 |
Preface to "Surgical Management of Endometriosis"by David B Redwine MD If you are a gynecologist dealing with endometriosis, you know the trite drill dictated by conventional wisdom: in the office diagnose pelvic pain as a sexually-transmitted pelvic inflammatory disease (PID) and treat with antibiotics; diagnose recurrent pelvic pain as recurrent PID in a woman with loose morals and treat again with antibiotics; when the patient (sometimes virginal) re-presents with pain thought to be due to yet another recurrent STD, perform a laparoscopy and finally diagnose endometriosis; shine a coherent beam of light at the disease or put a metal electrode on the various spots and step on a foot pedal to unleash unseen electrons and pronounce that the disease is treated; administer powerful and expensive medical agents with multiple side effects and reassure the patient that this combination of treatment will be the best treatment for her disease since this is what most clinicians use; shuffle the suffering patient to various other practitioners, including psychiatrists and pain clinics; question her about childhood sexual abuse when her pain doesn't respond well; repeat a laparoscopy; repeat the same therapies which didn¹t seem to work the first time; repeat these a third time to be certain they didn't work the second time; perform a total abdominal hysterectomy and bilateral salpingo-oophorectomy; rush off to perform a routine vaginal delivery when the patient returns to the office complaining of pain and vasomotor menopausal symptoms. Modern therapy of endometriosis has become unimaginative, rigid and dogmatic. It is universally acknowledged that endometriosis is a confusing, enigmatic, mysterious disease, but this need not be so. Confusion is an opportunity for change if this confusion is recognized for what it is: lack of accurate information. Whereas the debate about the origin of the disease rages confusingly, the debate on treatment has become quite distilled. The word "treatment" is used here in the same manner as when one talks about treatment of a urinary tract infection: the disease is gone when treatment is concluded, and symptoms once caused by the disease are gone as well. This use of the word "treatment" is familiar and comforting to patients and physicians and can be used to summarize modern therapy of endometriosis accurately in one sentence: Since no available medicine eradicates endometriosis, surgery is its only treatment. It thus becomes a question simply of which type of surgical treatment most effectively eradicates the disease. This book will help the reader answer that question. The introductory chapters written by me present my thoughts on various topics related to the history and treatment of endometriosis which I think are important. These chapters are based on a deep and broad familiarity of the literature as well as a quarter-century of personal and professional interest in the disease. Most of the confusion regarding endometriosis stems from long-held biases which are rooted in misinformation. This misinformation has entered our understanding due to a predictable phenomenon which has a name: Berkson's fallacy. This fallacy has operated from the very beginning of our understanding of the disease. Because it operated unidentified and uncorrected, its deleterious effects on our understanding were magnified over many decades and have become huge. This has led to enormous inertia both in treatment and research because we have been unwilling to give up the past, partly because of the fear that we have been so wrong for so long. Things can be made right by leaving our minds open to new thoughts regarding the disease, with the possibility that we must reject much of what we think we know. Understanding clearly the origins of our current confusion will make it easier to face a future which contains the real truth about the disease. Our profession must grapple with the probability that Sampson¹s theory of origin is incorrect because the facts upon which it was based were incorrect. Sampson did not have all the facts we have today when he devised this theory. It seems unlikely that he would have supported reflux menstruation as the origin of endometriosis if he was aware of the information in Chapter 2. Continuing support for his theory of origin is not just an intellectual question, because this theory directly affects the treatment of most women today. If the theory is wrong, then it is probable that most women are being poorly treated. Misunderstanding about endometriosis is due to a predictable phenomenon which has a name: Berkson¹s fallacy. This fallacy has operated from the very beginning of our understanding of the disease and its effects are discussed in Chapter 2. Because Berkson¹s fallacy has operated unidentified and uncorrected for many decades, its deleterious effects on our understanding have been magnified over time and have become huge. This has led to enormous inertia in understanding, treatment and research because we have been unwilling to give up the past, partly because of the fear that we have been so wrong for so long. Things can be made right by leaving our minds open to new thoughts regarding the disease, with the possibility that we must reject much of what we think we know. Understanding clearly the origins of our current confusion will make it easier to face a future which contains the real truth about the disease. The practice of medicine is sublimely simple because there are only three choices available for almost any ailment: 1. Do nothing. 2. Treat with medicine. 3. Treat with surgery. The patient with endometriosis will already have tried doing nothing, and that did not work because she is now in your office. This simplifies greatly the care of patients with endometriosis because once the diagnosis is made surgically, there are only two treatment options: medicine or surgery. (Observation of a treatable disease which has led to surgery is not ration by anyone¹s judgment. If observation seems ration. Then surgery should not have been done.) to decide between these two modalities, more information is needed, and this book provides that information. The history of development of medical therapy is outlined in Chapter 2, and modern medical therapy and possibilities for the future are discussed in Chapter 3. It should be apparent after reading these chapters that endometriosis is a disease which requires surgery for diagnosis and treatment, and this should be a part of the process of informed consent with the patient. The remainder of the book is its raison d'etre: how to treat virtually any manifestation of endometriosis surgically using any one of a number of surgical energy systems. Since surgery is a visual as well as a tactile and judgmental art, an effort has been made to provide illustrations of surgical strategies with the hope that if a surgeon sees what is supposed to happen, it can be made to happen in that surgeon¹s hands. The chapters by experts in surgical treatment of endometriosis will allow readers to compare surgical energy systems and perhaps choose one that is most adaptable to their surgical style. There is admittedly a heavy emphasis on excision, which alone is able to treat both superficial and invasive endometriosis completely anywhere in the body. Many of the chapters and accompanying illustrations were produced by myself. These images were selected to illustrate what I consider to be important points gained through the surgical treatment of over 2,500 patients with endometriosis from around the world. Most of these patients have had multiple surgeries and several rounds of medical therapy. One common thread clearly stands out: their disease has never been completely eradicated. They are dealing not with recurrent disease, but with persistent disease. Everything possible has been done to them and to their disease except one thing: the disease has never been removed from their bodies. This book will help surgeons to eradicate endometriosis from any location in the body. Endometriosis surgery is rightfully considered the most difficult surgery to be done in gynecology, and some cases will seem to be the most difficult surgery possible anywhere in the human body, maximally taxing the mental and physical strength of the surgeon. For those surgeons who relish challenge, endometriosis is the perfect disease.
Surgical Management of Endometriosis
(ISBN 1 84184 248 6)
|
