QC:From Left-Behind Lesions To Better Protocols: Rewriting Complex Endometriosis and MCAS Care

What if the reason you’re still in pain after surgery isn’t failure—it’s complexity that wasn’t fully addressed? We sit down with a neurogastroenterologist and a colorectal surgeon to unpack why deep endometriosis often persists, how bowel involvement gets missed, and what a truly coordinated plan looks like when disease touches the colon, rectum, bladder, and beyond. Their candid insights replace false hope with a roadmap: document what’s found, refer when needed, and assemble the right team before anyone picks up a scalpel.

From the GI side, we spotlight the often-ignored drivers of rough recoveries: mast cell activation, POTS, and hypermobility. You’ll hear concrete perioperative steps that make a difference—stabilizing the neck for craniocervical instability, aggressive pre-op hydration for dysautonomia, avoiding mast cell-triggering anesthetics and opioids like morphine, and keeping steroids plus H1/H2 blockers ready for intra-op flares. These are practical, repeatable moves any care team can adopt to reduce anaphylaxis risk, dampen post-op nausea, and prevent the multi-day crashes that erode progress.

On the surgical front, we examine why repeat procedures happen and when restraint is the safest choice. Rather than forcing a high-risk resection, skilled gynecologists who encounter rectal nodules document and refer to colorectal partners, which protects patients from complications. That’s not a setback; it’s modern care. We walk through how multidisciplinary planning—similar to rectal cancer pathways—improves detection of deep infiltrating endometriosis, clarifies whether staged surgery is wiser, and sets honest expectations about recovery timelines.

If you’re navigating persistent symptoms after “successful” surgery, this conversation offers clarity and a plan. Learn the questions to ask, the protocols to request, and the markers of a team that’s ready for complex disease. If this helped you, follow the show, share it with someone who needs answers fast, and leave a review with your top question for our next Quick Connect.

Chapters

• 0:00 Quick Connect Setup And Disclaimer
• 0:39 Meet The GI And Colorectal Experts
• 2:30 Why Symptoms Persist After Multiple Surgeries
• 4:27 Mast Cell And POTS Perioperative Protocols
• 6:00 Multidisciplinary Care For Complex Endometriosis
• 6:33 Closing And How To Send Questions

Transcript

SPEAKER_02: 0:00

Life moves fast, and so should the answers to your biggest questions. Welcome to Indo Batteries Quick Connect, your direct line to expert insights. Short, powerful, and right to the point. You send in the questions, I bring in the experts, and in just five minutes, you get the knowledge you need. No long episodes, no extra time needed. And just remember, expert opinions shared here are for general information and not for personalized medical advice. Always consult your provider for your case-specific guidance. Got a question? Send it in, and let's quickly get you the answers. I'm your host, Alana, and it's time to connect. Today I'm honored to welcome two incredible physicians, both whom bring unique expertise and deep commitment to caring for patients with complex conditions. First, we have Dr. Zach Spiritos, a neurogastroenterologist and internist. Dr. Spiritos trained at UNC School of Medicine, completed his residency at internal medicine at Emory University, and went on to a fellowship in gastroenterology at Duke. He specializes in a wide range of gastrointestinal and liver disorders with particular interest in irritable bowel syndrome, functional abdominal pain, motility disorders, and dysautonomia, including conditions like POTS and mast cell activation syndrome. He also has expertise in GI complications connected to hypermobility syndromes like E Lers downlos. Also joining us today is Dr. Vincent Obius, a professor of surgery and chief of the Division of Colorectal Surgery for the National Capital Region. Dr. Obias trained at the Medical College of Virginia, Eastern Virginia Medical School, and Cleveland Clinic with additional advanced training and laparoscopic colorectal surgery at University Hospital's Case Medical Center. He is double board certified in general and colorectal surgery, and his specialties include robotic minimally invasive techniques as well as surgery for deep infiltrating endometriosis. His research and clinical work have made a lasting impact, particularly in robotic surgery outcomes and complex endometriosis care. Together, these two doctors bring insights from both the gastrointestinal and surgical perspectives, making today's conversation one that promises to be both informative and empowering for patients and providers alike. Please help me in welcoming Dr. Zach Spiritos and Dr. Vincent Obius to the table. Vince, have you experienced that you've done resections and you've been in surgeries where they've had multiple surgeries, they continue having these symptoms. Is it typically disease state that you're seeing again, or is it something else completely?

SPEAKER_00: 2:46

Yeah, I I will say that um every time I'm in a case, um, especially now working with Dr. Vargas and Dr. Mikhail, you know, their success rates in finding nodules and of involvement of the bowel is like 100%. So whenever and and like we had mentioned and discussed earlier, sadly, most of the surgeries I've involved, there's been previous surgery, which is it's just sad to see. Honestly, um, the gynecologist did the right thing. Rather than tackle this complex nodule on the rectum and have a complication that's just terrible, don't do anything, document it, get it to an expert. But yeah, I mean, when they're having post-surgical and there's usually because of endometriosis that's been left behind, sometimes inadvertently and regrown, or and sometimes they knew it and they're like, look, I'm not gonna not gonna risk it. And it's the smart thing to do, understanding that you know they're a little bit out of their element. The patient is not aware a big surgery can happen. Um, and it's better to just, you know, get out, let them recover quickly. But it's very frustrating, honestly, for the patients who are like, they came in, they're hoping to have one procedure, they're hoping to have this done, taken care of, and they've been told not only that you know we're we're we're doing this, but there's gonna be, you know, we couldn't do it all, but there's also a worse situation, and we may need even more advanced extensive stuff. So um so yes, I absolutely have seen it. And the majority of the time it's because of this end of endometriosis being there.

SPEAKER_02: 4:10

Okay. Yeah. I would I think that's probably pretty common with people that I hear, including my own story of that of disease being left behind. But it, you know, that goes to say that that's why this education is so important, right? And we have to keep educating about this. Zach, is there a ideal pre and post-operative routine or things that we can do to help support us from the mast cell part of it? Because I know a lot of people, including myself coming out of it, things flare really bad. How do we help alleviate a little bit of that pre and post-operatively?

SPEAKER_01: 4:47

Yes, we want to make sure their mast cell is under as best control as possible pre-operatively. There's always, I tend to reach out to the surgeon to discuss the case and just say, hey, this is kind of this is how I would think about this specific patient. You know, whether they're hypermobile and they need a neck brace during a surgery because they have a lot of craniocervical instability. Do they have HOTS and just need very like, do they really need to be fluid resuscitated before the case and really just make sure that they're adequately hydrated? If they have mast cell activation syndrome, there's certain anesthetics that tend to flare mast cells and post-operative narcotics like morphine that tend to be more aggravating for mast cells. And there's also a dialogue like what happens if they have a huge flare and go in anaphylactic shock. Like, we should probably have like steroids and you know, H1 and H2 blockers ready to go in case that happens. And so I have a protocol that, you know, I've I've written with other, I haven't written, but I've adopted from other um mast cell clinicians. And I often will reach out to the surgical team and say, this is kind of what I would do uh and how I would approach this patient kind of perioperatively and intraoperatively just to get the best outcomes. Yeah. Yeah.

SPEAKER_00: 5:57

Honestly, like the way Zach pointed out, it it's important to emphasize that when you're dealing with something like endometriosis that can affect so many different areas: colon, rectum, diaphragm, bowel, bladder, it's multidisciplinary. Just like when I deal with rectal cancer, we talk, we have radiologists, oncologists, radiation oncologists. We we have a variety of people on the team to discuss it. And so it endometriosis, especially complex stuff, is is starting to lean that way where you have multidisciplinary teams talking about it so that we don't miss things. And Zach pointed out.

SPEAKER_02: 6:33

That's a wrap for this quick connect. I hope today's insights helped you move forward with more clarity and confidence. Do you have more questions? Keep them coming. Send them in, and I'll bring you the expert answers. You can send them in by using the link in the top of the description of this podcast episode or by emailing contact at indobattery.com or visiting the Indobattery.com contact page. Until next time, keep feeling empowered through knowledge.