Pär Myrelid, S-ECCO Member
Many technical innovations are facilitating the education process involved in training a skilled surgeon today. At the same time, this process is in many ways still a joint collaboration between a master and his/her apprentice, and will continue to be so. Fruitful training in any practical setting is based on trust, from both parties, in combination with application of the experience of the master in order to sort out any perioperative complications. Beyond acquisition of the necessary technical skill, becoming a surgeon requires the development of a sound understanding of when to operate and when not to, as well as the ability to choose the right surgical option. This is, of course, important in all surgical fields but it is perhaps especially true within the field of Inflammatory Bowel Disease (IBD).
Ulcerative Colitis (UC) and Crohn’s Disease (CD) are not only lifelong disorders but also often a set of very complex diseases in need of advanced medical and surgical therapies. Surgery in IBD can sometimes be life-saving, but most often it is aimed at improving nutrition, bowel symptom control and improvement of quality of life. This in contrast to cancer surgery, where both patients and surgeons may sometimes accept poor function and debilitating surgery as the alternative is death from malignancy. Cancer surgery is thus more ‘black and white’, with sharp contrasts, whilst IBD surgery is a grey scale when it comes to both indications and choice of procedures. As the indications for surgery are often less absolute, the room for a poor functional outcome is restricted, as it should be.
The sometimes relative indications for surgery, in combination with a rapidly increasing number of advanced medical therapies, necessitate the use of multidisciplinary teams (MDT). In order to understand the possibilities, as well as the risks and limitations, of new drugs, an IBD surgeon in training must participate actively in the MDT and work in close collaboration with colleagues at the gastroenterology department, preferably in joint outpatient clinics. This is, of course, equally true for trainees within the field of gastroenterology, who need to be fully aware of what surgery can offer and what it means for the patient. It is with great joy that I have seen all recent gastroenterology trainees at our hospital rotating through the colorectal unit and being involved in theatre and on the surgical ward. This has also opened up great discussions amongst us surgeons and improved our understanding of modern IBD therapy. Our common goal as gastroenterologists and colorectal surgeons is to give our patients the best and safest treatment. In doing this we have to work together and to understand each other. My strong opinion is that the best way to reach this goal is to create a common IBD language for the future IBD-ologists, regardless of whether a pill or a knife is used as the tool.
When it comes to surgical techniques, we have some demanding challenges for the future. In patients with CD, ileocaecal resection is still the most common procedure but an IBD surgeon must also be able to treat colonic and perianal disease. A laparoscopic ileocaecal resection in an uncomplicated CD patient may possibly remain in the hands of the more general colorectal surgeon for a long time ahead as it in many ways resembles a right hemicolectomy for cancer. However, there are new surgical treatment modalities that may affect the long-term outcome in a positive way while at the same time complicating the life of the surgeon, e.g. when should a resection be done and when is a strictureplasty preferable? And even more difficult may be the choice between a primary and a delayed anastomosis (with a temporary stoma), where ongoing medications and patient status must be taken into account. The use of a standard algorithm in abdominal CD surgery is history and has been replaced by a palette of surgical methods often combined with medical therapies.
Perianal CD is also a very challenging area, where close interaction is needed between patient, gastroenterologist and colorectal surgeon. In every single case the possible gain in terms of surgical repair must be weighed against the risk of injuring the sphincter, sometimes in a patient who already has borderline incontinence due to loose stools. The knowledge required to make appropriate decisions is not easily acquired and a lot of experience is needed from both medical professions. The only way to obtain such knowledge and experience is to see many patients and follow them up over a long period. We are also being provided with more and more data on the value of combining drugs and surgery to achieve the best outcome.
Surgery for UC also needs a well-trained team. In the emergency setting the team consists of the gastroenterologist and the surgeon, who together make sure that the patient has a timely colectomy, minimising the risk of morbidity and mortality. Modern reports of a 30-day mortality sometimes exceeding 10% after a colectomy due to acute severe UC probably indicate a deficiency in this area. When it comes to restorative procedures, we know from Sweden and England that fewer than half of UC patients undergo a restorative procedure within two years of their colectomy. We also know from many European countries that many hospitals and surgeons sometimes perform as few as one pelvic pouch a year. Many of these surgeons have previously been well trained at high-volume units and may in many cases perform a perfect pouch. The problem in this area is manifest when it comes to training, both of new surgeons and of the surgical team. It is not possible to train a new IBD surgeon at a unit doing only a single or a handful of pouches a year. It is even less possible to train a new IBD surgeon, and the surgical team, to deal with peri- or postoperative complications in a timely manner as these (hopefully) will be even more rare. Continuing to perform only a few pouches a year at a unit also diminishes the chance of training new IBD surgeons at high-volume units, as referral of all patients from low-volume units to high-volume units would enhance the training volume and velocity. Denmark is showing the rest of Europe the way in limiting restorative surgery in UC to only three units. In so doing, they have been able to show improvement in outcomes, and further long-term improvements may be anticipated as training will improve. Sweden is currently holding a governmental investigation into following Denmark’s model and has surgical training in mind. My wish is that more countries will follow suit.
Many surgeons are strictly focussed on surgical technique and the technical craft, but there is so much more to surgical skill. My mentor, Rune Sjödahl, once said that he would rather be operated on by a decent surgeon with good judgement than by a divinely gifted surgeon with poor judgement. IBD surgery is very much judgement, and in order to achieve good judgement we need to optimise the surgical training, both technically and by imparting the ability to select the right procedure at the right time for the right patient.