Outgoing ASCRS President Dr. Steven D. Wexner’s Presidential Address featured a virtuoso review of the medical history of treatment of anal fistulas and other colon and rectal diseases, beginning when “Hippocrates described the use of setons two and half millennia ago.”
Dr. Wexner’s main topic was the “global collaboration that enhances the mission of this Society and, ultimately, the care of our patients,” and the address included a paean to the Society’s important work and achievements and its value to surgery and practice.
A photo he took from a lithograph in a museum in Nanjing University Hospital, Nanjing, China, shows that the Ding family, now in their 10th generation as practicing colorectal surgeons in that hospital, struggled with the complexity of anal fistulas back to the Ming dynasty (1368-1644). In Europe in 1349, John of Arderne noted “that to fix a fistula, just as we heard from our seven past presidents [in an Annual Meeting program on “worst cases”], required a lot of expertise. Fortunately, some of that expertise was possessed across the channel by Charles Francois Felix, who performed a four-stage fisulotomy successfully, we’re told, on Louis XIV (1638-1715). Although we have no MRI documentation of healing, we know that Charles Francois Felix kept his head, so clearly he must have been successful,” he surmised.
“Fistulas are such a vexing problem that in 1835 Frederick Salmon opened the world’s first hospital for the treatment of fistulas, St. Mark’s Hospital on City Road in London, the hospital that Joseph Mathews [the Society’s founder and first president] visited, which gave him the idea to form the ASCRS,” Dr. Wexner continued.
The ultimate improvement in patient care, according to Dr. Wexner, might be the avoidance of a stoma, a high risk for patients with rectal cancer, mucosal ulcerative colitis, or fecal incontinence. He then reviewed treatment advances for each of these groups of patients. “Turning first to rectal cancer, Ernest Miles at the Gordon Hospital described the now eponymously named operation, also called the abdominoperineal resection, and noted that it was probably the best way to treat rectal cancer.” The next treatment innovation was the circular stapler, then double stapling, which led to facilitated total mesorectal excision (TME).
TME, Dr. Wexner told his Annual Meeting audience, “was part of an overall picture that evolved at the same time because also in 1983 Professor John Nicholls at the St. Mark’s Hospital started to challenge the 5-centimeter rule and suggested that it was a rule meant to be broken.” He continued along this line, making the point that important advances in treatment owe much to global collaboration.
In Sweden, Lars Pahlman noted improvements in outcome by adding neoadjuvant therapy. A Dutch TME trial later corroborated these findings.
International collaboration optimizes outcomes: (standing, left to right) Drs. Mariana Berho (U.S.) Pablo Piccinini (Argentina), Sthela Murad-Regadas (Brazil), Sergio Regadas (Brazil), Petr Tsarkov (Russia), and Phil Quirke (UK). Seated (left to right): Drs. Guillermo Rosato (Argentina), Bill Heald (U.K.), Steven Wexner (U.S.), and Mrs. Heald (U.K.).
“What about patients with mucosal ulcerative colitis?” [the second group at risk for a permanent stoma] Dr. Wexner rhetorically asked. “Well, initially, the Brooke ileostomy was the standard, as described by Bryan Brooke from the UK. But Nils Koch from Gothenburg, Sweden, in 1969 suggested that a pouch could be formed and obviate the need for a Brooke ileostomy. That concept evolved further in less than 10 years, when Sir Alan Parks and Professor John Nicholls at the St. Mark’s Hospital took a pouch and put it in the pelvis and anastomosed it to the anus. Within a few months, Professor Joji Otsunomiya, of Kyogo, Japan modified the ‘s’ to a ‘j’ configuration.”
A review of developments in Japan, England, and back in the United States led to acceptance of the double-stapled J-pouch. “Pouches were then reimported, if you will, to rectal cancer by a few people in France in 1986, including Professor Rolland Parc, who described the J-pouch for patients with rectal cancer, a now globally accepted gold standard operation.”
The next evolution in treatment was how to avoid surgery or make it minimally invasive: colonoscopy, therapeutic polypectomy, transanal endoscopic microsurgery, and laparoscopic colectomy. “All of these technologies—colonoscopy, transanal endoscopic surgery, laparoscopy—were melded together in the setting of a single integrated operating room, not an endoscopy suite, not a specific OR, not a laparoscopic setting, but an integrated operating room, by Professor Michael Li at the Pamela Youde Nethersole Eastern Hospital in Hong Kong in 1995,” he said. A way to expedite discharge of patients after using these minimally invasive techniques, now widely followed, came from Professor Henrik Kehlet, of Hvidovre, Denmark.
There have been a plethora of international innovations for treating the third group of patients at risk for a permanent stoma, people with fecal incontinence. Cor Baeten from Maastricht in the Netherlands, Professor Norman Williams from London, England, Enrico Cavina from Pisa, Italy all more or less simultaneously described the stimulated graciloplasty, an antecedent of sacral nerve stimulation, described by Klaus Matzel from Erlangen, Germany.
Dr. Wexner noted that the Society’s current membership is 27 percent international, and yet there are only 12 honorary international fellows, representing less than one-half of one percent of the membership. He and the Executive Council unanimously recommended addition of 18 new honorary international fellows, to be equally divided between this year’s ballot and next year’s ballot. They include many of the distinguished international collaborators mentioned in Dr. Wexner’s address: Professor Cornelius G. Baeten, The Netherlands; Professor the Lord Darzi of Denham, United Kingdom; Professor Adam J. Dziki, Poland; Professor Najib Haboubi, United Kingdom; Professor Angelita Habr-Gama, Brazil; Professor Richard (Bill) John Heald, United Kingdom; Professor Henrik Khelet, Denmark; Professor Zoran Krivokapic, Serbia; Professor Antonio M. Lacy, Spain; Professor Michael Ka Wah Li, Hong Kong; Professor Klaus E. Matzel Germany; Professor Tetsuichiro Muto, Japan; Professor Graham L. Newstead, Australia; Professor Lars Pahlman, Sweden; Professor Rolland Parc, France; Professor Philip Quirke, United Kingdom; Professor Petr V. Tsarkov, Russia, and Professor Norman S. Williams, United Kingdom.
Somehow Dr. Wexner managed to keep ASCRS—the work of its Executive Council and its many committees and leaders past and present—at the forefront of his engaging trip through the history of global medical advance and colorectal treatment innovation. It was a virtuoso performance that seemed to leave no one who deserves appreciation for his or her role in the enterprise overlooked. He started and closed by thanking those closest to him, movingly remembered mentors such as the late Dr. David Jagelman, and thanked just about everyone else in between.
“There’s no way the work of this society gets done because of a president. It gets done because of an executive council and many others,” he said. He added an impassioned synopsis of the Society’s purposes: “To provide a forum for presentation. That why we’re here at this meeting interacting, to improve the quality of care for our patients. That’s really why we practice as physicians and why we coalesce as a society. Towards that end, we need to publish our findings, here at this meeting and in our journal. We need to educate future generations. We need to continue to educate ourselves, we need to perpetually innovate and move forward, and we need to increase public awareness about the diseases we treat and the people who treat them.”