American Proctology Before 1899, Part 2: The Rise of the Rectal Specialists

Joseph M. Mathews' study at St. Mark's Hospital (London) in the 1877 to 1878 winter was followed shortly by a landmark move toward specialization in the United States: Mathews' heading of a Special Commission on Rectal Diseases appointed at the 23rd Annual Session of the Kentucky State Medical Society, held April 2 to 4, 1878. Various "rectal specialists," under various makeshift titles, were lecturing and publishing by the mid-1890s. The world's first proctologic journal, published between 1894 and 1898, was Mathews' Medical Quarterly, from its inception interpellating a community of colleagues.

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

[Historical review of colorectal cancer surgery]

The classical standard surgical technique for rectal carcinoma, abdominoperineal excision (Miles operation), has been gradually replaced by sphincter-saving surgery and more than 70% of rectal carcinomas are treated by anterior resection in which autosuture machines have played a major role in recent years. Wide lateral lymphadenectomy has been replaced by autonomic nerve preservation because of the high frequency of sexual and urinary dysfunction. Total mesorectal excision (TME) proposed by Heald et al which ignores the lateral nodes of the pelvic wall is the most popular technique in Western countries. The concept of TME is contradictory to that of wide lateral lymphadenectomy and the true merits of the latter should be examined in the near future. Minimally invasive surgery, including various procedures of local excision of low rectal tumors and colonoscopic polypectomy, has given great benefits to many patients. In Japan there seems to have been a lack of interest in adjuvant radiotherapy and chemoradiotherapy in the past, but they should be more seriously considered for the adjuvant treatment of advanced rectal carcinoma in the future.

The small polyp at flexible sigmoidoscopy: an historical perspective on why practices still vary

Current practices vary regarding the approach to small polyps discovered during screening flexible sigmoidoscopy. The most common practice is to perform colonoscopy whenever any adenoma is detected, a strategy that generally uses biopsy of polyps < or = 5 mm in size. However, data suggest that tubular adenomas < 1 cm in size in the distal colon have less predictive value than other distal adenomas for advanced adenomas in the proximal colon. Thus, some centers reserve colonoscopy for distal adenomas with tubulovillous or villous histology, > 1 cm in size, or with high-grade dysplasia. At the other end of the spectrum, another school of thought advocates screening colonoscopy, recognizing that most patients with advanced proximal adenomas do not have polyps in their distal colon. Advocates of this approach use any excuse to perform colonoscopy, whether it be a positive fecal occult blood test, minor symptoms, or small polyp at flexible sigmoidoscopy, even if hyperplastic. This review describes the history of the controversy regarding management of findings at flexible sigmoidoscopy, the data pertinent to the controversy, and the basis for the three approaches described above, all of which are currently within the standard of medical care.

[Colonoscopy: diagnostic and treatment methods]

The author presents the historical and technical development of the colonoscopy showing the advantages provided by the employment of the method, specially with the use of new equipment. He discusses different pre-colonoscopy bowel cleansing methods, and particularly the use of mannitol 10%.

Colonoscopy: history and development

Retrograde colonoscopy of the entire colon, and endoscopic excision of polyps from anywhere in the colon, began in June and September of 1969, respectively. Momentous advances have occurred over the past two decades, and the two procedures are now widely accepted and practiced. Development and perfection of the methodology were, at first, fraught with many difficulties, both procedural and technical, which had to be overcome. Significant opposition was engendered in the early years by some who claimed that the methods were both unnecessary and unduly dangerous. Time has proven otherwise. Progress came about as the result of a steady stream of publications from a number of centers documenting the successful and safe application of the methodology. A recounting is presented of the many contributions that predated development of the colonoscope and colonoscopy, and how the latter came about. For those coming into the art more recently, this review of beginnings is offered to allow a balanced evaluation of their craft.