Perspectives and reflections on integrated digestive surgery

Perspectives and reflections on integrated digestive surgery

Best Practice & Research Clinical Gastroenterology Vol. 16, No. 6, pp. 885±914, 2002 doi:10.1053/bega.2002.0351, available online at http://www.ideal...

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Best Practice & Research Clinical Gastroenterology Vol. 16, No. 6, pp. 885±914, 2002

doi:10.1053/bega.2002.0351, available online at http://www.idealibrary.com on

5 Perspectives and re¯ections on integrated digestive surgery Irvin M. Modlin

MD, PhD, FACS

Gastrointestinal Surgical Pathobiology Research Group, Yale University School of Medicine, New Haven, Connecticut, USA VA Connecticut Healthcare System, West Haven, Connecticut, USA

Mark Kidd Kevin Lye

PhD MD

Gastrointestinal Surgical Pathobiology Research Group, Yale University School of Medicine, New Haven, Connecticut, USA

The history of the integration of surgery is both extensive and complex involving internecine machinations that have, over time, variously encompassed the alchemical, religious, technological and biological phases of societal development. Thus, the discipline has evolved from a mystic rite through a guild phase to its current eristic status as a therapeutic modality considered by some as an art form as opposed to a quasi-scienti®c endeavour of often unpredictable bene®cial e€ect. This brief prolepsis provides an exposition of the evolution of surgeons and surgical thought proceeding from Galen in 3rd century Rome through Pare of Renaissance France, Billroth of ®n de sieÁcle Vienna, to Kocher and Whipple of Bern and New York respectively. It is apparent that in surgery, ontogeny may not readily recapitulate phylogeny and thus the need for a contemporary revaluation of integration within a novel educational nexus that encompasses the burgeoning matrix of biotechnological, ethical and ®duciary revolution is a critical requirement. Such an exercise must embody contemporary scienti®c and educational advance with evolving societal goals that include ethical variances, ®duciary issues and alterations in individual perceptions of life quality at both the medical and personal level. An incorporation of the basic tenets of digestive surgery as well as a delineation of its potential direction is both a vital and necessary exercise to ensure the attainment of appropriate future goals of medical, ethical, societal, scienti®c and educational validity. Current medical and surgical training programmes and the sub-specialization system are archaic, cumbersome, cost ine€ective and, for the most part, represent endless computations and permutations of intellectually antiquated and stultifying processes designed more than a hundred years ago. As such, the maieutic skills as well as the clinical vista available for the delivery of visceral disease care bear little relation to the needs and desires of contemporary society, whether medical or lay. Indeed, the century old notion of surgery and medicine as mutually exclusive disciplines that embraced diagnosis and therapy as divergent events needs to be cast aside to facilitate the development of a new model of disease management (organ speci®c). Speci®cally, training programmes require to be shortened (educational node) and their focus dramatically recon®gured (focus module) to ensure the establishment of a uni®ed group of specialists (cluster convergent) each interfaced in delivery of a particular skill (component speci®c) to the c 2002 Elsevier Science Ltd. All rights reserved. 1521±6918/02/$ - see front matter *

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resolution of a disease a€ecting a speci®c organ system. In this fashion, a time sensitive training programme producing educationally pre-focused physicians can be implemented to deliver time e€ective care in a cost contained environment with maximization of expertise and comprehensive interdisciplinary integration of knowledge, experience and skill (cluster care module). As such, digestive surgery itself should cease to be regarded as an end in itself or separate entity, but rather as representative of one facet in the delivery of a multifaceted integrated health care modality focused on the digestive tract. Key words: digestion; evolution; history; integration; organ speci®c care; surgery; teaching; technology.

The evolution of any discipline waxes and wanes in relation not only to the intellectual development of the individuals involved, but also the time frame within which the group functions. Nowhere is this more apparent than in the scienti®c arena, where additional factors, including the introduction of new technologies and the identi®cation of new concepts derived from di€erent but related ®elds, also mould the development of the particular discipline. In this respect, surgery has demonstrated an extraordinary ability to accommodate to the ¯ux of human knowledge and endeavour. Indeed, surgery may be deemed to occupy a nebulous middle ground between craftsmanship, scienti®c endeavour and emotion-based care-giving. As such, the discipline is bu€eted by a variety of in¯uences that are often disparate and themselves dependent on a number of pressures such as societal attitudes, patient expectations, the market place and scienti®c progress. In particular, the more recent focus on resource allocation and quality of life issues has dramatically altered the perceptions of surgical care that dominated society half a century ago when no cost was spared and no intervention too great if life could be preserved (Figure 1).1 It may be noted that one of the `power' words of the 20th century, namely `integration', is now being applied to the medical profession in an attempt to make sense of the proliferation of innumerable subspecies of health-care delivery. Although surgery is not immune to this issue, it should be noted that surgery has, over thousands of years, long been integrated into the evolution of society as well as integrating into itself numerous related facets of culture, science and technology. Although the concept of integration as applied to the realm of surgery is worthy of consideration, it is necessary to consider what constitutes the notion itself prior to re¯ecting on the integration of digestive surgery per se. In general, `integrated' is something that is regarded as made up as a whole of separate integrant parts, the composite belonging to such a whole and in so doing being deemed to render it complete, entire or perfect. An alternative consideration of the meaning may be deemed to refer to individuals (in this case surgeons) and as such pertains to or designates people with strong eidetic imagery. In such individuals, functions that are related are separate, but such independent traits are related to one another to a high degree and can thus in¯uence each other. The notion of integration is in fact fundamental from the evolutionary point of view, and to integrate and disintegrate are true essential forms of human existence corresponding in a sense to the elementary forms discovered by biology. As applied to surgical society, the use of the word `integrate' may be accepted as rendering a di€use form of specialization entire or complete and thereby composing or constituting a whole or separate entity. Alternatively, it might be considered as being applied to the discipline in order to render it complete or perfect, thus assuming that the current form is imperfect and can be amended by the addition of the necessary parts. A more literal interpretation might be accepted as the putting or bringing together of the

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Figure 1. A page from the text of the Celsus book on medicine with an overlay of an early Bougery etching of the abdomen. The text of the classical work De re medicina, by Aurelius Cornelius Celsus of Rome, was one of the ®rst medical books to be printed. It is the ®rst example of the integration of digestive remedies into the broad fabric of therapy. Although the work was ignored by the Roman practitioners of his day and slighted as mediocre by Quintilian, Celsus, who was not a physician but an aristocrat of the noble family of Cornelii, remains one of the authorities of his time. So highly rated was his writing that he was considered to be the Cicero of Medicine, and the eight books that constitute De re medicina are masterpieces of precise literary style. The ®rst of the four texts deals with diseases that may be treated by diet and an alteration of lifestyle, whereas the last four describe those amenable to drugs and surgery. Celsus believed that nutritive enemas were important in treating abdominal problems and provided a di€use and exotic list of herbal remedies that might be used to remove stomach discomfort and other digestive ailments (centre and right).

parts or elements of digestive disease care as currently constituted to form one whole or to combine all into a whole. The history of integration and surgery is a long and complex one.2 An early example is provided by the exorcism of evil spirits by trephining, scari®cation to ward o€ bad dreams and noxious spirits subsequently being utilized. An extreme use of the religious integration of surgery was provided by the Mayan technique of total `cardiectomy', while a less dramatic but just as exotic usage was the introduction of circumcision as a religious ritual (Figure 2). Physicians believing that disease could be freed from the body by venesection empowered surgeons to do this on their behalf

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Figure 2. The integration of surgical technique into religious rites. The Mayan reverence for the heart as a subject of absolute veneration required the use of early surgical skills. The integration of surgery into religious belief is exempli®ed by the use of surgical skills in the dramatic ceremonial excision of the heart as undertaken by the Mayans (bottom right), indicating their belief that the life principle resided in this organ. In their cosmology, the heart was rightly considered to be the seat of life. This concept survived for a thousand years until the ®rst successful `cardiectomy', performed in 1959 by Christian Barnard in Cape Town, South Africa.

and thus integrated surgical therapy into medical practice. As a better understanding of disease evolved, surgeons were integrated at all levels to provide diagnosis or care; thus, probing, extracting, bleeding, draining and bone-setting became integrated into the fabric of daily care. Within their own society, surgeons integrated their skills by training each other in the arcane rites of excision and developing associations and societies that promulgated the development of `integrated' surgeons. By the late 19th century, they also integrated pharmacology into their curriculum as well as new devices, and by the early 20th century, the integration of scienti®c advances into the warp and woof of the surgical discipline was well established.2 In terms of integration within the fabric of society, the early notions of surgeons as mere barbers and possessed of little sophistication faded as surgeons sought urgently to integrate their image of gallant life-savers possessed of the highest ethos into the

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perception of the populace. Furthermore, as attention was brought to bear on issues relating to quality of life and the realities of outcome in the context of resource allocation, surgeons clearly enunciated their position in terms dealing with the hopes of patients and the futility of some aspirations. Thus, integration and surgery have long been partners in the evolution of the human condition. Indeed, despite the consideration that there exists an inherent paradox in the notion of assimilation, given the `independent nature' of the surgical personality, it is certain that integration as a general concept has long been part of the discipline. Thus, no reason exists to doubt that further integration will occur, particularly in the sphere of visceral disease management.

REFLECTIONS For years, questions of surgical ontogeny and phylogeny have perplexed historians, sociologists and educators alike. More recently, however, it has become evident that the elucidation of the origin of surgery, as well as a delineation of its future direction, is necessary not only for the good of its clients (previously referred to as patients), but also for the educational and administrative regulation of phenotype (what constitutes a surgeon).3 In addition, the recon®guration of the archaic construct of surgical education (previously referred to as training) and the delivery of appropriately targeted care (formerly known as candidates for surgery or patients) into a socially and ®scally responsible resource allocation model is a critical issue. This recognition re¯ects a need to understand further both the human dynamics of what constitutes a surgical system (the psyche and physiology of a surgeon) and to identify the key elements and events related to the impending malfunction of the discipline (the surgical organism). In this respect, it has become crucially important to delineate and manage the biology of the disease processes currently threatening surgery lest they culminate in either a loss of surgical function (training and care delivery) or the advent of commercial proliferation and loss of quality (surgical neoplasia ± loss of regulation and the debasement of the product and judgement). The two critical developments of early 20th century surgery re¯ected the introduction of anesthesia and antisepsis.4 With their formal adoption, the surgical horizon expanded from a limited worldview (hernia repair, stone removal, joint and limb stabilization) to one capable of an almost global territorial perspective. Inherent in this advance was a recognition of the need for adequate education (curricula and communications) and an appropriate determination of competency (examination and certi®cation). It was soon apparent that an understanding of the issues within the areas de®ned for consideration often resembled the attempts of an inhabitant of a distant archipelago to solve the New York Times crossword puzzle. Di€erent countries, di€erent languages and cultures, as well as expectations and di€erent concepts of what constituted adequate or proper practice, resulted in seriously divergent postures regarding the institution of common criteria acceptable as a basis for a `surgical charter'. Potential hopes of solving the issues further by discussion were often dissolved by a recognition of the paucity of the data available, the epistemological nature of the questions and the lack of an obvious framework for interpolation of scienti®c facts with surgical desires, as well as the virtuoso personalities of many of the surgical leadership. Indeed, the discussion between the participants sometimes resembled Lewis Carroll's recounting of the colloquy between Tweedledee and Alice5:

890 I. M. Modlin et al `The time has come', the walrus said, `To talk of many things: Of shoes ± and ships ± and sealing wax ± Of cabbages ± and kings ± And why the sea is boiling hot ± And whether pigs have wings.''

Di€use and often heated discourse regarding surgical technique, the biology of disease, education, training, specialization and territorial imperative (therapeutic endoscopy, interventional radiology) eerily echoed the sagacity of the walrus. Nevertheless, the issues were not only dicult to pinpoint but, in much the same way, also quite thorny to resolve. Sapient members of the assembled surgical cognoscenti claimed that the mere thought of altering the hallowed precepts of Kocher, Billroth, Halsted and Moynihan might lead to or evoke Nietzchean if not Freudian degeneration of the sancti®ed followers of the mythical progenitors of the chosen tribe of physicians known as the `surgeons'6 (Figure 3). On the surface, it appeared that there was a meaningful basis on which the nature of the discipline of surgery and the regulation of its labour and education could be accommodated to embrace a framework capable of integrating other disciplines and achieving a form of lineage transformation while not signi®cantly disturbing the phenotype. On closer inspection, however, it was apparent that diverse and di€use components of the surgical system were simply points on a board that could be broadly recognized as an important intellectual backdrop against which the proposal to consider the exploration of an unknown area was being considered. After almost two decades of otiose discussion and persistent deliberation, one is still left with the impression of having surveyed a 17th century Hondian conceptualization of the world. Thus, recognizable continents, de®nable seas and strange denizens are apparent, but vast areas of the chart of surgical progress remain simply blank. Such comments should not be interpreted as denigratory since the participants in the debate of the future of surgery have been of the highest calibre and inspired by the highest motives and zeal. Unfortunately, the negligible outcome re¯ects a woeful ignorance of a vital area of recognition, namely the inability of the surgical community to look outside its own doctrine in the identi®cation of a new solution for the future. Indeed, the concept of integration, which was long part of the evolution of surgery, is currently more in need of reintroduction to the discipline than ever before. The di€erence is that integration may dramatically change the face of surgery such that an integrated discipline of surgery may no longer be surgery. Herein lies the paradox. Can a group advance when faced with the possibility that a successful advance may mean the extinction of the species as it knows itself? This overview seeks not speci®cally to critique any particular posture but rather to focus on the concept of integration as it may be applied to digestive surgery. It aspires to de®ne the lack of cohesion and the major areas of nescience that currently exist in a most critical area of visceral therapy. What is desperately needed is the establishment of a framework within which to de®ne a series of questions and goals, which should be resolved in an attempt to generate a cohesive integration of the area of visceral disease management. The importance of the project is self-apparent in that without the gut and its ability to function appropriately, all other human systems are impotent.4 Indeed, human survival depends on an adequate integration of all the systems of function, and in this respect the same principle needs to be applied to the disciplines responsible for the preservation of human life. Indeed, if one views the historical perspective, our early concepts of surgical

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Figure 3. Notable ®gures in the evolution of surgery. Surgical thought and technology have steadily evolved over time. Galen (top left) was an assiduous anatomist who, despite the limitations of his time (3rd century Rome), made accurate and sometimes perceptive anatomical observations. Ambrose Pare (centre left), a French military surgeon, dominated Renaissance medicine, exhibiting a disdain for dogma and introducing new therapeutic concepts. An experimentalist, he is best known for his abandonment of boiling oil to treat gunshot wounds and hot irons to cauterize blood vessels. Berkeley Moynihan (bottom left) won acclaim for his heroic surgical e€orts to treat peptic ulcer disease in the 19th century. Theodor Billroth (bottom), apart from being a great thought leader and teacher, may rightly be considered to be the father of upper gastrointestinal surgery, whereas his proteÂgeÂ, Mickulicz (bottom right) established many of the basic principles of bowel surgery. Halsted (centre right) was a pioneer of delicate surgery and emphasized haemostasis and antisepsis, as well as introducing new techniques for visceral wound closure. Halsted sought to emulate Kocher (top right), who was awarded the Nobel Prize for medicine in recognition of his contribution to the surgical treatment of thyroid disease. Whipple (top) is best known for his development of pancreatic surgery.

growth and development and the regulation of education and practice may be viewed as closely approximating the original Galenic concepts of human anatomy (structure with a nominal understanding of function).4 Thereafter, Vesalius de®ned and made their geographical relationship to each other apparent and delineated the potential function of the system as a whole in much the same way as the original colleges strictly de®ned training and certi®cation without fully understanding the limitations of their discipline.7 The later musings of Halsted, Flexner and the speciality and review boards further optimized our minimal knowledge, but the passage of time and the progress of

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knowledge and technology have vitiated their initial successful charting of the course of surgery.8±10 What is needed is a Morgagni of the new millennium who may de®ne the morbid condition of the body of surgery and propose the salvation of its soul (resurrecting the spirit and reincarnating the discipline as a new and integrated life form) (Figure 4).

CONSIDERATIONS The origins of surgery and the regulation of the proliferation of its diverse areas is a subject of considerable importance and should be considered in both an individual and a disciplinary context.4 It might be noted that the school of surgical thought functions as a form of clonality and may even generate an impression of ritual tribal behaviour.

Figure 4. The pathological observations of Morgagni provided the initial targets for surgical therapy. Once the general concepts of anatomical structure and physiological function had been established, attention was directed towards the anatomical basis of disease, namely pathological anatomy. Morgagni (left) was among the earliest to identify the precise lesions that constituted disease, and his seminal descriptions in De sedibus, et causis morborum provide some of the ®rst images of organ pathology and its relationship to clinical symptomatology and disease. His observations were subsequently extended by Cruveilhier of Paris and reached their acme with the work of Rokitansky in Vienna in the mid-19th century.

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Furthermore, the concept of a surgical personality niche, albeit Abraxian in its elegance, engenders a shimmering vision of an Atlantis that is doomed to perish unless integrated into a broader framework of patient care. Coleridge, in the deepest of his opiate-induced reveries, would have been proud of the sophistry that has allowed the interweaving of the persona of the prima donna with the deity-like ability to save life using hands imbued with Wittgenstinian properties. How can individuals possessed of such powers err in their judgement? Current information indicates that not only is the day of Atlantis at hand for surgery (in terms of ®duciary and regulatory overview), but also its sons may be doomed to the fate of Icarus if they ¯y too high (o€ering therapeutic bene®t not supported by outcome date). The thesis of this essay will be to provide an analysis of the di€erent subjects pertinent to the dramatic relevance of the current problems of surgery as it is currently situated and provide a lucid series of suggestions by which the discipline may integrate itself within the framework of a new biotechnological world yet maintain the vital spirit so unique to its existence. Indeed, it may not be possible to provide an entirely satisfactory recon®guration, but it is nevertheless necessary to derive a novel format for surgery within which the notion of individuals capable of biological mechanics can reconcile the diverse but heuristic propositions necessary for a future metamorphosis. Dare a discussion take place in which ®nance and resource allocation are not evoked as either the new holy grail of medicine or the star in the sky over the Judean desert? The relevance of the somatic mutations of the individual destined to practise surgery also require further adumbration, and the relevance of the quality-of-life issues incumbent upon training and practice need to be addressed in a stark and apposite fashion. The dreaded spectre of the surgeon as an individual not characterized by manual dexterity and fortitude, and not imbued with hope and knowledge, needs consideration in de®ning those skills required in the integrated design of a `new surgeon'. Who can deny the allure of the man or woman surgeon with powerful demeanour, steady hands and an iron gaze tinged with compassion, as opposed to the timid and retiring manner of the bank clerk? Should consideration be given to the integration of the popular concept of the image of a surgeon into role-modelling and lineage modi®cation? Can the general public accept the concept of the surgeon as a scientist, or the radiologist as a surgeon? Alternatively, might there be a place for introducing the reassuring concept of a group of molecular and manually trained policemen (integrated surgeons) capable of exerting continual vigilance in the viscera lest crime (disease) run rampant in the gut and its attendant organs? The de®ned role in society of those dedicated to protecting the barrier between health and disease might provide a sense of order in the hitherto disparate constellation of health and insurance information placed before the cognoscenti of the proletariat (Figure 5). HUMPTY DUMPTY AND THE JABBERWOCKY The subject of the nature and function of the myriads of physicians now present paints a Bosch-like picture of the disarray of health care. The surgeon as currently depicted in the medical scene is often no worse than many of his colleagues, but the dramatic nature of his role, as well as the major ®nancial implications of his presence, engender repetitive and excited comment. A utopian vision currently under consideration proposes that all diagnostic and therapeutic strategies can be implemented using a new model whereby purely technical operators (untrained in the cabbalistic and arcane arts

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Figure 5. The repetitive problem of the overambitious surgical conceptualization of therapy can be represented by the tale of Icarus. The story of Daedalus and his son Icarus, who perished by ¯ying too close to the sun, may be used as a metaphor for the overzealous application of new techniques. Having been invited by the Cretan king Minos to build a labyrinth to hold the Minotaur, both Daedelus and Icarus were jailed on completion of the task. Daedelus ingeneously constructed wings to facilitate their escape, but during their ¯ight to Athens, Icarus, delirious with his new-found technique, fell to his death after challenging the power of the sun. The Icarus syndrome represents the overzealous application of technology to the resolution of a problem.

of the medical school) can undertake not care but task delivery on demand (the mechanics of medicine). In a chiaroscuro commentary on the congeners available for such responsibility, the ephemeral outline of the possibility (dare one allude to it) of the regulation of therapy was dimly illuminated as a ¯ickering image of a dark dream (you purchase the therapy or therapist you can a€ord, and not the therapy available). An even more Dickensian notion might consider the future surgeon as being possessed of a chimeric phenotype capable of not only operating, but also undertaking diagnostic evaluations using sundry equipment and biochemistry while possessed of adequate biological skills to elucidate the best-de®ned path between pharmacological strategy and technical intervention. The unique possibilities intrinsic to the diversity of digestive surgery support the urgent need for the development of a concept of a scenario within which a unifying hypothesis might be developed whereby visceral surgery may be integrated at the levels of training, organization and care delivery.

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Since no current algorithm exists to synthesize the questions presented, it is probably most appropriate to summate the current status using poetic re¯ection and licence. The proposal of integration is like a star, globulating, scintillating and viviscent in its appeal. Yet like the evening star, it is distant, dicult to de®ne and currently unreachable in the galactic immensity of territorial imperatives, ®duciary considerations, tribalism and ego-directed feelings of surgical supremacy. Nevertheless, the unexplored biological space currently utilized by surgery needs to be better occupied and better addressed by the leadership of the discipline. The situation is currently akin to the explanation provided by Humpty Dumpty in response to Alice's request that he explain the notion of the `Jabberwocky' (probably

Figure 6. The Snark metaphor, as penned by Lewis Carrol, may be employed to assess the confusing outcome sometimes generated by the concept of ideological integration. The collage is composed of illustrations of the hunting of the Snark (background), which shared logico-structural similarities with the Jabberwocky and the Walrus (bottom right). Lewis Carroll was the pseudonym of the English writer and mathematician Charles Lutwidge Dodgson (1832±1898), known for his children's books that are distinguished as satire and examples of verbal wit. Carroll invented his pen name by translating his ®rst two names into the Latin ± Carolus Lodovicus ± and then Anglicizing it. In his diversions as an author of comic fantasy, he became noted for his creation of new words (neology) in the English language. There appears to be no basis for the proposal that he invented bariatric surgery in this capacity. As a mathematician, Carroll was conservative and derivative, and as a logician, he was more interested in logic as a game than as an instrument for testing reason; in this respect, he may be considered to share certain traits reminiscent of surgical thought.

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the earliest attempt by a mathematician, Dodgson, to embrace the concept of the rationale of surgery) (Figure 6):5 T'was brillig, and the slithy toves Did gyre and gimble in the wabe±: All mimsy were the borogroves, And the mome raths outgrabe.

Humpty explained that brillig meant it was 4:00 pm, the time when one began to broil things for dinner and meeting sessions wound down. Slithy meant lithe and slimy, which is active, so that the word is actually like a portmanteau and has two meanings packed into one word. This would presumably also re¯ect gut motility and the diculties inherent in anastomosis. Toves, on the other hand, are more dicult to understand because they are in between lizards and are something like corkscrews; they may represent gut cells of dubious lineage or new instrument types. In addition, it is proposed that toves live under sundials, where they survive by eating cheese. This surely is a comment on the role of luminal nutrients in ensuring wound healing, although it might be construed as re¯ecting on-call hours for residents and their appropriate sustenance. The nature of the cellular motion of the `gyres' is like that of a gyroscope, and their other function is to gimble, which is how a gimlet makes its hole. This of course addresses the nature of trocar insertion sites and, in terms of surgical science, alludes to tight junctions and membrane pores, vital for ¯uid management in compromised gut patients. The wabe is, of course, a grass plot around the sundial and is the milieu within which the toves function as they determine the length of operative time and billable events engendered by the gyres (junior sta€) or the Jabberwocky (departmental chair) himself. Overall, this concept embraces a description of the unstirred layer concept and crypt matrix so vital to digestive function. Mimsy means to be ¯imsy and miserable and is another portmanteau word that presumably re¯ects the desperate feeling of surgical investigators lost in the immensity of the digestive ®eld and regarded as neither ®sh not fowl (too technical to be physicians, too dull to be creative researchers and too insensitive to reality to determine policy).The borogrove is a shabby bird with feathers sticking all round it, something like an ambient mop and as early a description of a cell membrane receptor site as one can ®nd. Hardest of all to understand is the mome raths, since rath is a type of green pig and mome means lost or away from home. Whether this is an allusion to the derivations of those involved in the ®eld of digestive surgery is unlikely, but this may be resolved at the conclusion of the Tytgat memorial meeting. Of particular interest is the derivation of outgrabe, which is a sound similar to something between bellowing and whistling with a sneeze in the middle. The most likely explanation for outgrabe is the collective sound made by the audience at the recognition of the extraordinary value of the information provided at the Amsterdam meeting, although a similar resonance is commonly noted at the completion of a laparoscopic procedure or following a four-®nger anal dilatation at the conclusion of a low anterior resection. This brief whimsical perspective on the integration of digestive surgery is extended in a series of synoptic paragraphs that comprise the remainder of this article (Table 1).

EARLY SURGERY The earliest forms of surgery were devoted mostly to dealing with di€erent aspects of trauma and usually involved the repair of damaged limbs or the suture of penetrating

Re¯ections on integrated digestive surgery 897 Table 1. The evolution of surgical integration. . . . . . . . . . . . . . .

Gods and spirits Dreams and druids Structure and function Medicines and techniques Disease process Training and skills Societies and institutions Instruments and agents Science and biology Society and self Specialization and skill Technology and transplant Teaching and service Human aspiration and reality

wounds.2 In some societies, opening the brain or the thoracic cavity may have re¯ected early surgical endeavour but was principally aimed at liberating evil spirits or propitiating the gods deemed to be responsible for maintaining the balance of health and disease. Apart from the early societal taboo against the desecration of the human body, the two principal problems consequent upon surgical intervention were haemorrhage and infection; indeed these issues still remain the bane of surgery. Although earlier concepts regarded blood loss as related to the loss of vital spirit and likely to lead to death on this basis, they nevertheless encapsulated the principle of homeostasis and the critical role of the circulation in the maintenance of life. On the other hand, infection was usually construed as a sign of malign in¯uence consequent upon possession by an evil spirit, and demise regarded as an issue subject to the will of the gods (Figure 7). Progress in surgery was signi®cantly limited by the inability to deal with problems related to any of the body cavities. Indeed, prior to the 19th century, adventures into the peritoneal cavity were usually either desperate attempts by brave or misguided persons or wild experiments of an almost reckless nature.11 Although early experiences with caesarean section date back to old Roman edicts, the operation itself was dangerous and unsafe as late as the early 20th century. Surgical intervention in the peritoneal cavity on a regular basis to deal with the organs of digestion was initiated in the late 19th century and only became a relatively safe reality in the early part of the 20th. This advance was to a large extent due both to the introduction of anaesthesia and subsequently the development of at ®rst antiseptic agents and thereafter antibiotics.11 The early skills acquired by surgeons in the setting of bones, the reduction of dislocations and the treatment of open wounds were mostly acquired by experience ± better known as trial and error. Surgical skills were to a certain extent developed by those interested in manual intervention, and no formal training was required. The skills were in fact often handed down within particular families, such individuals also acquiring experience with medications that developed from infusions, tinctures and herbal concoctions.2 From the latter group of skills emerged individuals who were capable of treating symptoms, in particular those related to pain and fever. The recognition of the analgesic or sopori®c properties of plants such as the mandrake or poppy was useful in that these could be utilized not only for pain relief, but also to render people relatively insensate, with a view to undertaking brief and violent surgical interventions.

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Figure 7. An illustration of the use of setons by Albrecht Durer (1524) represents the integration of surgical technique with charlatanry. An article published 300 years later, in 1832, in The Doctor provides a succinct description of the medieval modus operandi: `Setons may be employed whenever it is required to keep up a discharge from the surface of the body. Their use is twofold ± to prevent disease and to cure it. A man gets worse of a local complaint his head becomes twice as heavy as it ought to be ± at least it feels so. He gets a seton made in the nape of his neck and feels as light as if his head had been relieved from a cargo or a crown. Some persons from predisposition to disease are never in health without a seton or issue (for they act in the same principle). Dry up the discharge and they are immediately a€ected with pain in the head, in¯ammation of the lungs or eye, disease of the skin, or the blue devils beyond bearing'.

The applications of such agents to surgical practice, coupled with manual speed and dexterity, moved surgery towards a plane not easily distinct from that of a brilliant swordsman or a manual labourer. Indeed, so distinctive had the art of medication as opposed to surgery become that the two groups were regarded as separate and distinct to the point that the surgeons were referred to as barbers. The Church forbade its minions to spill blood, and it was deemed a lowly occupation to wield a knife and bleed or trim the tonsures of the faithful. On the contrary, physicians were regarded as scholarly and wise compared with the surgeons, who were deemed to be mere practitioners capable of manual labour on the human body. Given the obvious limitations of the profession and the inability to address the bodily cavities (cranium, thorax and peritoneal) with any degree of safety, surgery remained for centuries con®ned to either the periphery (limbs) or the ori®ces, where treatment was

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generally directed at haemorrhoids, tooth extraction or stone removal. The latter arena provided ample opportunity for daring as the urethral ori®ce was, for practical purposes, too small to allow stone extraction, and audacious transperineal approaches were used to remove bladder stones. The technique may be best likened to a perineal stab followed by the intrepid manual or sometimes instrument-assisted removal of bladder calculi. The hernial ori®ces were addressed with more enthusiasm than skill, and trusses were likely to prove safer than surgical intervention, particularly if bowel was encountered.11 In most instances, the earliest introduction to visceral surgery represented either unexpected problems with the contents of a hernial sac or the protrusion of bowel through wounds engendered by knife, javelin or sword wounds in the abdomen (Figure 8). The rudimentary development of early surgery largely re¯ected the elucidation of anatomy. Thus, a de®ned structure became the ®rst basis for a therapeutic target. Galenic notions of anatomy proved useful for providing a foundation, but the restrictions placed upon human dissection by the Church led to distortion and misunderstanding. The advent of Vesalius in the mid-16th century enabled the basic structure of the human system to be identi®ed and provided some rationale for technical intervention, although the idea of disease still for the most part implicated unde®ned miasmas and evil omens, except in obvious instances of trauma. The relationship between health and disease

Figure 8. The role of Billroth in Vienna may be taken as representative of the integration of surgery with new thought, as represented by ®n de siecle ideology. Although Billroth (top left) was a pianist and violinist of consummate skill as well as a music critic of the highest quality, he is best remembered for his contributions to the development of surgery. Appointed professor of surgery in Vienna in 1867, he became the most distinguished surgeon of his time and attracted students from all over the world. While the Vienna General Hospital (top) achieved international status as the greatest teaching centre of the time, his trainees became leading ®gures in numerous departments of surgery in Europe and thus spread the words and techniques of their master throughout the continent. It might be noted in this respect that the `disintegration' of his department (dissemination of information) served surgery as well as the integration of his teaching methods with the disciplines of medicine, pathology and research.

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and the alteration in normal structure was most clearly delineated in the early 18th century by Morgagni.4 The subsequent understanding of pathological anatomy and the relationships of symptoms to disease process facilitated the initiation of the development of a coherent body of knowledge whereby structural alteration could be interfaced with disease. Unfortunately, the elucidation of symptoms, their relationship to disease and the ability to cure was still sadly lacking since neither appropriate drugs nor adequate surgical intervention were available. Thus, even as late as the turn of the 19th century, Vienna (the ®nest of the medical schools at the time) preached a policy of therapeutic nihilism, and physicians as well recognized as Naunyn regarded surgery as little more than an autopsy in vivo. Even as late as the end of the 19th century, a British internist of considerable wit and skill considered the idea of surgical intervention as `too quixotic to even contemplate'.4 TRAINING AND APPRENTICESHIP The earliest forms of surgical training mostly comprised the handing down of skills from one generation to the next.4 This was subsequently replaced by apprenticeships whereby an individual interested in obtaining such knowledge might work with a surgeon for a number of years and then move on as an independent practitioner. Skill was based upon the results achieved as well as on a reputation often garnered more by marketing ability than knowledge. By the 15th century, the advent of formal establishments that later evolved into the early medical schools, with a curriculum and designated teacher/practitioners, provided a central focus for medical training that included some basic surgical precepts. Such institutions were largely based around the Church and evolved from monastic orders as illness was considered to be a punishment from God for one's sin. As the result of a combination of ritual prayer and intervention centered around the houses of worship, early medical and surgical practices became codi®ed by priests skilled in the removal of a‚ictions. Such works led to the delineation of a body of knowledge that comprised the fundamentals necessary to be a physician. The centralization of knowledge, in conjunction with monastic or religious institutions, led to the development of centres of excellence including Salerno, Montpellier, Leiden, Paris and Gottingen.12 Here both patients and physicians congregated to learn, treat or be cured. Even prior to the development of such schools, however, individuals with special gifts and dexterity, such as Ambrose Pare, Guy de Chaulliac and John of Ardern, had distinguished themselves by their individual prowess and taught many who worked with them. Thus, a mixture of apprenticeship and formal curricula were available depending on the location and individual persuasion of those seeking to become surgeons (Figure 9). The subsequent development in the 16±17th centuries of great medical schools such as Leiden, Edinburgh, Vienna and Paris led to the establishment of formidable schools of surgery in which individuals were rigorously trained in the discipline.13 By the 19th century, such establishments had evolved to the point at which great surgical leaders such as Kocher, Billroth, Hunter, Lister and Langenbeck emerged as pioneers not only of individual operations, but also of entire disciplines of surgery.14 Indeed, this type of training led to the development of `schools' of surgical thought in which the practice of one surgeon became integrated as a body of thought that was then disseminated en bloc to a series of di€erent medical schools and hospitals as the pupils matured and accepted positions elsewhere. This era, which covered the late 19th and early 20th centuries, led to the development of surgeons who were for the most part trained to

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Figure 9. The integration of organ speci®city with surgical dexterity. J. Mickulicz (top left) contributed to the development of oesophagogastric surgery, pioneered the introduction of gastrointestinal endoscopy and ushered in a new era in the establishment of safe colonic surgery. Billroth (top right) was the ®rst to successfully resect a pyloric tumour and is credited with the ®rst survivor of a gastrectomy (1881). Langenbuch (centre left) was the ®rst to advocate and successfully remove the gallbladder (1882) for gallstones. Whipple (centre right) developed and re®ned a single-stage technique for the resection of an ampullary carcinoma over a 5 year span prior to the Second World War (1934±1939). McBurney (bottom right), in 1894, published a new operative approach to the appendix and in so doing engendered an operation of unprecedented ecacy. Miles (bottom left) was a doyen of rectal surgery and introduced the abdominoperineal resection for rectal carcinoma.

undertake all forms of surgery. In some instances, however, a surgeon might develop a particular predilection for an area of the body and become recognized as a specialist in that disease or anatomical location. This represented the earliest form of specialization and was deemed to exist only by repute or self-declaration. There was no formal de®nition of a speci®c expertise, and such recognition was usually derived by selfacknowledgement. As might be predicted, however, those a‚icted with a particular disease would in such circumstances gravitate to an institution that housed an expert, and in this fashion the informal basis of specialized hospitals was established. The formal development of specialized schools of training or focused curricula would, however, require the passage of a further half-century. As might be predicted, arguments raged regarding the pros and cons of specialization as purists claimed that such individuals

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were no longer `real' surgeons or, more realistically, that such focused skills diminished the practice domain of the generalist. Although inadequate resources in a particular institution could in many cases not sustain the speci®c development of an area, the problem was often more an emotional one as archaic practitioners of the discipline railed against disintegration. FLEXNER AND FORMALIZATION The introduction into the USA of formal training programmes in surgery represented an amalgamation of the late 19th century German system8,14 with the more novel and realistic assessment provided by the Flexner report of 1910. Overall, the entire system of medical education in the USA, and not just surgery, had been viewed with concern, and a signi®cant reform of the academic curriculum and clinical teaching was well underway by the beginning of the 20th century in America (Figure 10). Leaders in the medical profession were fully aware of the overproduction of physicians in a variety of poorly run proprietary schools, and by 1904 the American Medical Association had created a permanent Council of Medical Education that surveyed and rated the nation's schools. Thus, by 1910, the 166 medical schools of America had been reduced in number to 126. This atmosphere of national concern for the quality of American medical education prompted the Carnegie Foundation to commission Abraham Flexner to conduct a comprehensive, independent study of the nation's medical schools. His 1910 report, Medical Education in the United States and Canada (quoted in reference 8), represented a classic work typical of the progressive era of thought then prevalent. Using an intellectual style not signi®cantly di€erent from muck-raking journalism, Flexner revealed the discrepancies between school catalogue descriptions of courses and clinical opportunities and the realities of medical training in schools throughout the nation. He opined vehemently for the placement of medical education within the structure of American universities, away from the strict control of practitioners, and emphasized the need to close substandard schools. For Flexner, the desired ideal was truly academic training, clinical teaching taking place in close geographical association with university science departments. Much of his criticism was speci®cally applicable to the fashion in which surgery was taught and practised. Prior to this, the European system had resembled either prolonged servitude or patronage of the most extreme kind as individuals laboured for an inde®nite period of time in the hope of being awarded a fealty.14 The British surgical training system was little better organized and in addition bore the stamp of a class-conscious society whereby certain individuals, by virtue of their background, could not hope to aspire to a surgical training. By the turn of the century, both countries had nevertheless produced remarkable surgeons, established great schools of teaching and dramatically improved the quality of surgical care. Surgery in the USA was a haphazard a€air in the late 19th century.14,15 Prior to this, the majority of surgeons were informally trained or the benefactors of an apprenticeship, or had in some instances travelled to Europe where, as observers or occasionally as assistants, they had acquired some degree of expertise. At the turn of the 19th century, William Halsted of Johns Hopkins (Figure 11) became a prime mover in the formalization of an integrated approach to surgical education based upon his familiarity with the German system.16 At the turn of the 19th century, a degree of systematization was thus appended to the entire process of medical education, which, particularly in the USA, had begun

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Figure 10. The contributions of Flexner established the basis for the integration of surgical education. In the early 20th century, an impressive array of intellectuals, social critics and grassroots activists launched a progressive education movement that sought broad-based change in American educational practice. The crux of the progressive programme was the establishment of a plan emphasizing ¯exibility and critical thinking. Abraham Flexner (centre) stated in 1910: `The curse of medical education is the excessive number of schools. The situation can improve only as weaker and super¯uous schools are extinguished'. In 1916, he proposed an experimental school based on these ideas, and a year later he founded the Lincoln School in New York, which embraced many of these disparate elements. His evaluation of the medical educational system led to the development of the medical school model of the early-20th century, as exempli®ed by the Johns Hopkins School of Medicine. Interestingly, Flexner also considered Yale, although it had serious problems in comparison, to be among the schools that were redeemable.

to resemble a marketing operation as opposed to a formal education process. Similarly, the integration of the surgical curriculum with that of pathology and even physiology led to a substantial ampli®cation of the breadth and depth of surgeons who had previously been held to be little more than technicians. Thus, the implementation of the Flexner report in the USA and the assumption of many of the principles of practice and education that had developed within the German and Austrian systems led to a systematized approach to surgical teaching as opposed to either an apprenticeship or a degree purchased under marginal conditions vaguely characterized as education. The destruction of much of the infrastructure of European medical and surgical training by the First and Second World Wars led to a signi®cant diminution in the number of

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Figure 11. The Halsted address to Yale University in 1904 sought to integrate surgery into a formal education process. Halsted, who received his AB in 1874 from Yale University, gained high repute as a surgeon, diagnostician and advocate for aseptic techniques. He was among the ®rst to use cocaine injections to block pain transmission (1884), improved techniques for intestinal suture, and developed surgical methods based upon strict aseptic technique, the use of ®ne silk suture material and the complete closure of wounds whenever possible. One of his greatest legacies, however, was his success in training surgeons, the majority of his residents going on to other institutions to promote his techniques and to set up surgical residency programmes. In addition, Halsted was a major advocate of the establishment of formal medical training programmes and a strict critic of their failings. His thoughts on this subject were well summated in the 1904 Commencement Address that he delivered to the Medical School of his alma mater. Coincidentally, at the special request of his classmates, an honorary LLD degree from Yale was conferred on him in the same year.

American surgeons training in Europe and an increase in local resources. Thus, surgery in the mid-20th century began to resemble an integration of American styles of practice rather than an importation of European concepts. This change was further ampli®ed by the major advances in technology and biochemistry that emanated from the American industrial sector.1 SCIENCE AND TECHNOLOGY Given the fact that surgery depended on instruments as well as manual dexterity and knowledge, it was particularly susceptible to changes resulting from the advance of both science and technology. Thus, the chemical industry of the mid-19th century provided either pure compounds or synthetic agents that could be used as analgesics, anaesthetics and antiseptics.2 Similarly, the development of engineering and optical principles allowed for the construction of at ®rst rigid and then subsequently ¯exible endoscopes, which provided access to the interior. In addition, the introduction of X-rays by Roentgen in the last decade of the 19th century provided a further insight into the nature of disease processes, particularly in the abdomen (Figure 12).17

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Figure 12. The integration of new imaging technology into digestive surgery. Roentgen (top centre), while experimenting with a Crookes tube, unexpectedly produced strange and accidental shadows of solid objects. The use of bismuth, an opaque substance that absorbed the X-rays, led to the use of Roentgen's technology in the diagnosis of gastrointestinal diseases. Carman (top right), while demonstrating the technique of ¯uoroscopy on himself, correctly (and tragically) identi®ed the typical distorted gastric shadow consistent with gastric carcinoma on the ¯uoroscopic screen. The Schindlers (husband and wife) are seen performing an upper gastrointestinal endoscopy (bottom right). Rudolf Schindler was a brilliant individual who, perceiving the diagnostic restrictions of clinical gastroenterology, drove the development of endoscopy to the point at which it became a viable entity. McCormack and Houns®eld (bottom), realizing the limitations of conventional radiology, used the concept of X-ray attenuation to establish the principle of computerized tomographic reconstruction. The use of the isotopic labelling of ligands to identify lesions is best exempli®ed by a somatostatin receptor scintigram (a SPECT image using the 111Indium labelling of the somatostatin congener octreotide), demonstrating multiple sites of radionuclide uptake within the liver (bottom left) and the corresponding axial computed tomography image.

The synthesis of anaesthesia, antisepsis and technological advances further facilitated advances in digestive surgery. The development of adequate anaesthesia, coupled with the introduction of muscle relaxants, facilitated entry into the peritoneal cavity, and individual organs became the targets of visceral intervention. The early-18th century techniques of wound and gut suture introduced by Lembert were ampli®ed by the introduction of stapling devices (Humer Hultl, 1909), and individuals of considerable daring and technical virtuosity (Mickulicz, Czerny, Billroth and Kocher) implemented

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major advances in technical surgery. Thus, oesophagectomy, gastrectomy, cholycystectomy, colectomy, pancreatic resection and liver resection were soon all undertaken, albeit with often dismal early results.4 The integration into visceral surgery of early20th century scienti®c and chemical discoveries such as vitamin K, blood grouping and antibiotics further expanded the horizon of technical surgical possibilities, and the concept of `cure by knife' became an ineluctable dream. By the turn of the 20th century, the dyke of visceral surgery had thus been breached, and the armies of surgical intervention sounded the advance with gay abandon. SCIENCE AND SPECIALIZATION By the middle of the 20th century, the general surgeon was established as an individual who had undergone a broad surgical training, usually over a 5±7 year period and thereafter satis®ed a board of examiners, which deemed him capable of practising surgery. Such surgery was usually de®ned in its extent only by the powers of endurance of the surgeon and the willingness of the patient population to submit themselves to his care. Little consideration was given to speci®c areas of specialization, although certain individuals and institutions established areas of expertise and became renowned for specializing in a particular area of either bodily function or disease. For the most part, this separated ophthalmologists, orthopaedic surgeons and urologists, although general surgeons might in certain circumstances undertake all of the above. In the more sophisticated countries, specialist clinics proliferated, and special training and special certi®cates were provided for those individuals who underwent training in a particular area of surgical subspecialization. In this respect, visceral disease had lagged somewhat behind some of the other disciplines since it was only in 1896 that Ismar Boas in Berlin had declared gastroenterology to be a separate discipline.4 Even German physicians delayed a further two decades before grudgingly accepting visceral disease as a subspeciality worthy of separate consideration. Surgeons lagged even further behind, and visceral surgery was uniformly regarded as the province of the general surgeon. A major issue in the area of specialization re¯ected not only individuals' level of the training, but also the question of ®duciary compensation. On the one hand, those who were speci®cally trained in a particular discipline were, given their added expertise, likely to garner more patients, whereas on the other hand the resources and time were not necessarily available in all areas to enable physicians to specialize in a particular area. A period of confusion and turmoil thus arose as certain groups declared that some types of surgery could not or should not be performed by individuals who were not specialized. On the other hand, patients unaware of this distinction often sought surgery from any individual who claimed himself to be capable of treating the condition. The proliferation of a widespread group of specialization boards and specialization training programmes led to a major splintering of the surgical discipline into di€erent areas. For the most part, however, general surgery remained immune to this process, and the general surgeon was often regarded as the general contractor of digestive disease in that everything could be judged to fall safely under his knife unless an individual of highly speci®c expertise in a particular area could be identi®ed to deal with the problem (Figure 13). The advent of a more sophisticated group of clients and the natural progression of a capitalist-based market place nevertheless led to an inexorable pressure for a focus and speci®city of service delivery. General surgery thus began to ®nd itself fragmented into individuals who undertook either endocrine, breast or colorectal surgery and even

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Figure 13. The administration of the concept of integrated surgery may be considered as akin to a federation of states. The di€erent organs of the digestive system, much like the di€erent US states, are independent entities (separate states), each of which, although retaining control of its own internal a€airs (cellular function and physiology), must function as a whole (e.g. in the digestive process) under a central government (the CNS). Surgical intervention in one organ may in some cases have profound implications on the function of the whole system, whereas a central administration (a core educational/management programme) must be considered as part of any integration process.

further confused by the introduction of another group who considered themselves to be oncological surgeons. The latter represented a paradox in specialization whereby the adoption of a speci®c disease process as a speciality actually engendered the concept of decreased focus by the di€use targeting of a wide variety of organs. The province of general surgery thus shrank rapidly amidst the proliferation of subspecializations, each of which promoted itself based in terms of better training, greater expertise and a speci®c focus on either an organ or a disease process. Amidst this plethora of educational, marketing and surgical confusion, visceral surgery found itself even further embroiled in a struggle to remain a viable entity. A further problem was produced by the emergence of expertise in other groups of physicians, for example endoscopists and interventional radiologists. Their ability to deal with diagnostic and therapeutic issues that had previously been the eminent domain of visceral surgeons threatened the territory of the digestive surgeon and eroded the concept of the delivery of `surgical' care.

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VISCERAL SURGERY AS AN ENTITY The early 20th century saw visceral surgery develop as an important component of general surgery.4 The advances in special expertise in operations pertaining to speci®c viscera, such as the oesophagus, stomach, pancreas and colon, led to a consideration of groups of individuals as being primarily pancreatic, colonic, gastric or hepatic surgeons even though no speci®c mandate existed to distinguish them other than their own claims or the adulation of others of their expertise. The further consideration of the introduction of organ- or technique-speci®c training in particular types of visceral surgery resulted in the retrograde shift of the process of surgical training towards the 18th and 19th century concepts of an apprenticeship. Thus, individuals who regarded themselves as general surgeons but chose to focus on visceral surgery found themselves obliged to spend time with a particular surgeon or in an institution where the focus was speci®cally upon the management of a particular visceral disorder or organ. A failure to undergo such an `apprenticeship' (colloquially regarded as a fellowship) culminated in sanctions whereby privileging or credentialling issues might be raised to limit membership in a select group that empowered themselves to treat a disease. Such individuals were then, after a period of time, able to establish themselves and claim to be experts in a particular sub-branch of visceral surgery such as hepatic or pancreatic surgery. Some surgeons more skilled in administrative and political matters de®ned themselves early on and established separate disciplines such as colorectal surgery, and formally declared themselves to be a distinct and separate entity requiring novices to practise within certain programmes and obtain certi®cates in order to ensure their competency. In this respect, the late 20th century visceral surgeons reincarnated the guild system of the middle ages, with its attendant malodour of protectionism, feudal obligations and complacency vested in an optimistically unrealistic assessment of self-worth (Figure 14). A further problem that assaulted the discipline of visceral surgery was the rapid advance of biotechnology and invasive radiology such that the endoscopist and radiologist were able, in many circumstances, to compete e€ectively in the arena of therapeutic intervention. Thus, visceral surgeons found themselves not only beset with arguments on individual competency to deal with a speci®c organ or disease process, but also troubled by individuals (not previously considered as capable of administering therapy) now pro®cient in therapeutic intervention and also accomplished in doing this without much of the morbidity associated with traditional surgical techniques. Endoscopic polypectomy, abscess drainage, the control of ulcer haemorrhage, the banding of varices, the removal of calculi, the insertion of feeding tubes, the placement of stents and even the dilatation of strictures produced a staggering de®cit in the territory of visceral surgical.17 Thus, the disarray of the already fragmented world of visceral surgery was faced with shrinking boundaries and rapidly diminishing targets. A further issue of considerable importance was the recognition that adequate visceral surgery could not be optimally undertaken without a serious scienti®c understanding of either the biology of the disease process being addressed or the physiological function of the organ being resected. Similarly, the major alterations in homeostasis engendered by either surgical intervention or the pharmacological management of a particular organ resulted in patients requiring very speci®c kinds of care not necessarily addressed during a formal surgical training. The understanding of innumerable issues such as complex ¯uid and electrolyte shifts, the biology of neoplasia, the regulation of acid secretion, the neurohormonal control of sphincter

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Figure 14. The integration of surgery with anaesthesia and antisepsis. The introduction of anaesthesia (via an inhaler) by William Morton (top left) allowed for surgery to be performed in an unhurried fashion on a patient protected from pain. The subsequent advent of antisepsis (carbolic spray), as introduced by Lord Joseph Lister (top right), signi®cantly decreased the risk of infectious complications and facilitated the performance of careful and meticulous surgery. In addition, advances in haemostatic technique (the ®rst-time use of gloves), instituted by William Halsted (bottom right), and technical eciency, promulgated by Berkeley Moynihan (bottom left), facilitated the development of relatively safe surgery. The integration of these techniques into surgical strategies was matched by the integrated surgical training programme of Theodore Billroth on European surgery (centre).

function, the mechanisms of anastomotic healing and the e€ect of pancreatic enzymes or hepatic secretion on anastomoses and gut function thus added a further layer of complexity to the world of visceral surgery. Few adequate training curricula existed to educate the visceral surgeon in the complexities of a system that was previously regarded as little more than a conglomeration of conduits and ducts that required maintenance or replacement. TIME PRESENT IS TIME FUTURE The end of the 20th century produced a quagmire of con¯ict of responsibilities in the ®rmament of visceral surgery. The process clearly needs to be completely re-examined since the ®eld of play has so totally altered. Visceral surgery in itself almost certainly needs to be considered as a separate entity undertaken by a group of individuals with specialized knowledge in the ®eld. What needs to be addressed, however, is the manner in which these individuals arrive at this level of specialization and in what

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fashion they deliver their expertise to patients. Into this equation must be placed a number of variables, including the type of training, the individuals who should be trained, the skills with which they should be inculcated and the geographical or structural con®guration of the unit in which the discipline should be practised. In essence, the previous disciplines that were regarded as `merely' adjuncts to the practice of visceral surgery should now be incorporated into a main-frame concept of a visceral disease surgical group. In particular, it may even be necessary to remove the sux of surgery from the group and consider it to be a visceral disease group in which a number of di€erent individuals, each with a speci®c expertise, function together to treat either a de®ned disease or more probably an organ-based process (Figure 15). To achieve an integration of the various components necessary to ensure a complete diagnostic and therapeutic medical entity capable of managing visceral disease, the following considerations need to be developed. First, the overall concept of medical school training followed by specialization in the speci®c discipline needs to be evaluated. The current process of 6 years of medical school followed by 5±7 years of

Figure 15. A chronological assessment of a proposed strategy to streamline training in a focused manner, thus avoiding the expenditure of resources and time on training in areas of no direct bene®t to an individual seeking to become a digestive disease expert. A critical determinant is an early decision by the trainee on his or her area of interest. The pathway represented in this diagram targets digestive diseases, but similar paths can be designed for thoracic, cardiac, central nervous disease and so on.

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speci®c training in a broad discipline followed by subspecialization is too cumbersome and time-consuming. In addition, it is neither time- nor cost-e€ective for either the individual or the institution or government. A broad medical curriculum encompassing a huge and now unmanageable database, followed by a di€use discipline training, needs considerable abbreviation to ensure focus. Individuals interested in medicine should be asked at a pre-matriculation stage to consider their interest in a broad area of expertise (cranial, cardiac, thoracic, digestive, genitourinary, obstetric), and a 3-year medical school training programme should be utilized to bring them to the point at which they can address a speci®c discipline. A core curriculum based upon a tier system of the acquisition of information requires development in such a fashion as to embrace the principles of anatomy, pathology and physiology. This should be structured in such a way that a basis for the focused study of a particular system might then be grafted onto the previous layer. The discipline should no longer be surgery or medicine but instead be based upon either an organ or a disease focus. Thus, individuals who desire to move into the area of visceral disease should be entered into a targeting programme that focuses on the anatomical structure and biological basis of the function of visceral organs. The next phase would be a focused 2-year programme in which the pathophysiology of all visceral disease would be taught. This period of time would also include clinical instruction and technical training in a broad range of diagnostic and therapeutic interventions encompassing the di€erent visceral organs. At this point, a further 1-year specialization in a particular visceral organ could be undertaken in a unit dealing speci®cally with such issues. At this stage, a trainee would be deemed to be broadly trained in the principles of the practice of medicine and the principles and practice of the management of visceral disease and could then enter a speci®c unit where he or she would function for a further 2 years, gaining technical or clinical experience in either diagnostic and therapeutic interventions capable of managing visceral disease or, more speci®cally, the visceral disease of a speci®c organ. An individual interested in liver transplantation could, for example, focus on the study of the liver and thereafter pursue either transplant immunology and rejection management or enter the surgical branch of the programme and undertake the surgical module that addressed hepatic surgery. Individuals would thus be able to gain a broad area of knowledge in a very speci®c area of visceral disease and align themselves in a streaming process that would enable them to direct the precise focus of their interest towards either diagnostic or therapeutic intervention. The contemporary concept of separate endoscopic and interventional radiologist teams of therapists would therefore be subsumed into the diagnostic and therapeutic area of visceral surgical training. The individuals involved would undergo training not only as endoscopic therapists, but also as laparoscopic surgeons. Thus, those surgically inclined could direct their attention towards technical training, those endoscopically inclined might address laparoscopy, and those more inclined to intellectual assessment might focus on diagnosis and pharmacology (Figure 16). A visceral disease centre would thus comprise a core group of physicians trained in the diagnostic and therapeutic management of the disease process, supported by a number of individuals from the subspecialities necessary to provide a comprehensive management programme. In a similar fashion, a group of pathologists trained speci®cally in the elucidation of pathological material of the gastrointestinal tract would interface with a group of clinical diagnosticians, who would in turn interface with those trained more in the interventional aspects of disease management. Similarly, anaesthetists trained to administer anaesthesia to individuals with gastrointestinal problems would be

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Figure 16. A schematic of a digestive disease unit comprising nine separate but interlinked skill modules. The interactive relationship of the di€erent foci of this programme would allow individuals with special skills or inclinations to direct their knowledge into areas that allowed the entire group (the unit) to deliver health care to a patient with maximum eciency both from a time and a cost standpoint.

part of a critical care team experienced in the management of patients with visceral disease who had undergone surgery. This cadre of support would be bolstered by a group of physicians trained in both nutrition and the management of infectious diseases related to those with visceral disease.

QUO VADIS? The current medical training programmes and the system of subspecialization have led to a cumbersome as well as cost-ine€ective process for the delivery of care in visceral disease. A training programme that requires almost 15 years to produce a physician who still requires the help of three or four other physicians in managing a disease process is a legacy of a medical process that is now a century old. Knowledge considered to be adequate a century ago is now incapable of being assimilated adequately by one physician and is usually utterly ine€ective given the breadth of information now available (Figure 17). The training programmes need to be shortened, the discipline to be addressed needs to be identi®ed early on by the trainee, and the focus of the training programmes needs to be dramatically con®ned to ensure the maximum delivery of skill and expertise for a particular organ system. The parallel training of the di€erent subgroups of physicians required to support a visceral disease programme needs to be similarly curtailed and focused to avoid an unnecessary reduplication of skills, equipment and cost. In addition,

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Figure 17. The integration of the surgical past with a molecular future. In terms of current practice and future expectations, it is apparent that the knowledge of the past needs to be integrated with the science of the present and the advances of the future. The hope that is inculcated in future surgically based therapies may be tempered by the apt words of the great French literalist Marcel Proust, who stated, `What we call our future is the shadow which our past throws in front of us'. The penumbra of surgery has long borne the consequences of failing to recognize this need to integrate past dogma with present reality.

the development of a focused group with a self-standing core of expertise will dramatically decrease the time required to identify a particular disease process and manage it appropriately, thus rendering the process particularly cost- and time-e€ective for both the institution and society at large. In essence, the century-old concept of surgery and medicine as separate disciplines, and diagnosis and therapy as separate events, must be cast aside to facilitate the development of a new model of disease management. Digestive surgery should not be regarded as an end in itself but as one facet in the delivery of an integrated health-care modality focused on the digestive tract. Ultimately, however, it is important to realize that the most critical component of any integrative process lies at the personal level and that the intrinsic recognition of what it requires to be a physician will provide the ultimate integer of the success of any discipline, be it digestive or otherwise. In this respect, the comment of Steven Paget

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from Confessio Medici provides a ®tting close to the consideration of the integration of digestive surgery:18 Every year young men enter the medical profession who neither are born doctors, nor have any great love of science, nor are helped by name or in¯uence. Without a welcome, without money, without prospects they ®ght their way into practice and in practice; they ®nd it hard work, ill thanked, ill paid; there are times when they say, ``what call had I to be a doctor? I should have done better for myself, for my wife and the children in some other calling.'' But they stick to it and that not only from necessity, but from pride, honor and conviction; and heaven, sooner or later lets them know what it thinks of them. The information comes quite as a surprise to them being the ®rst received from any source that they were indeed to be called doctors; and they hesitate to give the name of divine vocation to work paid by the job and shamefully underpaid at that. Calls, they imagine should master men, beating down on them: surely a diploma, obtained by hard examination and hard cash, signed and sealed by earthly examiners, can not be a summons from heaven but it may be. For if a doctor's life may not be a divine vocation then no life is a vocation, and nothing is divine.

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