Hugo Verhoeven, MD: “Good afternoon, my name is Hugo Verhoeven from the Centre for Reproductive Medicine in Düsseldorf, Germany. I am reporting from the 12th annual meeting of the ISGE in Cancun, Mexico, and I have the great honour of talking this afternoon to Robert Franklin, who has been one of my friends for 20 or 22 years. Dr Franklin is still an active man; he is the medical director of the Women’s Hospital in Houston, Texas, and this was also the place I visited many years ago and I was always very impressed by his technical skills.
The topic we are going to discuss today is adhesion formation, adhesion prevention, and treatment of adhesions – especially in patients with endometriosis. We know that endometriosis can cause severe adhesions and are not easy to treat. So, Bob, thank you for giving me this pleasure. You are, I think, the ideal man to discuss this topic and to talk about treatment in the past, today, and maybe you can give some ideas for the future? So, when you started doing surgery, before the time of microsurgery, what did you do for the prevention of adhesions, especially in endometriosis patients?”
Robert Franklin, MD: “The interesting things about adhesions, in my residency in 1953 to 1957, adhesions were really not thought to be much of a problem. The few admissions to the hospital for adhesions were mainly for strangulated hernias. Only when increased abdominal surgery became obvious, we were doing so much more abdominal surgery, did adhesions become a very important problem and this started probably in the 50s when we had antibiotics that helped us, we had better anaesthesia, and we did more abdominal surgery.
Surgical procedures are still the most common cause of pelvic adhesions and have increasingly become so, almost to the fact that whenever you operate on somebody, you expect some adhesions. So everything we’ve done in the last 15 or 20 years has been: how can we reduce the number of adhesions and end up with adhesions that are not so called bad adhesions?
Bad adhesions in fertility practices, are ones that involve the tube and ovary or involve the bowel, ovary, and tube, where there is destruction of the canal so you don’t get good ovum pickup. The fertility surgeons, especially Dr. Swolin and Dr. Verhoeven, revolutionised, I think, the technique of the prevention of adhesions by realising how much damage we were doing with gross surgery, where you simply dissect with your finger or your cut and leave it bleeding or you use gauze and leave pieces of gauze in the abdominal cavity. The talc story is well known, all of these things - foreign bodies are very common causes of adhesions.
Of real interest in my practice, and I see maybe still 200 to 300 endometriosis cases a year, endometriosis is a problem of adhesions only in its third and fourth stages. You create problems in operating on young women in stage I and II by surgical procedures, so this makes me think that maybe the way to approach young women in the first one and two degrees is by medical means and certainly by laparoscopic techniques.
Our approach, first approach, in women of this age, is to simply try drugs like Danocrine and Lupron, most especially the LHRH agonists, with add-back therapy, and I don’t limit it to three months, I don’t limit it to six months, I limit it to how long I can get a good result and a good result is diminished pain and no obvious progression of the disease. If a patient doesn’t get good relief of pain or seems to be progressing, then we move from medical treatment to laparoscopic technique and when severe dysmenorrhoea is still present, we almost always do a presacral neurectomy.”
Hugo Verhoeven, MD: “But that’s only stages one and two?”
Robert Franklin, MD: “That’s just stage one and two. In stages three and four, we already have adhesion formation. It is very obvious that dealing with the ovary is a very difficult thing to do. Ovarian endometriosis, ovarian damage of any type, almost invariably leads to adhesions, and if you can operate on this patient with a laparoscope, by all means, do so. If you can’t operate with a laparoscope and you’re dealing with stages three and four disease, be prepared to do a laparotomy if you have to.
The laparotomy is going to leave you with much more adhesions and, hopefully, you can select the way your adhesions are formed. We still do suspensions, because it’s pretty obvious that adhesions are formed because of ischemic tissue. You try to reduce ischemia as much as possible, so no tight suture lines, and no large areas of necrotic tissue left. An important aspect of knowing about the adhesions formed by endometriosis is knowing that this is a very special kind of adhesion, usually. One of the filmy adhesions frequently has in it areas of endometriosis, so if you are going to operate on a patient with endometriosis, you want to remove the adhesions.
Secondly, the type of adhesions you see in these stage three and four patients are very dense, thick, cohesive, concrete-like adhesions, and I’ve heard people say these were burned-out endometriosis. These are not burned-out endometriosis, these are simply endometriosis patients where there’s been little leakage of hemoglobin with little ruptures of the ovarian cysts into the tissue and then there’s very dense reaction with a lot of white cell formation. This is important because when somebody operates on these patients and simply removes the ovarian cyst or removes the ovary and leaves the deep areas of adhesion, they still have pain. As a matter of fact, that’s where the pain is coming from, and so if you’re going to get a resection of endometriomas – of patients with an endometrioma with adhesions to the posterior wall – you want to come in extra-peritoneally and make sure this area is removed along with the ovary or with the endometrioma.
Our basic technique is to try to do it with the laparoscope if we can. We drain the endometrioma because if you let the endometrial contents of the endometrioma flow out into the abdominal wall, every place where you have damage, you stand a very high risk of implanting with your procedure on these, so we irrigate, suction out all of the material from the endometrioma, we irrigate profusely because we know that drying of the tissue is very much a cause of adhesion formation, so this is probably why we have so many less adhesions with laparoscopic procedures, although laparoscopic surgery doesn’t automatically mean you have less adhesions.”
Hugo Verhoeven, MD: “Because you do continuous irrigation?”
Robert Franklin, MD: “I think because we keep it moist, we don’t let it get dry, we have very much less tissue damage, much less foreign bodies, no packing, and we can do extensive dissections with our laparoscope. We do extensive dissections with the laparoscope. But if you don’t remove the disease, they still have pain. If you don’t remove the disease from the intestines, they still have pain, and in my discussion tomorrow, I will talk about the different techniques in removing it. It almost always has to be an excision. Simple cauterisation, or simple lasering over the top of this lesion leaves the roots and the roots come back to haunt you - especially in the bowel.”
Hugo Verhoeven, MD: “Do you believe that just a resection of the adhesion is the key, or do barrier methods, the covering of rough areas with different kinds of materials, or the application of Dextran and different solutions, do you believe in those things?”
Robert Franklin, MD: "I’ve done a lot of work with adhesion formation and I still use high molecular-weight Dextran and decadrone in patients with extensive dissection and I’ve done second-look procedures on my patients for a long time. Fewer now because of insurance reasons, but if you leave a wet surface and you try to use Interceed you get adhesions. It’s almost the creation of adhesions because you have a surface there that something comes back and sticks on. If you can do the procedure, especially laparoscopically, put in Dextran, have the patient up and around moving, it’s the movement that helps, I think, as much as anything else as far as keeping the adhesions from re-forming.”
Hugo Verhoeven, MD: “So the membranes are not a good solution in your theory?”
Robert Franklin, MD: “I used the membranes early on for some patients with multiple myomectomies, and the problem with that is that there is always some oozing under the membrane. The oozing goes out into the adnexa where you don’t want adhesions, so if you quickly get adhesions where you don’t want them, the membrane actually frequently stops the adhesion from the incision line in the uterus, but that’s not an important adhesion. The important adhesion is where the ovary and tubes are.”
Hugo Verhoeven, MD: “So this is still the technique you’re doing at this moment, because this is what we know from microsurgery? So that is, in your opinion, still the best?”
Robert Franklin, MD: “Still the best technique. The technique is a gold standard.”
Hugo Verhoeven, MD: “But … you are not happy with this treatment?”
Robert Franklin, MD: “Absolutely. Well, we’ve been working with material now that we squirt on to the adhesion site. The final word is not in on that. The research studies look pretty good, but for anything to really work, it has to be done by the general doctors.”
Hugo Verhoeven, MD: “So you mean that the spray that you’re putting in also, it’s a sort of membrane, and it’s not solid, it’s a membrane technique.”
Robert Franklin, MD: “It’s a membrane technique.”
Hugo Verhoeven, MD: “Okay. My final question is: what are you expecting for the future, any new ideas for the prevention of adhesions?”
Robert Franklin, MD: “The one area that we looked at that looked the best was the use of tPA.”
Hugo Verhoeven, MD: “What is tPA, please explain this to our listeners?”
Robert Franklin, MD: “tPA (tissue Plasminogen Activator) is a material that causes the rapid disintegration of the fibrinolysis and it works – the problem is it has to be used repeatedly. I’ve never liked to leave a catheter in the abdominal wall, abdominal cavity, because infection plays a role also in adhesions and invariably there is some contamination with catheters; so the only way the tPA really works is to be able to keep adding it over a one to two week time. But it actually does work in the prevention of adhesions. We’ve seen it in animals.
Dr. Dunn in our group and several of us work with it, it does work, and it’s just not a good technique. A slow-release material, which gives tPA over a period of time, might be the answer. Unfortunately, the two drug companies don’t work together.”
Hugo Verhoeven, MD: “In conclusion, respecting of the microsurgical principles is still the gold standard.”
Robert Franklin, MD: “Still the microsurgical procedures.”
Hugo Verhoeven, MD: “And all the rest is . . .”
Robert Franklin, MD: “There’s another interesting aspect of ovarian surgery and one of the things that is noticed by people that do a lot of IVF is that if they’ve been operated on for stage three or stage four endometriosis, a lot of the ovary and ovarian tissues has been ruined and this is because in trying to get hemostatis, you’ve destroyed normal ovarian tissue and so I still think the microscopic technique is best and, invariably, if I’ve got really big endometriomas where they just, say 5cm or 6cm endometriomas, I try to do it with the laparoscope first, I try to do it as avascularly as I can, then if I have to re-do it, I do it with an abdominal procedure where I go very slowly with the laser, taking off the tissue.”
Hugo Verhoeven, MD: “Trying to conserve as much ovarian tissue as possible.”
Robert Franklin, MD: “Trying to conserve. I think without removing the endometriomal capsule, you’re going to end up invariably with adhesions and invariably with recurrence, so you have to remove the capsule. This technique of aspirating it and treating it with LHRH agonists, there’s very little value in the prevention of recurrence.”
Hugo Verhoeven, MD: “The metaplastic capsula of the ovary needs to be coagulated with one technique or another . . .”
Robert Franklin, MD: “It has to be done.”
Hugo Verhoeven, MD: “Okay. Well, Bob, thank you very much. It’s been a very big pleasure.”
Robert Franklin, MD: “Thank you for asking.”
Hugo Verhoeven, MD: “I wish you all the best for, well, maybe another five years of clinical practice.”
Robert Franklin, MD: “Well, we’ll see.”
Hugo Verhoeven, MD: “Okay. Or ten years or fifteen years!”
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1 comment:
info on endometriosis here - Endometriosis May Lead to Infertility
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