Challenges, Evidence, Ethics and Surgeons: Lessons Learned From the Recent Evolution of Colorectal Surgery

The challenges surgeons face are ever-changing and unlimited but provide many opportunities for development. The evidence on which we base our actions are provisional and require adaptation. Nevertheless, ethical behavior should guide us, and, given the avalanche of scientific advances, we should be aware that new knowledge will bring about new challenges to face. In the coming years, the way we understand surgery will change due to the impact of innovation, the undefined borders of our specialty and the need for quality care. Even so, those who wish to venture into this ‘trade’ will still require a model they can trust: a mentor. We must learn not only from evidence and technological tools, but also from experience. We must take advantage of the immense amount of information available and from educational platforms that contribute toward democratizing training. We must observe, reflect and ask for answers. With all this, we can build our knowledge, adapt our criteria and continue to do so constantly.¹

To become well-trained and gain autonomy, we must develop our critical thinking. Success is not due to innate or special abilities but to effort and good teaching. In addition, perseverance and passion act as guiding forces to achieve objectives.² Medical knowledge is growing faster and faster, so we must focus on developing decision-making models, because trial-and-error treatment has expired.³ Artificial intelligence will collaborate with this, which will confront us with ethical problems, as medicine requires compassion and dedication to the patient. We can learn from social networks, and specifically from Twitter, where there are contributions from experienced surgeons as well as new challenges posed by younger ones. In this manner, information is amplified, bibliographies can be accessed, ideas are disseminated, interaction with experts is possible, and other audiences can be contacted.⁴ In addition, we must continue to research. Research is not an option; it is the very soul of surgery and part of the mission to improve standards for patient care.⁵

Colorectal surgery provides examples of the achievements of surgeons. In 1835, Salmon founded a dispensary, complaining that there was no other branch of medicine that had been given less attention. His challenge caused St. Mark's Hospital to change their concepts and attitudes, but even today we must not trivialize processes in which inappropriate actions can produce more important disorders than those originally being treated. The importance of expert surgeons was highlighted by Dukes when asked what procedure he would choose if he had to undergo rectal cancer surgery: “I would not choose the procedure, but the surgeon, and would do so with great care”,⁶ which was later paraphrased by Wexner when he said, “I would choose the surgeon more than the instruments,” when referring to new technologies, which for now are still controlled by humans.⁷

We need to be honest, treat patients personally, work humbly and temper our ego.⁸ Likewise, we should be curious, maintain a reasonable amount of doubt, and be able to cope with difficult situations. We must improve our skills and master new technologies before applying them in practice; a balance between skills and common sense is required, seeking to benefit patients and not recognition. It is necessary to work as a team, accept ideas from others, develop our own identity by getting involved in scientific societies and open our minds; nothing is worse than saying, “I have always done it this way.” Our critical thinking should make us not accept everything without prior analysis. Do you remember the fascination when the stapler was introduced to treat hemorrhoids? The evidence tempered this response, and many young surgeons today would not even understand. In contrast, pelvic floor and anal sphincter repair surgery has been lost in favor of other technologies (some without proven effectiveness) that require less technical anatomic mastery. Let us weigh our actions: the choice of technique should not only be based on the approach; we should remember that, when treating low rectal cancer, the objective is to meet the expectations of the patient with minimal morbidity,⁹ and when we cannot dissect it well or correctly staple laparoscopically, the alternative is not to amputate the rectum in a minimally invasive manner, or to convert when an accident has occurred, or to risk the patient's survival to feel satisfied. In short, “Decisions are more important than incisions.”

Let us take advantage of opportunities and discover our innate abilities; in doing so, support is essential for us to see our potential.¹⁰ We are leaders because of our ability to make decisions quickly or to stay calm in stressful situations.¹¹ Furthermore, we can confront evidence-based guidelines with experience-based knowledge, as surgical practice is often too complex to fit a guideline.¹² But even leaders are not exempt from spending sleepless nights if their behavior is ethical; we can all experience complications.¹³ We must never be complacent, and we should redefine our purposes to prevent surgery from becoming ‘just a job’. This involves self-auditing, because we can only improve our results if we actually know them. Remember how difficult it was to shake certain traditions, like catheters and routine drains, or prolonged postoperative fasting?¹⁴ Questioning the foundations leads to improvement.

Thus, trends have been changed and knowledge linked. In 1923, Miles described the best operation for rectal cancer. Then staplers were introduced, but it was difficult to establish sphincter-preserving surgery, which was believed to have a worse cancer outcome. Fundamental contributions were the emphasis on detail-based surgery: the circumferential margin, adequate staging, minimally invasive approach, multidisciplinary therapy and even the proposal of a non-operative treatment. What a dizzying evolution in just one century!

Let us also remember that we can offer our help to those who need it most: “Many, by giving a little, can do extraordinary things.”¹⁵ And when the time comes, we should share our perspective with young people, offered from our life-long experience and knowledge of the pendulum of scientific ‘truth’ acting as mentors and motivators.

In conclusion, may we take advantage of the opportunities offered by the advances that will change the way we understand surgery. The future will not wait for anyone; it is here now. Technology and innovation are very important, but our joy, dedication and moral values are even more so. The former must go hand in hand with the latter.