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BackTable / OBGYN / Podcast / Transcript #65
Podcast Transcript: Thoracic Endometriosis: Beyond the Pelvis in Diagnosis
with Dr. Shanti Mohling
Thoracic endometriosis occurs in about 12% of patients with advanced endometriosis. Due in part to its lower incidence and inherent diagnostic challenges, many providers are not well-versed in the workup and management of this advanced disease. In this episode of The BackTable OBGYN Podcast, host Dr. Mark Hoffman interviews Dr. Shanti Mohling, a gynecologic surgeon at Northwest Endometriosis and Pelvic Surgery, regarding her approach to thoracic endometriosis. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Endometriosis & Pelvic Pain: An Underappreciated area of Gynecologic Care
(2) Thoracic Endometriosis: Evaluation, Diagnosis, & Approach
(3) Pre-surgical Counseling: Benefits & Risks of Diaphragmatic Excision
(4) Medical Management of Endometriosis
(5) Ultrasound: A Crucial Tool for the Diagnosis of Endometriosis
(6) Thoracic Endometriosis & Catamenial Pneumothorax: Bridging Gaps in Multidisciplinary Care
(7) Innovative Surgical Techniques in the Management of Upper-Abdominal Endometriosis
(8) Strategies for Remote Management of Chronic Endometriosis
(9) Beyond Surgery: Future Implications and Etiological Theories
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[Dr. Mark Hoffman]
Hello, everyone, and welcome to The Backtable OBGYN Podcast, your source for all things obstetrics and gynecology. You can find all previous episodes of our podcast on Spotify, Apple Podcasts, and on backtable.com. Welcome back to another episode of Backtable OBGYN. This is your host, Mark Hoffman, and we've got another great guest today, Dr. Shanti Mohling, who is a gynecologic surgeon at Northwest Endometriosis and Pelvic Surgery. Dr. Mohling, welcome to the show.
[Dr. Shanti Mohling]
Thank you so much. It's an honor, and great to see you, Mark.
[Dr. Mark Hoffman]
Yes, thank you. It's okay if I call you Shanti?
[Dr. Shanti Mohling]
Absolutely.
[Dr. Mark Hoffman]
Wonderful. We like to begin every show by allowing our guests the opportunity to introduce themselves, talk to us about how you got to where you are in your current position and your practice, so our listeners can get to know you a little bit.
[Dr. Shanti Mohling]
Excellent. Thank you. As you said, my name is Shanti Mohling, and I currently practice in Portland, Oregon, here in the Pacific Northwest, where I've lived now for five years. I originally grew up in Colorado and did all of my medical training through University of Colorado in Denver and trained as an OBGYN graduating back in the '90s and practiced in northern New Mexico in a little town called Taos, New Mexico, for about 15 years, almost 15 years, and really did everything OBGYN. I was, for a while, the only doctor in that small community.
Over the years, I began to realize that I wanted to focus more on minimally invasive surgery, and so unusually, at the age of 50, I went and did a fellowship, and focused, during that fellowship, predominantly on pelvic pain and endometriosis. That was just how it worked out, which worked for me because I started out thinking, before I even went to medical school, that I wanted to focus on pain management, and even thought about going into physiatry and focusing exclusively on pain. Ended up being an OBGYN, but still focusing on pelvic pain over the years, and more and more, and then really, in the last decade-plus, have focused almost exclusively on pelvic pain and endometriosis. It's been challenging, as you might guess, and also profoundly rewarding. That brings me here today.
(1) Endometriosis & Pelvic Pain: An Underappreciated area of Gynecologic Care
[Dr. Mark Hoffman]
No, we're glad to have you. I think focusing on pelvic pain is certainly a specialty or subspecialty that has its challenges, but ultimately, I think it's something I can speak for myself that in residency, we just didn't learn a whole lot about it. It just wasn't a big part of our training. As we know, surgery, and surgical care, and gynecologic care is a small percentage of what we do in our OBGYN residency programs. What do they say? It's like 15 months of surgery out of 4 years. Even within that, to think about chronic pelvic pain and endometriosis, it's really a fraction of the time we spend in our training.
I had a similar experience in that. Doing fellowship, it was a pelvic pain-heavy program at the University of Michigan, really just stuff I had never seen before, and treating patients in ways that I had not been able to learn about as a resident. There's so much more, obviously, for us to learn. To be able to do that, and then move back to Kentucky 12 years ago and was the only person really doing what I do until recently was, that was it for a while, at least in the region. The need is great. The knowledge that I think most of us have, as you probably also would say, is there's always room for improvement. I think for the general OBGYN, it's, we don't learn as much as we should, or as we could.
[Dr. Shanti Mohling]
Definitely.
[Dr. Mark Hoffman]
It's not because we don't care, but because the residency program is very obstetrics-heavy.
[Dr. Shanti Mohling]
Yes. Also, the teachers in OBGYN residency programs themselves didn't get a lot of training in pelvic pain, for the most part.
[Dr. Mark Hoffman]
No, I think that's right, and so I'm glad that we've had that opportunity. Now you're in Portland. Talk about your practice. Is it primarily surgical endometriosis? Is it just pelvic pain, and some of that is endometriosis?
[Dr. Shanti Mohling]
It is primarily endometriosis surgery. I practice at Northwest Endometriosis and Pelvic Surgery with Dr. Nic Fogelson, who started that practice. It's been the best place to land. It's been the best clinical setting that I've had in my career. Partly because Fogelson and I see really eye-to-eye on our care, and because within this practice, I'm really able to push my own envelope, which is what brings us partly to this meeting today, been able to do things that I never dreamed I was going to do 15 and 20 years ago when I was a generalist OBGYN.
I see patients from all over the world, but mostly from all over the US who are looking for someone who will focus on excision of endometriosis, no matter where it is. That is the bulk of what I focus on. I also do some things like vestibulitis, and vulvodynia, and vaginal Botox, and that kind of thing, but I would say mostly endometriosis surgery.
[Dr. Mark Hoffman]
When you say you guys see eye-to-eye, what do you mean by that? I say that meaning, what is specific about the way you two practice that may be unique compared to other, not just general OBGYNs, but other minimally invasive GYN surgeons?
[Dr. Shanti Mohling]
That's a great question. We both do a very similar history-taking. I think it's super thorough. It's listening to all the components of the pain. Then we do a very comprehensive, or super comprehensive exam that includes doing our own ultrasounds, looking for disease, looking for movement of the structures in the pelvis. Then similar methodology for when we might order an MRI, when we might use a consultant. We're both very lucky to work with a group of general surgeons who includes a foregut surgeon who can do VATS for us, which is video-assisted thoracoscopic surgery for those who don't know.
[Dr. Mark Hoffman]
Oh, wow.
[Dr. Shanti Mohling]
That really opened the door for me to be able to feel comfortable approaching the diaphragm. The group also helps us when we have colon resections. Of course, we don't have full privileges to do our own colon resections, of course. We can do disc excisions on our own. Then if there's anything bigger than that, I'll call in one of our specialists.
[Dr. Mark Hoffman]
I'm going to get to the surgical part a little bit later on, but that's a big piece of how we develop our skillset. That's finding colleagues and partners who share our interests and how lucky you are and how lucky I've been to have surgical colleagues where I am, that are interested and willing to operate together to help us all get better because that's what it is. We're all just trying to get better for our patients.
[Dr. Shanti Mohling]
You have to feel safe. You have to feel like, if I do this, I've got backup and support. That enables us to push the envelope to excise disease that otherwise people are living with and to do it in a safe way.
(2) Thoracic Endometriosis: Evaluation, Diagnosis, & Approach
[Dr. Mark Hoffman]
Patient safety is always first. Let's start in the clinic. A patient comes to see you. We're talking about thoracic endometriosis today. I think most of us think about endometriosis as a pelvic disease or disease that typically resides in and around, including primarily pelvic structures, but we see it on the diaphragm. I'm not sure most of us know what to do with it, but ultimately, talk about those patients that you see, or in whom you may suspect thoracic endometriosis.
[Dr. Shanti Mohling]
Yes, right. That's the biggest question. In a way, I suspect it in everyone. Just, I think it's more prevalent than we realize, although the numbers are that it's going to be up to 12% of people with invasive endometriosis, advanced endometriosis, that are also going to have extra pelvic disease. When I am meeting with someone, and we are pretty sure from their history, from their exam, from their family history, or from prior surgical documentation that they have endometriosis, and they want to have surgery and they want to have either just excision or they want to have excision with hysterectomy, very rarely, but occasionally, also oophorectomy, especially if they're over 50 and have involvement of the ovaries, I'm going to say, "Listen, some of my patients have diaphragmatic disease."
We have a conversation. "One, do you have symptoms? Do you have chest pain? Do you have shoulder pain? Do you have, or if anyone has a history of catamenial, meaning with the menstrual cycle, pneumothorax, or symptoms?" I'm going to have an increased threshold of interest that they might have diaphragmatic or thoracic disease. I start out, before we even go to surgery, I counsel them that I always look, and if I find it, do they want me to remove it? The reason we have that conversation is there are risks. There are risks of removing it.
One of the risks is if you even just remove superficially the disease, you don't do full thickness through the diaphragm, you might make that area more vulnerable and create, ultimately, a diaphragmatic hernia. You might injure the phrenic nerve. You might injure the liver in your process of getting up there, which can cause some bleeding. I had a Jehovah's Witness the other day, and happily, she did not have a-- Actually, no, she had a spot of diaphragmatic disease, but prior to our surgery, we had a conversation. She said, "I don't want you to remove it."
She had one spot of disease. She had incredible pelvic disease. She wanted to preserve fertility, so her goal wasn't to go searching disease everywhere in the whole body. She also had no symptoms of diaphragmatic disease. She elected, prior to surgery, to say, "No, don't remove it." That's a case I'm going to absolutely honor that. We'll have that conversation because a lot of the time, you don't know someone is going to have that disease. It doesn't show up on MRI. It doesn't show up on any imaging, and yet you see this disease when you go and look.
When I say when I go and look, I mean every single patient who I operate on for endometriosis at the beginning. I do most of my surgery robotically. Before I dock, I put them in reverse Trendelenburg, maybe 15 degrees, and I look at the whole upper abdomen. I elevate the liver, look under the liver on the right. I look at the surface of the kidney. Of course, the gallbladder, if it's there, I'm going to be visualizing it. Then I mobilize just using my suction irrigator. I just press on the liver louder, pushing it medially, pushing it down, taking my 30-degree camera all the way up so I can see the whole right dome of the diaphragm. Then I do the same on the left. Of course, sometimes you find a little pericardial disease too, and that's a whole nother threshold of conversation ahead of time.
(3) Pre-surgical Counseling: Benefits & Risks of Diaphragmatic Excision
[Dr. Mark Hoffman]
How do you counsel patients on that? Obviously we talk about the risks of hernia or putting a hole in the diaphragm. Obviously, there are significant risks associated with this. What do we know about the benefits?
[Dr. Shanti Mohling]
That's a great point. I think that if you start out with symptoms, you're going to have a benefit, ultimately, of decreased pain. My patients who have chest symptoms, shoulder pain, flank pain even, and we've removed that disease, they feel so much better. I think the literature supports that. I don't know about those patients who have a couple spots. I don't know if those patients benefit from the trauma of excising off of the diaphragm. I'm not sure how much benefit we get. With aggressive full-thickness disease, I think we make a huge impact on their catamenial chest pain.
I want to add one thing, and that is that I really have found, in my practice, that the recovery from diaphragmatic excision takes longer than just recovering from pelvic excision, that it may take 6 to 12 months to really feel that benefit and feel like you can really take deep breaths and stretch your lungs again, and realize, oh, you don't have pain when you do that. It takes longer to recover from full-thickness excision.
[Dr. Mark Hoffman]
This is a conversation we've had with other guests, and I'll continue to have with guests, just because what we know about endometriosis, in general, is limited and where it comes from. We all have theories and we all have ideas. I think most of us doing this would say excision is better than ablation. Ultimately, I think it's an important conversation to have with patients about potential outcomes, which it sounds like you're doing, and that's how you're describing your visit. This could help. This could be a benefit, balancing it with the risks.
(4) Medical Management of Endometriosis
[Dr. Mark Hoffman]
Ultimately, how much does medical management play into it for you? I know patients probably by the time they come to see you have gone through a bunch of that stuff. How much in your practice are you talking about medical management with surgical excision, after surgical excision? Do you always recommend hormonal suppression after surgical resection, or do you feel like you got it all, there's nothing to treat?
[Dr. Shanti Mohling]
This is the million-dollar question. I do not insist on hormonal management after excision, and I've had good success with that so far. I almost never use GnRH analogs, almost never. I prefer progestin because that combination, birth control pills, I think that we don't really have good information about how they really affect endometriosis. I do know, we know, that the levels of estradiol are four to five times physiologic levels when you're using a birth control pill.
[Dr. Mark Hoffman]
Is norethindrone your primary?
[Dr. Shanti Mohling]
Norethindrone, drosperinone, some of the progestin-only pills have other-- A Mirena IUD can be a wonderful option for people. Some of my patients also want bioidentical progesterone, and they prefer it. By the time patients come to me, they have run the full gamut of hormonal trials, and they don't even want to hear me ask them if they've used them in the past. I have to reassure them that I'm not quizzing them to make sure they will stay on it or something. They're so hypersensitized to being asked to be on hormones.
I'm very gentle with my approach in that I think that it's very individual, and it may be that it is beneficial. I would say most endometriosis excision surgeries across the world even, insist on some type of hormonal treatment postoperatively. That's really rare in that, actually, that I don't. I do love when someone is willing to do a Mirena IUD unless they are looking forward to trying to get pregnant. I also am open, if someone has done well in the past with a Nexplanon or with a birth control pill, I'm happy to let them stay on it and support that, yes. Does that answer your question?
[Dr. Mark Hoffman]
Yes, no, I like to ask about practice patterns because ultimately, I think a lot of us are out there trying to help patients with endometriosis. We have, again, some good information, but it's pretty limited information. We all have a little bit of a variable practice in how we do it. I think our approach to management of endometriosis is variable because there's no standard data. There's no paper that says this is the way to do it. That's unfortunate for our patients. I'm always curious to know how other surgeons, how other gynecologic experts are managing endometriosis because I'm with you.
I don't insist on treatments. I see myself as a consultant, they come to see me. I tell them what I know. I tell them what I think. I'll do a thorough evaluation, like you said, a complete history, a thorough pelvic exam, which can be very helpful in finding other non-gynecologic causes of pain as well. Ultimately, I make recommendations. Patients don't want to do something, then that's, of course, it's their choice. Patients have to be a part of the decision-making. They're the ones, it's their bodies. We have to be respectful of that. I don't want hormones.
I don't talk about hormones. I want surgery. Okay. You've had that opportunity to discuss it, and this is what I think and this is, but ultimately this is what you decide. These are the numbers that we know. When patients make a decision for themselves, we respect it. I think it's an important thing to listen to our patients and allow them to guide the care to a degree that both the physician and the patient feel comfortable with. I think that's the other piece. If someone says, "I want this thing done, that makes no sense," the physician can also say, "I understand you. I trust you. I believe you. That's not something I'm comfortable with. Here's a name of a person who might be willing to do it."
[Dr. Shanti Mohling]
[chuckles] Indeed.
[Dr. Mark Hoffman]
I'm not saying they can tell us what to do, but at the same time, it's important to make them feel heard and valued and to believe their pain, and all those things. It is a relationship that you have to work at for sure because this is something, especially I'm guessing in the population of patients that you see, these are folks that have been suffering for a very long time.
(5) Ultrasound: A Crucial Tool for the Diagnosis of Endometriosis
[Dr. Mark Hoffman]
You talked a little bit about your exam, talk to us about your in-office ultrasound, how you do that because that's pretty unique. Then we'll talk about other imaging modalities after that.
[Dr. Shanti Mohling]
Interesting. I was very lucky that, I think this is lucky, I trained in the era in the '90s before the rules changed about 80-hour work week thing. I did those exhaustive hours, which was horrible at the time, but in a way, I got a lot of experience. In addition to those experiences, I got to do a lot of my own ultrasound, and I had some great folks. I don't know if you've heard of Jim Shwayder. He used to be in Kentucky.
[Dr. Mark Hoffman]
He used to be at Louisville. Yes, I know Dr. Shwayder.
[Dr. Shanti Mohling]
When I was a resident in the '90s, he was one of my attendings in Denver Health. He was fabulous and really insisted that we all learn gynecologic ultrasound. We also had one of the premier OBGYN maternal-fetal medicine docs who had written books on OB ultrasound, who also trained us. I benefited from that, and since then have done my own ultrasounds that I've built on that in my own training with conferences and how you evaluate for adenomyosis, for example. Then augmenting that, you can use, of course, the slide test, which you're familiar with, where you press on the belly or you move the probe and you see how the structures move with each other.
That helps a lot to identify adhesions. I am discovering now that I do my pelvic exam before the ultrasound, of course. Just that's the sequence. Because of that, I know where that intense nodular disease will be. I'm seeing that, I'm finding that I can actually see it with my ultrasound probe. I can't tell you that I would be able to do that had I not also done an exam, that refinement of that, like uterosacral thickening, I don't know that I quite have that skill set, but I'm building it. Of course, I've already felt it with my fingers, so then I'm developing that.
I would say that some of the times, even if I've had an MRI that was negative for invasive bowel disease, I've been able to see the bowel so plastered on the uterus that you see this almost rickrack where it's fused. When I'm there laparoscopically, and indeed, the bowel is entirely fused and we have to do a resection, it plays out. I'm learning also to trust my own ultrasound skills because these aren't the things I was learning 20 years ago. Some of them are things I'm learning as I go.
[Dr. Mark Hoffman]
Yes. It's putting it all together. It's, if they're having bowel symptoms associated with their cycles, you get very suspicious exam findings. We have great MRI radiologists here where I work, but again, being able to match the clinical findings and the history with what you're seeing, it doesn't always correlate with what they see versus what you see. Having that little voice in your head, go, "I know the MRI is negative, but man, this feels like there's going to be something else there," and involving your colorectal colleagues. If they're always next door, it's not as big a deal, but things like bowel prep, and those are the things that you can do to anticipate those surgeries and making sure your colorectal colleagues are available as opposed to, oh man, we're just finding out, and more importantly, counseling the patients.
Surprise advanced colorectal disease, patients are typically very understanding, but they don't like surprises. If you're going to do bowel surgery, you have to talk about that in-depth and at length prior to surgery. Yes, as much as we can learn before surgery, the more we can appropriately counsel patients about the types of advanced surgery that you're doing. It sounds like you're doing some of the most advanced endometriosis surgery there is.
[Dr. Shanti Mohling]
Absolutely. I find that more and more, I'm doing bowel preps ahead of time just because I've been surprised. Even when I think, oh, they may not have it, I just more and more, any small trigger that makes me think maybe bowel, I'm going ahead and having them do a bowel prep so I'm ready.
[Dr. Mark Hoffman]
No, I think I've gotten to that point to a degree as well. I don't know, there's just something seems a little bit more than I'm thinking, and more and more, maybe it's just the blink thing. If you've read Malcolm Gladwell, there's just something about this picture that just seems suspicious to me, and understanding what that gut feeling is and go, "Okay, I'm not going to ignore that little voice in my head, and I'm going to be more prepared." Those are the things you learn after years of experience, good and bad, that allow you to hopefully have a better experience in the OR as you get further along in your career. How often do you and Nic operate together?
[Dr. Shanti Mohling]
Pretty rarely. I think a couple of times this summer, our assistant was out of town. We have an assistant who works for us who is a nurse surgical assist, RNFA, registered nurse first assist, and she is fabulous, and Carrie Swanson. If she happens to take a vacation, Nic or I have to assist each other, and that's hilarious. I say it's hilarious because we are both somewhat headstrong in the OR.
[Dr. Mark Hoffman]
I can't imagine that.
[Dr. Shanti Mohling]
I totally defer to him, and he does not very well defer to me, I might say, but he does. He's fantastic. I actually say that really lovingly because I will also say that Nic's support of me has been the thing that allowed me to just say, "I can do this. I'm going to just go for this. I can do this." His belief in me was a true gift.
[Dr. Mark Hoffman]
No, that's great. I'm lucky where I am, I've got great partners because I'd gone a long time with no other MIG surgeons except me for a very long time. To have not just MIGs partners, but Urogyn partners and other specialties around, it just makes the work-- The work is hard enough. Doing what we do is hard enough. To do it with good people just makes it enjoyable at times.
(6) Thoracic Endometriosis & Catamenial Pneumothorax: Bridging Gaps in Multidisciplinary Care
[Dr. Mark Hoffman]
Getting back to thoracic endometriosis, there's someone you suspected, we talked about bowel prep for bowel endometriosis, what are you doing? Is there anything special you do to prepare patients? You've talked to them, you're concerned, you have thoughts about it. If you're going to resect it, talk to me about how you prepare patients about the risks and benefits of resection of thoracic endometriosis, diaphragmatic.
[Dr. Shanti Mohling]
Yes, okay. That's, you bring up a beautiful point. I myself don't do pulmonary excisions, but I have someone who can if that's needed. I think that one thing that's very important to clarify is that one of the symptoms we talk about is catamenial pneumothorax. Really, that is more a pulmonary pleura disease, more than a diaphragmatic disease. You can have diaphragmatic disease and even full thickness and never have a pneumothorax if you don't have pulmonary disease. If sometimes when someone has really significant symptoms, I will have them go ahead and consult with who we use, which is a guy, a doctor named Jeff Watkins, and they'll have a consultation.
He's then available for VATS. It's very, very rare in the literature to have disease above the diaphragm with no documented disease visualized below the diaphragm. Some patients have significant enough symptoms that they want the VATS. They want to have it confirmed that it's not seen there. Of course, 90% of the lesions are going to be on the right. That's how we'll set it up, and that will be the approach if we're going to do VATS.
[Dr. Mark Hoffman]
How many of those are you doing in a year? Is that a pretty common part of your practice?
[Dr. Shanti Mohling]
I would say that it comes up maybe once a month on average.
[Dr. Mark Hoffman]
Wow, that's a lot.
[Dr. Shanti Mohling]
It is. It comes in clusters. There might be months where I don't see it. Then, of course, Nic also. We have a probably similar average on that.
[Dr. Mark Hoffman]
These are all patients who have a history of catamenial pneumothoraces, or this is just people who have sick chests?
[Dr. Shanti Mohling]
No. Advanced endo.
[Dr. Mark Hoffman]
Okay.
[Dr. Shanti Mohling]
Remember that if you've got advanced endo, you're going to have about up to 12% chance of having diaphragmatic disease. I see a lot of patients with Stage 4 endo.
[Dr. Mark Hoffman]
What percent of those are going to have pulmonary disease though that are going to have–
[Dr. Shanti Mohling]
Much lower. This brings up a really, really important issue, Mark. I think it's one of my, how am I going to get this issue out there? That is that patients who have pneumothorax, they don't get seen by us. They get seen in the ER. Then they get shuttled to pulmonary medicine and cardiothoracic surgeons who do pleurodesis. What happens is, then you can never get to their diaphragmatic disease. I have a patient who has had a couple of pleurodeses, and she has still recurrent pneumothorax. We did VATS, the lower part of her diaphragm, you can see where it was stapled from above so you can't see any disease.
Then if you go in on VATS, it's just scarred completely from the pleurodesis. You can't just go cutting blindly into the lung, and you can't access the disease anymore. Another person I just spoke with has something called talcomas from the talc from pleurodesis, creating these granulomatous lesions throughout the lung. We have this really complex problem where cardiothoracic surgeons are treating pneumothorax, which is catamenial, which is endometriosis in etiology, and they're treating them with pleurodesis without removing the disease.
Then they still have the symptoms of endometriosis and then they have this completely scarred pulmonary cavity. It creates an untenable situation that we cannot really address any longer. Maybe they are somewhat successful. In the literature, sometimes they're doing pleurodesis, and then they're adding GnRH analogs temporarily, and they get relief. Then how long can you do that? Not forever. I think one of my goals in the next few years is to figure out a way to somehow open the door for conversation with cardiopulmonary providers so that we can share that, the care of those patients. Now, you asked me a question and I took off on that tangent. What was it, Mark?
[Dr. Mark Hoffman]
No, that's why you're here. We talk about thoracic endometriosis, we talk about endometriosis, I was thinking more like diaphragmatic, but it's not thoraxes, the diaphragm, as we see it from the peritoneal cavity, from the abdominal cavity. Now with pneumothoraces, you're talking about endometriosis that is in the pleura, inside the chest cavity, is that what you're describing?
[Dr. Shanti Mohling]
Yes, and even into the lung. Yes, exactly.
[Dr. Mark Hoffman]
Into the lung, okay. That is far out there, not in terms of make-believe, but it's something that we just don't talk about much in our world,-
[Dr. Shanti Mohling]
Right.
[Dr. Mark Hoffman]
-but that you're here to tell us that it is something we need to be talking about in our world.
[Dr. Shanti Mohling]
Absolutely. We need to educate our other ancillary providers that this is an issue that we could share and we might get better outcomes for the patient.
(7) Innovative Surgical Techniques in the Management of Upper-Abdominal Endometriosis
[Dr. Mark Hoffman]
Working with the RCT surgery colleagues, now, when it comes to abdominal surgery, and you're looking in the upper abdomen, you're talking about the diaphragm, you're talking about the liver, the gallbladder, are you seeing endometriosis everywhere, that it's anywhere we could access?
[Dr. Shanti Mohling]
I've never seen it on the gallbladder or the spleen, although we have ended up having a couple of patients come back for splenectomies when they had this chronic left upper quadrant pain. We were able to diagnose this a few times now, this very interesting vascular malformation that was not endometriosis. They had endometriosis also, but in the left upper quadrant, they had this other unusual thing. That's a whole tangent. I have removed it from the peritoneal surface of the kidney on the right, not the left, obviously it can't really access it, in a patient who also had diaphragmatic disease.
What I've developed in my own practice, I told you that I put everyone in reverse T, and I explore the upper abdomen before I do the pelvic surgery. Then if we need to, we'll go back, undock the robot, put them back in reverse Trendelenburg, and turn the robot around and address the upper abdomen. If it's pretty significant disease, what we're going to do, what I'll do, is release the coronary ligament, the triangular ligament, these are the ligaments of the liver, onto the diaphragm and the falciform, to mobilize that liver away from the diaphragm so I can just more easily jump up there.
[Dr. Mark Hoffman]
Are you always doing this with a cardiothoracic surgeon or an upper abdominal surgeon? Is this stuff you've gotten comfortable doing on your own now?
[Dr. Shanti Mohling]
I'm comfortable doing that. The caveat to that is that if I've already consulted someone for the VATS, and they have made the time to be there for me, I sometimes will let them do part of that surgery because they've already allocated time, and so I want to share the coding and everything. No, I'm comfortable doing the release of those ligaments and accessing some of that disease on my own, absolutely.
[Dr. Mark Hoffman]
Most of us out there listening are not.
[Dr. Shanti Mohling]
I've taught it a bit through AAGL, and round tables, and so forth. I got to go say, it was bold. I never thought that I was going to venture out to this.
[Dr. Mark Hoffman]
Venture north.
[Dr. Shanti Mohling]
Venture north. I did not think I would be the one to venture north. I'm an ordinary person. We can all do this.
[Dr. Mark Hoffman]
You've got a good partner, and you've got good colleagues outside of your specialty to allow you to learn these things and to be available and to be patient enough to do that education.
[Dr. Shanti Mohling]
Definitely.
[Dr. Mark Hoffman]
In a private practice setting no less, where I think we think about academics and we've got all the time in the world, and the reality is we all have RVU pressure or productivity pressure in other ways. To have somebody who's willing to teach you, who's willing to work with you, and I've got that where I am too, is so valuable to allow us to get better, to get more competent because we can't go and do these things on our own to try them. It's not safe. It's not what's best for the patient. We also can't just keep doing the same stuff forever, knowing, like you said, we have to push the envelope to try to understand this disease better and to care for our patients better.
[Dr. Shanti Mohling]
Absolutely. I think you bring up a good point, and that is, I don't know if you brought this up, but it sounded like it, that there is this disease on the diaphragm. It's on the lower diaphragm accessed by the abdomen. Who is going to take care of that disease? I don't know who's going to do it. At a certain point, I said to myself, "Okay, Mohling, you just do it. Just go for it. I also had the hand-holding in the beginning, of Jeff Watkins saying, "Yes, good, yes." Learning how to control when I had a little bleeding on the liver from retracting it. Wow, okay, whoa, these wonderful robotic instruments work. We can do this, and it's okay.
[Dr. Mark Hoffman]
Now I remember operating with an upper abdominal surgeon and liver surgeon when I was a resident. He was operating on the liver and boving all over it. We get the bleeding, he would just fry it. Someone asked him, "Why do you have the bovie set to 100?" He goes, "Because it won't go any higher."
[Dr. Shanti Mohling]
That's so great. That's such an old surgeon thing to say. Oh, my God.
[Dr. Mark Hoffman]
Operating on the liver, just cook it hot or something.
[Dr. Shanti Mohling]
Char it.
[Dr. Mark Hoffman]
Yes, exactly. I was like, "I'll let you guys do this stuff." I've watched videos, peeling the peritoneum off, just like we do in the pelvis, careful dissection and you see the muscle layers above that and that kind of thing. It's probably a moving target, I guess, when they're breathing for you.
[Dr. Shanti Mohling]
It is, that's true. Also, it is so profoundly innervated that if you touch it with monopolar, it jumps and suddenly you're into the lung.
[Dr. Mark Hoffman]
Sounds like you're speaking from experience.
[Dr. Shanti Mohling]
Indeed, yes. That was the one and only time, early on, that a patient had to stay overnight with a chest tube. Oh, in fact, sometimes these patients will go home same day, even if I'm full thickness.
[Dr. Mark Hoffman]
No kidding?
[Dr. Shanti Mohling]
Yes.
[Dr. Mark Hoffman]
By full thickness, you mean?
[Dr. Shanti Mohling]
Into the lung.
[Dr. Mark Hoffman]
You're just sewing the muscle closed?
[Dr. Shanti Mohling]
Yes, and then you can use a red rubber or even the suction irrigator to vacuum, suction back at the last stitch to recreate that.
[Dr. Mark Hoffman]
Then the anesthesiologist just tells you, "Oh, lung sounds like it's full and you're good to go." How do you know?
[Dr. Shanti Mohling]
Yes, with experience we've learned they do okay. We don't get a chest X-ray in PACU.
[Dr. Mark Hoffman]
No kidding.
[Dr. Shanti Mohling]
Yes, but I'm not alone making these decisions.
[Dr. Mark Hoffman]
No. They're right. This is not a, you're a cowboy. This is, you're doing advanced surgery safely. That's something that we all–
[Dr. Shanti Mohling]
Correct, I'm 61 years old. I've taken so many years to have the confidence to do this.
[Dr. Mark Hoffman]
It's incredible. To think about what it takes to get there, it's not easy.
(8) Strategies for Remote Management of Chronic Endometriosis
[Dr. Mark Hoffman]
Let's talk about your practice. It sounds like it's a referral practice that is national and international. I've heard some other destination surgeons talk about management of a chronic disease. Patients fly to see you, they have surgery. Are you doing a lot of your work up remotely before you see them? Are you doing your post-op care remotely? It doesn't sound easy.
[Dr. Shanti Mohling]
No. I do really careful consultation ahead of time. Then they fly in, in time to have a pre-op with me. I have a low threshold for bowel disease if I haven't been able to see someone before scheduling them. They're almost all doing bowel preps and they're all doing robotic, not laparoscopic when they come in. They will then schedule to stay at least a few days after surgery. Sometimes I have pictures from their prior surgery and that really helps guide me. Then I always want them to have flexibility to stay longer, especially if they end up having a hospitalization for a bowel resection.
Then it's because we're out of network, we have the ability to really have a little more tailored care, concierge care. People have access to me post-op, even if they're from afar. I'm texting them, I'm checking in on them. It's not ideal because they're not local. I consulted with someone recently who has a myriad of other complex health issues. I really discouraged her from coming here because I don't want to feel like I can't manage her post-operatively. I screen for, am I going to be able to manage your care post-operatively before you come here. I also don't like people to come internationally because they have to pay their hospital bill, and their hospital bill is going to be five times my bill or more.
[Dr. Mark Hoffman]
When they have their surgery, how they do long-term, I think perioperatively is one thing. Long-term, are you seeing these patients three, six months out? Some other surgeons I've heard give talks and someone asked them, "How do your patients do long-term?" and they always said, "I don't know, I don't ever see them again." How do you know the work you're doing has value when you can send them home and you never see them again?
[Dr. Shanti Mohling]
I think that I leave an open door really carefully with patients. I also do at least a six-week check-in on Zoom and make sure they're doing okay.
[Dr. Mark Hoffman]
Great. Are you talking directly with their primary docs where they are, to help coordinate any complications? Are they doing anything like that?
[Dr. Shanti Mohling]
Fortunately, I haven't had to do that, but I certainly would.
[Dr. Mark Hoffman]
Then, again, I'm just trying to think about how, for our listeners to build something like this, to learn how to do it, it's always, when we have unique practices and providers like you who are doing things that are different than the rest of us, I like to really think about the whole practice all the way through and how you do it. It sounds like you guys have built something pretty special where you are, and the question is how the rest of us can learn this. That's something that, it takes time, it takes dedication. Like you said, you went back after being in practice, and as a practicing generalist, to then go back into fellowship probably was not an easy decision. It sounds like you're a lifelong learner. Sounds like something you're constantly working on.
[Dr. Shanti Mohling]
Definitely. For better or for worse, God, when do I end,
[Dr. Mark Hoffman]
Our patients deserve that, I think. We have to have the understanding that we just don't know enough about this disease. We have to constantly be learning about all of it, chronic pelvic pain, about endometriosis, and all the other non-gynecologic causes of pain. I think it's very impressive what you've done. Oh, the other question I had was flying after surgery like this when you're doing chest surgery. Are patients allowed to get in a plane after they've had a diaphragmatic surgery? Are you worried about, I'm not that into physics to know the air pressure. Is that something you even think about?
[Dr. Shanti Mohling]
I don't think about it. I'm trying to think. Certainly haven't had a problem. I've had people come from further away. Have I had someone really fly? I'm sure I've had people fly after diaphragmatic excision.
[Dr. Mark Hoffman]
It sounds like you're doing that more commonly than you're doing VATS and things like that, right? The diaphragmatic surgery sounds like it's a pretty frequent occurrence in your practice.
[Dr. Shanti Mohling]
Correct. Originally, I was having them get VATS more often. Then I realized if I'm getting full-thickness disease, then I can look in there with my robotic scope anyway.
(9) Beyond Surgery: Future Implications and Etiological Theories
[Dr. Mark Hoffman]
Yes. Talk about the disease we leave behind because this is something that I ask a lot of our guests about. Reading The Emperor of All Maladies, which is a book I talk about not infrequently on the show, but the idea that back in the day, we saw cancer as a surgical disease, we just had to cut more of it out. Then you realize, no, this is cellular disease. This is DNA. This is not something we can see with our naked eyes. One of my GYN oncology colleagues told me the other day, she's like, "If you look back 100 years, all of the surgical advancement we have in cancer care is medical."
All of the advancements, whether it's chemo, whether it's radiation, whether it's targeted therapies and those kinds of things, the surgery hasn't really-- Laparoscopic, sure, but otherwise, in terms of we're doing less surgery, that's really the advance. We don't have to do as much because of the medical management because of the neoadjuvant therapies and those things, or targeted therapies. It still feels like with endometriosis, that we're a little bit behind. I think what you do is so important because we don't know the source or cause of endometriosis, and we have to deal with more advanced disease.
Do you have a theory about endometriosis, about what it is, where it comes from? I think we all have our own ideas about it, but the idea that it's just retrograde menstruation, come on. Everyone has that, and most people don't have endometriosis. How do you get it in the lung from retrograde menstruation? We have all these theories, but I always like to ask what do you think endometriosis is and where does it come from?
[Dr. Shanti Mohling]
Yes, okay. You asked me two questions. I'm going to answer the first one first, which was, do I leave disease behind? Of course, sometimes I'm sure I'm leaving some cells behind. Sometimes I'm probably leaving a little fibrosis behind. When someone's primary goal is fertility, I'm sure that I'm leaving a little disease on the ovaries because I don't want to compromise their reserve. Generally, I do pretty wide excision peritonectomy way beyond the high focal points of what appears to be disease.
[Dr. Mark Hoffman]
Are you doing that for even Stage 1? You're doing Y resection, or are you really talking about more advanced disease?
[Dr. Shanti Mohling]
It depends. If someone is a teenager and they have a tiny spot, I'm not going to do a full peritonectomy. I've seen teens with Stage 3 disease too. It depends on their history, it depends on our conversation and depends on their age and their future goals, and in how much normal-appearing tissue I would take. I'm going to limit that in a teenager, for sure, or a young person who hasn't-- If they have really early disease, it depends on their pain and their future fertility. That conversation we would have had. In answer to etiology of endometriosis, of course, being an excision person, I'm sitting on the Müllerian embryology post. I believe we were mostly born with it, and then we have an overlay of environment.
Genetic predisposition plus environment overlay. I don't know if you know I published a paper on intestinal permeability and endometriosis, which is a pilot study, but suggesting that there is increased what we call leaky gut or impaired intestinal permeability in patients with endometriosis, as opposed to controls. That is true very high percentage-wise with celiac disease. Celiac patients have markedly increased intestinal permeability at the onset of their disease. That's a whole nother conversation.
In terms of etiology, I think most of it is embryologic, congenital. We're born with these gonadal tracks that somehow, the cells migrating during embryogenesis didn't fully make it and then become dysfunctional, somehow. That's my working theory. On the other hand, I do think that there is the possibility that there are some cases where retrograde menstruation may play a role in a truly unhealthy environment of the pelvis. We, for sure, know that we get seeding at the time of a C-section that becomes an endometrioma in 1% to 3% of C-sections. We can also have spontaneous abdominal wall endometriomas too, which may be more Müllerian.
I do believe that most of it is derived congenitally or embryologic in origin, but that there certainly are going to be other factors. It's been found in lymph nodes. Is there some other etiology? Sometimes, like cancers too, not everything starts in one specific way. Some of it's viral, some of it's environmental, some of it's genetic predisposition. Definitely, I think there's genetic predisposition. I think there is epigenetic overlay in terms of environment impact. Some of it may be retrograde, in some cases, retrograde menstruation. I don't know.
[Dr. Mark Hoffman]
Love it. No, I think that's where we don't have a lot of diseases. We just don't know where it comes from. They're out there in other specialties, but certainly, for us, it's one of those things. We think about preeclampsia in our world, but it is something that I'm eagerly anticipating a breakthrough. I think our patients are long overdue for an answer. It is going to be something that will be cause for major celebration if we can understand where this comes from so we could think about other modalities, other ways to treat it. In the meantime, we have people like you who have dedicated their lives to being able to treat this disease when it becomes more advanced.
I'm grateful for you, for what you do for your patients, for what you contribute to our specialty and our subspecialty. Thank you for coming on Backtable to share with our guests the work that you're doing because this is how we all get better. This is how we all learn more. This is how we all are able to do more to help our patients.
[Dr. Shanti Mohling]
Throughout this conversation, if it weren't this setup of you interviewing me, I had questions I wanted to fire back at you because obviously, you're doing great things yourself. I appreciate the opportunity.
[Dr. Mark Hoffman]
It's our pleasure, and our guests are the star here. This is, I get to play the dumb guy in the room, which I know it's hard to believe, but I'm quite good at that. Whatever I don't know, I'm assuming some of our listeners out there also are curious about, and that's what makes this thing work. Thank you again for your time. It's been an absolute pleasure and I look forward to seeing you hopefully November in New Orleans.
[Dr. Shanti Mohling]
Yes, I'll be there. Thank you so much, Mark.
[Dr. Mark Hoffman]
Thanks again. Thank you so much for listening. If you haven't already, make sure to follow the podcast, rate it five stars, and share with a friend. If you have any questions or comments, direct message us @ _backtableOBGYN on Instagram, Twitter, or LinkedIn.
Podcast Contributors
Dr. Shanti Mohling
Dr. Shanti Mohling is a gynecologic surgeon in Portland, Oregon.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2024, September 17). Ep. 65 – Thoracic Endometriosis: Beyond the Pelvis in Diagnosis [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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