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Editorial
Challenges, Evidence, Ethics and Surgeons: Lessons Learned From the Recent Evolution of Colorectal Surgery
Retos, evidencia, ética y cirujanos. Lecciones aprendidas de la evolución reciente de la cirugía colorrectal
José Vicente Roig Vila
Unidad de Coloproctología, Centro Europeo de Cirugía Colorrectal, Hospital Vithas-Nisa 9 de Octubre, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The challenges surgeons face are ever-changing and unlimited but provide many opportunities for development&#46; The evidence on which we base our actions are provisional and require adaptation&#46; Nevertheless&#44; ethical behavior should guide us&#44; and&#44; given the avalanche of scientific advances&#44; we should be aware that new knowledge will bring about new challenges to face&#46; In the coming years&#44; the way we understand surgery will change due to the impact of innovation&#44; the undefined borders of our specialty and the need for quality care&#46; Even so&#44; those who wish to venture into this &#8216;trade&#8217; will still require a model they can trust&#58; a mentor&#46; We must learn not only from evidence and technological tools&#44; but also from experience&#46; We must take advantage of the immense amount of information available and from educational platforms that contribute toward democratizing training&#46; We must observe&#44; reflect and ask for answers&#46; With all this&#44; we can build our knowledge&#44; adapt our criteria and continue to do so constantly&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">To become well-trained and gain autonomy&#44; we must develop our critical thinking&#46; Success is not due to innate or special abilities but to effort and good teaching&#46; In addition&#44; perseverance and passion act as guiding forces to achieve objectives&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Medical knowledge is growing faster and faster&#44; so we must focus on developing decision-making models&#44; because trial-and-error treatment has expired&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Artificial intelligence will collaborate with this&#44; which will confront us with ethical problems&#44; as medicine requires compassion and dedication to the patient&#46; We can learn from social networks&#44; and specifically from Twitter&#44; where there are contributions from experienced surgeons as well as new challenges posed by younger ones&#46; In this manner&#44; information is amplified&#44; bibliographies can be accessed&#44; ideas are disseminated&#44; interaction with experts is possible&#44; and other audiences can be contacted&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition&#44; we must continue to research&#46; Research is not an option&#59; it is the very soul of surgery and part of the mission to improve standards for patient care&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Colorectal surgery provides examples of the achievements of surgeons&#46; In 1835&#44; Salmon founded a dispensary&#44; complaining that there was no other branch of medicine that had been given less attention&#46; His challenge caused St&#46; Mark&#39;s Hospital to change their concepts and attitudes&#44; but even today we must not trivialize processes in which inappropriate actions can produce more important disorders than those originally being treated&#46; The importance of expert surgeons was highlighted by Dukes when asked what procedure he would choose if he had to undergo rectal cancer surgery&#58; &#8220;I would not choose the procedure&#44; but the surgeon&#44; and would do so with great care&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which was later paraphrased by Wexner when he said&#44; &#8220;I would choose the surgeon more than the instruments&#44;&#8221; when referring to new technologies&#44; which for now are still controlled by humans&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We need to be honest&#44; treat patients personally&#44; work humbly and temper our ego&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Likewise&#44; we should be curious&#44; maintain a reasonable amount of doubt&#44; and be able to cope with difficult situations&#46; We must improve our skills and master new technologies before applying them in practice&#59; a balance between skills and common sense is required&#44; seeking to benefit patients and not recognition&#46; It is necessary to work as a team&#44; accept ideas from others&#44; develop our own identity by getting involved in scientific societies and open our minds&#59; nothing is worse than saying&#44; &#8220;I have always done it this way&#46;&#8221; Our critical thinking should make us not accept everything without prior analysis&#46; Do you remember the fascination when the stapler was introduced to treat hemorrhoids&#63; The evidence tempered this response&#44; and many young surgeons today would not even understand&#46; In contrast&#44; pelvic floor and anal sphincter repair surgery has been lost in favor of other technologies &#40;some without proven effectiveness&#41; that require less technical anatomic mastery&#46; Let us weigh our actions&#58; the choice of technique should not only be based on the approach&#59; we should remember that&#44; when treating low rectal cancer&#44; the objective is to meet the expectations of the patient with minimal morbidity&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and when we cannot dissect it well or correctly staple laparoscopically&#44; the alternative is not to amputate the rectum in a minimally invasive manner&#44; or to convert when an accident has occurred&#44; or to risk the patient&#39;s survival to feel satisfied&#46; In short&#44; &#8220;Decisions are more important than incisions&#46;&#8221;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Let us take advantage of opportunities and discover our innate abilities&#59; in doing so&#44; support is essential for us to see our potential&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> We are leaders because of our ability to make decisions quickly or to stay calm in stressful situations&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Furthermore&#44; we can confront evidence-based guidelines with experience-based knowledge&#44; as surgical practice is often too complex to fit a guideline&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> But even leaders are not exempt from spending sleepless nights if their behavior is ethical&#59; we can all experience complications&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> We must never be complacent&#44; and we should redefine our purposes to prevent surgery from becoming &#8216;just a job&#8217;&#46; This involves self-auditing&#44; because we can only improve our results if we actually know them&#46; Remember how difficult it was to shake certain traditions&#44; like catheters and routine drains&#44; or prolonged postoperative fasting&#63;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Questioning the foundations leads to improvement&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Thus&#44; trends have been changed and knowledge linked&#46; In 1923&#44; Miles described the best operation for rectal cancer&#46; Then staplers were introduced&#44; but it was difficult to establish sphincter-preserving surgery&#44; which was believed to have a worse cancer outcome&#46; Fundamental contributions were the emphasis on detail-based surgery&#58; the circumferential margin&#44; adequate staging&#44; minimally invasive approach&#44; multidisciplinary therapy and even the proposal of a non-operative treatment&#46; What a dizzying evolution in just one century&#33;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Let us also remember that we can offer our help to those who need it most&#58; &#8220;Many&#44; by giving a little&#44; can do extraordinary things&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> And when the time comes&#44; we should share our perspective with young people&#44; offered from our life-long experience and knowledge of the pendulum of scientific &#8216;truth&#8217; acting as mentors and motivators&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; may we take advantage of the opportunities offered by the advances that will change the way we understand surgery&#46; The future will not wait for anyone&#59; it is here now&#46; Technology and innovation are very important&#44; but our joy&#44; dedication and moral values are even more so&#46; The former must go hand in hand with the latter&#46;</p></span>"
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