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Accuracy of laparoscopic diagnosis of endometriosis
Peter Maher, MD and Liselotte Mettler, MD Peter
Maher, MD:
Liselotte Mettler, from Kiel, Germany is joining us today for an
interview and we are going to talk about the accuracy of the laparoscopic
diagnosis of endometriosis. I know that you have a specific interest in
endometriosis; could you tell me what particular features about laparoscopy that
you look for in making the diagnosis? Liselotte
Mettler, MD:
Peter, it’s my pleasure to answer this question on this level at the
AAGL here in Las Vegas. Endometriosis
has always been my particular disease of interest, and we have no other
possibility to diagnose it really other than by histological diagnosis with
laparoscopy. Because all the visual
aspects may or may not be endometriosis, and the tumour markers that we use are
really not that specific. So we tried to re-evaluate our visual diagnosis
compared to the histological result, and especially we did that looking at red,
white and black lesions. Now what do you think; which of the three kinds of
lesions, the red, white or black ones, gave a better correlation to the
histological findings? Peter
Maher, MD:
I would have been looking at the red or the white lesions over the black
lesions for specific correlation. Liselotte
Mettler, MD:
Well, we found that in the 216 patients, where we took biopsies from and
checked for all the different types of lesions, that the physiological outcome
in the red lesions was actually 100% in which we could really detect
endometriosis. That was surprising to me. And the second most frequent one was,
at 67%, the black lesions. Unfortunately for the white lesions, it was only
around 50% that were really found it to be endometriosis. Now,
looking to the different types of histology, of course in the white lesions we
found many times, fatty tissue in it – fibro-fatty tissue. I was wondering if
it was maybe true that we didn’t go deeply enough for the biopsy, because
we’ve had some white lesions, rectovaginal lesions, that you don’t even see,
and we call them white lesions. So actually I would like to say that the
findings brought a security in the red, and a good security also in the black
lesions, but not in the white lesions. Peter
Maher, MD:
Do you have a view on the place of bringing laparoscope up very close to
the peritoneum, and looking at any rough areas on the peritoneum? Do you have
any thoughts that may be of value in detecting very, very early lesions of
endometriosis? Liselotte
Mettler, MD:
We do that always if we want to see if some scar tissue may be
endometriosis. But only if you come really close can you see that there’s an
alteration. There is also the touching laparoscope idea, like with a contact
micro-hysteroscope, to do the laparoscopy. I couldn’t find a very good
application of laparoscopy really. Peter
Maher, MD:
Well, considering the very close correlation you do have with, as you
say, the red lesions and the black lesions, what are your thoughts about some
surgeons who treat endometriosis just by ablation of the tissue rather than
excision? Liselotte
Mettler, MD:
I think that is really not correct. The endometriotic lesions cannot be
just superficially ablated, they have to be really excised. Don’t you agree? Peter
Maher, MD:
I certainly do. At the Mercy Hospital of Women in Melbourne, we always
excise any suspicious looking lesions. Liselotte
Mettler, MD:
And it is our custom to do that, and we find also very good causation for
treatment after that. If we really go deeply down and excise them as much as we
can see, I think that the white lesions, they are sometimes where we are going
deeper down, we don’t get enough tissue with the biopsy to verify. Peter
Maher, MD:
One of the criticisms of that treatment is that it’s very, very
aggressive and may result in scarring post-operatively. It’s been our
experience that these patients heal up very, very well with minimal invasions
following excision. And I’m always weary about the dangers of deeply
coagulating any lesions for fear of damage to underlying tissues. Liselotte
Mettler, MD:
In the area where we do these excisions, in the broad ligament area and
the Pouch of Douglas, I think is not so dangerous to produce scar tissue there.
I think we can be excising in the safe part because there are not organs there
that bring about pain later on. There are no nerves really. Of course, if we go
deep down to the pelvic wall, then we should be careful. I
think a good excision is still the best treatment that we can give to our
patients. We can rely to a certain extent on the aspect that we should try,
before we do a very serious medical treatment of six months or longer, and a
costly one, and just also very effective in the patient because she is having
menopause symptoms and so on, we should be sure it’s endometriosis and not
just treat medically without having the diagnosis. Peter
Maher, MD:
What’s your view on excision of peritoneal patches? Do you think that
there’s a correlation between the peritoneal patch, do you understand what I
mean? Liselotte
Mettler, MD:
Do you mean a broad area? You mean to take an area 3 x 4 cm and excise
it? Like a peritoneal ablation in a
way? We would do this with a bipolar coagulation, or argon beam coagulation, or
laser beam unit; we use the argon beamer and I think that is quite effective. Peter
Maher, MD:
We are doing a trial at the moment and excising two cm around isolated
lesions and we’re finding quite a high incidence of satellite lesions that
aren’t visually detectable. Liselotte
Mettler, MD:
I think that’s very good to go in this so-called safe area, go around
even the area where you don’t see it; if you don’t produce scars generally
in the place where you go about. Peter
Maher, MD:
Do you think we’re any further advanced with our treatment of
endometriosis? Liselotte
Mettler, MD:
As in the versions of the last century, they settled on excision, and
we’re back with excision in spite of all the medical treatment we have tried. Peter
Maher, MD:
I think you’re right! Well, I thank you very much indeed. Liselotte
Mettler, MD:
Thank you.
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