Management of patients with polyposis

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Excerpt

As the 70th anniversary approaches of the first subtotal colectomy and ileo‐rectal anastomosis (performed at St. Mark's Hospital, London, in 1948), the paper by Chittleborough et al.1 updates us on five issues relating to the surgical management of patients with familial adenomatous polyposis (FAP). While much has changed in the intervening years, including the very name of the condition, and there will be more disruption in the next decade with the advent of genetic engineering, presently it is the surgeon in whose hands these patients primarily remain. The question today is – which surgeon? There would hopefully be little dispute in Australia today that a specialist colorectal surgeon is the doctor of choice – but which colorectal surgeon?
It has never been truer that while all colorectal surgeons are equal, some are more equal than others (apology to George Orwell). Not all can be up to the task of maintaining the highest level of expertise in inflammatory bowel disease, pelvic floor disorders, cancer AND hereditary colorectal cancer syndromes. The last includes FAP, Lynch syndrome, Peutz–Jeghers syndrome and a myriad of other polyposis syndromes and subtypes of the major syndromes that can present via multiple medical specialities. Yet, the local anecdotal experience supports the contention that some general surgeons still deal with polyposis patients, being of the view that the technical operative challenges are minor. Indeed, some colorectal specialists also see and treat only the occasional such patient. Both groups may not keep up to date with advances, such as those presented at the biennial scientific meeting of the International Society for Gastrointestinal Hereditary Tumours (InSiGHT, www.insight‐group.org). This multidisciplinary meeting is marked by the presence of senior colorectal surgeons, such as the international co‐authors of the paper by Chittleborough et al.1 While other centres of excellence and hereditary cancer registries are also amply represented at the InSiGHT meetings, they represent a tiny percentage of the total number of colorectal specialists who treat these patients.
Chittleborough et al.1 discuss several issues in some depth in order to educate a broader surgical cohort, but the surface is only scratched with regard to the complexities and challenges of this condition. FAP and the other conditions mentioned above represent a prime opportunity for prevention – for the patient at hand and for their relatives. This possibility is maximized when patients can be filtered to centres of excellence that incorporate or work closely with hereditary cancer registries and who have genetic testing readily available.
Our health system is not optimally designed to take advantage of this opportunity, which is presumably why the authors1 perceived a need to clarify at least a limited number of issues. That is a pragmatic approach; more effective in the long term perhaps would be an initiative whereby consensus could be reached as to which centres could be designated ‘excellent’, and which surgeons and others and teams could be credentialled and regularly accredited as being up to the mark as subspecialists in this area. The flow on to research is obvious. Examples do exist internationally, and we have centres here also, but they could be so much more effective if properly supported.
As surgeons, we know who we would see, a decision based on patient volume, outcomes and the expertise that we observe in our colleagues.
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