taking suggestions for topics to write on. Let me know what you're interested in, if I'm answering your questions, if you think I should take a different tack, or whatever. I'm like the genie in the bottle - your wish is my command.
A Hui Ho (Hawaiian for "Until next time"),
Dr. Mos
Thursday, March 29, 2007
Tuesday, March 06, 2007
Endo of the bowel
Hi there once again.
Well, I had a request to do a little review of endometriosis of the bowel. Bowel endo is actually more common than one might think, with over 25% of our patients here in Bend having intestinal endometriosis. That number is most likely higher than the general population, as our patients typically have more severe disease than what the average gynecologist sees. Most doctors aren't familiar with the treatment for bowel endo, so these patients tend to float around from doctor to doctor looking for someone who can help them. Unfortunately, usually nobody has until they get to us.
The most common site of intestinal endometriosis is the sigmoid colon, the portion just above the rectum that lies on the left side just beneath the left hip bone. Following that, the rectum (behind the vagina and cervix) is next, then the last part of the small bowel, appendix, and cecum (beginning of the large intestine). Some patients have bowel disease in more than one location, and it is often associated with ovarian endometriomas (also called "chocolate cysts"). (as we said in Med school, "there goes another food group....")
If the lesion is of sufficient depth, endo of the sigmoid and rectum will cause pain with bowel movements (sigmoid - left lower quadrant pain, rectum - midline pain right where the lesion is). Most of the time these will hurt all month but can get worse during the menses, and rarely (if the lining or mucosa is involved) they can cause rectal bleeding during menses. Some women have diarrhea, constipation, or both in an alternating fashion, but these symptoms alone do not necessarily indicate bowel involvement as they can be seen in those with pelvic (non-bowel) endo as well. Endometriosis of the appendix, cecum, and ileum tend not to cause pain, but in rare cases if the lesion is large enough obstructive symptoms (nausea, vomiting, intermittent crampy pain) can occur.
Why can't some cases of bowel endo get diagnosed? Doctors of old had very few "tests" to do (x-rays, lab studies), so they had to rely on their ability to ask the right questions, listen to what the patient was telling them, and gather the data they needed by their 5 senses. Nowadays, since the advent of CT scans, MRIs, Nuclear medicine scans and the like, plus the atmosphere of "defensive medicine", most docs have lost at least some of the old-fashioned ability to make a diagnosis with their brain, eyes, ears, and their own 2 hands. Imaging studies are notoriously poor at finding endometriosis (with the exception of endometriomas), so in order to diagnose it, one must have a strong suspicion from the history and the physical exam. Rectal nodules can usually be felt on exam and are exquisitely tender, reproducing the defecatory pain, but nodules of the sigmoid colon or higher oftentimes cannot be palpated. Disease is then confirmed by surgery where the surgeon sees the lesions, then by biopsy where the pathologist verifies the lesion to actually be endo and not an imposter. If the surgeon doesn't routinely look at or think about the bowel as many GYNs do (or don't), even at surgery lesions on the bowel can be missed. For those docs who don't trust their own suspicions as much as they trust a CT scan, bowel endo will be missed because it usually doesn't show up on ultrasound, CT, MRI, or most other imaging study. Once in a while if the lesion is large and the radiologist knows what to look for these lesions can be seen, but not commonly. Colonoscopy and flexible sigmoidoscopy (a "mini-colonoscopy" where only the rectum and sigmoid are inspected) typically do not reveal endometriosis either, so unless one is both familiar with and suspicious of bowel endo, it likely will go undiagnosed.
What can be done for bowel endo? The good news is that most patients who undergo surgery to remove the lesion have excellent, long-lasting pain relief. The bad news is that these lesions (even when they are diagnosed) are typically not removed by gynecologists because most don't operate on the bowel. Some patients are referred to general surgeons for treatment, but most are placed on Lupron for suppression, even though it has never been proven to work for this type of lesion. When Dr. Redwine and I remove bowel lesions, most of the time the lesion can be removed by either a partial thickness or full thickness resection of a disc-shaped area, then the hole is sutured closed in layers. This is almost always done laparoscopically, and most patients go home within 24 hours of surgery. Sometimes if the lesion is very large or more circumferential, a segmental resection must be done. This involves removing a whole segment of bowel, sometimes up to a foot in length, then reattaching it using a stapling device. Because of the larger dissection involved and the longer operating time, these types of procedures will usually require a 3-4 day stay in the hospital to allow for normal bowel function to return, marked by the passage of gas (flatus is the $10 medical term). The irony is that these patients very often have immediate pain relief, and when they wake up from anesthesia they can tell that that deep, burning, agonizing pain they've been living with for years is gone. Their postop pain is usually nothing compared to what they've been dealing with preop, and it has been my experience that these ladies are the happiest patients of all. In fact, for both Dr. Redwine and myself, seeing these women pain free for the first time in years is our reward for the physical challenge of a long, demanding surgery. Long-term results of these surgeries are excellent with about 80% cured at 5 years, and fertility rates above 40% (not perfect, but much better than preop).
Our experience thus far has been to operate on almost 800 cases of bowel endometriosis, and to be honest, it is my favorite type of patient to take care of. The surgery is challenging, fun, and satisfying because these women do so well, both in terms of their immediate postop course and their long-term pain relief.
I hope this helps those of you who see a little of yourselves in the above descriptions, and I wish you the best in dealing with your disease. Remember, I'm doing free record reviews through the end of March, so if you think this might be you but you're not sure, don't hesitate to contact us. I'm really not typically into self-promotion, but in this case, I have to because not very many other docs in this country do this well, and I have to say, David's the best. And I'm getting there. Let me know what other topics you're interested in.
Take care, and have a great week.
Dr. Mos
Well, I had a request to do a little review of endometriosis of the bowel. Bowel endo is actually more common than one might think, with over 25% of our patients here in Bend having intestinal endometriosis. That number is most likely higher than the general population, as our patients typically have more severe disease than what the average gynecologist sees. Most doctors aren't familiar with the treatment for bowel endo, so these patients tend to float around from doctor to doctor looking for someone who can help them. Unfortunately, usually nobody has until they get to us.
The most common site of intestinal endometriosis is the sigmoid colon, the portion just above the rectum that lies on the left side just beneath the left hip bone. Following that, the rectum (behind the vagina and cervix) is next, then the last part of the small bowel, appendix, and cecum (beginning of the large intestine). Some patients have bowel disease in more than one location, and it is often associated with ovarian endometriomas (also called "chocolate cysts"). (as we said in Med school, "there goes another food group....")
If the lesion is of sufficient depth, endo of the sigmoid and rectum will cause pain with bowel movements (sigmoid - left lower quadrant pain, rectum - midline pain right where the lesion is). Most of the time these will hurt all month but can get worse during the menses, and rarely (if the lining or mucosa is involved) they can cause rectal bleeding during menses. Some women have diarrhea, constipation, or both in an alternating fashion, but these symptoms alone do not necessarily indicate bowel involvement as they can be seen in those with pelvic (non-bowel) endo as well. Endometriosis of the appendix, cecum, and ileum tend not to cause pain, but in rare cases if the lesion is large enough obstructive symptoms (nausea, vomiting, intermittent crampy pain) can occur.
Why can't some cases of bowel endo get diagnosed? Doctors of old had very few "tests" to do (x-rays, lab studies), so they had to rely on their ability to ask the right questions, listen to what the patient was telling them, and gather the data they needed by their 5 senses. Nowadays, since the advent of CT scans, MRIs, Nuclear medicine scans and the like, plus the atmosphere of "defensive medicine", most docs have lost at least some of the old-fashioned ability to make a diagnosis with their brain, eyes, ears, and their own 2 hands. Imaging studies are notoriously poor at finding endometriosis (with the exception of endometriomas), so in order to diagnose it, one must have a strong suspicion from the history and the physical exam. Rectal nodules can usually be felt on exam and are exquisitely tender, reproducing the defecatory pain, but nodules of the sigmoid colon or higher oftentimes cannot be palpated. Disease is then confirmed by surgery where the surgeon sees the lesions, then by biopsy where the pathologist verifies the lesion to actually be endo and not an imposter. If the surgeon doesn't routinely look at or think about the bowel as many GYNs do (or don't), even at surgery lesions on the bowel can be missed. For those docs who don't trust their own suspicions as much as they trust a CT scan, bowel endo will be missed because it usually doesn't show up on ultrasound, CT, MRI, or most other imaging study. Once in a while if the lesion is large and the radiologist knows what to look for these lesions can be seen, but not commonly. Colonoscopy and flexible sigmoidoscopy (a "mini-colonoscopy" where only the rectum and sigmoid are inspected) typically do not reveal endometriosis either, so unless one is both familiar with and suspicious of bowel endo, it likely will go undiagnosed.
What can be done for bowel endo? The good news is that most patients who undergo surgery to remove the lesion have excellent, long-lasting pain relief. The bad news is that these lesions (even when they are diagnosed) are typically not removed by gynecologists because most don't operate on the bowel. Some patients are referred to general surgeons for treatment, but most are placed on Lupron for suppression, even though it has never been proven to work for this type of lesion. When Dr. Redwine and I remove bowel lesions, most of the time the lesion can be removed by either a partial thickness or full thickness resection of a disc-shaped area, then the hole is sutured closed in layers. This is almost always done laparoscopically, and most patients go home within 24 hours of surgery. Sometimes if the lesion is very large or more circumferential, a segmental resection must be done. This involves removing a whole segment of bowel, sometimes up to a foot in length, then reattaching it using a stapling device. Because of the larger dissection involved and the longer operating time, these types of procedures will usually require a 3-4 day stay in the hospital to allow for normal bowel function to return, marked by the passage of gas (flatus is the $10 medical term). The irony is that these patients very often have immediate pain relief, and when they wake up from anesthesia they can tell that that deep, burning, agonizing pain they've been living with for years is gone. Their postop pain is usually nothing compared to what they've been dealing with preop, and it has been my experience that these ladies are the happiest patients of all. In fact, for both Dr. Redwine and myself, seeing these women pain free for the first time in years is our reward for the physical challenge of a long, demanding surgery. Long-term results of these surgeries are excellent with about 80% cured at 5 years, and fertility rates above 40% (not perfect, but much better than preop).
Our experience thus far has been to operate on almost 800 cases of bowel endometriosis, and to be honest, it is my favorite type of patient to take care of. The surgery is challenging, fun, and satisfying because these women do so well, both in terms of their immediate postop course and their long-term pain relief.
I hope this helps those of you who see a little of yourselves in the above descriptions, and I wish you the best in dealing with your disease. Remember, I'm doing free record reviews through the end of March, so if you think this might be you but you're not sure, don't hesitate to contact us. I'm really not typically into self-promotion, but in this case, I have to because not very many other docs in this country do this well, and I have to say, David's the best. And I'm getting there. Let me know what other topics you're interested in.
Take care, and have a great week.
Dr. Mos
Thursday, March 01, 2007
Hi there and Happy March!
I saw Bob Woodruff on TV last night, (he's the anchorman who nearly had his head blown off in Iraq last year), and he was in amazing shape. I couldn't believe how well he had recovered, especially when I saw a picture of him without part of his skull. I just wanted to take a minute and give out a big Oo Rah to all of the phenomenal military surgeons, nurses, corpsmen, and the entire group that is keeping our fighting soldiers and sailors alive and well over there. Most people may not know this, but most of the major advances in trauma care and surgical intensive care medicine have come from the battlefields. So, I'm proud to come from a military background (my dad was a cook in the Navy in WWII), and proud to have served in the Navy, and to have trained at Bethesda Naval Hospital. Stateside and peacetime military medicine may have some flaws, but if I was in Bob Woodruff's shoes with a major head injury, there's nobody in the world I'd rather see than the Navy or Army docs and crews.
Now to endometriosis.....
I'm having fun doing all these bowel cases. It's really true that endometriosis follows repetetive patterns, hanging out in nearly the same spots in most people. Once you get the hang of looking for important structures like ureters (the tubes that bring the urine from the kidneys down to the bladder), and you learn how to separate them from the fibrous web of scar tissue woven by the endometriosis-driven silk worms (just kidding - no worms, just scar tissue), and you figure out how to do all this without injuring the large vessels carrying blood to and from your legs that live just beneath all the endometriosis/fibrosis/scarred in junk, then the only thing left to do is to take the endo off the bowel wall, sew it up, and be done. That's a little like saying, "just give the space shuttle a little tune-up". Easier said than done. But, with practice and a great teacher (Dr. Redwine), it truly is getting easier.
The hard part is convincing the scientific establishment that endometriosis can be cured by removing it from the body. They all want to cover it up by giving Lupron, and now aromatase inhibitors. All that does is suppresses the activity of the endometriosis cells for a while, and lessens their ability to produce all those little biologically active molecules that cause pain, then when your menopause (induced by the Lupron) gets better, your pain gets worse again. I really think they don't want to admit that if endometriosis can be cured by surgical excision, then we need better surgeons than we have in general gynecology, and that 4 years of residency for learning all of obstetrics, office gynecology, surgical gynecology, and primary care (thrust on our specialty about 10 years ago for dubvious reasons) is just Not Long Enough to train excellent surgeons. I can truly understand the frustration of many of our patients who have been told "there's nothing we can do for you" by doctor after doctor.
Well, time to get off my soap box.
If you have issues related to endo, pelvic pain, incontinence, or women's health in general that you would like me to address, please let us know.
Take care, and have a great week.
Dr. Mos
I saw Bob Woodruff on TV last night, (he's the anchorman who nearly had his head blown off in Iraq last year), and he was in amazing shape. I couldn't believe how well he had recovered, especially when I saw a picture of him without part of his skull. I just wanted to take a minute and give out a big Oo Rah to all of the phenomenal military surgeons, nurses, corpsmen, and the entire group that is keeping our fighting soldiers and sailors alive and well over there. Most people may not know this, but most of the major advances in trauma care and surgical intensive care medicine have come from the battlefields. So, I'm proud to come from a military background (my dad was a cook in the Navy in WWII), and proud to have served in the Navy, and to have trained at Bethesda Naval Hospital. Stateside and peacetime military medicine may have some flaws, but if I was in Bob Woodruff's shoes with a major head injury, there's nobody in the world I'd rather see than the Navy or Army docs and crews.
Now to endometriosis.....
I'm having fun doing all these bowel cases. It's really true that endometriosis follows repetetive patterns, hanging out in nearly the same spots in most people. Once you get the hang of looking for important structures like ureters (the tubes that bring the urine from the kidneys down to the bladder), and you learn how to separate them from the fibrous web of scar tissue woven by the endometriosis-driven silk worms (just kidding - no worms, just scar tissue), and you figure out how to do all this without injuring the large vessels carrying blood to and from your legs that live just beneath all the endometriosis/fibrosis/scarred in junk, then the only thing left to do is to take the endo off the bowel wall, sew it up, and be done. That's a little like saying, "just give the space shuttle a little tune-up". Easier said than done. But, with practice and a great teacher (Dr. Redwine), it truly is getting easier.
The hard part is convincing the scientific establishment that endometriosis can be cured by removing it from the body. They all want to cover it up by giving Lupron, and now aromatase inhibitors. All that does is suppresses the activity of the endometriosis cells for a while, and lessens their ability to produce all those little biologically active molecules that cause pain, then when your menopause (induced by the Lupron) gets better, your pain gets worse again. I really think they don't want to admit that if endometriosis can be cured by surgical excision, then we need better surgeons than we have in general gynecology, and that 4 years of residency for learning all of obstetrics, office gynecology, surgical gynecology, and primary care (thrust on our specialty about 10 years ago for dubvious reasons) is just Not Long Enough to train excellent surgeons. I can truly understand the frustration of many of our patients who have been told "there's nothing we can do for you" by doctor after doctor.
Well, time to get off my soap box.
If you have issues related to endo, pelvic pain, incontinence, or women's health in general that you would like me to address, please let us know.
Take care, and have a great week.
Dr. Mos
Subscribe to:
Posts (Atom)
