|Year : 2020 | Volume
| Issue : 1 | Page : 16-22
Colorectal surgery: Is there a need to recognize it as a separate super specialty in India?
Asif Mehraj, Nisar A Chowdri
Department of Colorectal Surgery, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
|Date of Submission||08-Aug-2020|
|Date of Decision||11-Aug-2020|
|Date of Acceptance||24-Aug-2020|
|Date of Web Publication||02-Oct-2020|
Dr. Asif Mehraj
Department of Colorectal Surgery, Sher I Kashmir Institute of Medical Sciences, Srinagar, Srinagar - 190 018, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Colorectal surgery is an established super specialty in most parts of the world. However, in India, this is yet to be recognized as a separate super specialty. Colorectal surgery has a vast scope and needs dedicated training to treat complex colorectal diseases. There is enough scientific evidence to prove that outcomes for such diseases are improved in the hands of dedicated colorectal surgeons. So far in India, the process of granting it the status of a separate super specialty has been initiated but it needs further efforts to formally do so and also start super specialty courses such as MCh/DNB in the field. In this review, we will give a brief historical background of the specialty of colorectal surgery, the scope of colorectal surgery, the scientific evidence to prove that better patient outcomes are achieved in the hands of dedicated colorectal surgeons and finally the journey of efforts that have been carried so far for recognizing this as a separate super specialty in our country.
Keywords: Colorectal surgery, India, separate, super specialty
|How to cite this article:|
Mehraj A, Chowdri NA. Colorectal surgery: Is there a need to recognize it as a separate super specialty in India?. Indian J Colo-Rectal Surg 2020;3:16-22
|How to cite this URL:|
Mehraj A, Chowdri NA. Colorectal surgery: Is there a need to recognize it as a separate super specialty in India?. Indian J Colo-Rectal Surg [serial online] 2020 [cited 2020 Oct 21];3:16-22. Available from: https://www.ijcrsonweb.org/text.asp?2020/3/1/16/297102
| Introduction|| |
Colorectal surgery is an established super specialty in the west and other developed nations, however in India, though it is upcoming but is still considered a part of general surgery. Colon and rectal surgery is one of the oldest recognized specialties. Writings dating as early as 1250 B. C. dealt with anorectal diseases and indicate there were practitioners devoted to this specialty. The history of colorectal surgery is a fascinating journey of continual innovation that spans regions globally and emphasizes the significant advances made in the field. Various ointments, suppositories, and enemas were used by ancient Egyptians for the treatment of diseases of the colon. Greeks performed surgery in the form of cautery, sewing and binding. Later, Romans encouraged the use of surgery for treating perianal fistulas. Sushrut about 1000–2000 BC in his Sushrut Samhita described Incision and Drainage of Perianal Abscesses. He also described ligation of piles and devised instruments for anorectal surgery.
The beginning of modern colorectal surgery began in England in 1835, when Frederick Salmon decided to found his own institution named the “Infirmary for the Relief of the Poor afflicted with Fistula and other Diseases of the Rectum,” which was later on expanded as the St. Mark's Hospital, London on 25 April 1854. Salmon remained the only surgeon at the Hospital until his retirement in 1859, when he was succeeded by two surgeons carefully chosen to carry on his work. His most notable successors at St. Mark's were William and Herbert Allingham, both of whom helped create the specialty of proctology and continued the successful development of the hospital.
From the USA, Dr. Joseph Mc Mathews visited England in 1878 and studied under Allingham, the celebrated proctologist at St. Marks Hospital in London. After thorough training under this great master, Dr. Mathews returned to America and became the pioneer specialist in the USA for rectal diseases. He became the President of the American Medical Association in 1899 and during his tenure, he met 12 other colleagues who were also committed to the specialty and founded the American Proctologic Society on June 6, 1899, with Dr. Mathews serving as its first President. In 1934, the American Board of Proctology was established. It was the sixth specialty board to be organized and tenth board to be incorporated. After becoming a subsidiary of the American Board of Surgery from 1935 to 1949, there were continued efforts for independence. After continuing efforts to gain independent status, in February 1949, The American Board of Proctology was granted independent status. In 1961, the Advisory Board for Medical Specialties granted the American Board of Proctology to adopt the name The American Board of Colon and Rectal Surgery.
In India, the concept of Colorectal Surgery as a separate specialty was realized 50 years back by Dr. R. K. Menda. He emphasized that proper evolution of colorectal surgery cannot take place unless a separate section is created within the Association of Surgeons of India (ASI). By his efforts, the Association of Colon and Rectal Surgeons of India (ACRSI) was ultimately formed in 1977. Unfortunately, in spite of being so old, it has not been recognized as a super specialty as compared to other newly formed surgical specialties.
| Scope of Colorectal Surgery|| |
Incidence of colorectal cancer (CRC) in India has increased many folds in the past few decades and is expected to increase further in coming years due to increase in urbanization and rapid changes in lifestyle among the population. Another worrisome issue is the higher incidence of CRC among young patients. This group of patients present more challenge to a surgeon because of their aggressive disease and on top of that their expectations to preserve their sphincters and sexual function.
With more and more knowledge and dedicated experience about CRC, more sphincter saving options have been offered to patients such as intersphincteric resections, ultralow anterior resections, TaTME, TAMIS, TEMS depending on the stage of their presentation. However, all this can be done only once a surgeon has a dedicated high volume experience with such procedures.
Pelvic floor disorders
Constipation is usually underestimated by surgeons and most of the times by the patients themselves. The treatment of constipation satisfactorily is one of the most daunting tasks a surgeon can face. There are various types of constipation [Figure 1] which needs to be properly understood for the management of a particular patient.
|Figure 1: Types of constipation (STC: Slow transit constipation, NTC: normal transit constipation, IBS C: Constipation predominant irritable bowel syndrome, ODS: Obstructive defecation syndrome)|
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Besides the common sequel of constipation such as hemorrhoids, fissures, prolapse, it may also lead to psychiatric symptoms, heart attacks, strokes, and other serious health problems.
Constipation is very common in our country and is usually under reported. Lack of proper definition among general public makes the prevalence of reported constipation as perceived by patients to range between 11.6% and 53%.
With such a huge number of patients suffering from this apparently simple problem, which actually is very complex, needs specialist care from a trained colorectal surgeon. Specialized investigations are needed for proper evaluation of a patient suffering from constipation.
Rectal and pelvic organ prolapse is again one of the complex clinical problems a surgeon faces in his practice. Since there is no single operation which is the gold standard of management, patients are usually unsatisfied with the treatment. Since rectal prolapse is associated with prolapse of other pelvic organs usually, it is imperative for a surgeon to have an in depth knowledge of the etiopathogenesis of the disease and also possess good expertise in various surgical operations which may be suitable for a particular patient. A general surgeon in his or her routine practice may encounter very few such patients and most of the times do not have skills to offer various surgical options best suited for a particular patient. Many latest operations have been added to the armamentarium to deal with this problem such as laparoscopic ventral mesh rectopexy [Figure 2] and stapled transanal rectal resection which are showing good results in carefully selected patients. These procedures need special training and perfect surgical skills to produce good results. One needs to be updated with these latest developments and that will be possible only if there is a huge case load of such patients.
Fecal incontinence (FI) is one of the worst problems a person can suffer from. Besides being a complex clinical problem it has a lot of social stigma associated with it. In a country like ours, women especially are very reluctant to present with complaints of FI to their health-care providers. Obstetrical sphincter injuries continue to be the most common cause of FI in our country. We have seen in our dedicated colorectal practice over the years that ladies sometimes present to us after two to three decades after onset of their symptoms, just because of the taboo associated with this condition. However, over the recent years, more and more patients come to our clinic with this condition, due to better awareness among masses about obstetrical practices. In a huge country, it is not possible that all normal vaginal deliveries are attended by health-care workers and as such a large number of obstetrical sphincter injuries occur.
Other common causes of FI are old age. With the life expectancy increasing in our country, we will be facing with more such problems in coming years. In order to mitigate the sufferings of such patients we need dedicated colorectal surgeons who have a lot of experience in treating such conditions and produce satisfactory outcomes. This is a complex surgical condition which at times needs complex surgical options like the one shown in [Figure 3] and [Figure 4] (Graciloplasty). There are other procedures such as sacral nerve stimulation, besides others, which are used to treat these patients and surgeons with special training in colorectal surgery implant it. With increase in number of such patients, few centers in our country have started this procedure in their practice.
|Figure 3: Graciloplasty (Pedicled gracilis muscle being harvested) for the treatment of fecal incontinence|
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Rectovaginal fistula is again one more complex clinical condition which presents great challenges to the treating surgeon. Unless a surgeon does not have experience of dealing with a high number of cases, the outcomes are not going to be satisfactory. Again many specialist surgeons including our gynecologist colleagues are performing such surgeries but outcomes are not that satisfactory, not that they are not skillful, but the case volume is low. Hence, if we have dedicated colorectal surgeons who will focus on treating such patients, definitely volume will increase and ultimately better outcomes will be achieved.
Inflammatory bowel disease
Inflammatory bowel disease (IBD) was thought to be not very common in our country few decades back, but because of life style changes incidence of IBD is increasing every year. More often we see a lot of ulcerative colitis patients in our routine practice these days. These patients are usually managed by our medical colleagues, but are often referred to us for the management of complications, intractability, etc., In the west, there are colorectal surgeons who have dedicated their practice toward the management of IBD, suggesting how vast and complex the treatment of such patients is.
Fortunately, diverticular diseases are not that common in our country yet, though their incidence is also increasing in some parts of the country. This is again one more complex field in surgery which needs dedicated colorectal surgeons for providing best outcomes.
Proctology is considered to be bread and butter of majority of general surgeons. In our country, this is not only being practiced by qualified surgeons, but even by quacks. Undoubtedly, the management of simple hemorrhoids, fistulas and fissures can be well managed by any experienced surgeons with good outcomes. However, at times, complications associated with such simple procedures are so devastating and disabling that it makes patients life miserable. However, problem arises when the clinical situation is not that simple [Figure 5]. In such cases, it is the case volume and experience of the surgeon which is crucial for achieving best results.
There is enough scientific evidence to prove that patients suffering from colorectal diseases and managed by colorectal surgeons have better outcomes than those operated by general surgeons. The next section shows the current scientific evidence to prove these facts.
| Scientific Evidence in Support of Colorectal Surgery as a Separate Specialty|| |
Brown et al. published a retrospective study of patients who underwent emergency abdominal procedures on the gastrointestinal (GI) tract in England from 2001 to 2016. Patients were grouped as per operating surgeon's subspecialist interest (Upper GI surgeons [UGI], Colorectal Surgeons and General surgeons). Thirty days' postoperative mortality was the primary outcome of interest. A total of 24,291 emergency laparotomies were studied. Laparotomies undertaken by upper GI or colorectal surgeons had significantly lower mortality when compared with other sub specialties. There was higher utilization of laparoscopic surgery in both UGI and colorectal procedures, when the causative pathology was relevant to the surgeon's subspecialty.
A study from Sweden aimed at evaluating the importance of the formal competence of surgeons for survival and morbidity. Data were obtained from a cohort of patients operated for colon cancer between 2007 and 2010 and were followed for 5 years after surgery. Postoperative morbidity, mortality and long-term survival were compared with regard to formal competency of the most senior surgeon attending the procedure. A total of 13,365 patients were operated which included 10,434 elective procedures and 2931 emergency cases. Their results showed that overall 5-year survival was higher for those operated by subspecialist colorectal surgeons compared with general surgeons. Thirty days and 90-day postoperative mortality was less in patients in whom surgery was performed by colorectal surgeons as compared to those who had their surgeries performed by general surgeons. From their study, they concluded that subspecialization in colorectal surgery is associated with better outcome in patients of colon cancer, and every effort should be made to increase the availability of colorectal surgeons for both acute and elective colon cancer surgery.
There was a study published recently in Lancet where they highlighted that around 313 million surgical procedures are performed worldwide each year. More than 4.2 million people worldwide die within 30 days of surgery each year, and half of these deaths occur in low- and middle-income countries. Postoperative deaths are the third most common cause of worldwide mortality with ischemic heart disease and stroke at number one and two, respectively. These deaths are mostly preventable if proper operating facilities are available. Furthermore, important in reducing these numbers is the proper training of surgeons in a particular operation. Focused training in separate field of surgery rather than a generalist approach will help in mitigating this problem. Better mortality outcomes are achieved with subspecialty approach.
In a study from New York, data of 7798 rectal cancer resections from 2000 to 2011 were analyzed. They divided surgeons and hospitals into four groups with top most group including high volume surgeons (≥10 resections/year) and hospitals (≥25 resections/year) and compared it to three other groups. They found that high-volume surgeons at high-volume hospitals were associated independently with both less nonrestorative proctectomies and mortality rates. This study suggests that the current trend toward regionalization of rectal cancer care to high-volume surgeons and high-volume centers has led to improved outcomes.
A study from Germany compared outcomes following surgery for colon and rectal cancer by general surgeons and colorectal surgeons [Table 1].
|Table 1: Difference in outcomes between patients of colon and rectal cancer operated by General Surgeons (clinical cancer registry) and Colorectal Surgeons (Colorectal cancer centre)|
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The data clearly indicate that all the four parameters studied show better outcomes in the hands of colorectal surgeon as compared to general surgeons.
Huo et al. from Australia published a large systematic review and meta-analysis involving 11,22,303 patients, 9877 hospitals and 9649 surgeons for the assessment of association between hospital or surgeon volume with outcomes for the surgical treatment of colon and/or rectal cancer. They demonstrated that there is a volume-outcome relationship that favors high volume facilities and high volume surgeons. Higher hospital and surgeon volume resulted in reduced 30-day mortality and intra-operative mortality. High volume surgeons are associated with greater 5-year survival and greater lymph node retrieval, while reducing recurrence rates, operative time, anastomotic leak, and length of stay and cost. They concluded that high volume surgeons and hospitals are associated with better outcomes for CRC surgery.
Apart from malignancies, outcomes for benign colorectal diseases are better in the hands of a dedicated colorectal surgeon as compared to general surgeon. A study from Arizona, USA included patients undergoing procedures for benign diseases including abscess drainage, hemorrhoidectomy, fistulectomy, and bowel resections. The population was divided into two groups based on the location of treatment into urban and rural. Various outcome measures that were studied included short-term complications, mortality, and hospital treatment costs. Urban centers (UC) were further divided into centers with colorectal surgeons and centers without colorectal surgeons. A total of 20,617 patients who underwent different surgical procedures for benign colorectal diseases across 496 (urban: 342, rural: 154) centers, were included. More than one-third of centers among 342 UCs had colorectal surgeons. After analyzing the results, they found that complication rate was low in patients managed at UC, hospital length of stay was shorter and hospital treatment costs were higher as compared to rural centers. On subanalysis, patients managed in UC with colorectal surgeons had lower incidence of short-term complications and a shorter hospital stay when compared with patients managed in UC without colorectal specialization. They concluded that there are disparities in outcomes of patients with benign colorectal diseases managed surgically in urban versus rural centers. Further, specialized care with colorectal surgeons at UC helps in reducing adverse patient outcomes.
Hence, it is clear from various authentic studies that outcome of both benign and malignant colorectal diseases is better in the hands of well-trained colorectal surgeons working in high volume centers dedicated to the field of this specialty.
| Marching to Start Super Specialty Course in Colorectal Surgery in India|| |
ACRSI is one of the largest and most vibrant sections of ASI with around 2000 members and about 300 fellows. The Indian Journal of Coloproctology is the official journal of ACRSI. The fellowship examinations and instructional courses are conducted every year by the Board of Examination to train our surgeons in this field. The association is also sponsoring outstanding surgeons for national and international fellowship programs to update their knowledge and expertise in the field. National level conferences and CMEs are organized regularly to share and update knowledge and skills with tremendous response both from different parts of the country and abroad.
Having such a large and experienced surgical body, dedicated to colorectal work with renowned stalwarts in the field in our country, it is surprising that our surgeons interested in this subspecialty go to foreign countries to get formally trained. To overcome this problem it is important to recognize this specialty as a separate subspecialty in our country and relevant training courses are started like other branches which are having lesser patient volume than colorectal surgery.
Since last more than 5 years, there have been efforts by various renowned colorectal surgeons of the country to highlight the importance of colorectal surgery as a separate super specialty. Many representations from individual high volume colorectal surgery centers in country were made to the then Medical council of India (MCI) for starting of MCh course in the subject. The Secretary of the ACRSI also wrote to the apex body with strong recommendation to establish colorectal surgery as a separate super specialty in the country. MCI took an initiative in 2014 and constituted a high level committee, comprising of academicians of great repute from all over country including Prof Sivalingam from Madurai, Prof Sanjay Gupta from Delhi, Prof. Nisar A Chowdri from Srinagar and Prof Shiv Kumar Utture from Mumbai. They framed teacher's eligibility criteria, syllabus and minimum standard requirements relevant to starting MCh program in colorectal surgery in the country, which was approved by the Academic committee of MCI. However, few members of postgraduate committee of MCI raised some objections and recommended it to be considered for postdoctoral certificate course (PDCC). This was however not accepted by the colorectal surgeons of the country. In response to such communication from MCI, in a representation it was made clear that no doubt colorectal disorders are managed by general surgeons, surgical gastroenterologists, and surgical oncologists and even though training of these surgeons may be adequate, it is impossible for such surgeons to maintain an adequate case volume to reach the level of excellence required to achieve good treatment outcomes. Moreover, the management of colorectal disorders has changed significantly in the past two decades and various advances have been made in the field only with the help of dedicated colorectal surgeons working in high volume specialized centers in various parts of the world.
Keeping in view the above facts it is mandatory for us in India to recognize colorectal surgery as a super specialty and structure formal training program which is complete and adequate (MCh/DNB) rather than short training fellowships and certificate courses like PDCC.
Although the volume of colorectal diseases is high in our country; to start with we can identify centers that have high patient volume for starting this program, subject to fulfillment of other requirements as laid down by the National medical commission (NMC)/National board for such courses. The work in this direction was already initiated but due to reframing of the MCI, it did not progress significantly. However, now with a restructured NMC things are expected to move more swiftly and the day is not very far when colorectal surgery will be officially recognized as a separate super specialty and appropriate training courses approved.
| Conclusion|| |
The concept of super specialization is gaining importance and is growing in every medical field throughout the world. Specialization in various fields of surgery has evolved to provide better care to patients. Specialization provides state-of-art knowledge and care of complex areas, high volumes of routine procedures besides imparting better training and education to postgraduates. The controversy over specialization in surgery has existed since decades, but still newer subspecialties have emerged. Colorectal surgery needs to be recognized as a separate super specialty in our country in order to achieve better outcomes for both benign and malignant colorectal diseases. There are multiple issues that need to be addressed before establishing colorectal surgery as a separate super specialty in our country like:
- It must be accepted by our peer surgeons
- High volume colorectal surgery centers must work together to highlight the importance of separate super specialty of colorectal surgery
- ACRSI should lead by front and pursue with NMC and national board for allowing higher study courses (MCh/DNB/FNB) in colorectal surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 4], [Figure 3], [Figure 5]