Current Research on Endometriosis: An Interview with Dr. Emad Mikhail

The first thing I learned in endometriosis is that you should listen to the patient.

Dr. Emad Mikhail is an associate professor of Obstetrics and Gynecology (OB-GYN). As a practicing surgeon at Tampa General Hospital, he has insights into the clinical practice as well as the research regarding endometriosis. During the 15th World Congress on Endometriosis in Edinburgh, Nadine, the Endometriosis App’s medical director, spoke with Dr. Mikhail about his work.

Dr. med. Nadine Rohloff: Welcome, Dr. Emad Mikhail. Could you introduce yourself, please?

Dr. Emad Mikhail: My name is Emad Mikhail. I’m an endometriosis surgeon in Tampa, Florida. I have worked at Tampa General Hospital for the past ten years and am an associate professor at the University of South Florida.

Dr. med. Nadine Rohloff: How did you come to be a surgeon and specialize in endometriosis?

Dr. Emad Mikhail: I trained for general surgery in Egypt before moving to the United States, after which I completed OB-GYN training and completed a fellowship in minimally invasive surgery. When I was figuring out where my expertise would fit patient care best, endometriosis came by as an ideal space for me. For the past seven years, I have dedicated all my clinical practice to taking care of endometriosis patients. I have a practice for surgical referral of endometriosis patients. There is a big team to help me because endometriosis requires a multi-disciplinary team approach. I feel blessed to work with such great people who are passionate about dealing with such a tough disease.

Dr. med. Nadine Rohloff: What would you say are the biggest challenges for endometriosis treatment in the US at the moment?

Dr. Emad Mikhail: The biggest challenge is the absence of funding for research. I am not aware of any other disease that affects 10 percent of a population and has so little funding. We have a lot yet to discover about endo, and we can only improve our knowledge when there is dedicated research funding and expertise. Another problem is the care for endometriosis patients in the US, and worldwide is that it is still sporadic, incomplete, and lacks a uniform approach. Patients must seek information on their own. They support each other, which is great, but there is also a need for an solid structure. Everything is left to people to advocate for themselves. We need to establish dedicated accredited centralized centers for people to know that if they have endometriosis, they’re going to get treatment there.

Dr. med. Nadine Rohloff: Could you tell us a bit more about your research as well as other work that you do?

Dr. Emad Mikhail: One current study is focusing on what factors affect a pathological positivity rate for endometriosis. If the surgeon does endometriosis surgery and excises the lesion, often of the time, it is positive pathologically. But what affects that ? it is the previous surgery, the experience of the surgeon, the specialty of the surgeon, and concomitant diseases. We look at what factors play into that because we want people to exercise the right lesions. Some people advocate for complete peritonectomy, which is to excise the whole surface of the lining of the abdomen. There is a role for this for certain patients, but is this the right way for every patient? We do not know.

Another topic that is very close to my heart is the utilization of laparoscopic and robotic intraoperative ultrasound inside the abdomen. We use it to work on deep endometriosis, to detect endometriosis, and to choose the surgical technique appropriate for the patient. Commonly, transabdominal, transvaginal, or transrectal ultrasound is used for scans. In these methods an exterior probe scans on the surface of the body. Laparoscopic and robotic ultrasound are a brand-new technique that we are studying and exploring. In laparoscopic ultrasound, the probe goes through the laparoscopic port, a keyhole incision in the abdominal wall that is only 10 mm wide. We use this technology in laparoscopic cases, but also in robotic surgery. Unlike with the other methods, we use the probe directly on the surface of the organ itself and scan there. The most common location of application is the rectum and the sigmoid colon. We get a very close look at the lesion’s thickness. How far does it go in the bowel layers and how big is it? then it helps us to decide on the right technique  of excision to make sure that we preserve all the normal bowel. We don’t want to remove any normal tissue, just the endometriosis. However, we also don’t want an incomplete excision, which is taking a piece and leaving the rest of the disease back. These patients come back with recurrent symptoms and need more surgery, which is usually more difficult. When we have a good visualization of the lesion, we decide how to proceed in surgery according to how deep it goes in the layer of the bowel. For bowel endometriosis, there are three ways of surgical treatment, shaving, discoid resection, and segmental resection.

Dr. med. Nadine Rohloff: Could you explain these three surgical techniques? What differentiates them?

Dr. Emad Mikhail: The bowel is a tube, and endometriosis usually starts on the surface of the tube and invades deeper. If the lesion is only superficial, we shave it, removing the lesion from the bowel’s surface without opening the bowel wall. The recovery is amazing and complication rates are very low. The problem with shaving is, that usually rates of recurrence in the future are higher than with other methods. Discoid is taking out a whole piece of the bowel surface. It is a tube where you remove part of the front wall of the bowel. The morbidity and the complication are very low, and it has lower rates of recurrence, but it’s not for every lesion. If the lesion is bigger, you have to take a whole segment of the bowel. This is what we do in the third treatment called segmental resection. The ultrasound helps us decide what method is the best for this specific patient. We use preoperative ultrasounds and preoperative MRIs, but so far the amount of delineation of the lesion that we get with the laparoscopic or robotic ultrasound is amazing.

Dr. med. Nadine Rohloff: Are there cases where you wouldn’t have been able to see the lesion with the naked eye using only laparoscopy?

Dr. Emad Mikhail: The evidence on that is still very scarce. The first two papers in the literature about it were published by our team. There are patients in whom we cannot see the lesion at all preoperatively. For example, I know a patient has deep endometriosis by her symptoms, and her preoperative imaging is suggestive but not very clear. We do a laparoscopy to look, but the surface of the bowel is normal. How come then that the patient reports these symptoms? The first thing I learned in endometriosis is that you should listen to the patient. You cannot imagine how much it helps. I listen to the patient, and this patient does sound like she has bowel endometriosis. Then why can’t I see it? I use the ultrasound and I scan the bowel, and there it is: The lesion is visible. The future point is finding out the scope of that technology. Should it be used for screening when patients report bowel symptoms as it is better than the human eye? These are questions that need research. I’m trying to get a randomized controlled study to see if the technique changes the outcome or not. To do that you need time, personnel, and, of course, funding.

Dr. med. Nadine Rohloff: What needs to be done so that such studies can be conducted?

Dr. Emad Mikhail: Surgical research is not easy, because there is no common language between different institutions. For treatments to be comparable, you have to have used the same staging systems and have done the same surgeries. In everyday clinical practice, people do very different things in similar cases because again, care is not centralized. Instead of simply doing surgeries, we have to study, criticize, and improve what we are doing.

Dr. med. Nadine Rohloff: For the patients reading, in the US, but also in general, what is your advice to patients? Is there something you would like to say to them?

Dr. Emad Mikhail: The first advice I have for people is to advocate for themselves. If you do not get the answers that you are looking for, or your symptoms are not taken seriously, advocate for yourself and find teams or centers that provide the care that satisfies you. Number two, do not accept to be dismissed by doctors. Usually doctors do not intentionally dismiss symptoms, but it seems that way because they are not sure what to do. Endometriosis is a lifelong struggle and there is no cure as far as we know. However, there are multiple treatment modalities. I like to use the analogy that you are driving on a multi-lane highway, and every lane is a different aspect. One lane is surgery, one lane is medicine, one lane is nutrition, one lane is physical therapy, and so on. Endometriosis is a highway, and you have to manage all the lanes. It’s not like a tiny, tiny town road. No, the treatment is multi-lane, and it has to accommodate all of that.

Dr. med. Nadine Rohloff