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Dr. Francesco Di Chiara, a leading consultant thoracic surgeon at John Radcliffe Hospital in Oxford, shares his expertise on thoracic endometriosis – when endometriosis affects the chest cavity, diaphragm and lungs. He illuminates the challenges patients face with this often-overlooked manifestation of endometriosis that can cause collapsed lungs, shoulder pain, and breathing difficulties.
• Thoracic endometriosis causes symptoms including pneumothorax (collapsed lung), shoulder pain, hemoptysis (coughing blood), effusions and hemothorax
• 90% of patients with thoracic endometriosis first see orthopedic surgeons for shoulder pain before correct diagnosis
• Symptoms are often “self-limiting” which leads to medical dismissal since they temporarily resolve after each cycle
• Imaging challenges include MRI movement artifacts and that lesions are often thinner than MRI resolution capabilities
• Surgical excision involves a thoracoscopic or robotic approach with most complex procedures involving the diaphragm
• Diaphragmatic surgery requires special consideration for patients planning pregnancy due to added strain on surgically repaired tissues
• Multi-disciplinary care is crucial with thoracic surgeons involved early rather than being called in only after discovery during gynecological surgery
• Dr. Di Chiara classifies thoracic endometriosis lesions in a color spectrum from pink (superficial) to white (scarred) with purple and brown in between
• Thoracic surgeons with endometriosis expertise are rare – patients should seek high-volume centers with established multidisciplinary teams
If you suspect thoracic endometriosis, seek out high-volume endometriosis centers that work directly with thoracic surgeons, and insist on meeting your entire surgical team before committing to treatment.
Website endobattery.com
Introduction to Thoracic Endometriosis
Speaker 1
0:00
Do
you
sometimes
have
a
hard
time
breathing
,
especially
during
your
cycle
,
or
do
you
have
that
right
shoulder
pain
that
just
won't
go
away
?
Maybe
your
lung
collapses
during
your
cycle
and
no
one
seems
to
think
it's
that
big
of
a
deal
,
or
they
just
can't
figure
it
out
.
Well
,
stick
around
,
because
Dr
Francesco
Di
Chiara
is
here
to
explain
what
you
could
potentially
have
.
Have
you
ever
heard
of
cardiothoracic
endometriosis
,
or
extra
pelvic
endometriosis
or
extra
pelvic
endometriosis
?
Or
maybe
you've
heard
about
diaphragmatic
endometriosis
?
He's
here
to
address
these
,
the
symptoms
and
how
he
can
address
them
.
Stick
around
.
Speaker 1
0:37
Welcome
to
EndoBattery
,
where
I
share
my
journey
with
endometriosis
and
chronic
illness
,
while
learning
and
growing
along
the
way
.
This
podcast
is
not
a
substitute
for
medical
advice
,
but
a
supportive
space
to
provide
community
and
valuable
information
so
you
never
have
to
face
this
journey
alone
.
We
embrace
a
range
of
perspectives
that
may
not
always
align
with
our
own
,
believing
that
open
dialogue
helps
us
grow
and
gain
new
tools
.
Join
me
as
I
share
stories
of
strength
,
resilience
and
hope
,
from
personal
experiences
to
expert
insights
.
I'm
your
host
,
alana
,
and
this
is
Endobattery
charging
our
lives
when
endometriosis
drains
us
.
Welcome
back
to
Endobattery
.
Grab
your
cup
of
coffee
or
your
cup
of
tea
and
join
me
at
the
table
Today
.
Speaker 1
1:22
I
am
joined
at
the
table
by
my
guest
,
dr
Francesco
Di
Chiara
,
a
leading
consultant
thoracic
surgeon
at
the
John
Radcliffe
Hospital
in
Oxford
and
a
true
pioneer
in
minimally
invasive
chest
surgery
.
Renowned
internationally
for
developing
and
refining
cutting
edge
techniques
,
including
groundbreaking
single
incision
procedure
for
thoracic
outlet
syndrome
,
dr
Di
Chiara
is
transforming
the
way
we
approach
complex
thoracic
conditions
.
With
deep
expertise
in
lung
cancer
,
chest
wall
trauma
and
disorders
like
thoracic
endometriosis
,
he's
not
only
a
gifted
surgeon
,
but
also
a
passionate
educator
and
an
innovator
.
I
am
thrilled
to
be
diving
into
this
conversation
with
someone
who
is
shaping
the
future
for
thoracic
endometriosis
.
Please
help
me
in
welcoming
Dr
Francesco
Di
Chiara
.
Thank
you
so
much
,
dr
Di
Chiara
.
I'm
so
thrilled
that
you
sat
down
with
me
today
.
We
met
at
the
summit
and
it
was
one
of
those
moments
where
I
was
just
enthralled
by
everything
that
you
were
talking
about
,
so
I'm
honored
that
you
sat
down
with
me
at
the
table
today
.
Speaker 2
2:26
Well
,
thanks
for
your
invite
.
It's
very
kind
and
I'm
eager
to
hear
the
questions
you
gathered
,
and
thanks
so
much
for
inviting
me
.
Speaker 1
2:37
Of
course
,
it's
just
an
honor
for
me
.
For
anyone
that
is
unfamiliar
,
what
does
cardiothoracic
surgeon
typically
entail
,
or
what
is
cardiothoracic
in
general
,
and
how
does
it
relate
to
endometriosis
?
Speaker 2
2:53
So
cardiothoracic
is
a
medical
term
for
heart
and
lungs
or
heart
and
chest
.
So
it
usually
according
to
when
a
person
is
studying
and
specializing
.
For
example
,
in
North
America
it's
normally
a
general
surgery
that
develops
a
skill
in
cardiac
and
thoracic
surgery
.
We'll
see
in
other
parts
of
the
world
,
for
example
Northern
Europe
,
that
it
will
be
cardiothoracic
a
standalone
specialty
.
But
it
deals
with
the
diseases
of
the
heart
,
revascularization
or
disease
of
the
chest
,
most
commonly
lung
cancer
and
other
malignancies
of
the
chest
.
Speaker 1
3:39
How
does
that
relate
to
endometriosis
?
Because
not
a
lot
of
people
are
very
familiar
with
that
,
Even
in
the
medical
industry
they
kind
of
are
unfamiliar
with
the
fact
that
endometriosis
can
happen
in
the
heart
,
in
the
lungs
,
in
the
diaphragm
.
Speaker 2
3:56
So
yeah
,
that's
a
very
good
question
.
The
reality
is
that
endometriosis
is
a
systemic
disease
,
can
go
anywhere
in
the
body
.
It's
been
found
in
every
organ
,
including
the
brain
,
the
eye
,
and
the
most
common
extra-thoracic
,
extra-pelvic
location
is
the
diaphragm
.
So
the
thoracic
surgeon
historically
has
been
involved
by
gynecologists
that
advocated
for
excision
,
but
many
times
it
was
an
ad
hoc
involvement
and
often
also
involved
during
the
operation
.
So
that
does
make
it
quite
difficult
for
the
surgeons
and
for
the
patients
to
be
involved
during
the
operation
because
there
was
a
surprise
at
diaphragmatic
disease
.
Speaker 1
4:41
How
did
?
Was
it
a
patient
?
Was
it
something
that
you
were
seeing
commonly
?
Because
I'm
sure
that
wasn't
something
that
you
thought
of
when
you
first
went
to
medical
school
.
I'm
going
to
do
endometriosis
surgery
,
you
know
,
on
the
heart
.
Speaker 2
4:53
Conversely
to
the
idea
that
it
happened
like
this
.
So
I
was
preparing
my
final
board
exam
and
we
were
studying
,
actually
,
an
American
book
called
Shields
it's
got
these
two
big
volumes
on
this
and
it
was
this
huge
chapter
about
plural
diseases
,
plural
conditions
,
and
then
benign
and
malignant
.
And
then
there
was
a
big
chapter
on
the
forex
and
then
in
this
chapter
it
was
analyzing
every
little
aspect
of
minute
detail
there
was
this
little
paragraph
literally
like
this
,
saying
that
individual
female
during
menstruation
may
experience
hemothorax
.
Full
stop
,
no
reference
,
no
further
explanation
.
And
I
thought
to
myself
this
is
amazing
.
How
can
I
link
a
hormonal
change
to
a
collapsed
lung
?
It
seems
so
interesting
.
How
can
I
link
,
like
,
a
hormonal
change
to
collapsed
lung
?
It
seems
so
interesting
.
And
the
more
I
was
trying
to
find
information
and
interest
,
the
least
I
found
.
And
actually
I
found
some
resistance
from
my
colleagues
onto
the
idea
of
going
across
your
specialty
.
Often
karyothoracic
is
a
bit
of
a
conservative
speciality
and
collaboration
is
not
always
that
easy
.
Speaker 1
6:10
Yeah
,
so
when
you
talk
pneumothorax
,
can
you
explain
that
a
little
bit
?
And
that's
why
that
kind
of
led
you
into
thinking
more
about
the
cardiothoracic
endometriosis
.
Speaker 2
6:21
Yes
,
so
a
pneumothorax
is
a
collapsed
lung
and
is
a
common
presentation
of
thoracic
endometriosis
.
The
collapsed
lung
can
be
partial
or
complete
,
and
one
of
the
main
myth
busters
that
I
often
explain
is
that
the
typical
thoracic
endometriosis
patients
are
between
15
and
50
years
old
,
will
not
be
extremely
breathless
as
often
like
might
suggest
when
you're
looking
for
the
symptoms
,
because
they
say
our
pneumothorax
is
intense
breathlessness
.
It's
not
true
.
The
patients
can
have
a
significant
pneumothorax
and
continue
to
go
.
Especially
the
endometriosis
patients
is
a
subgroup
of
individuals
that
have
been
coping
with
pain
and
discomfort
since
age
12
,
11
,
when
they
have
the
first
menses
,
so
they're
actually
very
resilient
to
pain
and
discomfort
in
the
chest
.
Speaker 2
7:21
The
other
common
symptom
is
pain
in
the
shoulder
,
which
is
another
very
big
branch
of
elements
that
is
often
confused
.
I
would
say
that
I
don't
have
the
full
statistic
,
but
I
would
say
that
probably
90%
of
my
patients
have
seen
either
a
chiropractor
or
an
orthopedic
surgeon
before
seeing
me
,
because
of
pain
in
the
shoulder
is
considered
,
you
know
,
to
go
see
somebody
fall
on
the
shoulder
.
The
pain
in
the
shoulder
is
actually
related
to
the
phrenic
nerve
,
which
is
the
nerve
that
controls
the
diaphragm
.
The
hemidiaphragm
has
these
two
big
muscles
that
control
the
breathing
at
the
bottom
of
our
chest
,
and
so
when
you
have
an
irritation
or
some
trouble
of
the
phrenic
nerve
,
the
pain
is
actually
perceived
up
here
and
in
the
neck
.
So
these
are
the
two
main
symptoms
,
and
there's
a
lot
of
other
things
that
can
happen
.
I
would
say
collapsed
lung
and
pain
,
shoulder
pain
and
probably
the
commonest
.
Speaker 1
8:21
Are
there
more
symptoms
that
kind
of
relate
to
that
?
Maybe
that
get
misinterpreted
as
other
conditions
that
people
would
not
even
consider
as
endometriosis
?
Speaker 2
8:33
The
related
thoracic
endometriosis
.
Yes
,
there
is
hemoptysis
,
which
is
coughing
up
blood
,
which
is
one
of
the
rarest
and
most
difficult
to
diagnose
,
and
when
it
comes
to
thoracic
endo
,
rarity
often
for
me
means
that
it's
not
that
rare
,
it's
just
trickier
to
diagnose
.
Speaker 1
8:51
Right
.
Speaker 2
8:51
Because
when
it
comes
to
hemoptysis
you
can
be
confused
with
disease
,
with
reflux
,
with
anything
Right
,
and
so
the
patient
should
keep
a
diary
.
And
the
hemoptysis
does
not
present
Understanding Cardiothoracic Surgery
Speaker 2
9:04
with
every
menstruation
,
so
it's
just
trickier
to
diagnose
.
And
then
there
is
also
a
presentation
with
hemothorax
,
which
is
blood
in
the
chest
,
and
again
,
extremely
rarely
this
is
a
dramatic
hemothorax
.
Until
they
get
to
the
OR
or
to
the
ITU
,
it
is
a
modest
hemothorax
,
causing
a
lot
of
irritation
,
a
lot
of
discomfort
and
some
effusions
which
is
fluid
filling
up
that
space
at
the
bottom
of
the
chest
.
These
are
quite
tricky
to
diagnose
and
there
are
lots
of
investigations
and
they're
often
dismissed
because
they're
self-limiting
.
Speaker 2
9:48
So
the
concept
of
self-limiting
symptom
is
probably
the
biggest
barrier
in
diagnosing
patients
with
thoracic
endometriosis
.
Doctors
are
trained
since
their
infancy
of
their
training
that
any
symptoms
or
any
sign
that
is
self-limited
that
basically
resolves
itself
,
or
any
sign
that
is
self-limited
that
basically
resolves
itself
is
not
something
that
we
need
to
worry
about
.
So
let's
say
that
a
patient
comes
to
see
you
and
he
has
a
little
bit
of
a
fusion
,
a
bit
of
fluid
in
the
chest
,
and
then
you
say
,
well
,
a
bit
concerning
fluid
in
the
chest
can
be
even
a
sign
of
malignancy
.
Let's
repeat
it
an
extra
week
and
then
a
week
later
the
infusion
is
gone
and
the
family
doctor
will
feel
rightfully
in
his
own
mind
to
reassure
the
patient
and
say
,
okay
,
it
was
nothing
,
because
if
the
infusion
had
gone
by
itself
then
it
was
nothing
,
nothing
to
worry
about
anyway
,
and
most
of
the
synthet
drasticriosis
are
self-limiting
.
Speaker 1
10:48
Do
you
find
that
that
causes
even
more
of
a
delay
in
diagnosis
,
because
patients
kind
of
give
up
,
they
just
live
with
it
?
Speaker 2
10:52
Oh
yeah
,
so
that's
one
of
the
things
I
often
say
when
I'm
talking
about
thoracic
endometriosis
.
Speaker 2
11:00
The
most
knowledgeable
and
prepared
patient
I've
ever
seen
comes
with
a
folder
called
the
chapters
of
their
history
,
and
they
know
everything
about
it
.
And
if
you
go
through
their
history
,
they've
been
fighting
for
10
years
and
they
had
their
family's
support
,
their
financial
means
,
see
many
doctors
and
they
didn't
give
up
on
frustration
.
So
that
actually
I
don't
find
it
reassuring
.
I
find
it
very
concerning
because
that
gives
me
the
idea
of
the
thousands
and
thousands
of
patients
they
gave
up
,
maybe
year
two
,
year
,
five
,
year
,
seven
or
something
else
happened
in
their
life
,
another
health
problem
or
something
else
,
and
I'm
seeing
only
the
one
that
managed
to
go
through
10
,
15
years
of
various
attempts
.
And
then
obviously
they
go
through
phases
in
which
they
feel
convinced
that
they
probably
it's
all
in
my
head
and
then
so
it's
not
in
my
head
,
and
then
you
know
I
can't
be
,
and
then
they
start
fighting
again
to
find
someone
.
But
it's
a
very
long
journey
and
so
I
think
we
are
missing
out
.
I
don't
know
how
many
.
Speaker 1
12:08
And
that
is
only
you
know
,
those
that
can
afford
to
continue
that
process
.
A
lot
of
people
in
this
process
because
this
disease
is
so
expensive
,
don't
have
the
means
.
Don't
have
the
means
to
continue
that
trajectory
.
So
that
makes
it
even
a
little
bit
more
challenging
,
I
would
assume
,
for
a
lot
of
those
patients
.
Speaker 2
12:27
Yeah
,
yeah
.
And
sometimes
it's
even
more
heartbreaking
because
they
might
have
the
means
finally
to
find
a
specialist
that
knows
about
drastic
endo
and
have
the
suspicion
,
but
then
to
get
an
operation
might
be
too
expensive
and
that's
very
difficult
sometimes
.
Speaker 1
12:46
Is
there
imaging
that
can
help
detect
thoracic
endometriosis
,
or
is
?
That
similar
to
the
pelvis
,
where
it's
hard
.
Speaker 2
12:55
It's
similar
to
the
pelvis
,
it
probably
was
.
So
the
best
investigation
that
we
have
now
is
the
same
,
is
MRI
with
specific
endometriosis
protocol
and
with
T1
fat
saturated
and
so
on
.
So
there
are
two
main
barriers
for
diagnosis
.
One
is
the
training
of
radiologists
,
which
I
often
discuss
with
because
I
think
they
want
to
find
the
reassuring
finding
of
the
round
endometrioma
,
which
is
a
solid
,
definite
lesion
of
the
round
endometrial
.
Speaker 2
13:23
One
,
which
is
a
solid
,
definite
lesion
,
is
almost
never
there
in
the
chest
and
they're
often
very
thin
and
widespread
lesions
,
the
nooks
and
crannies
of
the
chest
.
And
the
second
main
barrier
is
that
the
lesions
are
thin
and
below
the
resolution
of
the
MRI
.
And
I
can
add
a
third
barrier
to
the
diagnosis
the
most
common
area
where
the
endometriosis
in
the
chest
is
present
is
the
diaphragm
,
which
is
the
area
where
there
are
more
movement
artifacts
,
because
MRI
is
not
a
breath-hold
investigation
.
So
during
an
MRI
we
don't
hold
our
breath
for
30
minutes
,
obviously
,
so
we
keep
breathing
and
the
acquisition
,
although
filtered
through
algorithms
and
computer
system
,
is
still
a
bit
artifact
,
movement
artifacts
.
So
what
you
should
have
the
highest
resolution
is
actually
where
you
get
the
least
resolution
.
Speaker 1
14:18
Interesting
.
How
deep
can
these
lesions
go
,
though
?
I
mean
we're
talking
some
superficial
,
but
how
deep
can
they
go
?
Can
,
though
I
mean
we're
talking
some
superficial
,
but
how
deep
can
they
go
?
Can
they
go
into
the
lung
?
Can
they
go
even
deeper
than
that
?
Speaker 2
14:31
So
they
can
definitely
go
through
the
diaphragm
and
I'm
trying
to
work
together
to
build
a
classification
in
deep
infiltrative
and
diaphragmatic
disease
and
non-deep
infiltrative
diaphragmatic
disease
,
because
they
tend
to
present
with
different
colors
according
to
if
they
are
infiltrative
or
not
,
and
also
the
yastric
and
going
the
lung
.
I've
seen
anecdotal
cases
of
lung
endometriosis
.
I
was
at
least
lucky
enough
,
when
I
often
don't
see
any
cases
that
are
severe
,
but
certainly
I've
seen
in
the
prura
,
so
the
lining
of
the
lung
,
and
I've
seen
a
lot
of
deep
infiltrative
endometriosis
in
the
diaphragm
and
I
have
at
least
about
five
,
Symptoms and Diagnosis Challenges
Speaker 2
15:22
six
cases
of
very
suspicious
airway
endometriosis
.
But
it's
very
difficult
to
catch
because
it's
although
I've
done
bronchoscopy
,
a
camera
test
of
the
airway
it's
normally
located
very
peripherally
where
the
airway
is
so
thin
that
you
can't
fit
the
bronchoscope
in
even
using
a
thin
one
.
Speaker 1
15:42
Interesting
,
do
you
?
Okay
side
note
on
that
?
Maybe
this
is
curiosity
from
my
standpoint
when
you're
talking
about
that
For
those
people
who
they
.
For
myself
in
particular
,
I've
been
diagnosed
with
vocal
cord
dysfunction
and
it's
interesting
to
me
that
maybe
that's
not
always
vocal
cord
dysfunction
,
maybe
it's
something
more
.
Would
you
have
that
right
shoulder
pain
along
with
that
as
well
,
like
that
trouble
breathing
?
It's
getting
harder
type
of
thing
,
or
can
that
?
Happen
simultaneously
on
its
own
.
Speaker 2
16:16
I
think
that
an
individual
who
has
a
diagnosis
of
endometriosis
should
have
a
very
high
level
of
suspicion
for
symptoms
that
have
this
kind
of
pattern
,
in
which
they
tend
to
come
with
the
ovulation
period
and
then
they
fade
and
the
patient
gets
better
without
any
treatment
.
Speaker 2
16:34
Whatever
is
the
symptom
migraine
,
blurred
vision
,
change
in
the
voice
,
coughing
up
blood
,
change
in
the
performance
,
pain
in
the
shoulder
,
pain
in
the
diaphragm
,
pain
in
the
chest
,
all
these
symptoms
if
they
come
and
go
with
the
period
,
they
might
be
related
to
extra
pelvic
endo
.
I
think
we're
only
scratching
the
surface
in
these
years
of
what
is
the
true
diagnosis
.
I
have
patients
a
couple
of
them
with
this
migraine
and
since
we
know
that
a
catamenial
epilepsy
exists
,
I
wonder
also
if
it's
maybe
another
form
of
presentation
of
extra
pelvic
endometriosis
.
I
cannot
prove
it
because
,
again
,
mris
didn't
help
.
But
it's
very
interesting
also
because
we
know
that
the
patient
,
when
they
are
young
,
the
symptoms
tend
to
have
this
pattern
and
when
they
get
older
they
are
chronic
because
the
pain
can
escape
,
you
know
,
can
become
chronic
pain
.
You
know
the
pattern
of
chronic
pain
when
it's
prolonged
and
then
it's
always
there
.
But
at
least
initially
they
can
refer
a
very
good
history
of
having
a
pattern
of
these
symptoms
and
for
five
years
it
was
coming
and
going
,
and
then
with
full
resolution
.
Speaker 1
17:54
Yeah
,
it's
interesting
.
You
said
earlier
the
color
spectrum
.
You
have
this
brilliant
way
the
color
spectrum
,
the
rainbow
,
if
you
will
.
Speaker 2
18:06
Do
you
?
Speaker 1
18:07
want
to
explain
that
a
little
bit
,
just
because
I
think
that
it
would
help
a
lot
of
people
kind
of
understand
the
variations
of
this
disease
.
Speaker 2
18:14
So
it
is
my
very
own
classification
and
I've
noticed
that
there's
patterns
in
presentational
disease
.
On
the
lesion
they're
pink
and
sessile
.
That
seems
to
be
the
most
superficial
.
I
get
that
with
a
brown
cauliflower
shaped
ones
that
are
very
superficial
and
when
I
go
at
the
base
the
diaphragm
underneath
looks
,
or
the
pleura
looks
,
completely
fine
.
Instead
there
are
the
purple
which
are
hemocytinine-filled
Hemocytinine
is
like
a
fancy
name
for
old
blood
and
white
,
which
we
all
know
why
it's
scarred
.
Scar
is
always
the
end
stage
of
a
very
prolonged
inflammatory
process
in
our
body
.
So
the
idea
that
I
haven't
proven
yet
is
that
this
is
a
pathway
or
steps
to
get
to
the
final
scarring
.
Although
there
are
elements
supporting
my
theory
and
elements
not
supporting
it
,
I
am
still
thinking
that
it
shows
a
lot
of
elements
supporting
this
and
at
least
it
gives
some
way
to
approach
the
disease
systematically
,
systemically
,
in
a
way
that
we
know
what
to
do
.
Speaker 1
19:30
Right
.
I
mean
,
it's
similar
to
the
pelvis
,
right
?
There's
different
variations
of
the
disease
as
far
as
coloration
is
concerned
,
and
so
I
think
a
lot
of
times
that's
what's
missed
,
even
in
the
pelvic
region
.
A
lot
of
times
is
that
what
we're
taught
is
the
powder
burn
lesions
,
that's
the
endometriosis
,
but
it
comes
in
so
many
different
,
various
forms
,
and
if
you
don't
know
what
you're
looking
for
,
it's
often
going
to
be
missed
even
by
some
specialists
,
because
it
varies
for
everyone
.
So
I
think
it's
interesting
that
it's
similar
throughout
the
body
.
It's
not
just
into
the
pelvis
,
you
know
,
it's
all
the
way
up
,
and
I
think
that's
an
interesting
thing
for
us
to
know
as
patients
is
that
if
someone
says
,
no
,
you
don't
have
this
,
it's
worth
investigating
more
because
they
may
not
be
able
to
identify
it
.
Which
to
my
next
point
is
is
it
important
for
someone
that
is
an
excision
specialist
to
have
a
cardiothoracic
surgeon
be
able
to
do
these
surgeries
?
Speaker 2
20:35
Yeah
,
I
think
one
of
the
big
discussion
I
had
with
you
know
,
andrea
Vidali
,
which
I
started
collaborating
also
with
Martin
Hirsch
,
is
that
the
role
of
thoracic
surgeon
should
come
much
earlier
and
not
,
as
it
was
historically
,
that
often
or
sometimes
was
called
directly
in
the
OR
when
something
was
found
on
the
diaphragm
.
I
think
the
role
of
thoracic
surgeon
has
a
huge
impact
on
the
quality
of
life
for
the
patient
and
the
patient
has
the
right
to
speak
early
with
the
thoracic
surgeon
to
make
plans
ahead
to
you
know
,
potential
example
impact
on
quality
of
life
sacrificing
the
phrenic
nerve
,
plans
for
fertility
because
diaphragmatic
surgery
can
impact
pregnancy
.
There
are
elements
that
need
to
be
discussed
and
the
patient
should
have
a
consent
to
all
these
aspects
.
So
I
think
that
the
role
of
thoracic
surgeon
should
change
and
you
know
multidisciplinary
meeting
in
which
you
at
least
see
the
gynecologist
and
thoracic
surgeon
or
,
if
you
need
bowel
resection
,
the
gynecologist
and
the
colorectal
surgeon
.
So
I
think
only
meeting
the
lead
gynecologist
is
not
the
way
to
go
about
this
disease
in
the
future
.
Speaker 1
21:51
I
agree
.
I
think
everyone
has
a
place
in
that
room
to
give
the
patient
the
best
quality
care
that
they
can
and
the
best
outcome
.
Are
there
risks
associated
with
like
not
doing
surgery
and
not
catching
that
?
I
?
Speaker 2
22:07
mean
I'm
sure
there's
a
good
question
.
So
when
it
comes
,
for
example
,
to
pneumothorax
,
the
obvious
risks
in
leaving
the
disease
,
because
the
more
episodes
of
pneumothorax
,
the
more
the
inside
of
the
chest
becomes
scarred
and
oftentimes
the
lung
sort
of
tries
to
heal
on
its
own
.
But
it's
the
same
idea
of
a
fracture
left
untreated
the
bone
doesn't
really
heal
that
nicely
,
isn't
it
?
It
heals
all
in
a
funny
position
.
It's
the
same
thing
when
a
pneumothorax
tries
to
heal
on
its
own
inside
the
chest
,
somewhat
the
lung
comes
up
,
but
the
scarring
is
in
the
wrong
position
and
the
lung
is
Imaging Limitations and Disease Patterns
Speaker 2
22:48
in
an
awful
partially
expanded
way
,
which
then
opens
the
gates
to
a
lot
of
complications
.
Speaker 2
22:57
A
fusion
which
is
fluid
,
the
fluid
can
get
infected
,
becomes
an
empyema
,
or
repeated
pneumothoraces
can
break
the
adhesion
and
cause
pneumothorax
,
which
is
blood
.
So
there
are
risks
,
especially
in
the
repeated
pneumothoraces
.
When
it
comes
to
that
paracetamol
,
it
only
causes
pain
.
I
don't
think
you
can
underestimate
it
,
say
,
oh
,
it's
only
pain
,
because
it's
probably
the
thing
that
affects
the
quality
of
life
the
most
.
So
eating
pain
,
I
don't
think
it's
something
we
should
overlook
.
It
is
for
me
a
very
important
indication
.
Speaker 1
23:35
Yeah
,
and
I
think
what's
interesting
too
and
you
had
talked
about
this
before
is
pregnancy
in
that
as
well
.
Can
you
explain
that
a
little
bit
and
why
this
is
so
important
for
those
who
maybe
?
Speaker 2
23:49
are
struggling
with
fertility
.
Speaker 2
23:51
Yes
.
Well
,
when
it
comes
to
thoracic
endometriosis
and
diaphragmatic
endometriosis
,
so
operating
on
the
diaphragm
,
we
have
some
data
of
operating
on
the
diaphragm
and
then
pregnancy
,
but
these
are
not
specific
of
thoracic
endometriosis
.
These
are
for
another
type
of
diaphragmatic
surgery
.
So
,
when
it
comes
to
this
surgery
major
diaphragmatic
surgery
some
recommend
including
me
to
have
elective
C-sections
because
the
risk
of
delivering
the
child
in
a
natural
way
can
put
a
lot
of
strain
on
the
diaphragm
.
Now
,
by
general
terms
,
surgery
to
the
diaphragm
is
meant
to
be
solid
in
physiological
condition
.
Speaker 2
24:38
Pregnancy
is
a
situation
in
which
the
diaphragm
is
under
extreme
strain
and
this
can
disrupt
reconstruction
.
And
also
,
additionally
,
when
there
are
those
major
diaphragmatic
surgeries
in
which
the
phrenic
nerve
may
be
sacrificed
,
then
the
phrenic
nerve
is
not
working
and
the
diaphragm
rises
,
which
is
something
that
can
be
managed
when
the
patient
is
not
pregnant
.
When
the
patient
is
pregnant
,
the
intra-abdominal
pressure
rises
significantly
and
the
diaphragm
,
which
has
a
non-functioning
phrenic
nerve
,
can
have
a
lot
of
trouble
and
they
need
to
see
a
specialist
.
They
need
to
be
followed
up
closely
during
the
pregnancy
.
I
don't
think
I
don't
want
to
scare
people
off
about
being
pregnant
,
but
they
should
have
a
specialist
following
them
up
during
the
pregnancy
.
I
don't
think
.
I
don't
want
to
scare
people
off
about
being
pregnant
,
but
they
should
have
a
specialist
following
them
up
during
the
pregnancy
Because
,
if
this
is
not
happening
,
at
least
there
is
a
plan
to
deliver
the
baby
and
then
operate
on
the
mom
,
rather
than
be
all
a
surprise
and
maybe
her
being
very
unwell
,
very
breathless
and
in
trouble
all
of
a
sudden
as
a
surprise
.
Speaker 1
25:46
Which
goes
back
to
the
point
earlier
of
having
someone
on
your
team
that
specializes
in
this
.
Yeah
,
because
those
are
the
people
that
are
going
to
catch
that
.
Speaker 2
25:54
Yes
,
because
I
can't
think
of
all
the
nuances
that
a
gynecologist
can
think
of
.
I
don't
think
a
gynecologist
,
even
with
a
lot
of
experience
in
diaphragmatic
endometriosis
,
they
still
,
I
don't
think
,
have
the
training
to
think
of
all
the
implications
and
ramifications
that
I
have
in
my
mind
and
that
may
be
obvious
to
me
.
It
may
be
very
tricky
to
a
gynecologist
.
Speaker 1
26:17
Right
,
we
talk
about
the
risks
with
pregnancy
,
but
what
are
the
risks
for
surgery
when
it's
not
pregnancy
?
Are
there
risks
associated
,
of
course
,
with
every
surgery
?
There
is
,
but
what
are
some
of
the
risks
?
Maybe
?
Speaker 2
26:31
Yes
.
Well
,
when
we
are
operating
inside
the
chest
,
we
have
the
most
vital
structures
in
the
body
except
the
brain
.
So
you
have
the
heart
,
the
aorta
,
the
superior
vena
cava
all
the
largest
blood
vessels
in
the
body
.
So
clearly
,
we
are
in
a
delicate
area
in
which
expertise
and
surgical
skills
and
steady
hands
are
very
important
.
When
it
comes
to
pleural
surgery
,
it
is
normally
the
lowest
risk
type
of
surgery
when
it
comes
to
thoracic
endo
,
and
that
there
is
lung
surgery
,
which
is
something
that
thoracic
surgeons
perform
routinely
.
So
,
in
my
mind
,
one
aspect
that
has
to
be
looked
at
closely
and
the
surgeon
needs
to
have
specific
training
and
expertise
is
diaphragmatic
surgery
,
because
it's
not
part
of
every
thoracic
surgeon
experience
and
some
surgeons
might
not
ever
do
diaphragmatic
surgery
because
it's
not
part
of
every
thoracic
surgeon
experience
and
some
surgeons
might
not
ever
do
diaphragmatic
surgery
in
their
career
.
Speaker 2
27:31
When
it
came
to
me
,
I
already
had
the
interest
in
diaphragmatic
surgery
and
then
also
added
on
into
thoracic
endo
.
So
diaphragmatic
surgery
is
a
skill
in
itself
because
it's
basically
between
the
abdomen
and
the
chest
,
and
so
there
are
a
lot
of
implications
with
that
.
So
you
know
,
the
anatomy
below
the
right
hemidiaphragm
is
very
different
to
the
anatomy
that
is
below
the
left
hemidiaphragm
,
and
also
the
appearance
of
the
two
hemidiaphragm
is
very
different
,
because
on
one
side
you
have
the
heart
,
on
the
left
,
on
the
other
you
have
inferior
vena
cava
and
the
connection
that
the
liver
has
with
the
underbelly
of
the
hemidiaphragm
.
So
there
are
a
lot
of
anatomical
implications
to
consider
.
Speaker 1
28:12
Right
,
it's
so
complex
.
This
is
why
we
talk
about
you
know
that
specialty
aspect
.
You
have
your
knowledge
of
the
heart
,
but
your
pelvis
knowledge
is
probably
not
as
good
as
maybe
Vidali
or
someone
like
that
.
You
know
you
guys
are
all
so
good
,
but
that
you're
so
much
better
together
when
you
work
together
as
a
team
.
Speaker 2
28:30
Yeah
.
Speaker 1
28:31
And
that's
for
the
patient
.
Speaker 2
28:33
Yeah
.
So
if
you
take
a
highly
skilled
and
experienced
surgeon
and
you
show
them
any
surgical
technique
,
any
surgical
procedure
,
like
10
times
,
let's
make
like
an
experiment
.
Now
let's
say
that
Vidal
showed
me
10
easy
hysterectomies
.
With
my
20-year
surgical
training
I
could
probably
replicate
,
but
will
I
be
able
to
know
exactly
what
I'm
doing
?
In
the
same
way
,
I
could
take
him
through
an
easy
lobectomy
.
But
you
know
,
it's
not
just
the
acts
of
doing
things
,
it's
the
deep
understanding
of
the
anatomical
nuances
,
the
implications
,
the
slight
difference
that
in
doing
something
or
not
doing
it
has
an
outcome
.
Because
in
modern
surgery
thankfully
for
the
patients
we
are
not
looking
at
differences
.
There
are
large
differences
in
5%
,
10%
.
A
good
surgeon
or
a
bad
surgeon
now
is
quantified
in
2%
or
0.5%
better
outcomes
.
Speaker 1
29:41
Are
there
ways
that
people
you
know
similar
to
the
pelvis
?
A
lot
of
people
want
to
find
ways
that
they
can
help
manage
some
of
the
pain
without
surgery
.
Is
that
poethorastic
endometriosis
or
is
that
something
that
really
you
need
to
address
because
of
quality
of
life
?
Speaker 2
29:56
So
excision
versus
medical
treatment
is
a
very
well
debated
topic
very
well
debated
topic
and
you
know
,
if
you
look
at
the
ASHRAE
guidelines
that
are
in
Europe
are
advocating
lots
of
steps
of
medical
treatments
before
attending
excision
,
and
will
other
practitioners
and
gynecologists
offer
excision
almost
as
mainstream
treatment
and
then
consolidate
with
hormonal
treatment
.
When
it
comes
to
trasequendo
and
generally
the
generalities
of
medical
treatment
for
endometriosis
,
I
prefer
to
leave
it
with
the
gynecologist
.
I
still
feel
that
that's
more
their
patch
.
But
when
it
comes
to
trasequome
,
something
I've
seen
in
clinic
and
it's
my
main
advice
to
the
patients
is
don't
consider
it
as
a
long-term
solution
,
because
you
know
,
I've
seen
patients
that
maybe
they
start
having
chest
symptoms
and
they
went
on
some
hormonal
treatment
and
when
they
were
I
don't
know
,
37
,
38
,
they
decided
okay
,
now
I'll
stop
hormonal
treatment
,
I
want
to
have
children
,
and
all
of
a
sudden
they
started
having
lung
collapses
,
horrific
chest
and
diaphragmatic
pain
and
they
eventually
come
to
me
.
Speaker 2
31:17
It
takes
two
,
three
years
to
see
a
specialist
find
the
right
one
and
they
look
inside
there's
lots
of
endometriosis
and
the
clock
is
ticking
and
they
plan
for
fertility
.
Now
they're
40
years
old
,
41
,
and
are
still
struggling
with
their
chest
symptoms
.
So
you
see
where
I'm
going
.
So
my
opinion
is
,
if
you
have
endometriosis
and
chest
symptom
and
maybe
you
have
something
short
term
,
like
you
want
to
get
your
degree
or
getting
married
or
something
important
a
few
years
of
hormonal
treatment
is
probably
a
good
idea
to
maybe
achieve
your
Surgical Approaches and Considerations
Speaker 2
31:51
goals
and
then
,
in
the
long
run
,
maybe
consider
having
a
specialist
referral
,
having
a
thoracic
surgeon
looking
inside
the
chest
with
an
idea
of
what's
going
on
,
because
the
hormones
sometimes
are
very
good
at
masking
the
symptoms
but
they
don't
cure
the
disease
.
Speaker 1
32:06
Right
Right
,
which
is
probably
one
of
the
biggest
misconceptions
that
we
often
hear
right
yeah
,
it's
a
curative
measure
,
and
I
think
that's
why
it's
really
important
for
a
lot
of
us
to
understand
the
fact
that
a
hysterectomy
is
not
going
to
cure
your
thoracic
endometriosis
,
and
I
think
that
this
is
just
further
proof
of
that
.
It's
knowing
your
team
,
knowing
that
they
specialize
in
endometriosis
specifically
and
have
really
good
evidence-based
education
and
knowledge
to
accompany
their
skill
set
,
because
you
can
have
knowledge
and
not
skill
,
but
you
can
also
have
the
skill
and
not
the
knowledge
and
not
skill
,
but
you
can
also
have
the
skill
and
not
the
knowledge
.
Speaker 2
32:48
Yeah
,
it's
true
.
When
it
comes
to
evidence
,
nowadays
there's
a
great
deal
of
debate
where
the
evidence
comes
from
Right
.
Speaker 2
32:54
Because
there's
pharmaceutical
companies
that
are
producing
the
evidence
on
various
hormonal
treatments
.
And
when
it
comes
to
surgery
and
excision
,
it's
a
little
bit
harder
to
produce
it
because
you
have
a
few
specialists
that
do
a
lot
of
surgery
but
then
the
rest
is
a
high
number
,
especially
with
a
small
number
of
procedures
.
So
to
collectively
get
all
those
numbers
together
and
see
the
benefit
of
excision
,
it
is
a
challenge
that
we
need
to
face
,
the
challenge
we
need
to
do
this
,
but
it
is
not
an
easy
task
because
even
in
thoracic
endo
you
have
only
a
small
handful
of
thoracic
endo
doing
maybe
higher
volumes
,
and
then
you
have
surgeons
that
maybe
do
two
cases
in
their
career
,
but
you
have
hundreds
of
hundreds
of
surgeons
that
may
do
one
,
two
cases
,
three
cases
.
Speaker 1
33:53
Yeah
,
how
do
you
excise
thoracic
endometriosis
?
I
mean
,
we're
talking
about
excision
.
I
know
that
scares
a
lot
of
people
to
maybe
even
think
about
.
You're
going
to
cut
what
out
of
me
and
what
organ
.
How
do
you
do
things
like
this
and
I
know
that
this
is
complicated
to
explain
,
maybe
if
you
don't
have
a
medical
degree
but
is
there
a
way
that
you
explain
this
to
your
patients
as
how
you're
going
to
approach
excision
?
Speaker 2
34:17
Yeah
,
so
the
approach
is
either
thoracoscopic
or
robotic
,
which
is
various
modality
of
minimally
invasive
surgery
,
and
there
are
all
investigations
that
are
so-called
keyhole
,
which
you
insert
a
camera
,
and
then
you
have
arms
that
you
know
,
instruments
that
you
use
inside
the
chest
and
we
address
first-tier
mapping
,
which
is
a
high
definition
4K
or
6K
camera
.
I
look
at
every
corner
of
the
chest
,
we
take
pictures
all
over
and
then
these
pictures
stay
with
the
patient
and
with
us
to
have
a
database
of
images
to
keep
for
record
.
And
then
we
identify
all
the
areas
of
suspected
thoracic
endo
.
When
it
comes
to
the
pleura
,
we
excise
them
,
them
and
we
go
down
to
the
thoracic
fascia
.
The
pleura
is
the
lining
of
the
chest
cavity
.
When
it's
the
surface
of
the
lung
,
often
we
use
automatic
staplers
,
which
are
the
same
we
use
for
lung
resection
.
Fortunately
,
endometriosis
is
often
superficial
,
so
the
loss
of
lung
tissue
for
the
patient
is
minimal
and
the
breathing
capacity
is
virtually
the
same
after
resection
of
thoracic
endo
.
Speaker 2
35:34
The
most
impactful
operation
by
far
is
diaphragmatic
resection
because
at
least
when
I
see
deep
filters
to
the
diaphragmatic
endometriosis
,
I
excise
it
,
I
go
full
thicks
and
not
the
diaphragm
.
And
this
is
a
sore
procedure
because
the
more
your
surgeon
makes
an
effort
to
preserve
the
branches
and
fibers
of
the
phrenic
nerve
,
the
more
you're
going
to
feel
the
operation
after
.
So
if
you
just
go
and
make
a
big
cut
with
a
lot
of
energy
and
then
you
cut
all
the
branches
of
the
phrenic
nerve
,
normally
you
feel
less
pain
but
also
less
functional
phrenic
nerve
in
the
end
.
If
you
instead
do
like
a
tissue
sparing
procedure
in
which
you
just
take
exactly
the
area
which
is
affected
and
try
to
spare
as
much
as
possible
,
you
do
complex
reconstructions
.
You
know
it's
better
in
the
long
run
,
initially
actually
the
patient
the
area
which
is
defective
and
try
to
spare
as
much
as
possible
.
You
do
complex
reconstructions
.
You
know
it's
better
in
the
long
run
.
Initially
actually
the
patient
feels
the
operation
more
because
you
spare
the
fronting
nerve
branches
more
.
Speaker 1
36:35
I
mean
nerve
sparing
is
so
important
anywhere
in
the
body
.
There's
a
reason
we
have
our
nerves
right
.
Speaker 2
36:42
Yeah
,
but
unfortunately
the
structure
on
the
diaphragm
is
something
we
try
to
do
.
We
try
also
to
put
like
local
anesthesia
directly
on
the
frenteal
nerve
,
which
seems
to
give
like
a
little
bit
of
48
,
72
hours
,
but
unfortunately
it's
a
little
bit
of
a
slower
procedure
.
It's
important
that
I
communicate
this
to
the
patients
when
they
are
prepared
yeah
,
prepared
and
amazingly
I
had
patients
that
came
out
of
surgery
and
day
one
they
told
me
it's
achy
and
I
can
feel
it
.
But
they
said
I
can
feel
it's
not
classic
,
I
can
feel
it's
not
end
of
pain
.
I
can
tell
this
is
acute
pain
,
it's
like
something
bites
in
on
that
,
but
I
can
feel
that
it's
going
to
go
.
It's
nothing
to
do
with
that
heat-throbbing
,
dull
ache
that
they
felt
with
thoracic
endometriosis
,
which
is
amazing
because
obviously
I
know
thoracic
endometriosis
a
sore
operation
is
painful
and
they
immediately
detect
that
the
pain
has
changed
.
Speaker 1
37:45
I
mean
,
I
think
that's
similar
.
You
know
,
I
have
only
had
surgery
in
my
pelvis
really
,
but
it's
a
similar
thing
where
you
wake
up
and
you're
like
I'm
in
pain
.
But
it's
not
the
same
pain
.
I
feel
so
much
better
,
in
fact
the
energy
was
back
more
.
And
you
know
,
it's
just
very
,
very
different
between
healing
pain
and
your
body
telling
you
something's
wrong
pain
.
You
know
,
I
think
that
there's
that
somatic
pain
and
which
is
I
think
so
interesting
.
Speaker 2
38:13
It's
amazing
if
you
think
that
in
a
few
years
we
went
from
many
doctors
even
denying
the
very
existence
of
thoracic
and
diaphragmatic
endometriosis
,
and
now
we're
discussing
a
patient
realizing
when
they
wake
up
from
surgery
that
the
traumatic
pain
is
gone
,
the
endo
pain
is
gone
and
now
the
feeling
that
the
healing
pain
and
surgical
pain
is
an
amazing
transformation
Treatment Options and Pregnancy Concerns
Speaker 2
38:36
in
just
a
few
years
.
Speaker 1
38:38
What
is
a
typical
healing
time
for
surgeries
like
this
,
because
that
is
another
thing
people
are
a
little
leery
of
.
Speaker 2
38:45
Yeah
,
so
patients
,
normally
they'll
be
walking
a
few
hours
after
surgery
.
So
I
don't
want
to
scare
people
off
too
much
about
the
impact
.
So
it
is
manageable
and
they'll
be
walking
hours
after
the
operation
.
Normally
the
lines
they
have
is
one
chest
strain
or
not
.
Always
they're
going
to
have
a
chest
strain
,
it
depends
on
the
entity
of
what
they
had
.
I
am
trying
to
minimize
the
user
chest
strain
.
Sometimes
they
don't
have
any
lines
.
They're
going
to
have
the
incisions
on
the
chest
.
Speaker 2
39:14
And
there's
another
thing
that
,
working
towards
minimizing
,
we're
trying
to
do
single
axis
surgery
.
So
either
going
on
the
chest
and
then
through
the
diaphragm
to
look
in
the
abdomen
or
from
the
abdomen
through
the
diaphragm
to
look
in
the
chest
.
Try
to
avoid
having
dual
axis
because
when
you
operate
on
somebody
through
the
abdomen
they
breathe
with
their
muscles
in
the
chest
the
chest
muscles
.
When
you
operate
them
through
the
chest
you
use
their
abdominal
muscle
to
breathe
.
It's
intuitive
that
if
you
go
through
both
cavities
it
is
difficult
to
breathe
after
surgery
.
So
that's
the
idea
.
You
know
,
in
recovery
you
stay
in
hospital
two
,
three
nights
and
then
they
will
go
home
.
We
normally
say
stay
off
,
work
a
couple
of
weeks
,
Okay
,
and
you
know
,
keep
taking
painkillers
and
doing
physio
.
Speaker 1
40:10
The
quality
of
life
.
There
are
restrictions
after
endometriosis
surgery
like
this
that
maybe
they
shouldn't
go
back
to
.
Speaker 2
40:19
Expectation
.
Actually
they
will
be
doing
better
.
They
should
have
less
restriction
to
the
quality
of
life
.
That's
the
whole
purpose
of
the
operation
.
So
if
,
for
example
,
they
had
probably
pneumothorax
,
repeat
the
collapsed
lung
,
they
might
be
able
to
finally
travel
and
take
a
plane
,
because
they
were
very
scared
to
do
so
because
of
their
previous
collapsed
lung
,
or
even
travel
to
somewhere
exotic
.
They
were
scared
to
do
that
because
of
the
you
know
,
were
afraid
to
have
a
pneumothorax
in
somewhere
that
you
cannot
have
,
you
know
,
appropriate
care
and
also
when
it
comes
to
cyclic
and
diaphragmatic
pain
.
That
should
also
improve
their
quality
of
life
.
Speaker 1
40:59
Yeah
,
this
is
all
really
good
.
Okay
,
here's
where
it
gets
really
good
.
What
are
you
excited
for
in
thoracic
endometriosis
in
surgery
?
What
do
you
see
changing
?
Speaker 2
41:12
I
am
excited
One
aspect
about
international
collaborations
to
make
sure
that
some
centers
have
a
high
volume
of
thoracic
endometriosis
.
That
,
I
believe
,
is
the
way
you
increase
knowledge
in
surgery
.
Initially
,
it's
very
important
to
have
a
few
centers
have
high
volumes
.
They
can
create
a
pathway
and
start
the
operative
procedures
and
then
they
can
disseminate
out
that
.
The
second
aspect
I
am
excited
is
education
,
and
I've
been
working
with
European
society
.
I'm
director
of
the
European
exam
and
the
Jurassic
course
and
this
year
we'll
have
,
for
the
first
time
,
jurassic
and
the
Machios
be
part
of
the
curriculum
.
And
also
I
believe
that
I'm
very
excited
about
this
era
of
the
appropriate
and
good
use
of
social
media
,
because
I
think
social
media
are
really
the
game
changer
because
they
can
reach
anyone
Like
I
don't
know
.
Tomorrow
,
anyone
a
politician
in
Polynesia
will
come
see
this
interview
and
they
will
learn
something
they
didn't
know
,
and
I
think
this
is
incredibly
powerful
too
.
And
social
media
,
if
used
correctly
,
are
a
force
for
good
.
Speaker 1
42:32
Yeah
,
it
can
be
a
great
tool
.
You
have
to
be
mindful
of
who
you're
listening
to
.
Obviously
that's
for
anything
,
right
,
but
it
can
be
such
a
great
tool
and
a
great
way
of
getting
really
good
education
out
there
and
ways
to
navigate
our
care
better
.
What
would
you
tell
the
patient
that
suspects
they
potentially
have
thoracic
diaphragmatic
disease
?
What
would
you
tell
them
if
they
are
struggling
finding
the
proper
care
?
Speaker 2
43:03
I
would
probably
advise
to
seek
out
a
high
volume
center
in
endometriosis
and
ask
them
if
they
have
contact
with
the
thoracic
surgeon
that
also
can
see
them
,
because
often
the
answer
is
yes
,
we
have
a
thoracic
surgeon
that
works
with
us
.
Don't
worry
,
when
we
need
them
,
we
call
it
or
we
call
her
.
That's
not
the
answer
that
I
would
be
satisfied
with
.
I
would
like
to
meet
with
the
person
and
have
an
encounter
with
the
person
and
see
what
the
answer
is
going
to
be
,
what
experience
,
what
their
ideas
and
and
the
surgical
plans
as
well
.
Speaker 1
43:46
Yeah
,
it's
key
to
know
your
team
and
if
they
can
follow
you
in
everything
you
do
and
continue
working
with
you
,
because
this
is
you
know
,
a
lot
of
times
we
talk
about
this
disease
as
it
being
,
you
know
,
a
whole
body
.
It's
a
whole
life
disease
too
.
You
have
to
be
aware
of
everything
that
kind
of
coincides
with
this
disease
,
which
are
there
other
diseases
that
tend
to
like
to
partner
with
cardiothoracic
endometriosis
?
Are
there
things
that
you
see
in
correlation
?
Speaker 2
44:16
Well
,
thoracic
endometriosis
in
general
is
an
association
with
many
other
conditions
LN
dollars
,
connective
tissue
or
fibromyalgia
.
Although
,
when
it
comes
to
this
chronic
pain
condition
,
I
often
wonder
if
it's
a
chicken
and
egg
situation
which
,
when
you
have
chronic
pain
in
the
chest
and
the
abdomen
,
it's
easy
to
diagnose
also
a
pain
in
the
muscles
or
the
joints
,
because
the
body
is
all
connected
and
,
for
example
,
having
adhesions
in
the
abdomen
can
lead
to
the
big
muscle
at
the
bottom
of
our
lumbar
spine
which
is
the
alio
stoas
muscles
,
and
this
can
create
a
whole
lot
of
back
pain
and
shoulder
pain
and
other
issues
.
So
,
you
know
,
also
sadly
,
is
depression
because
and
anxiety
,
because
chronic
pain
has
a
huge
impact
on
our
mental
health
.
So
,
yeah
,
it's
connected
with
various
aspects
and
also
the
anxiety
of
having
a
repeated
neural
thorax
and
being
dismissed
,
having
chest
pain
or
shoulder
pain
.
Speaker 2
45:19
I
think
that
medical
dismissal
and
gaslighting
is
a
disease
in
itself
,
because
you're
in
pain
,
you're
in
trouble
and
you
seek
out
the
expert's
opinion
and
the
expert's
opinion
is
oh
,
it's
all
in
your
head
.
I
often
admire
the
patient
that
went
on
for
years
because
I'm
not
sure
if
I
would
do
the
same
.
I
,
you
know
,
maybe
seek
one
specialist
and
another
one
and
they
tell
me
no
,
look
,
don't
worry
,
it's
all
fine
,
it's
all
in
your
head
.
Just
take
this
pill
.
It
will
help
you
sleep
and
be
less
anxious
and
go
ahead
with
your
life
.
I
probably
would
listen
.
Speaker 1
45:58
And
that
goes
to
the
fact
that
we
are
loyal
a
lot
of
times
to
our
medical
providers
,
whether
they're
serving
us
well
or
not
.
Speaker 1
46:04
Sometimes
and
that's
what's
really
hard
for
patients
specifically
is
that
we
the
gaslighting
.
It
becomes
a
mental
struggle
and
then
it
kind
of
exacerbates
the
depression
anxiety
even
more
,
and
that's
what's
so
challenging
,
and
especially
when
you
have
complex
disease
that
isn't
widely
recognized
.
I'm
sure
in
this
case
you
know
a
lot
of
your
patients
have
experienced
that
where
they're
constantly
seeking
care
for
something
and
being
told
that
it's
nothing
,
it's
just
anxiety
,
it's
just
depression
,
which
it
turns
into
.
That
you
know
.
So
I
think
your
job
is
even
more
challenging
than
probably
some
other
areas
of
medical
care
because
you're
seeing
patients
who
have
been
doing
this
for
years
.
You're
not
only
a
doctor
,
a
surgeon
,
but
you
in
some
ways
are
the
one
that's
helping
their
mental
health
because
you
believe
them
,
you
know
,
and
finding
them
a
better
care
team
that
will
believe
them
and
not
just
settle
for
it's
in
your
head
or
you
just
have
anxiety
.
Future Direction and Patient Advocacy
Speaker 1
47:09
So
I
have
to
imagine
that
takes
a
toll
on
you
sometimes
too
is
to
see
your
patients
walk
through
that
.
Speaker 2
47:15
It
is
.
It
is
.
You
know
,
oftentimes
they
are
difficult
.
I
mean
,
I
would
say
everyone
is
very
nice
.
It's
just
that
it
took
a
toll
on
my
trust
and
faith
in
my
own
medical
profession
listening
to
all
these
stories
.
But
at
the
same
time
I
don't
feel
I
want
to
chastise
my
colleagues
,
because
they
were
trained
to
do
diagnosis
and
they
were
also
trained
not
to
believe
every
symptom
because
they
felt
especially
the
older
generation
of
doctors
that
they
were
the
one
that
will
filter
through
the
noise
and
then
find
the
diagnosis
.
I
feel
that
older
generation
doctors
they
were
not
everyone
,
of
course
,
but
they
were
more
about
saving
lives
,
the
mortality
of
things
.
Now
medicine
is
more
about
quality
of
life
,
in
which
it's
not
all
important
.
You
recognize
an
important
symptom
but
if
it
is
a
great
deal
for
the
patient
,
if
the
patient
feels
it
as
they're
perceiving
that
,
then
it's
the
big
deal
.
It's
important
,
regardless
of
the
fact
that
maybe
not
relevant
for
what
you
were
trained
as
a
doctor
.
I
think
there's
a
shift
in
the
medical
profession
understanding
what's
relevant
.
Speaker 1
48:35
Yeah
,
I
think
there's
also
a
shift
too
.
I
mean
,
I
think
there's
probably
.
This
could
go
either
way
,
but
I
think
a
lot
of
providers
are
coming
to
terms
with
the
fact
that
the
patients
are
becoming
more
savvy
,
and
so
they
themselves
are
becoming
more
curious
,
and
maybe
not
even
more
curious
,
but
they're
like
,
well
,
they're
saying
this
over
and
over
again
.
I
got
to
figure
out
why
,
you
know
so
.
I
think
that
it
is
shifting
a
little
bit
.
Speaker 2
49:00
Yeah
.
So
when
you
mentioned
before
going
back
to
your
previous
question
what
would
you
want
for
your
doctor
,
you
know
,
thoracic
surgeon
or
gynecologist
?
I
think
for
me
,
one
of
the
most
important
green
flags
when
you
go
and
see
a
specialist
is
a
specialist
that
doesn't
mind
to
be
challenged
and
doesn't
get
annoyed
when
you
mention
Dr
Google
.
Speaker 1
49:20
Yes
.
Speaker 2
49:20
Because
I
actually
like
it
,
because
it
keeps
me
always
informed
.
It
happens
very
rarely
that
the
patient
comes
up
with
something
that
I
didn't
hear
before
,
but
nonetheless
I
still
enjoy
it
because
I
like
when
the
patients
are
knowledgeable
and
they
come
up
with
their
own
ideas
.
And
if
the
specialist
offers
just
listens
for
the
first
bit
of
the
consultation
,
normally
you
establish
their
reports
of
trust
and
people
relax
and
opens
up
.
If
especially
starts
immediately
being
defensive
and
seems
annoyed
,
I
think
is
a
sign
of
a
bit
of
your
shaky
knowledge
and
not
so
confidence
in
that
level
of
depth
of
knowledge
,
right
.
So
I
would
advise
the
patient
.
You
know
he
has
a
green
flag
,
he's
a
doctor
,
doesn't
mind
to
be
challenged
.
Speaker 1
50:13
Yeah
,
I
agree
,
because
we're
all
complex
humans
.
We
all
deserve
that
bit
of
curiosity
in
our
care
right
,
having
a
provider
go
alongside
you
with
that
means
a
lot
to
us
as
patients
,
but
also
it
can
change
the
face
of
medical
care
across
the
board
,
which
is
why
I'm
excited
that
you
are
doing
what
you're
doing
,
because
that
curiosity
,
that
drive
to
continue
seeking
better
care
for
the
patients
and
understanding
the
disease
,
understanding
the
patients
with
the
disease
and
all
the
nuances
that
come
with
it
,
are
imperative
for
the
future
of
endometriosis
.
So
thank
you
for
continuing
to
be
curious
,
thank
you
for
taking
the
time
to
sit
down
and
explain
this
to
people
so
that
they
have
better
knowledge
and
have
a
better
understanding
of
potential
risks
of
extra
pelvic
endometriosis
.
And
so
thank
you
so
much
for
taking
the
time
.
I
know
it's
precious
.
Speaker 2
51:09
Pleasure
.
Thanks
so
much
.
Speaker 1
51:12
Absolutely
.
Thank
you
Until
next
time
.
Everyone
continue
advocating
for
you
and
for
others
.