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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 23-25

Should colorectal surgery be a separate superspecialty in India?


Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India

Date of Submission08-Sep-2020
Date of Decision08-Sep-2020
Date of Acceptance09-Sep-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Dr. Subhashish Das
Room No 29/13, Upper Ground Floor, East Patel Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcs.ijcs_29_20

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  Abstract 

Colorectal surgery is demanding and requires a certain degree of operative skill. The literature also suggests that the outcome of patients after colorectal surgery depends on the surgical expertise as well as the volume of colorectal cases in a hospital. Most parts of the world have already designated colorectal surgery to be a separate superspecialty, but in India, there is still little enthusiasm for this idea. However, considering the increasing incidence of colorectal cancer in India, especially in our younger population, we should consider whether it has become necessary to train doctors in such complex procedures from the beginning of their careers. However, whether colorectal surgery should be designated to be a separate superspecialty in this country is still debatable, but the initiative taken by the Association of Colon and Rectal Surgeons of India with their fellowship and instructional courses should be examined carefully.

Keywords: Colorectal surgery, India, superspecialty


How to cite this article:
Das S, Nundy S. Should colorectal surgery be a separate superspecialty in India?. Indian J Colo-Rectal Surg 2020;3:23-5

How to cite this URL:
Das S, Nundy S. Should colorectal surgery be a separate superspecialty in India?. Indian J Colo-Rectal Surg [serial online] 2020 [cited 2020 Dec 3];3:23-5. Available from: https://www.ijcrsonweb.org/text.asp?2020/3/1/23/297103


  The Arguments in Favor of Specialization in Colorectal Surgery? Top


The proponents for separate departments advance the views that colorectal surgery needs a background knowledge of many different disciplines.[1] The anatomy of the colon and rectum is complex, their physiology is poorly understood by many outside the specialty, a knowledge of pharmacology is important with reference to the intricate anal sphincter mechanisms, and the pathology is varied. An understanding of genetics in relation to the hereditary colorectal cancer syndromes is becoming more and more important. Many surgeons outside the specialty are unaware of the importance of a knowledge of the mechanisms of genetic transmission to prevent, make an early diagnosis, and provide appropriate treatment and counseling to the patients and their families who have hereditary cancer. After understanding the role of all these factors, specialists in colorectal surgery will be able to apply their state-of-the-art knowledge in the care of complex problems, attract a higher number of patients, perform more procedures, and provide educational benefits to students and young surgeons in training.

Clinically, the conditions the colorectal surgeon will meet will be varied and challenging. He or she will have to manage young adults who need to undergo major intestinal resection for inflammatory bowel disease, older patients with fecal incontinence, a large number of individuals who have severe constipation that hampers their daily lifestyle, those who fear having a permanent stoma after cancer surgery as well as the myriads who have anal disease in the form of piles, fistulae, or itching. These seemingly simple conditions, if mismanaged, can prove costly to patients, and if incorrectly handled, the results may range from mild local discomfort to major fecal incontinence. Therefore, to learn the correct management, young surgeons should be trained in specialized centers.

Colorectal surgeons will also need to become familiar with the newer modalities of investigation and treatment and appraise their cost-effectiveness. Magnetic resonance imaging of the pelvis is now considered to be the gold standard investigation for local staging of rectal cancer as well as other benign diseases of the rectum and anal canal.[2],[3],[4] Similarly, a major breakthrough was achieved when the end-to-end anastomotic® stapler was introduced in the year 1979 by the United States Surgical Corporation®. However, in India, staplers which were introduced in the year 1981 and have only gradually gained popularity, but because of their cost and the fact that most colorectal anastomoses can be handsewn by skilled colorectal surgeons, their use is not more widespread.

In India, the number of patients with colorectal cancer is said to be increasing, with rectal cancer being more common than colon cancer, especially among young males.[5] This rise cannot be explained either by heredity or a major change from our traditional diets, which has not occurred. Thus, it has become necessary not only to develop colorectal cancer departments which offer multidisciplinary management but also to initiate research into the possible causes for this phenomenon. However, for a start, it has become necessary to generate data from the Indian population with particular reference to their family history and lifestyle. This is not yet available because of various reasons, namely that the incidence of colorectal cancer in India is low in comparison to the West,[5] there are very few teams performing dedicated colorectal surgery, and accurate and comprehensive patient records are nearly nonexistent. Establishing a separate specialty perhaps even a separate hospital like the St. Mark's Hospital in London, England, which deals exclusively with these patients and has made major contributions to their management, is now becoming important for India where the patient population, environment, and social milieu are so different.

Evidence suggests that colorectal surgery specialists have better outcomes after managing their patients. Huo et al.[6] conducted a systematic review and meta-analysis with an aim to examine the association between hospital and surgeon volumes on the outcomes of patients after colorectal surgery. Their study of 47 articles included 1,122,303 patients, 9877 hospitals, and 9649 surgeons. They found that there was a volume–outcome relationship that favored high-volume facilities and high-volume surgeons. Higher hospital and surgeon volumes resulted in reduced 30-day and intraoperative mortality rates. High-volume surgeons were also associated with longer 5-year survival rates and greater lymph node retrieval numbers, a reduction in recurrence rates, operative times, length of stay, and cost.

A similar study was conducted in India by Shetty et al.[7] on 401 consecutive patients undergoing resection for colorectal cancer by senior surgeons compared the morbidity and mortality with global standards. They reported an overall complication rate of 12.2% and mortality of 1.2%, which was at par with the global figures and suggested that specialized units be developed in high-volume centers to train future specialist colorectal surgeons. This would ensure improved quality assurance and delivery of health care even to peripheral, low-volume centers.


  The Arguments Against Having Separate Departments of Colorectal Surgery? Top


The Secretary of the Association of Colon and Rectal Surgeons of India has written to the Medical Council of India (MCI), recommending that colorectal surgery be established as a separate superspecialty in this country. The MCI in 2014 constituted a high-level committee, which framed the teacher's eligibility criteria, syllabus, and minimum standard requirements relevant to starting a MCh program in colorectal surgery, which was approved by its academic committee. However, this course has not yet been started, and there is now only a postdoctoral certificate course.

To a certain extent, we agree with the MCI that it may not be wise to designate colorectal surgery to be a separate specialty just yet. Surgical colonic diseases such as cancer, ulcerative colitis, and diverticulitis are not as common in this country as they are in the West. For instance, the age-standardized incidence rate per 100,000 of CRC worldwide is 19.7,[8] with some countries like the USA having 35.3 per 100 000 in males and 25.7 in females, whereas in India, the corresponding figures are 4.2 in males and 3.2 in females.[9] Moreover, most hospitals have to deal with a variety of patients locally because sending them to major specialized hospitals will involve expense and long waiting periods. The differences in outcome in patients managed by specialists and nonspecialists, though statistically significant, may not be very different if one considers absolute numbers. However, perhaps, setting up a few departments initially in some major centers may be a way forward to see whether they are viable and whether their management of patients is better than nonspecialized general units.


  Conclusion Top


Thus, although the arguments put forward for having separate colorectal disease departments are strong, they are more relevant to Western countries than to ours. However, this proposal needs to be reconsidered after more data are formally acquired from many centers in this country regarding the demand for specialized departments in terms of patient volumes, a variety of cases, and outcomes. Alas, these data are generally lacking.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Longo WE. The specialty of colon and rectal surgery: Its impact on patient care and role in academic medicine. Yale J Biol Med 2003;76:63-77.  Back to cited text no. 1
    
2.
Patel UB, Taylor F, Blomqvist L, George C, Evans H, Tekkis P, et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol 2011;29:3753-60.  Back to cited text no. 2
    
3.
Taylor FG, Swift RI, Blomqvist L, Brown G. A systematic approach to the interpretation of preoperative staging MRI for rectal cancer. AJR Am J Roentgenol 2008;191:1827-35.  Back to cited text no. 3
    
4.
Glynne-Jones R, Wyrwicz L, Tiret E, Brown G, Rödel C, Cervantes A, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017;28:iv22-40.  Back to cited text no. 4
    
5.
Mohandas KM, Desai DC. Epidemiology of digestive tract cancers in India. V. Large and small bowel. Indian J Gastroenterol 1999;18:118-21.  Back to cited text no. 5
    
6.
Huo YR, Phan K, Morris DL, Liauw W. Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery. J Gastrointest Oncol 2017;8:534-46.  Back to cited text no. 6
    
7.
Shetty GS, Bodhankar YD, Ingle S, Thakkar RG, Goel M, Shukla PJ, et al. Complications as indicators of quality assurance after 401 consecutive colorectal cancer resections: The importance of surgeon volume in developing colorectal cancer units in India. World J Surg Oncol 2012;10:15.  Back to cited text no. 7
    
8.
Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Pineros M, et a l. Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer; 2018. Available from: http://gco.iarc.fr/today/data/factsheets/cancers/10_8_9-Colorectum-fact-sheet.pdf,18. [Last accessed on 2020 Nov 02].  Back to cited text no. 8
    
9.
Patil PS, Saklani A, Gambhire P, Mehta S, Engineer R, De'Souza A, et al. Colorectal cancer in India: An audit from a tertiary center in a low prevalence area. Indian J Surg Oncol 2017;8:484-90.  Back to cited text no. 9
    




 

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