New GuiCom Members

Michel: Where do you work and what is your main professional activity?

Javier: I am a gastroenterologist at La Princesa University Hospital in Madrid, Spain. In my clinical role, I am Head of the Inflammatory Bowel Disease Unit, a national and international reference centre, one of the largest in Spain, which was the first IBD Unit to receive quality certification from the Spanish Working Group of Crohn’s Disease and Ulcerative Colitis (GETECCU). And as regards teaching, I am a tenured professor at the Universidad Autónoma de Madrid.

Javier: You are a surgeon. Tell me more about your background, current activity and relation to IBD care

Michel: I graduated in general surgery at the University of Basel in Switzerland while on a surgeon-scientist track. My initial research focus was cancer immunotherapy and we developed gene therapy vectors and ran two clinical trials using recombinant vaccinia virus harbouring multiple cancer epitopes and costimulatory molecules. Later, I spent 3 years in clinical fellowships in colorectal surgery, first at the University of Toronto in Canada and then in Cleveland, Ohio. I was privileged to work with some of the brightest leaders in cancer and IBD care in units which drew very large numbers of patients and dealt with highly complex situations. My scientific focus turned to clinical research and I graduated in clinical epidemiology in Toronto with a thesis on decision analysis modelling the choice of a stoma from the patient’s perspective, using nationwide data and complex Bayesian models. I returned to Switzerland and was appointed first in St. Gallen, then in Winterthur, where I currently lead the third largest colorectal unit in Switzerland. My inaugural lecture as a professor of surgery at the University of Basel dealt with interdisciplinary and interprofessional models of care, key aspects of sound IBD care which I am proud to have in my institution. I am also running the European Colorectal Congress of St. Gallen, one of the largest congresses in colorectal surgery worldwide with a dedicated ECCO Session, and I have an interest in educational and leadership topics in health care. I am a member of the Education and Training Committee of the European Association of Endoscopic Surgery (EAES) and the Programme Committee of the European Society of Coloproctology. Lastly, I learned the nuts and bolts of economics with an executive MBA from the University of St. Gallen and was a founding member of the Swiss Biodesign programme at the Zürich University of Applied Sciences. I believe that a good IBD surgeon needs a creative mind, empathy and leadership skills on top of technical expertise in order to optimise outcomes and provide the best possible care in the individual context of patients who suffer from chronic diseases.

Michel: Before joining GuiCom, did you have previous experience on other ECCO Committees?

Javier: Yes, I was lucky enough to previously form part of the ECCO ClinCom, and I am at present a member of the ECCO UR-CARE steering committee. My previous experience on these committees has been very positive indeed, and I hope that it will help me to be as efficient and productive as possible in my new role at GuiCom.

Javier: What about your own experience with ECCO?

Michel: I got to know ECCO as I transitioned from a fellowship to clinical practice and attended the first S-ECCO IBD Masterclass. I was thankful to participate in the development of several ECCO Guidelines and honoured to join the Surgeons of ECCO, and ultimately to chair S-ECCO until my election to GuiCom. I am indebted to ECCO for the opportunity to contribute in raising the standard of care in IBD in an interdisciplinary context and to gain and share knowledge and friendship. The unique spirit and contribution of ECCO are remarkable and it is a true privilege to be part of the ECCO Family.

Michel: What is your previous experience regarding ECCO Guidelines/Consensus?

Javier: I have had the great fortune of being able to participate in many ECCO Guidelines, dealing with anaemia, extra-intestinal manifestations, malignancy, diagnostic techniques and monitoring, standards of care and treatment withdrawal, among others. In the first guidelines, my role was fundamentally as a reviewer, but progressively I have been taking on greater responsibility in the organisation of some more recent guidelines, as in the case of the ECCO Crohn’s Disease and Ulcerative Colitis treatment Consensus Guidelines.

Javier: You alluded to your own participation in the development of ECCO Guidelines

Michel: Yes, indeed. I first contributed as a working group member to the Crohn’s Disease and Ulcerative Colitis treatment guidelines, as you did. I then led topical reviews with D-ECCO on Perioperative Dietary Therapy in IBD and with H-ECCO, EduCom and GuiCom on Optimising Reporting in Surgery, Endoscopy, and Histopathology. Also, I was part of the ECCO COVID Taskforce providing recommendations during the COVID pandemic. I am currently involved as one of the coordinators for the upcoming Crohn’s Disease guidelines and I am participating in the Topical Reviews on Perioperative Care and Core Outcomes for Real-Word Data in IBD.

Michel: Apart from ECCO, have you had previous experience in the field of clinical guidelines and/or consensus?

Javier: Yes, I have had the opportunity to be coordinator of more than ten Consensus Conferences and Clinical Practice Guidelines, including the Ist Spanish Clinical Practice Guidelines in IBD, the Ist Spanish Microscopic Colitis Consensus Conference and the Ist to Vth Spanish Consensus on the management of Helicobacter pylori infection. I have also participated in several international consensus meetings, coordinating various working groups. I hope that this previous experience will be useful to me and make it easier to get the most out of my participation in GuiCom.

Javier: What about surgical guidelines and consensus conferences?

Michel: Besides IBD, I led a consensus conference on transanal total mesorectal excision for rectal cancer endorsed by the EAES and co-authored multi-society dynamic guidance on the same topic. Another contribution was an international consensus on standardisation of complete mesocolic excision for colon cancer, and we have just submitted the Swiss interdisciplinary treatment algorithms for the treatment of peritoneal cancer of gastrointestinal origin. Further consensus conferences were related to the interdisciplinary management of constipation and to the surgical management of obstructed defaecation. I am presently part of two ongoing consensus conferences on appendicitis and on parastomal hernia under the patronage of EAES. Lastly, I was part of national and European advisory boards for the provision of surgical services amid the pandemic and coordinated nationally the participation of Swiss institutions in the international CovidSurg Collaborative.

Michel: And what about systematic reviews and meta-analyses? Were you previously familiar with this type of scientific evidence review?

Javier: I have been interested in the subject of critical review of the literature and the synthesis of scientific evidence for many years, and I have had the opportunity to work on numerous systematic reviews and meta-analyses. In particular, I am currently proud to be one of the International Editors of the “Gut Group” of the Cochrane Collaboration, and I have also had the privilege of conducting several systematic reviews and meta-analyses for this institution.

Javier: I am sure you are also well acquainted with the systematic appraisal of evidence?

Michel: Indeed, I performed several systematic reviews starting with cancer immunotherapy as my first major scientific focus, then learned and published about more sophisticated methodologies like propensity score, Bayesian analysis and non-inferiority trials. A further research focus was enhanced recovery pathways and management of complications in surgery – I performed meta-analyses and cost-effectiveness analyses, including models to allow for safe and early discharge of patients who have undergone colorectal surgery. I am now investigating whether machine learning models may outperform classical risk scores and better inform decision-making than currently available instruments.

Michel: As you well know, ECCO has been using the GRADE system in recent years to grade the quality of the evidence and the degree of recommendation in its guidelines. What do you think of this system?

Javier: Well, I am glad you have asked me this question, because I feel great pride remembering that I participated as a member of the ECCO GuiCom GRADE Taskforce to evaluate the appropriateness of the use of this system in 2017; so, I humbly think that I was one of the initial supporters of use of the GRADE system within ECCO. Obviously, the GRADE system has limitations, but I think it is the least imperfect system currently available.

Javier: You were one of the surgical coordinators of the first ECCO Guidelines taking advantage of the GRADE framework. What was your own experience with GRADE?

Michel: This was a great opportunity to learn the strengths and limitations of the GRADE methodology. GRADE allows for a very stringent appraisal of the evidence at hand and it provides a conceptually sound framework to the provision of care recommendations. However, GRADE may not allow actionable recommendations whenever the available evidence is not of superior quality. This is an important limitation in clinical practice, as many daily situations are not addressed in high-quality randomised controlled trials (RCTs) or cannot be reliably inferred from network meta-analysis. Compared to large industry-funded RCTs executed in the context of high regulatory demands, surgery suffers from a relative paucity of RCTs and this tends to prevent the provision of useful practice recommendations. A very important task of expert societies is to provide actionable guidance to clinicians and patients. Hence, in the context of the most recent ECCO Guidelines on therapeutics for both Crohn’s Disease and Ulcerative Colitis, we decided to assess surgical topics, taking advantage of the Oxford framework, as in previous ECCO Guidelines. The decision to keep Oxford instead of using GRADE was not taken lightly, and we discussed this point extensively with the clinical and methodology leads of both guidelines. Ultimately, I believe that the right decision was taken, and I hope that the most recent ECCO Guidelines are proving useful and informative.

Michel: What moved you to present yourself as a candidate for GuiCom?

Javier: I have always been attracted by the great relevance of the work carried out by GuiCom, since the clinical guidelines are tremendously useful for all the doctors who work in IBD. In fact, the ECCO Guidelines have become standard references for IBD management in Europe and around the world. I believe that being part of GuiCom is one of the best ways to contribute in improving the clinical practice of IBD clinicians and, of course, myself. From a "selfish" perspective, I think being part of GuiCom is a great way to stay up to date on IBD. In this respect, I am convinced that this will allow me to learn a lot from my fellow committee members, Hannah Gordon, Tim Raine, Torsten Kucharzik and, of course, yourself.

Michel: Thank you Javier! I share your views. Being part of GuiCom is a unique opportunity to contribute to our IBD Community at large and to learn from each other. I worked in many different settings over the years and I realise how important the provision of evidence-based recommendations and sound guidance is to the improvement of clinical care. Today, the majority of IBD patients are taken care of outside of expert centres, whereas the sheer quantity of IBD knowledge published every month can barely be handled. Keeping abreast and making sense of clinical knowledge, and sharing that knowledge, is therefore of the utmost importance to promote state-of-the-art interdisciplinary care for every single IBD patient. The opportunity to contribute to this vision motivated my decision to apply for GuiCom.

Michel: What priority objectives have you set for yourself during your stay at GuiCom?

Javier: I am committed to contributing to the development, implementation and evaluation of evidence-based guidelines on IBD in order to improve the management of IBD in all ECCO Member Countries and to foster interaction with other specialist organisations with a view to joining forces in the creation and implementation of relevant guidelines. Nevertheless, my first task is to learn as much and as quickly as possible from my colleagues at GuiCom, so that I can fulfil the objectives of this committee as effectively as possible.

Michel: We are again on the same wavelength Javier! For myself, I would add to our common perspective that I intend to highlight surgical aspects in the multidisciplinary care of IBD patients. Also, in line with my participation in the E-Quality ECCO project, I want to contribute to a better understanding of the gaps and barriers between ECCO Recommendations and real-life practice, taking advantage of the UR-CARE database to which you are yourself contributing greatly and hence fostering implementation of best practice interdisciplinary care for IBD patients.