The making of an IBD surgeon
Alaa El-Hussuna, S-ECCO Member
How do you make a surgeon? Not by the preliminaries, the 6-7 years of medical college and the years that follow in residency training, but by the six or seven years subsequently spent after medical school learning the surgical trade. Exactly what happens in this apprenticeship that transforms him\her from a helpless, frightened medical school graduate into a (hopefully) capable and confident surgeon?
This is not an easy question to answer. The transformation is a slow process marked by the acquisition of more dexterity, improvements in judgement and a gradual growth in confidence. Not big jumps, just small steps forward . The same pathway applies to the making of an IBD surgeon. But do we really need surgeons dedicated to IBD surgery?
While in many industrial countries, structural pathways have been established for the management of cancer, this is not true for IBD , and although a multidisciplinary approach is obligatory in cancer patients, it is not in those with IBD. Furthermore, subspecialisation and training to master cancer surgery is mandatory in many countries but this is not the case for IBD.
Yet this is counter-intuitive given that IBD is a complex disease entity. The causes, diagnosis and treatment are all complex. The disease may involve not only the gastrointestinal tract but also other organs. It may be associated with other autoimmune diseases such as psoriasis and rheumatoid arthritis. To add further to the complexity, no treatment will cure the disease. The disease goes through many remissions and relapses during the patient’s life time. Despite all this complexity, we do not have IBD-dedicated surgeons.
How should IBD surgeons be chosen and trained?
IBD surgeons should be chosen from a pool of dedicated surgeons who are not only interested in surgical handwork but also cherish the multidisciplinary team approach and the implementation of evidence-based medicine. IBD surgeons must be trained to understand IBD patients’ mind set. IBD patients suffer from chronic disease which may threaten to destroy their jobs or family lives (if it has not already done so). Some are burdened with depression and most have an anxiety disorder of one kind or another. Moreover, surgery is not a cure for the disease as it may be when performing a cancer resection. The IBD surgeon must master and develop techniques to minimise bowel loss while giving the patient the longest possible time in remission. Optimisation of IBD surgery requires research and collaboration and is a life-long process, another reason why we need dedicated IBD surgeons.
IBD surgery is different from cancer surgery
In IBD surgery, the inflammatory process, the pre-operative optimisation and the postoperative care are much more complex. IBD patients may need longer postoperative stays in hospital compared to those undergoing colorectal cancer resections even though patients with cancer are older, have more comorbidities and undergo more extensive surgery . If we agree on the concept of IBD surgeons, the next most challenging task will be the establishment of proper training centres. Few centres in the well-developed countries have dedicated IBD facilities, hold regular MDT meetings and offer proper pre-operative optimisation of IBD patients.
We must promptly go into action and start the long process involved in “the making of IBD surgeons” by increasing the number of IBD-dedicated centres globally.
A training scholarship from ECCO might be a good start.
- Nolen WA. The making of a surgeon. Mid-List Press Minneapolis, USA, 1990.
- Myrelid P. National IBD Pathways. ECCO News 18, Issue 2, 2023. https://www.ecco-ibd.eu/publications/ecco-news/item/2023-2-national-ibd-pathways.html
- 2015 European Society of Coloproctology (ESCP) collaborating group. Patients with Crohn's disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications' rate. World J Gastrointest Surg 2019;11:261-270. doi: 10.4240/wjgs.v11.i5.261.