Mauricio Abrao by Tamer Seckin
Dr. Tamer Seckin
Hello everyone, I am Dr. Tamer Seckin reporting from Sao Paulo, Brazil. We are at the first Global Congress of Brazilian Endometriosis Association and ISGE (International Society of Gynecological Endoscopy). It is a great pleasure for me to introduce you whose expertise, leadership, besides his skills of keeping friendships always alive, I have Professor Mauricio Abrao from Sao Paulo, Brazil. Mauricio, it is a great pleasure to be in Sao Paulo and you really know, the whole world knows that your life is focused on endometriosis, not only simple endometriosis, but deep endometriosis, all class, and you are to be I think honored by the years to come by many, having also a endometriosis department on the wings in the university. I think this is very important. We all strive for excellence, precision, but the women in the world who are sufferers of endometriosis are still in need for good treatment, quality treatment, and we want this disease not to debilitate women and women can do their things that they do best, being part of a healthy society. I would like to ask you, I think, you should really say how your journey into endometriosis changed over the years and we should get your opinion in the early diagnosis, its impact on prevention of endometriosis, and I would like to conclude with the issues of deep endometriosis, but before that, one thing in your presentation that I see, as you know we all learnt things significant, advanced laparoscopy techniques from Dr. Harry Reich not to say that the others are not any less important, but when Harry first, he is very sensitive about the issue of deeply infiltrating endometriosis versus deep fibrotic endometriosis. That is important with description, I see that that issue is being more right now being used as deeply infiltrating endometriosis. I wanted you to start that because I think that area needs to be clarified in my mind. I would like you to give the talk right now.
Professor Mauricio Abrao
Okay. Tamer, my friends, it is a great pleasure to be here and to sit with you and really endometriosis is a lot of my work and my life and talking first of all about the deep endometriosis, in fact, I think that the best way to call this kind of a disease deep endometriosis on _______, but it is more simple and it is a easier way to eliminate this kind of a lesion. And as in our country, we know that 40% of endometriosis respond to deep endometriosis and half of these cases, there is some lesions in the bowel so if we are talking about, we are talking of a disease that compromising 10 to 15% of women in reproductive ages and 40% less deep endometriosis and it corresponds in Brazil as more than 6 million of women having endometriosis in Brazil concerning our informations about our population and 40% of around 200, 2400 millions having deep endometriosis and half of them endometriosis compromising the above.
Dr. Tamer Seckin
That is a great number.
Professor Mauricio Abrao
Important number. So it is a real problem.
Dr. Tamer Seckin
Do you believe that if endometriosis is diagnosed early, the prevention and the advancement of the disease can be halted. In other words, if we are keen on diagnosis of endometriosis in adolescents, if we set up an algorithm that at one time during early 20s or around 20s if we timed their surgery well, the first surgery is the best surgery that is most opportunistic. If we do the first surgery well, do you think these womens’ disease could be halted from the experience?
Professor Mauricio Abrao
I really think and have some evidence that can show that, for example, the deep endometriosis is not very frequent in adolescent women.
Dr. Tamer Seckin
That’s correct.
Professor Mauricio Abrao
So probably there is an evolution of the disease towards the deep endometriosis. And so it is absolutely necessary for us to diagnose as soon as possible this disease. There is another data and with many studies in the world, we have a study function in the human reproduction of 2003 showing that in our experience, the time elapse between the beginning, onset of the symptoms and the diagnosis of the disease is around seven years and the younger is the patient, this delay is higher for example, the time elapse of the patients with 20 years old, but the symptoms beginning with 20 years old is more or less 12 years. So, it is important to perform the diagnosis as soon as possible. At the beginning of this, we have some ways. The first way is to sensibilize the people about to look for the doctor when these women have symptoms of endometriosis, dysmenorrhea, dyspareunia, pains, pelvic pains, and bowels and bowel symptoms, urinary symptoms, and infertility. On the other hand, the doctors must think about the disease, so this is why the societies of each continent, the world societies, are doing so much work towards, to tell the doctors that it is necessary to think about the disease. So in this way…..
Dr. Tamer Seckin
So, certainly there is a place for legislative action and for education and awareness and that is what coming to the previous point that what you are saying and which I also said this all days ago in Croatia. Early diagnosis and intervention by excision is probably currently the best way of handling this disease, particularly when we look at the deep excision experience, the recurrences, and the paler symptoms, with a good surgery, completeness of the surgery determines the absence of recurrences and the disappearance of symptoms. We know this from your experience and the way you have expressed today. So, I would like to ask you some I am curious about this also. Why does endometriosis in some women even though in advanced stages are asymptomatic? Isn’t some women just do not want to accept their symptoms or we are not asking the right question?
Professor Mauricio Abrao
No, I think that there is a percentage, 10% or something of this, patients does not have symptoms. And I think that there may be some reasons, one of them is the profile of the patient below, some patients are in more pain than other patients. So this is why probably one cost of the situation and another cost is the nerves compromising by the disease. For sure, for some patients the disease involved more nerves than for other patients. So probably both of these situations are perhaps more things and must be important for us to justify why they do not show pain.
Dr. Tamer Seckin
Do you have, how do you see the, I understand there is right now, there is a talk of reclassification of the endometriosis. I know you cannot go into detail, but I would like the viewers understand that one of the reasons why endometriosis is misunderstood is at these physicians have looked at the disease for mainly from infertility aspect and infertilitists have classified the disease initially and everybody followed, but as pain surgery has advanced, as excision surgery has advanced, as laparoscopy techniques have advanced, we find ourselves in serious need, dire need of reclassifying the disease, because the patient are getting lost under the impression that their disease are not taken seriously by doctors because there is no place of deep endometriosis in overall infertility classifications. I know you are one of the leaders in this renaming of the class. I really want to inform you, our viewers. This is an important thing historically.
Professor Mauricio Abrao
In fact, Tamer, when we have, as we have so many classifications…
Dr. Tamer Seckin
For everything.
Professor Mauricio Abrao
For everything for endometriosis why does we have, why do we have so many classifications probably because lot of them can be considered the best. Of course, the ASRM classification that was done in 1985 and we have done in 1996 considered some other aspects, is the most useful classification nowadays, but this is a classification that do not look for the pain, it is more useful for infertility patients and another aspect is that this classification is not considered the most important type of endometriosis that is the deep endometriosis. So, for this reason we are working hard, not working by only one or two people, working in a very strong team to give it a new classification, but not to put the name of people of this thing in the story, nothing about this to help patients. So this is why I think that considering the deep endometriosis, considering pain, of course, it is not easy to do it, but there is a very strong work that I think that we will succeed.
Dr. Tamer Seckin
It is important for the viewers that when we say deep endometriosis beyond 5 mm of peritoneal invasion, it does not necessarily means it is rectum, it is deep invasion of the pelvic side walls, it is the ligament, periurethral tissue, it is cul-de-sac side wall, the lateral aspects of the rectum, then it comes to the organ involvements, their layers and lymph nodes and obviously deep, more deep spaces of nerves and vessels. It is really a pleasure, these meetings really gives us to learn, to exchange and makes us more deeply concerned about issues that we could have handled differently in the past and we change our attitudes. I think endometriosis, we cannot solve endometriosis in this little short talk, however, it is truly an honor that where we are going to with the signs, the surgical techniques, but I want your personal opinion on two more things, since I would like to hear young patients, do you, if their symptoms are on a regular basis, established, firm, good doctor and patient relationship, how soon you want to do their surgery? Do you hesitate?
Professor Mauricio Abrao
What is important to be known is that nowadays we can consider a lot of good criteria to indicate a surgery, to indicate a laparoscopy. One of them is the symptom as we are talking about. The other criteria that we are struggling to use not only here in Sao Paulo, but in a lot of specializing centers, although we work is that imaging methods for us to have a good diagnosis to help us how to indicate a procedure. So, it is possible the sensitivity of the imaging methods, for example, for rectum is about 98% for the rectal lesions and is of 95% for uterosacral ligaments for retrocervical endometriosis. So if we use the clinical aspects and the imaging methods, we can go towards very competitive diagnosis with good indication, not only about who should use, who should be submitted to laparoscopy or not, but which, what kind of laparoscopy should be done that is also another very important issue for this purpose.
Dr. Tamer Seckin
Last question, infertility, I want your opinion. We know what is being written and what the infertilitists say. As you know, the infertilitists are happy if their patient gets pregnant most of the time whether their endometrium stays there or not. The symptomatology may not be overwhelmingly important, the patient wants to get that rush of pregnancy. I want your opinion, patients with infertility with symptoms of endometriosis, with history of endometriosis what would you do, do you delay surgery, do you advise them not to have surgery, go for IVF or what is the advantage of having surgery getting it cleaned and then go for IVF?
Professor Mauricio Abrao
It depends, Tamer. In terms of the patient, that it depends on the age of the patient, it depends of what kind of endometriosis does she have and it is possible to know a lot of information before the surgery to help us decide which way to go. So in fact, we do not have much evidence on the massive studies that allow us to indicate for all cases of deep endometriosis, the surgical way or not.
So we need to have a good sense, good criteria for us to choose the best way. If I have a patient with tubal obstruction and bilateral and with advanced endometriosis with 30 years old and with low pain, I think that for these patients, the beginning of the treatment nowadays, because we do not have advanced enough is to start with IVF and if there is a failure after two cycles, we can discuss the surgery. If this patient has pain, obviously we need to consider these symptoms to indicate the surgery. And obviously there are added criteria. The age is an important criteria, so it is not a very simple question. The decision depends on each patient.
Dr. Tamer Seckin
History of breast cancers in the family, history of ovarian cancer in the family, does that change the intraoperative way or does that affect the way you talk to patients, I want to ask you, does endometriosis have anything to do with cancer?
Professor Mauricio Abrao
History of breast cancer does not change the way of treatment. The familial risk of ovarian cancer needs to be the detected because it depends on which cancer which who had because the ovarian cancer or other, but it obviously depends also on the age of the patient and the obstetric history of the patient. But in fact for this patient, _____ with ovarian cancer, if she is more than 40 years old and two or three kids obviously , good alternative should be to remove the ovaries, but obviously it depends on other evidence that genetic studies is giving to us.
Dr. Tamer Seckin
What is your incidence of catching endometriosis on ovarian cancer in your experience?
Professor Mauricio Abrao
It is a less than 1%.
Dr. Tamer Seckin
Less than 1%, but the association in that 1% if there is that association, that endometriosis related ovarian cancers are important to be diagnosed. That puts us to the end of this wonderful meeting again, Professor Mauricio Abrao from Sao Paulo, Brazil.
Thank you, Mauricio.
Professor Mauricio Abrao
Thank you very much.
