The Great Debate 2002

Click here to view the video (requires free Windows Media Player)

William Schlaff, MD: “My name is William Schlaff. I’m the Vice Chairman and Chief of Reproductive Endocrinology at the University of Colorado. I’m here today with Professor William Ledger from Sheffield in the United Kingdom. We’re at the American Society for Reproductive Medicine Annual meeting in Seattle, Washington, and much of the discussion at this meeting has to do with infertility but another major topic is endometriosis. Indeed, there was a debate this morning about the role of laparoscopy in the diagnosis and treatment of chronic pelvic pain. 

And while I have Dr. Ledger here I thought this would be a great time to pin him down and ask him something about how this might be approached in the UK, and maybe we can contrast a little bit by looking at a couple of different cases. 

So Bill my question is related to a 30-year-old who has significant dysmenorrhea, who has some dyspareunia and minimal non-cyclical pain. She is otherwise healthy, is not trying to get pregnant right now and has been treated with non-steroidal anti-inflammatories and oral contraceptive pills as well, with no real benefit. Her discomfort is really problematic for her. In the UK, in Sheffield, what would you be doing with her? What would you advise her?”

William Ledger, MD:  “Well, we see a lot of these people is the first thing to say, and I just go back to the start and take a full history, which you’ve glossed over because there are many other questions that you need to ask before you start talking about treatment. For example you say that she’s not trying to become pregnant now, but obviously whatever treatment we offer would be predicated on her future plans. 

We try to take a full family history, because so often you uncover either a family history of endometriosis or some such or anxieties about other illnesses. Fairly frequently ovarian cancer for example, which raises issues about pain and perception of pain. Having done the history we go on to a proper clinical examination, which in our centre would include a vaginal exam and if appropriate a rectal exam, along with a trans-vaginal ultrasound on the same day. That’s done with the physician present so you get a good picture of the structures within the pelvis. Probably you are going to go on to do a laparoscopy if it’s not been done before. As you describe often these people are treated in family care initially so they’ll have had a trial of drug-therapy before a diagnosis is really reached so we’ll try to schedule laparoscopy within a few weeks of the initial clinic visit.”

William Schlaff, MD: “And how do you do that in the UK? It seems like it’s a problem to make a distinction between just a diagnostic approach in the operating room versus a diagnostic approach followed by treatment in the same anaesthesia. How is it approached and what are the pitfalls in the UK?

William Ledger, MD:  “One of the big problems in this sort of practice in the UK is that we are really restricted in the amount of operating theatre time that we can have. So, one view is that you take a 30-minute slot of time and you perform the diagnostic procedure to image the pelvis, see whether there’s disease there and then the patient would recover, have a discussion and plan surgery on the second occasion. That was the traditional way in the UK. It means that you can schedule your operating time and spread it quite carefully and get through a large number of cases in one session. 

However, the patients hate it. You or I would hate it if we had to come back six weeks later, have a second anaesthetic for the same problem. So the more modern approach perhaps, is that we try and operate on the see and treat principle. That is an intellectual exercise to juggle the patients so you get finished at 5:00 o’clock and don’t finish at 3:00 o’clock and use the operating time, and it requires a guesstimate of how long each case is going to take.”

William Schlaff, MD: “And what happens when you embark on a see and treat approach and the patient has fixation of the ovaries to the pelvic sidewalls and what appears to be transrectal involvement of endometriosis. What do you do?”

William Ledger, MD:  “It’s got to go one of two ways. The first thing is we take great trouble to get real important consent from people beforehand. Because if you do see and treat you have to cover a number of possible options because you don’t quite know what you are going to find. Part of that consent is that we tell them that there is a chance that you might be bumped off the end of the operating list if one of the patients who is before you has more has more disease than we think.”

William Schlaff, MD: “Is there a lottery for who goes first?”

William Ledger, MD:  “Just about, yes. Again, we try and get people home the same day if we can, so if we think they’re going to be more minor we put them on high up the list because then there is a longer time to recovery from anaesthesia before they go home. If we know they’re going to need to stay a couple of nights we do those later on in the afternoon.”

William Schlaff, MD: “Now, in the US there is something of a controversy. For instance when I do a laparoscopy as you describe, I videotape the laparoscopy findings and I give the videotape to the patient. Many physicians are advised that this may be inappropriate because of concerns over medical/legal ramifications and the like. Is there any similar discussion in Britain?”

William Ledger, MD:  “Yes, this is one of the hot areas at the moment. We’ve just completed a study on this with a clinical psychologist who looked at the woman’s perception of her disease before she had a laparoscopy, and after laparoscopy following the presentation of a video with me and the patient and the psychologist sitting together describing what we’re seeing. 

The way I’ve done that is that we video the state of the pelvis before surgery and then it’s videoed afterwards. I don’t give them a video of the procedure itself because the psychologist was worried that the images of having the structures burnt, diathermied, whatever, might have a negative connotation with that woman rather than a positive one. So far we’ve done 16 patients in this pilot study and the results have been extremely positive. 

The feedback the psychologist gets is the women feel much more in control of their pelvis. They can visualise what’s really in there and when you talk to them about the kind of pictures they have of the aggressive nature of the disease, which in reality is perhaps minor endometriosis, using the video helps them, greatly. So I try and encourage my colleagues to do this. But you’re absolutely right again, the older colleagues are generally less keen to give control to the patient perhaps. Because when only we know what we’ve really seen, and you know the quality of most people’s drawings and old operation notes, who’s in control? We are.”

William Schlaff, MD: “Well, I would have the same thing thought. I have similar concerns over managing operating room time. I suppose what we do at some subliminal level is that we budget everyone perhaps 30 minutes more than we think will be required. Then, if you have the whole day scheduled in the operating room, at the end of the time, someone will be shorter, someone will be longer but at the end of the day you finish on time. In this way you’re able to do the see and treat at the same time approach. Let me ask you about a patient, which I hope you won’t return and ask me about.”

William Ledger, MD:  “Go on.”

William Schlaff, MD: “Now let me ask you about a 27-year-old who we’ve seen with chronic pain throughout her abdomen. The pain is constant and it’s everyday. It is associated with dysmenorrhoea a bit in that her periods make it worse, and she has dyspareunia. The problem here is that this patient has had three or four laparoscopies already. The first surgeon saw a little bit of endometriosis, the second one saw a little bit of endometriosis plus adhesions, which may have been a result of the treatment the first time. And then the third laparoscopy was some variation on a theme. The patient has been treated with one or two courses of a GnRH analogue in addition to other general analgesics and the like. All of these treatments produced minimal, if any, improvement.”

William Ledger, MD:  “Yes, we see a lot of them as well. I think again that’s where the video helps from the start because it’s much more reassuring to me if that patients brings a video that some other physician has made because then you know whether the quality of the laparoscopy done in another unit has been good or bad.”

William Schlaff, MD: “Well, let’s guess it was my videotape.”

William Ledger, MD:  “Oh, in that case…”

William Schlaff, MD: “And it showed that there was indeed some findings but the patient hasn’t really had improvement from any of her treatment?”

William Ledger, MD:  “The first thing with these more difficult cases is to enter into a discussion, to find out what she wants from us. To find out perhaps that she appreciates that this is not necessarily going to be a curable condition. It might be having to learn to live with this now because an excellent surgeon has failed to produce a cure on three or four occasions. That to me is the first step. 

The second thing is to try and break this vicious cycle of annual laparoscopies, which I see in quite a few people; they begin to believe that if they haven’t had a laparoscopy for twelve months they’re not being properly looked after. We use MRI quite a lot as the non-invasive method to see whether there is deep disease that you can’t detect with a laparoscope.”

William Schlaff, MD: “Are you able to see that pretty well?”

William Ledger, MD:  “Not pretty well but occasionally you get somewhere, all right? It’s more useful as a negative finding actually I find, because in a way you know in your heart that you’ve done three or four laparoscopies that hasn’t brought benefit. Therefore you don’t really want to do a fifth, because in your heart you think I really can’t help by doing surgery. If the patient believes that surgery is the only answer and she’s had negative laparoscopy and a negative MRI, that’s kind of reinforcing the medical approach, the psychological approach and I think most importantly, the multi-disciplinary approach, where you have your pain clinic team, your psychological support team, your pain nurses and what-have-you to help us help the patient. That’s my answer to that one. So now tell me what you would do.”

William Schlaff, MD: “Well, as usual I would agree with you. The multi-disciplinary pain team I think is critically important in a patient like this because we have both data and observation that would reinforce that in chronic pain syndromes the anatomic nature, or the anatomic findings don’t necessarily correlate at all, or at least minimally so, with the degree to which the patient is uncomfortable. 

This always leads one to question whether adhesions or manifestations of chronic infection or even endometriosis may be more of an association or a contributor, rather than the aetiology. There are some emerging data showing what’s been described as somatic or visceral convergence at the level of afferent input in the dorsal horn of the spinal cord showing a wind-up effect that results in even relatively trivial or minor irritations being manifested legitimately in those individuals as substantial pain. And how to go about addressing this problem, I think, requires the approach you describe.”

William Ledger, MD:  “It’s a lot of skill. It’s going back to Nelzak and Wall 20 years ago, the Gate Theory, and if you can’t alter the input from the spine, you can alter the way it’s handled centrally and you can try and push the gate closed by helping that woman understand her pain better.”

William Schlaff, MD: “Let me ask you a…”

William Ledger, MD:  “Stuck like a zipper here aren’t we? Go ahead, carry on.”

William Schlaff, MD: “Let me ask you another question that relates to that. You know, in many circumstances we look at our data and we show a substantial placebo effect from the laparoscope. Is the laparoscope a big acupuncture needle? And the reason patients get better for several months is because we closed the pain gate by virtue of putting a very large acupuncture needle through the navel?”

William Ledger, MD:  “Chris Sutton, who’s one of the extremely skilled surgeons from this area in the UK has recently published some data showing that at five years for these sort of patients, with chronic pain operated on with laser laparoscopy in a good centre he has 47% who are still pain free. Now you can look at that one of two ways. I think that’s an excellent result given the kind of patients we deal with. That in essence half of them have gone beyond anything that might be seen as a placebo effect, because I don’t believe it can last for five years, the placebo. In Chris’s earlier work, the first three or four months people improved and then they get worse even if they’ve actually not had surgery but mainly had a GA and an incision made and so, yes, I agree it can be a huge acupuncture needle short term, but not long term. I hope we’re right because it’s a kind of dangerous acupuncture needle and there are much safer ways of doing this than using large trocars.”

William Schlaff, MD: “Well, I really appreciate your input as always and I’ll know whom to call next time.”

William Ledger, MD:  “Okay.”

William Schlaff, MD: “Thank you.”

William Ledger, MD:  “Thank you.”