ISGE News

 Inside this Issue:

• Editor's Corner
• President's Message
• Vice Presidents Message 
• Endometriosis Association
• Registry of Cervical Pregnancy
• Endometriosis: Personal opinions

Editor's Corner
Plagiarism

It was brought to my attention that a member of our society recently published an article using another person’s written words. In fact, some of the sentences were taken from another published article. Whether it was a deliberate or an inadvertent act, it is considered a plagiarism. Merriam-Webster dictionary defines “plagiarize” as to commit literary theft: present as new and original an idea or product derived from an existing source. In academia, a charge of plagiarism carries severe penalties including failing a course, eviction from a university or prohibition of future publications by scientific journals.

Purdue University lists actions that might be seen as plagiarism. They include “buying, stealing or borrowing a paper”, “using the source to closely when paraphrasing”, hiring someone to write your paper”, “building on someone’s ideas without citation”, and “copying from another source without citing (on purpose or by accident).” Perhaps, the latter is the most common form of plagiarism. With the ease of electronic editing and writing, one could “copy” paragraphs or sentences of others and “paste” them to his or her own writing. It is acceptable if the author includes a citation or acknowledgement to the source. The writer should provide credit to the original author/s and does not claim the information as his or hers even if it is in different language.

I spend time explaining plagiarism to our trainee before she or he starts writing a manuscript. I often said “use your own words, even if they are grammatically incorrect and I will correct them.” Other types of plagiarism are duplicate publication where the authors published an article that is similar or overlaps their previous publication. Another form is “salami publication”, where the authors divide data from a single study into several pieces and publish them separately.

Plagiarism dishonors an institution and more importantly the writer him or herself. Others would lose confidence in his or her future writing. Some journals rightfully will publish the name of the authors who have committed this act. As a Society, we have an obligation to increase awareness towards plagiarism.

Togas Tulandi MD, MHCM Editor

President’s Message
Harry Reich, MD

Dear Members,

I welcome the opportunity to serve as the president of ISGE. Fortunately, this is a two year term as the first 6 months have been a time consuming learning experience. I thank the board for bearing with me. I hope to accomplish my major goals over the next 18 months.

We had a great 14th annual congress in London, April 2005, with attendance of over 550 gynecologists. I expressed my appreciation to Jeremy Wright and Ellis Downes.

Our 9th regional meeting in September was titled “The Uterus and More”. As those in attendance know, it certainly was more! We thank Prashant Mangeshikar for organizing this meeting. Though Mumbai was recovering from recent floods, attendance at the meeting was over 600.

I look forward to 2006 and our 15th annual meeting in Buenos Aires, Argentina starting March 29, 2006. Preliminary attendance reports look great, and I know that Roberto Sainz has worked hard to make this a successful meeting. It has been difficult finding speaking space for many who want to come, but the scientific program and the social pro gram will make this meeting a great value. I have done two ISGE surgical workshops in Buenos Aires five years ago and still cannot tango. This time I will do my best as Roberto may have tango teachers in the hospitality suite. I encourage you to be there.

In September 2006, we will have our 10th Regional meeting in Beijing, a vibrant city with much shopping at low prices. The Great Wall is not far from our meeting place. Gynecologic endoscopic surgery with live demonstrations will be highlighted. I believe that China is rapidly adapting to minimally invasive surgery and will be a large part of our future. From my ISGE experience there, I see few negatives and believe that this meeting should not be missed.

In 2007, our annual meeting is in Osaka, Japan and our regional meeting is in Munich, Germany. Osaka is a modern city not far from Kyoto, the ancient capital of Japan. The Munich meeting is a two and a half day event ending at noon Saturday for the opening of Oktoberfest. Reservations are usually impossible for this international event, but we have reserved 200 rooms for our meeting. The topic “adhesions” will certainly attract gynecologists, general surgeons, and basic scientists. Please note that attendees may choose to see and/or experience the life in the largest beer tent in the world. Book early! This is a once in a lifetime opportunity to combine study and a global festival.

The ISGE board members negotiations with the European Society of Gynaecological Endoscopy (ESGE) to organise our 2008 annual meeting in Bari, Italy have been challenging. I wish to express my appreciation to our board member, Stefano Bettocchi, for his active participation in organising this ISGE annual meeting.

My goals for this year are as follows:

• Make the website user friendly, including a chat line and monthly updates on controversial areas in our specialty, flavored by many opinions.
• Increase membership.
• Increase patient access to our membership.
• Work more closely with AAGL, ESGE, APAGE, AGES, and SLS.
• Encourage and recognize Centers of Excellence for patient referral for difficult cases.
• Promote reusable instruments for advanced laparoscopic surgery.
• Promote public awareness that robotics are rarely advantageous in gynecologic surgery.
• Support courses in the Caribbean, Central America, South America, Eastern Europe including Russia, and China.

I have operated in many different parts of the world teaching endoscopic surgery over the past 20 years. The drive for gynecologic endoscopy is very much alive worldwide.

Gynecologists are often embarrassed discussing laparoscopic surgery with general surgeons, or should be. General surgeons have taken the lead in laparoscopic surgery, a trend considered impossible a few years ago. In contrast, very few gynecologic surgeons excise endometriosis or perform total laparoscopic hysterectomy.

I am a product of the most expensive fragmented health care system in the world. Laparoscopic surgery especially gynecologic surgery in the USA is still not the standard. In fact, we have no standards. I used to say that we have a long way to go. However, in the USA and many other countries, governments might tell us how to practice medicine.

I believe it is time for the ISGE to play a leading role in gynecologic endoscopic surgery worldwide, both the surgery and the politics. We need to form a World Federation of International Societies of Gynecologic Endoscopy. Note that the general surgeons already have their world federation of laparoscopy.

At our Annual Congress in Buenos Aires, we are inviting representatives from other societies to attend our board meeting as non-voting participants. When Federation time comes around, these participants would represent their region of the world.

At the General Assembly, we will discuss the concept of a World Federation of International Societies of Gynecologic Endoscopy. We look forward to receiving your opinions and we will assemble them into an ISGE policy. With other endoscopic societies, ISGE will be a leader in creating a Federation. We must create a prestigious entity for the benefit of our patients.

Finally, I encourage you to read Johan Van Der Wat’s contribution about endometriosis from his successful Capetown, South Africa meeting September 2004 on our website www.isge.org.

Best wishes for the coming year 2006 to you and your loved ones.

Dr. Harry Reich
ISGE President

Vice President's Message

Greetings from Australia and your new Vice President. The editor of the ISGE Newsletter has been keen for members of the Executive Committee to speak to the members, in particular to keep them up with all the challenges facing the ISGE. I was voted into the position of Vice President at the London meeting, which was well attended by our members. It presented an excellent program and social program.

Living in the southern hemisphere and close to Southeast Asia, I spend most of my traveling time attending National Society meetings of countries such as Indonesia and China. China is one of my favorite places to visit. In fact, as Chairman of the ISGE Training Committee, I have made several trips to China, particularly Shanghai and in the latter half of my term in Beijing.

The training program was set up by Alan Gordon 10 years ago and has been a great success, not only in Southeast Asia but also in Baltic states under the careful supervision of Ivo Brosens and in Central and South America under the watchful eye of Ray Valle. There has been one course in South Africa. As political situation in Central Africa is resolving, the new Chairman of the Training Committee, Yap Lip Kee will start courses in the area.

I would like to take this opportunity to update you on where the ISGE is heading and the role of the Federation. The Federation Working Committee, headed by Jack Sciarra, has developed guidelines for the formation of the Federation. The proposal was voted upon in London; however it was rejected by the general assembly. Subsequently, Sciarra and his team tried to address the problems facing the transition from the ISGE to the Federation.

Their proposal will be presented at the 2006 general assembly in Buenos Aries. It is essential for all members to have a voice in the future of the ISGE and you can communicate through the website: www.isge.org  or through myself or Harry Reich. Under Harry’s guidance, the Society has continued to grow in strength and numbers. He has worked feverishly at all the meetings he attended to increase the membership. We have been able to offer incentives for endoscopists throughout the world to join the ISGE.

The interaction of the ISGE with the AAGL, ESGE, ARPAGE and the Australian Society of Gynaecological Endoscopy is encouraging. It is without doubt that the only way that we can all move forward is to work together as a dedicated group in our pursuit of gynaecological endoscopy providing better health care for women. 2006 provides an exciting calendar with our annual congress in Buenos Aries, Argentina and the regional meeting in Beijing.

I am thankful for all members of the Executive and co-opted members of the Executive for working actively to ensue the long term well being of ISGE, even as a Federation. The Executive and Board of ISGE will be opened with the members and will provide as much detail as is necessary so as you can all make a well informed decision as to where you would like your Society taken.

I look forward to another year under the leadership of Harry Reich and I would like to wish you all the very best for the New Year from “Down Under”.

Peter J. Maher, Melbourne, Australia peterm2@tpg.com.au

Endometriosis Association: Serving Families, Physicians, and Scientists Worldwide

About Endometriosis Association
The Endometriosis Association is an international nonprofit organization founded in 1980, by Mary Lou Ballweg, a writer, filmmaker and consultant, after she became bedridden with the disease. The mission of the Association is to provide support and information for females with endometriosis and their families, to educate public and medical community about the disease, and to promote and conduct research related to endometriosis. With its international headquarters in Milwaukee, Wisconsin, U.S.A., the Association was the first organization in the world devoted to endometriosis. It includes women affected by endometriosis as well as the world’s leading experts on endometriosis. The Association has 179 support groups in the United States and Canada, and several hundreds worldwide.

Worldwide education
Throughout its history, the Association has been the leading producer and distributor of educational materials about endometriosis and the only organization providing support to women worldwide who suffer from the disease. Numerous publications are available, including four books published by the Association, international newsletter, scientific articles, and brochures in 29 languages, videos, CDs, DVDs, and audiotapes. We are grateful to ISGE for providing booths at many conferences making our educational materials available to healthcare professionals around the world.

In October of 2005, the Association held its 25th Anniversary Conference in Milwaukee, filling a 14,400 square foot exhibit hall, hosting approximately 700 participants, and covering a wide range of topics making this conference the most comprehensive on endometriosis ever. The conference included a debate about two different perspectives on endometriosis, arguing that endometriosis is a body-wide immune system disease requiring comprehensive treatment by Deborah Metzger, M.D. Ph.D., from Los Altos, California, vs. David Redwine, M.D., from Bend, Oregon, stating that endometriosis is a locally-focused disease only requiring good surgery. Louise Brinton, Ph.D., from the U.S. National Cancer Institute, talked about “Cancer and Endometriosis.” Roberta Ness, M.D., M.P.H., the Chair of the Department of Epidemiology at the University Pittsburgh presented “A Unifying Theory on Endometriosis: Inflammation, Autoimmunity, and Cancer.” The conference also addressed endometriosis and infertility, autoimmune diseases, traditional Chinese medicine, prevention, nutrition, new approaches to pain, surgical and medical treatments, and many other topics. In the months to come, many of the talks at the conference will be available in an online webcast and selected presentations are available on DVDs, CDs, and audiotapes. (Contact the Association if you would like more information on the webcast or conference materials.)

Groundbreaking research
Perhaps the Association’s most significant work is in the area of research and its creation of the largest database for research on the disease. Our partnerships with Vanderbilt University School of Medicine, the National Institutes of Health, and others have served to produce groundbreaking research results. In 1992, our discovery that rhesus monkeys exposed to dioxin developed endometriosis shook the endometriosis community. Never before had environmental toxins been linked to the disease. Our research has also led to the development of a blood test to diagnose endometriosis which may be commercially available at the end of 2006 or early 2007. Work done collaboratively with the National Institutes of Health utilizing our large research registry found a higher risk for six autoimmune diseases in women with endometriosis. (Contact the Association for a reprint).

We look forward to continuing to work with ISGE to continue to build our understanding of endometriosis. All ISGE members are welcome to join the Endometriosis Association-please contact our International Headquarters, 8585 North 76th Place, Milwaukee, Wisconsin, 53223, U.S.A. at 414-355-2200 or Endo@EndometriosisAssn.org  for more information.

Registry of Cervical Pregnancy

Cervical pregnancy is a rare form of ectopic pregnancy. However, it is far more common in pregnancies achieved through assisted reproductive technologies. There are many reports on medical and surgical management of these conditions. However, due to its low incidence, most authors published only case reports of small number of patients. In order to evaluate the best management of cervical pregnancy, a registry is needed. Gynecologists who encounter this condition are requested to contact Dr. Togas Tulandi to obtain a simple and standardized form. He can be contacted at togas.tulandi@mcgill.ca  or by fax at 1-514-843-1448. Your participation is important.

Endometriosis: Personal opinions
Harry Reich MD

Please note that these are my opinions and not reflective of current gynecologic practice in the United States. Extensive endometriosis surgery, often involving rectal lesions, is the most difficult surgery a gynecologist encounters. In most cases, it is much more difficult than cancer surgery.

I have had a considerable experience in surgical excision of endometriosis for over 30 years, and I am convinced that what is excised never recurs. My results in over 1000 cases of deep endometriosis excision confirm that less than 20% of these women will require further treatment.

Diagnostic approach
1. In most cases of severe endometriosis, the endometriosis surrounded by scar tissue can be palpated by a simple rectovaginal examination. These areas are usually very tender to palpation, and this tenderness can be used to guide the surgeon to the area to be removed. On postoperative examination 3-6 months after surgery, patients should be tenderness-free if the appropriate area was excised.

2. Diagnosis of endometriosis requires a positive biopsy documenting endometrial glands at laparoscopy. In my opinion, studies using only visual documentation of endometriosis are worthless.

3. I believe that most women with the diagnosis of endometriosis without biopsy do not have endometriosis. Visual diagnosis without endometriosis is insufficient. Biopsy of these areas would reveal “hemosiderin ladened macrophages” which are white blood cells filled with iron, the normal product of the body getting rid of blood from retrograde menstruation.

Therapeutic approach
1. Enterolysis. Many women with extensive endometriosis have had multiple laparotomies that result in small bowel adhesions to the peritoneum of the anterior abdominal wall preventing access to the pelvic organs. Thus, the first part of many endometriosis operations is to release these adhesions.

2. Separate all pelvic organs including the ovaries, uterus, cervix, upper vagina, and rectum.

3. Excise the endometriosis. Endometriosis is surrounded by fibrous scar tissue from a repetitive longstanding inflammatory response. This scar tissue that contains endometriosis glands should be excised from the ovaries, the posterior cervix and vagina, the rectum, and the uterosacral ligaments (and ureters if necessary).

4. Rectal resection if the endometriosis penetrates the rectal and/or rectosigmoid wall.

5. I use various agents to separate the operated organs during early healing.

6. I do not use GnRH agonists. I believe that they have never been shown to destroy endometriosis glands, even when used long-term.

American situation
1. Very different than Europe. I believe there is insufficient interest in gynecologic endoscopic surgery in academic institutions or in ACOG (American College of Obstetricians and Gynecologists). Two distinct laparoscopists have evolved: a very large group performing surgery for diagnosis and minimal treatment and a much smaller segment doing it for optimum treatment in place of laparotomy.

2. Poor level of surgical training to deal with endometriosis. In contrast to the situation in Europe, we who perform this type of surgery have few followers.

3. Poor reimbursement for complex endometriosis surgery despite the increasing medicolegal risk. Furthermore, the malpractice insurance coverage is high.

4. The practicing gynecologist is penalized financially for spending too much time in the operating room instead of in the office. Office patient visits and procedures pay much more than surgery. Understandingly, only a few gynecologists perform complex endometriosis surgery involving rectum, ureters, or small bowel.

5. I can practice surgical treatment of extensive endometriosis only because I do not participate in the U.S. managed health care system; patients pay me “out of pocket” which is much higher than most insurance payments.

6. I believe that many women who undergo multiple laparoscopies for endometriosis have no disease. Most surgeons perform a diagnostic laparoscopy without biopsy followed by 6 months of GnRH agonist treatment and subsequently by another “diagnostic” laparoscopy. This approach does not provide any long-term benefit as the disease remains.

7. I consider “recurrent” endometriosis as a persistent disease that was not treated in the first place.

With the managed care and medico-legal environment in the United States, progress in surgical excision of endometriosis in Europe looks more promising. Other continents such as South America, Australia, and Asia will follow. Beware: “Outsourcing” in our global economy with medical tourism.com company startups is just beginning. Endometriosis is a great starting point, as endometriosis patients will often travel to obtain the best treatment.