Endometriosis UK
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Advice about getting a surgeon who does excision.

Can anybody help? I feel so left in the dark.... My understanding from researching this fairly rigorously, is that identifying all the endo lesions and excision is the gold standard of treatment. It is also extremely important that surgeons should be validated by the BSGE but do all surgeons working within BSGE centres use excision? Is the only way to ensure you get excision to go down the private route? Any advice would be so helpful. I don't know where to turn.

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In many ways the only way of assuring thorough treatment is through the NHS route as most BSGE centres are NHS and the BSGE specification sets certain requirement such as a team of surgeons being required as necessary to include urologists and colorectal surgeons. Many BSGE endo surgeons doing private surgeries seem to do them on their own which is not ideal. The centres use all methods of treatment as appropriate for the endo involved. They are all required to have done at least 2 years' advanced excision training that meets the standard set by the Royal College of Gynaecologis (RCOG) in its module. The only thing to look out for is that some BSGE surgeons are more experienced than others and we do seem to be coming across some suggesting a 'pelvic clearance' - aka hysterectomy and removal of ovaries - in very complex cases. Sometimes this is indicated if those organs are too diseased to save or if excision in some areas is genuinely too dangerous but I would always recommend a second opinion if a centre recommends this in case it suggests a lack of experience with the most complex surgery that another surgeon could do.

Have a look at my posts on the treatment pathway and on how to find a specialist centre and look at all the links.

Where in the UK are you?

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Thanks for your reply Linda. We are in Brighton. My daughter had a diagnostic lap with a general gynae who was not an expert in endo. He said there were only 2 lesions which he ablated. Her pain has not improved. My understanding is that all the lesions need to be identified and then excised to prevent them growing further. My daughter is only 20 so we don't want it growing further plus their is a risk the consultant may have missed lesions as inexperienced consultants don't know what to look for, especially in someone young.

Will all consultants excise lesions in someone where it is deemed to be mild or moderate or will they only offer ablation? Is excision only offered on the NHS when the endo is deemed to be severe?

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Hi - will get back later as going out but they will treat the endo in the right definitive way to ensure it doesn't come back. Will go through the methods used. Have a look at my post on the diagnostic lap as it may be interesting.

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Hi again - sorry for the delay.

It's not as straightforward as excision is good and ablation is bad. When we do talk of 'ablation' in this way we are usually referring to what is done in general gynaecology and that is blasting endo with heat which will typically just treat the surface. This is problematic because whilst this might destroy very shallow plaques of peritoneal endo there is no way of knowing how deep the endo goes and if it has all been destroyed. Typically women being treated in general gynaecology by this method with have repeated laps to just have the same done each time so active endo is always left untreated. As more invasive surgeries are done the more scar tissue is likely to form (adhesions) that can then compound the problem without ever addressing the endo fully. Flaws of this kind of treatment are that the heat conducts through adjacent tissue and can therefore damage normal tissue or structures and because the tissue is burned it cannot be sent for biopsy to confirm the presence of endo.

The ablation methods used in this context are:

1) Cauterisation: passing electrical current through tissue to cause coagulation - a type of electrical burn.

2) Coagulation: Disruption of tissue by heat causing denaturation and clumping of protein.

3) Fulguration: Drying tissue by high frequency electrical current.

So these methods do not remove endo and don't guarantee its destruction.

The skilled specialists use wide excision (cutting) to remove a margin of healthy tissue and this can be by two methods:

1) Mechanical which is what we most likely think of - the actual cutting away of tissue by the force of laparoscopic scissors without the aid of electrosurgery.

2) Thermal excision by laser or the harmonic scalpel. This is called linear vaporisation and involves cutting by electrosurgery to create intense focused heat that completely vaporises the tissue being cut. The heat employed affects only the area being cut and so does not damage adjacent tissue. Nowadays this is the excisional method mostly used.

Unlike the above methods of ablation, excision allows for the assessment of underlying tissue to determine if deeper disease is still present and for in tact samples to be sent to the path lap for histology.

However, when in the hands of the skilled specialists laser can also be used for ablation as a secondary tool when required and this is called Ablative Vaporisation. This completely removes the endo. Because only small areas are vaporised at a time it would be too time consuming to vaporise large and deep areas of endo as each layer of cells would have to be vaporised one by one. But this is a useful technique where precise work is undertaken on structures such as blood vessels, the bowel or the ureter or for small, superficial endo on the ovary or tubes.

Have a look at my posts on the treatment pathway and on how to find a specialist centre.

You would find the following book very informative that can be obtained from Amazon:

Stop Endometriosis and Pelvic Pain by Dr Andrew S Cook.

x

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Thank you Linda, this is a very thorough description x

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