by EFHou
Editor’s Note: The Endometriosis Foundation of Houston sometimes invites experts to share their work, opinions, and thoughts with our endo community as a part of our Tea Talk Series. These "tea talks" cover a wide range of health topics meant to educate and inform our community. For more information, visit https://www.efhou.org/events.
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Dr. Tamisa Koythong is an up-and-coming minimally invasive gynecological surgeon affiliated with Baylor College of Medicine. Following a fellowship where she trained in endometriosis excision with Dr. Xioaming Guan, Dr. Koythong began seeing her own patients full time in August 2021. She performs surgery at St Luke's and Texas Children's Hospital Pavilion for Women. In March, Dr. Koythong took part in EFHou's Tea Talk. We appreciate the opportunity for the Houston community to get to know Dr. Koythong better.
EFHou: What is your philosophy of care for endometriosis? What theory (or theories) of origin inform your approach to treating the disease?
I believe it is important to not only acknowledge endometriosis as a source of a patient’s chronic pain but also to identify other potential etiologies contributing to her pain. Typically patients who suffer from such chronic issues may have more than one trigger. Essential to creating a treatment plan is recognizing all of these factors in order to optimize the alleviation of her symptoms.
Additionally, if left untreated, endometriosis can go on to drastically affect the urinary and gastrointestinal symptoms – and radical excision is truly the best option to prevent or treat this outcome. This may involve collaboration with other surgical subspecialties, such as colorectal, urological, and cardiothoracic surgery teams.
We are traditionally taught Sampson’s theory of retrograde menstruation as an explanation for the development of endometriosis – but this theory is widely regarded by endometriosis specialists as false. Now, there is more acceptance of an embryological/stem disease theory of its development. Taking this into account, I am more cognizant of a family history of endometriosis; that it can occur in pre-menarchal adolescents and post-menopausal women; and that extra-pelvic disease may rarely occur without pelvic manifestations.
EFHou: Do you perform excision surgery? If you use techniques besides excision, why do you use these and under what circumstances? What are your thoughts on ablation?
I typically perform excision surgery in all of my endometriosis cases. Ablation surgery for endometriosis is usually incomplete in the treatment of the disease, as you are limited by the depth of ablation you can achieve due to risks of injuring surrounding vital structures such as vessels, nerves, and the ureter. At best, you may achieve temporary relief of symptoms, but we find that it will always return because the disease can be much deeper than appreciated. Fibrosis secondary to ablation may also make it more difficult for an excision surgeon to subsequently treat the disease, as well.
However, there are two instances in which I perform ablation: 1) For very superficial uterine serosal disease in a patient desiring fertility, or 2) For small, very superficial ovarian lesions (separate from an endometrioma!) in an attempt to preserve hormonal status for the benefit of heart, bone, and mental health in my younger patients.
EFHou: Can you describe your surgical training and experience with endometriosis?
My surgical training during residency was pretty much non-existent. My familiarity with the disease and its surgical treatment is primarily through my fellowship training at Baylor, of which a little over half the time was spent directly with Dr. Guan. As such, my surgical approach to endometriosis essentially mirrors his, and we both use the robotic platform and consult surgical subspecialties as necessary in order to eradicate disease.
EFHou: In what circumstances would you leave disease behind?
My goal is always to remove all pathology at the time of surgery. Hopefully pre-operatively we have identified any potential subspecialties necessary at the time of surgery – but if not, an intraoperative consult can always be called.
At Texas Children’s, there are no cardiothoracic surgeons with privileges. It has not occurred yet, but if I identified extensive unanticipated diaphragmatic disease I would pause the surgery and speak with family or support in the waiting room – and likely leave that disease as that particular hospital also would not be equipped at handling postoperative care of such patients. If this is anticipated, I would, of course, schedule the surgery with the surgeons on hand in a hospital equipped for adequate postoperative care – and this would be at St. Luke’s.
Similarly, if I identified unanticipated extensive disease involving the rectum, bowel, or ureter that would likely require extensive resection by colorectal or urologic surgery requiring an ostomy and I have not had that conversation with the patient, that may be an instance I may leave disease behind so that both me as a surgeon and the patient may be better prepared.
EFHou: How do you manage your patients post-surgery? What if they continue to experience symptoms after surgery?
If my patients are discharged home on the same day of surgery, either I or a member of my team will call the patient the next day at home to ensure that they are still doing well. I see my patients at least twice postoperatively – once at two weeks post-op and again at six weeks postop. Depending on the extent of their surgery, I recognize that their recovery may take longer than that – and see them throughout the post-op period, however long it may be.
If they still continue to experience pain, I think it is important to identify any other potential sources of these symptoms. Thanks to Dr. Guan, I am confident in my ability to excise such disease, but would not take offense at a second or third opinion. I do not want to dismiss ongoing issues, and finding an answer together is my goal.
EFHou: Generally speaking, are there any situations where you would NOT recommend surgery for a patient presenting with endometriosis?
A shared-decision making model respecting patient autonomy and physician/patient comfort with the plan is very important in my philosophy of in-patient care. I tend to leave the decision for surgery up to the patient, and the extent of surgery is an open discussion.
My choice to strongly recommend surgery in a patient takes into account their goals, as well as the anticipated stage of the disease – of course, I may tend to recommend surgery in patients who have disease already affecting adjacent or non-adjacent organs.
EFHou: How did you become interested in endometriosis? Why did you decide to focus on this?
I remember my very first day of fellowship with Dr. Guan. We saw one of his post-operative patients together, and as soon as we walked in the door she cried and embraced him because it was the first time she had been pain-free in many years. Seeing this outcome made me curious – to have such a profound and drastic effect on a patient, improving her quality of life in a relatively short amount of time.
As time went on during my fellowship, my curiosity grew and I began to recognize the scarcity of surgeons trained to offer this to patients. I saw a niche that could be developed and hopefully trusted by patients for their care.
EFHou: We understand that you are recently out of fellowship with Dr. Guan. What are your career goals in the coming years?
I hope to become a trusted resource for patients who seek care for endometriosis. Along with Drs. Guan and Nassif, we are hoping to develop a center for endometriosis care at Texas Children’s Pavilion for Women that can hopefully be all encompassing with collaborative efforts between multiple surgical subspecialties, mental health resources, and any other adjunct therapies in addressing the whole patient.
EFHou: What do you find most difficult or frustrating about endometriosis care?
My primary frustration with endometriosis care may or may not reflect frustrations from a patient standpoint – and that is finding health care providers familiar and comfortable enough to collaborate with. There are so few providers dedicated to the treatment of endometriosis that they easily become overwhelmed with patient volume once their expertise becomes known, and there may be a delay in establishing care with these individuals – which may then further lengthen someone’s entire (and most of the time very long) journey to be treated.
EFHou: What is your experience with diagnosing and managing adenomyosis? What options do you offer?
I discuss with patients that an “official” diagnosis of adenomyosis technically requires surgical pathology – which is typically achieved with hysterectomy. Obviously, this may be too drastic of an option for many patients. There are imaging studies that we can perform to evaluate for such disease, but like endometriosis, a negative imaging study does not rule out disease, and if it is visible in these imaging studies, adenomyosis may already be advanced.
It is a tricky situation in terms of diagnosis and treatment. Hormonal therapy, like endometriosis, may alleviate symptoms associated with adenomyosis but the disease is likely to persist until definitive surgery with hysterectomy can be performed.
EFHou: Why should patients trust you with their care? What sets you apart?
My approach to endometriosis and medicine, in general, is this: we are all learning together. I find that my endometriosis patients are often the most well informed prior to even stepping into my office because they have dealt with symptoms for years prior to finding resources such as the [Endometriosis Foundation of Houston] that provide a wealth of information. As time goes on, I am hopeful that we can understand endometriosis as a disease more – and I am sure these patients may be the first to educate me on any advances.
I recognize that I am very early on in my practice and welcome an open discussion and appreciate any and all feedback – good or bad. I want to become the best version of myself as a physician and as a resource for my patients, and I always want my patients to feel comfortable enough to bring any concerns to me without fear of retaliation.
EFHou: Is there anything else you would like to share with us?
Thank you for taking the time to ask these thoughtful questions and for meeting me! I know it is difficult to find physicians to trust in the care of endometriosis patients, and I look forward to developing a relationship with the community.
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Dr. Tamisa Koythong is an Assistant Professor in the Division of Minimally Invasive Gynecologic Surgery within the Department of Obstetrics and Gynecology at Baylor College of Medicine. She completed her undergraduate studies at the University of Texas at Austin prior to obtaining her medical degree at the University of Texas Health Science Center at San Antonio. She then moved back to her native home of Houston, where she completed her residency training in obstetrics and gynecology and fellowship training in minimally invasive gynecologic surgery at Baylor College of Medicine. During residency, she was the recipient of the AAGL Recognition of Excellence in Minimally Invasive Gynecology award. Her experience with surgical training in the treatment of endometriosis has been under the direction of Dr. Xiaoming Guan.