COLORECTAL SURGERY  

INTRODUCTION:Colorectal surgery is the surgical specialty that deals with investigation, diagnosis, and treatment of disorders of the colon, rectum and anus in adults.

The specific objectives of the residency program in colorectal surgery are divided into five categories.

  1. Cognitive Knowledge (general areas)
  2. Cognitive Knowledge (disease entities)
  3. Clinical Skills
  4. Psychomotor skills
  5. Affective Domain
  1. Cognitive Knowledge (General Areas)

At the completion of the residency program the resident must be able to demonstrate knowledge in the following basic science areas to the satisfaction of the residency program committee.

    1. Anatomy, physiology and genetics and embryology of the colon, rectum and anus.
    2. Pharmacology as related to diseases of the colon, rectum and anus.
    3. Microbiology of the intestine.
    4. Nutrition in colorectal disease
    5. Critical care.
    6. The principles of medical and radiation oncology in the treatment of colorectal and anal cancers.
  1. Cognitive Knowledge (Disease Entities)

To be able to manage fully (investigation, diagnosis and treatment) and demonstrate comprehensive knowledge of normal anatomy, physiology, pathology, pathophysiology, etiology and radiology of the following disease entities.

    1. Abdominal Disorders
      1. Congenital malformation of the colon
        • imperforate anus
        • Hirschprung's disease
      2. Inflammatory diseases
        • bacterial, viral, fungal infection
        • Salmonella, Shigella, fungi, actinomycosis
        • Brucella, Proteus, Yersinia, Chlamydia
        • campylobacter, tuberculosis
        • pseudomembranous colitis - Clostridium difficile
        • parasitic infections
          • amebiasis, enterobiasis, schistosomiasis
          • balantidiasis, ascariasis, giardiasis
          • trichuriasis, strongyloidiasis
      3. Diverticular disease and its complications
      4. Mucosal ulcerative colitis
        • proctosigmoiditis
        • acute complications
        • chronic complications
      5. Crohn's Disease
        • small bowel
        • large bowel
        • anal
      6. Vascular Disease
        • occlusive disease
        • arterial
        • venous
        • ischemic colitis
        • arterio-venous malformations
      7. Neoplastic Disease
        • polyps
        • polyposis syndromes

Tumors

benign

§         lymphoid hyperplasia

§         lipoma

§         leiomyoma

§         lymphangioma

malignant

        • adenocarcinoma
        • carcinoid
        • sarcoma
        • lymphoid
      1. Obstruction
        • mechanical
        • paralytic
        • pseudo-obstruction
      2. Fistulas
        • small bowel
        • large bowel
      3. Functional disturbances
        • irritable bowel
        • chronic constipation
        • absorptive disorders
        • motility disorders
      4. Volvulus
      5. Radiation enterocolitis
      6. Traumatic injury to colon and rectum
    1. Anorectal Disorders
      1. Abscess simple/complex
      2. Fistulae - rectovaginal
        • fistula in anno
      3. Sexually transmitted diseases
        • condylomata acuminata
        • gonorrhea
        • syphilis
        • AIDS/HIV
        • herpes
      4. Vascular disease
        • hemorrhoidal disease
      5. Neoplastic disease
        • epithelial
          • squamous
          • basal cell
          • mucoepidermoid
          • mucinous adenocarcinoma
        • retrorectal tumors
        • melanoma
        • Bowen's disease
        • Paget's disease
      6. Sphincter disorders - incontinence
        • idiopathic
        • traumatic
        • anal stenosis
        • fissure in ano
      7. Miscellaneous
        • pilonidal disease
        • procidentia
        • pruritis ani
        • anorectal trauma
        • foreign bodies

 

  1. Clinical Skills

Given a patient with a condition listed in the section on disease entities, the resident will be able to do the following to the satisfaction of the residency program committee:

    1. Take a relevant history.
    2. Perform an acceptable physical exam concentrating on the relevant areas.
    3. Arrive at an appropriate differential diagnosis.
    4. Order appropriate laboratory, radiologic and other diagnostic procedures demonstrating knowledge in the interpretation of these investigations.
    5. Arrive at an acceptable plan of management, demonstrating knowledge in operative and nonoperative management of the disease process.
    6. Manage patients in the ambulatory setting, demonstrating a knowledge of common office techniques and procedures.
    7. Manage the patient throughout the entire in hospital course, demonstrating knowledge of and being able to treat potential complications of disease processes and operative procedures and their treatment.
    8. Provide a plan for patient follow up.
  1. Psychomotor Skills

At the completion of the residency program in colorectal surgery, the resident must show technical competence in the following procedures to the satisfaction of the residency program committee.

    1. Anorectal procedures
    1. Endoscopic procedures
      • Colonoscopy with biopsy and polypectomy
      • Proctosigmoidoscopy, rigid and flexible
    2. Operative Procedures
      • Right hemicolectomy with anastomosis
      • Left hemicolectomy with anastomosis
      • Sigmoid colectomy with anastomosis
      • Proctocolectomy with ileostomy
      • Proctocolectomy with ileoanal anastamoses, pelvic pouch procedures
      • Colectomy with ileorectal anastamosis
      • Subtotal colectomy with ileostomy
      • Anterior proctosigmoidectomy with colorectal anastomosis
      • Hartmann procedure
      • abdominoperineal proctosigmoidectomy
      • small bowel resection
      • small bowel stricturoplasty
      • pull through coloanal anastomosis
      • ileostomy (conventional/continent)
      • colostomy (closure, construction, relocation and revision)
      • parastomal hernia repair
      • lysis adhesions (bowel obstructions)
      • procedures for procidentia
      • cecostomy
    3. Miscellaneous Procedures
      • local treatment rectal cancer
      • liver biopsy
      • colovaginal fistula
  1. Affective Domain

At the end of the training, the resident must have demonstrated to the satisfaction of the residency program committee:

    1. The ability and willingness to work in a cooperative manner with other health care personnel, being sensitive to their roles and abilities; and to be able to give and receive advice in a manner that is consistent with the harmonious operation of a healthcare team.
    2. The ability to communicate with patients and their families explaining to them their disease process and the benefits, risks, and complications, and alternatives of management recommendations in terms each individual can comprehend.
    3. Respect for patients' rights to privacy.
    4. Sensitivity to the sexual, moral, ethical, and religious characteristics of the patient and family, understanding of the special psychological needs of the patient with colorectal disease, and the capacity for supportive and compassionate care in the course of terminal disease.
    5. A knowledge of the ethical and legal aspects of colorectal surgery.
    6. The ability to critically evaluate scientific information.
    7. Honesty, reliability, and respectfulness in working with patients and colleagues alike.
    8. The discipline of continued self-education and the appropriate application of this current knowledge to the clinical setting; the ability to supervise and educate undergraduate students in colorectal surgery,the skills to educate colleagues, patients, families, and other health care professionals, the capacity to undertake research, and be aware of the importance of peer review of protocols, ethical considerations, and the limitations of such endeavours.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The following are the minimum educational requirements in the subspecialty of colorectal surgery. Additional experience may be required by the program director.

  1. Pre-requisite:

Experience in general surgery which must be completed prior to entry into the colorectal surgery program.

  1. Program requirements:

Colorectal surgery,which may be undertaken during the final year of general surgery with the joint approval of the program director in general surgery and the program director in colorectal surgery.This period must include:

    1. senior residency clinical colorectal surgery,
    2. one or both of the following:

                                                         i.            further residency in clinical colorectal surgery or disciplines related to colorectal surgery that are consistent with the educational objectives in colorectal surgery, and acceptable to the program director; and/or

      1. research, relevant to the educational objectives of colorectal surgery, and acceptable to the program director.

During the program, the resident must be provided with a graduated increase in personal responsibility for the management of colorectal surgical patients. Personal operative experience, including the major procedures in the specialty must be provided under appropriate supervision. Each resident must keep a validated record of all operative procedures in which he or she has participated either as assistant or operating surgeon.

This should include care of the patient in the ambulatory setting, with special attention to the application of specialty care in the community and a focus on issues of prevention of colorectal disease. 

There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents to complete the program and achieve the educational objectives in colorectal surgery.

  1. Teaching Faculty

There must be a sufficient number (minimum of 2) teaching staff to supervise residents. The surgeons attached to the teaching service must have special expertise in colorectal surgery.

  1. Number and Variety of Patients

The number and variety of patients available for teaching must be appropriate to provide:

    1. an adequate knowledge of the natural history, clinical manifestations and treatment alternatives of benign and malignant colorectal and anal conditions and other gastrointestinal diseases which have colorectal manifestations,
    2. an adequate knowledge of the natural history and clinical manifestations of complications related either to the disease process or its treatment,
    3. an adequate knowledge of the interpretation of common laboratory procedures used in the investigation of these diseases and the principles involved in management of the physical, psycho-social, and ethical aspects of these disorders. A progressive responsibility in all aspects of the investigation and management of these diseases, including in-patient, and ambulatory patient care including endoscopy and anal manometry, and the practical application of community care, particularly related to preventative medicine.
    4. an adequate knowledge of colonic, rectal and anal cases of various disease entities as listed in the objectives.
  1. Clinical Services Specific to Colorectal Surgery

The facilities of a gastrointestinal function laboratory and a full range of endoscopy must be available. Residents must be provided an opportunity to acquire competence in colonoscopy. In addition to standard facilities for radiological investigation of the gastrointestinal tract, special facilities for ultrasound including transrectal ultrasound, scanning studies and angiography should be available.

Ambulatory Services - Inpatient and outpatient clinical teaching services should be integrated as much as possible, in order to provide continuity of care. Organized clinics such as anorectal clinics or other facilities, whether general or specialized in nature, must provide opportunities for pre-operative investigation and post-operative discharge follow-up of colorectal surgical patients in all the categories mentioned above.

  1. Supporting Services — Clinical, Diagnostic, Technical
    1. Liaison with Other Specialties and Subspecialties

The colorectal surgery program should have a close relationship with a gastroenterology service. There must also be appropriate liaison with teaching services in anatomical and\or general pathology, diagnostic radiology, anesthesia, radiation oncology, and general surgical oncology.

    1. Diagnostic Services

The following services must be available:

      1. a full range of diagnostic facilities including:
        • radiology with ultrasound, CT scanning, MRI ;
        • gastrointestinal endoscopy;
        • anorectal motility laboratory;
      2. biochemical laboratory resources including facilities for determinations of carcino-embryonic antigen;
      3. hematology, blood coagulation and blood transfusion resources;
      4. microbiology resources;
      5. close association with an active anatomical pathological service including cytology.
    1. Intensive Care

Residents in colorectal surgery must have an opportunity to follow the designated colorectal patients within an intensive care unit.

    1. Emergency Facilities

There must be systematic supervision of residents in colorectal surgery to ensure expertise in the initial management of surgical emergencies related to colorectal disease. Experience in providing a consultative service is an important feature of this training.

    1. Additional Facilities

There should be access to enterostomal therapists, nutritionists, social  services, palliative care specialists, psychiatrists, occupational therapists and, infection disease control personnel and community health nurse organizations as may apply to the outpatient.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

  1. Organized Scholarly Activities

A co-ordinated educational program must be provided in colorectal surgery and associated fields. The program may include lectures and seminars, technical demonstrations, journal clubs, in addition to teaching rounds, special conferences and visiting lecturers. Wherever possible the educational program should emphasize a close association between clinical clerks, residents, staff and other health care professionals to provide a multidisciplinary approach to the more complex colorectal patient. Combined conferences with the gastroenterology service are a desirable part of the program as are colorectal surgical rounds and visiting professorships during the academic year. Service demands must not seriously interfere with the ability of the residents to follow the academic program.

  1. Basic and Clinical Sciences Relevant to Colorectal Surgery

The educational program must include teaching in basic sciences and principles of colorectal surgery and also advanced scientific and clinical knowledge essential to the practise of colorectal surgery.

  1. Biomedical Ethics

The academic program must provide opportunities for residents to gain an understanding of the basic principles of biomedical ethics as it relates to colorectal surgery.

  1. Communication Skills

The program must provide opportunities for residents to learn effective communication skills for interacting with their patients and their families, colleagues and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

  1. Teaching Skills

The resident in colorectal surgery must be given opportunities to develop effective teaching skills and is expected to take part in the teaching of students, nurses and residents, and to participate and organize colorectal surgical rounds.

  1. Quality Assurance/Improvement

Residents must be exposed to systematic programs that address the quality of clinical care and quality of academic efforts that are being made in a colorectal program. This may include systematic review of quality assurance efforts and a scheduled review of morbidity and mortality.

  1. Research Opportunities for Residents

Residents must be given the opportunity to participate in research projects under the supervision of appropriate investigators. This research may be either clinically oriented or of a basic science nature. If the latter is chosen, it should be in a location with adequate space for research and situated close to patient care facilities. Residents should be encouraged to complete one research project for each year of training. Completion of the research project would usually entail a written manuscript, publication of the work, and presentation of the work at a national and/or international meeting. Residents should be exposed to faculty members who are actively conducting research.

  1. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

EVALUATION OF RESIDENT PERFORMANCE:

There must be mechanisms in place to ensure the systematic collection and interpretation of evaluation data on each resident enrolled in the program.

As there is no summative evaluation at a national level, it is particularly important that the evaluation of residents in the program be rigorous and well documented. Programs must have a comprehensive assessment plan including assessment criteria and methods, based on the objectives of the program. Assessments of the performance of individual residents in the program are to be kept on file in the office of the postgraduate dean for review at the time of on-site surveys.

SPECIALTY PROGRAMS (WITH TRAINING REQUIREMENTS):

Master of Surgery(M.S):

Thirty six months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.