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Proctologist


What Is a Proctologist?

 

Proctology, or colorectal surgery, is a field in medicine that deals with conditions of the rectum, anus and colon. Proctology comes from the Greek words πρωκτ?ς (proktos) meaning "anus" or “hind parts", and -λογ?α (-logia), meaning "science" or “study”. However, the term “proctology” is now very seldom used. In fact, this term has not been in use since 1961. The more appropriate term to use now is colorectal surgery. The distinction lies between their scope. Proctology is limited to conditions of the anus, rectum, and the sigmoid colon. On the other hand, colorectal surgeons specialize in the medical and surgical treatment of the entire gastric tract. This is very similar to the responsibilities of a gastroenterologist. However, unlike gastroenterologists, colorectal surgeons are capable of providing surgical treatment.

 

Role & Responsibilities of a Proctologist

 

A colorectal surgeon is capable of treating a wide variety of conditions. As such, their expertise often overlaps with other physicians, like gastroenterologists and gynecologists, often requiring them to work together with these physicians.

 

Here are some of the common disorders in the gastric tract that a colorectal surgeon treats.

 

Hemorrhoids are varicosities, which are swollen or inflamed veins, located around either the anus or in the lower rectum. This is a fairly common condition, occurring in 50% of adults by the age of 50. Hemorrhoids can be internal or external. Internal ones are found within the anus or rectum. On the other hand, external hemorrhoids develop outside the anus, and are further known as piles. This latter type of hemorrhoid is more bothersome. They may cause difficulty sitting, pain and severe itching. Possible factors that cause hemorrhoids are: straining during bowel movement, complication of chronic constipation, and sitting for long periods of time, particularly on the toilet. In severe cases, this condition is treated through a surgical procedure called hemorrhoidectomy.

 

Anal fissures are small tears in the mucosa, which is a thin moist tissue, that lines the anus. This happens when a person passes hard or large stools during bowel movement or due to childbirth. It typically causes bleeding and pain during bowel movement. In some cases, there are also spasms in the anal sphincter, the ring of muscle at the end of the anus.

 

The diagnosis of an anal fissure may be conducted through various ways. The first is a digital rectal exam. This involves inserting a gloved finger into the anal canal. The second is the use of an anoscope, a short lighted tube. If the first two methods cause too much pain for the patient, it may be possible to diagnose through mere observation. However, the first two are preferred because the location will offer clues as to its cause, especially for chronic anal fissures.

 

Fistulas are abnormal passageways formed between the rectum or other anorectal area to the skin surface. This happens when the small glands inside the anus are blocked and form an abscess, or an infected cavity. When left untreated, the abscess may develop into a fistula.

 

In some cases, an anal fistula may be diagnosed easily if it is visible. However, if it is not, your colorectal surgeon may perform various tests like anoscopy, ultrasound and MRI.

 

Fecal incontinence is also called bowel control problem. It is the accidental passing of stool or mucus from the rectum, either in solid or liquid form. It can manifest as an inability to hold bowel movement before reaching the toilet or passing stool in one’s underwear without even being aware of it happening. This is common in diarrhea and constipation patients, but usually disappears as the main condition is treated. However, in some cases, it requires the attention of a colorectal specialist. This happens when fecal incompetence becomes a result of these circumstances: nerve or muscle damage, hemorrhoid, rectocele or childbirth by vaginal delivery.

 

Rectal prolapse is the condition where the rectum, which is the last part of the large intestine, turns itself inside out. In the early stages of the condition, merely a portion of the rectum slips past the anus during bowel movement, and goes back afterwards. In order to diagnose this, a person will have to bear down, as if passing a bowel motion, to allow a doctor a chance to examine the condition. However, if an internal prolapse is suspected, other tests like ultrasound, specialized x-ray, and anorectal manometry may be performed.

 

Imperforate anus is a congenital defect, which means it is present since birth, where the anus is blocked or missing entirely. This condition is suspected if a child does not pass stool 24 to 48 hours after birth, has a swollen belly, or if the stool passes through the vagina, urethra, base of penis or scrotum. In such cases, a colorectal surgeon should be consulted for reconstructive surgery called anoplasty.

 

Crohn’s disease is a chronic disease that causes irritation and inflammation in the digestive tract. It can affect any part of the digestive tract, from the mouth to the anus, but often it occurs in the small intestine or the beginning of the large intestine. It commonly manifests as three symptoms: diarrhea, abdominal pain or cramps, and weight loss. In order to diagnose the condition, the doctor may perform a physical exam to check for abdominal bloating, to listen to sounds within the abdomen using a stethoscope, or to tap the abdomen to check for tenderness or pain. Aside from these, lab tests, upper gastrointestinal (GI) series, computed tomography (CT) scans and intestinal endoscopy may also be done.

 

Ulcerative colitis is another chronic and long-lasting condition that causes inflammation and ulcers in the inner lining of the large intestine. This happens when a person has overactive intestinal immune system but also due to genetic or environmental causes. Its most common symptoms include an urgent need to pass stool, exhaustion, nausea, fever, weight loss and anemia. The condition is diagnosed through physical exams, lab tests, colonoscopy or flexible sigmoidoscopy.

 

Pelvic floor dysfunction is a group of diseases that cause pelvic pain and abnormalities in bowel storage and emptying. This may be caused by rectocele, paradoxical puborectalis contraction, and pelvic pain syndromes. This condition is diagnosed through the following tests: endoanal or endorectal ultrasound, anorectal manometry testing, prudenal nerve motor latency testing, electromyography (EMG) or video defecography.

 

Aside from these diseases and many others, the colorectal surgeon also handles irritable bowel syndrome, colorectal cancer, colorectal polyps, anal injuries and the removal of objects inserted into the anus.

 

In order to diagnose and treat the diseases mentioned above, colorectal surgeons are also responsible for the administration of various surgical treatments and diagnostic procedures.

 

Colorectomy involves the resection of the colon. In other words, it is the surgical removal of a part of the colon. If the rectum is included in the resection, the procedure is called proctocolectomy. This is often done to treat patients with colon cancer and inflammatory bowel diseases.

 

Colostomy is a surgical procedure where an incision is made on the anterior abdominal wall, from which the healthy end of the large intestine or color is drawn out and sutured into place. This forms a stoma, an opening that allows an alternative channel for fecal matter to leave the body. A stoma appliance is then placed to collect the feces.

 

Polypectomy is the removal of polyps in order to prevent the condition from escalating into cancer. For colorectal polyps, it is not necessary to do polypectomy through surgery. This procedure can also be done through colonoscopy or esophagogastroduodenoscopy.

 

Stritureplasty is a surgical procedure that reduces bowel narrowing from built-up scar tissue in the intestinal wall. This is usually done to restore the free flow of bowel movement in patients with inflammatory bowel conditions. This condition causes the accumulation of scar tissue through repeated damage and healing, thus requiring strictureplasty.

 

Laparoscopic surgery is also called minimally invasive surgery or MIS. It is a modern surgical technique where small incisions are made far from the actual location of the operation. This reduces the pain and risk of hemorrhage. Plus, recovery times are far shorter.

 

Fistulotomy is done in order to treat anal fistula. In this procedure, the skin and the muscle over the passageway or tunnel are cut open, and then converted into an open groove. This allows the fistula tract to heal and close from the inside out.

 

Colonoscopy is a procedure done with the use of a flexible and lighted instrument. It is inserted into the colon, through the anus. It is performed under a light anesthetic of conscious sedation.

 

Proctoscopy is another diagnostic procedure that is typically done in the doctor’s office. It is used to examine the gastric tract using a proctoscope, a short, rigid and hollow metal tube that usually has a small light bulb mounted at the tip. A proctoscope differs from an anoscope and rectoscope mostly by the size. An anoscope is 10cm, proctoscope 13cm and a rectoscope is 25cm.

 

Anorectal manometry testing is a test that measures the anus’ and rectum’s ability to contract. This employs a balloon that is inserted into the rectum to distend it. A pressure sensor then measures the presence or absence of the reflex actions of the anal sphincter.

 

Electromyography (EMG) evaluates the nerve and muscle activity in the anal sphincter and pelvic floor. This is done by placing small needles on the muscles or a plug into the anal canal. This procedure is a little uncomfortable for the patient, but provides valuable information towards the diagnosis of their disease.

 

Video defecography is a procedure where the patient is given an enema using a thickened liquid or “contrast” that can be seen on x-rays. Then, a special x-ray machine is used to take video pictures of the patient while they sit on a commode. This records the movement of the muscles in the patient.

 

Flexible sigmoidoscopy uses a flexible and narrow lighted tube that has a camera on one end. It is inserted into the rectum to look inside the sigmoid color, and sometimes, the descending colon as well. It is usually performed without the aid of anesthesia.

 

Education of a Proctologist

 

Before a physician becomes a full-fledged colorectal surgeon, he or she has to gain at least 14 years of education and training. The journey begins in undergraduate school, where a physician spends four years. Afterwards, he or she joins an accredited 4-year medical program. After eight years of education, a physician still has to undergo five to six years of residency in general surgery. Upon completion, the physician undergoes additional training as a fellow specializing in colorectal surgery. This lasts one to two years. Only then can a physician apply for board certification.

 

In the United States of America, it is the American Board of Colon and Rectal Surgery or ABCRS that certifies colorectal surgeons. Once certified, a physician adds the initials F.A.S.C.R.S at the end of their name. This stands for Fellow of the American Society of Colon and Rectal Surgeons.

 

A colorectal surgeon has a very impressive and comprehensive academic and practical background. Listed here are the qualifications a physician must meet in order to become a board-certified colorectal surgeon.

  • Undergraduate or advanced degree
  • Graduate of an accredited medical school
  • Minimum of 5 years of General Surgery Residency
  • Minimum of 1 year in Colon and Rectal Surgery Residency, where they should have gained an adequate level of experience in management of colorectal disorders from the preoperative, operative, and postoperative stages
  • Completion of written qualifying examinations and oral certifying assessment from the American Board of Surgery
  • Recommendations from training program directors

 

These are qualifications that will get a physician through the doors of the ABCRS. However, they still have to successfully complete the assessment that the agency will provide. A candidate must also provide a detailed record of their experience in colorectal surgery. Then, the ABCRS facilitates an oral examination to assess the candidate’s qualifications. The interview is attended by three teams of prominent colorectal surgeons. They evaluate the candidate’s ability to identify and manage colorectal problems.

 

Aside from the initial certification, colorectal surgeons are also re-certified every decade. There are three criteria reviewed during this process: (1) Does the surgeon actively practice colon and rectal surgery? (2) Did the surgeon maintain continuing medical education in the field? (3) Is the surgeon respected by peers? On top of these three, the surgeon also takes a written examination. Once all of that has been successfully passed, a colorectal surgeon is re-certified.

 

History of Proctology

 

Proctology may not be as popular as cardiology or neurology, but it is an integral part of the surgical field. Earliest mention of proctology dates back to ancient Egyptian medicine. A stone slab was found by German archaeologist Hermann Junker in 1926, in one of the tombs in Giza. It shows the hieroglyphic record of Iry, the chief court physician, ophthalmologist, and more importantly, the “guardian of the king’s anus”. The reason for this was the climate of the Nile River. It was home to plenty of parasites, especially intestinal parasites that caused the widespread diseases that affect the digestive organs, including the colon.

 

Ancient Egyptian Medicine

 

Out of the eight known medical papyri, the most important one is the Beatty’s papyrus which contains a short monograph of various anal diseases and their respective treatments. Egyptian doctors are also believed to have first introduced the practice of bowel flush into medical practice. An example of this procedure is enema. Today, it is one of the most commonly practiced therapeutic procedures that prevent the accumulation of feces in the lower digestive tract. It is said that they learned of the practice from the bird ibis (God Toth), a permanent resident of the Nile River. The Egyptians believed that while standing in the Nile, the bird ibis introduced water into the rectum using its long beak, hence flushing and cleansing the final part of the colon.

 

Egyptians also practiced the regular intake of purgative drugs, three days each month. They believe that this hygiene practice is key to the regulation of digestion which was essential to good health.

 

Ancient Indian Ayurvedic Medicine

 

Proctology is also very much present in early Indian Ayurvedic medicine. Sushruta, an influential and important medical writer, wrote samhita which dedicates a section for surgery. Here, perianal fistula and its treatment are discussed. They employed cauterization, which is the burning with use of hot iron; and the pulling of fibers soaked with plant alkaloids, which destroys the callus tissue of the fistula and further encourages growth of granulation tissue.

 

Hippocratic Medicine

 

The study of operative proctology, and in fact surgery in general, reached its peak with Hippocrates. This was around 460-377 BC. Procedures were described in detail, at length, and with special care in Hippocratic writings. Of particular note is the fistula surgeries performed by Hippocratic doctors. They used linen threads pulled through the fistula using a tin probe. Through gradual tightening of the threads, the fistula is eventually cut. A skin excision and ligation of the fistula channel followed this step. Aside from surgical treatment, Hippocratic school doctors also employed chemical cauterization to treat fistula. This was done through various ways: (1) through burning sulfur powder, and (2) injection of sulfur and saltpeter myrrh powder.

 

Ancient Roman Medicine

 

Greek doctors later brought their knowledge and expertise to their Roman brothers. The greatest of Roman physicians was also one of the greatest physicians of all time. Galen was the first to describe the anatomy of anus muscles. Fistulas were treated in a somewhat different manner. The pus was extracted from the fistula channel through syringe and needle. After which, medical agents are administered via tamping to speed up healing. He is also renowned for the invention of syringotom, a tool used for fistula incision.

 

Aullus Cornelius Celsus was another prominent figure in Roman medicine. Although he was not a physician or surgeon himself, he exhibited extensive medical knowledge through high education. He wrote a scientific encyclopedia called Artes which contained his entire medical knowledge. In it, he described the procedure for operations on hemorrhoids through ligature and fistula surgery.

 

Byzantine Medicine

 

The transfer of knowledge moved from the Greek to the Roman and now to the Byzantine. They had strong influences from these great teachers. Oreibasios of Pergamon (325-400) was a personal physician and friend of Emperor Julian the Apostate. He wrote a monumental 70 books of medical encyclopedia. In his works, he described the surgical treatment for perianal fistula, as performed by second century Greek physicians Antyllus and Helyodorus. A probe is pulled through the fistula channel, which allows the physician to see the direction of the fistula. Then, skin and subcutaneous tissue incision is performed, ad the remaining callus tissue is excisioned. However, a common complication of this procedure is the complete cutting off of the anal sphincter, causing incontinence. He mentioned this in his writings, and Aegineta Paulos (625-690) particularly warned surgeons of this.

 

Paulos was a physician in Alexandria who lived and stayed there even after the arrival of the Arabs. He performed procedures on perianal fistulas using a curved knife.

 

Arabic Medicine

 

In the seventh century, the Arabs controlled and occupied the Mediterranean. One of the greatest contributions of the Arab doctors to medicine, and surgery in particular, is their non-use of knives for operations. For nearly all surgical procedures, they made use of cauter. The only exception was for amputations.

 

Abu al-Qasim az Zahrawi (Died 1013) wrote a lot about his surgical knowledge in his encyclopedic work Al Tasrif. He described the use of cauter to stop bleeding, sew wounds, treat fractures, manage dislocations, and execute obstetric, eye and other surgeries. He treated penetrating perianal fistulas by cauter, which ran through the length of the fistula channel entirely. For complete fistulas, he excised below the sphincter, after which styptic tampons were pulled into the fistula channel, then ligation was done according to the Hippocratic method. However, he considered fistulas that ended up int he urinary bladder and pelvic joints completely incurable.

 

Arab doctors particularly dealt with anorectal surgery seriously. Abu Ali al Husain ibn Abdallah ibn Sina or Avicenna (980-1037) was the most famous Arab physician and one of the greatest of all time. In his work, Canon medicinae, he explained his procedure for the surgical treatment of perianal fistulas. He used silk thread for ligature. He also described the anatomy of the anal sphincter. In 1465, a book in the Arabic language appeared, with over 140 illustrations showing the treatment of anorectal diseases using hot iron, among many others.

 

Medicine in Medieval Europe

 

Europe’s first and oldest schools were founded in Salermo, Italy. The Master Roger of Palermo published a book in 1170, Practica chirurgiae, describing two treatments of perianal fistula. The first is fistula ligation using horse hair and the other is the destruction of the fistula channel using ungentum ruptorium, consisting of soap and quicklime.

 

Teaching in the Western medicinal schools created an impact even on Serbian medieval medicine where texts were written based on Salermo medical school. One of these Serbian texts was the Hodok code, which provided guidance on the treatment of a prolapsed rectum. It states, prior to the repositioning of a prolapsed intestine, it is advisable to first rinse with warm water and sprinkle with a mixture of powdered snail shells and incense.

 

At the end of the 13th century, Henry de Mondeville (1260-1320) and Lanfranco de Mila (Died around 1300), shared their Italian surgical experiences to France. Soon, French surgery took a leading role in European medicine. A particular surgeon worth noting was Guy de Chauliac (1300-1368) who was familiar with Arabian techniques in treating anorectal diseases. To treat fistulas, he used hot knife incision and ligation. Through this method, after the pulling in of the linen thread and cutting off the tissue covering the fabric with a curved knife, thus freeing the tread and the wound healed per secundam.

 

Ambroise Paré (1510-1592) treated perianal fistulas with threaded horse hair, infiltrated by a probe, instead. He used a probe with a thread hole at the top. When he encountered an obstacle in the callus tissue while pulling the tread, he placed a thin knife along the probe to cut the callus tissue to remove it, paving the way for the probe.

 

In 14th century, British surgeon John Ardeme (d. 1377) was renowned for his skill, performing difficult, dangerous, and even lethal surgical procedures. He cut off a fistula using a special syringotom, which had four threads previously pulled in through a probe with the head at its tip. His method was published in 1588 in a book The practice of fistula in ano.

 

Medicine during Europe’s Renaissance

 

The reform of anatomy began in Bologna and reached full swing at the University of Padua. Andreas Vesalius (1514-1564) described the technique for the dissection of the final part of the colon, external anal sphincter and anal levators in his work, De humani corporis fabrica.

 

Girolamo Fabrizio ab Acquapendente (1533–1619) is considered by some as the greatest proctologist of the renaissance. He was an opponent of fistular ligation because he believed the procedure is too painful and the recovery, too long. He also described in his book, Opera Chirurgica, anal fistulas and their treatments. He practiced and supported the methods of Celsus, replacing the linen thread with a dark red silk, which had a better grasp with hard and late decaying. He also described two kinds of syringotom: (1) one that was spiky and (2) one with a rounded top with a small ball, for penetrating fistulas. He also invented modified syringotom and other proctological instruments.

 

Medicine in 17th to 19th Century Europe

 

At this time, the social position of doctors saw a great improvement, and that accompanied the quick development of new techniques and instruments. Giovanni Battista Morgagni (1682–1771) was the founder of pathological anatomy. He was the first to explain that hemorrhoid disease is caused by the upright position of man. He also described a series of pathoanatomical changes that occurred in rectal cancer.

 

In 1689, French surgeon Louis le Monnier published Traite de la fistula del anus which translates to “Treatment of perianal fistula”. He described three types of surgical treatments for perianal fistula: (1) fistula ligation using linen thread, (2) burning of fistula, (3) incision of fistula. He advocated the last procedure, deeming the first one, too painful and too long, and the second one “terrible”. Another French surgeon, Pierre Dionis, held similar views, saying that incision does cause pain, but it does not last long.

 

A case of particular interest in the history of proctology is the treatment of the perianal fistula or King Louis XIV. His chief physician Aquin employed conservative methods of treatment without much success. Frustrated with his doctors, the king decided to have an incision. It was done using the method of Fabricio Aquapendente using a special curved knife. The scars and adhesions were removed using scissors. Treatment was successful only after three consecutive procedures (January 15, 1686, December 1, 1686 and January 1, 1687). His treatment was managed by surgeos Felix and Besieres. After the king’s recovery, the procedure gained some popularity but atittudes changed again over time due to the risk of bleeding after incision.

 

Proctology in Modern Medicine

 

In the 19th Century, French doctors particularly dealt with anorectal disorders. Jacques Lisfranc (1790–1847), a famous French surgeon, introduced a new method on perineal rectal resection due to cancer in 1826.

 

Another French doctor, Guillaume Dupuytren (1777–1835), was renowned for his successful treatment of Napoleon Bonaparte’s hemorrhoids.

 

In 1710, Alexis Litré handled a case of anal atresia and was the first to perform anus praeter naturalis, or as we call the procedure today, colostomy.

 

The early 19th century also saw the introduction of a conservatory therapy for hemorrhoids with the use of suppositories with astringent agents. Meanwhile, in 1860, Morgan was the first to cure hemorrhoids using sclerotherapy, which uses the injection of a ferrous sulfate solution in the nodes.

 

Conrad Langenbeck (1810–1887) commonly performed a procedure called paquellinisation. It uses the Paquellin device to burn the hemorrhoid nodes as they are pulled out by the gripper.

 

London’s St. Mark’s Hospital was considered as one of the most important centers in the 19th century for the development of modern proctology.

 

Endoscopic diagnosis and therapy was intiated in medicine by several inventions. The first rectoscope was constructed in 1895 and it was introduced into practice by Howard Atwood Kelly, an American gynecologist and surgeon, at Johns Hopkins University in 1903. In 1865, Antoine Jean Desormeaux (1815–1894) presented an endoscope with a mirror and Bozzini’s lighter as a built-in light apparatus to the French Academy of Sciences in 1865. It was used to examine the final part of the colon.

 

After the World War II, progress in the diagnosis and treatment of anorectal diseases gained new momentum, which continues to this day. Medicine saw the invention and introduction of better equipment and procedures.

 

Dr. Joseph Matthew from Louisville, Kentucky is revered as the father of modern colon and rectal surgery in the USA. He studied in St. Mark’s Hospital in London and in established the field of proctology after a meeting in Columbus, Ohia in 1899. In 1933, it was decided that a clear curriculum of the specialty was necessary, as well as a method of identifying physicians who are qualified to practice and use the title of a specialized surgeon. To execute this, the American Board of Proctology in 1935. In 1973, it changed its name to American Board of Colon and Rectal Surgeons. This is because colorectal surgeons are also well-trained in general surgery, so it was necessary that the scope be changed to include colon to rectal and anal surgery.


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