ESCP are delighted to be welcoming Jeryl Reyes from the Philippines to our upcoming meeting in Nice. Read Jeryl's report on the state of coloproctology in the Philippines.
History
The Philippines is an archipelago nation in Southeast Asia, situated just above the equator. It consists of about seven thousand islands, roughly the size of England. There are three main geographical regions from north to south: Luzon, Visayas, and Mindanao, with the capital Manila located in Luzon. Our country at present has a population of about 100 million. Notable in the history of the Philippines is the long era of colonialism, first under Spanish rule for 333 years, then under the USA, and finally under Japan during World War II. Before this, there were strong influences from other Asian neighbors, such as the Chinese and the Malays. The country is now a democracy and considered a newly industrialized country.
These facts about the Philippines help one understand the current state of medical practice in the country. Most universities and colleges are situated in Metro Manila, as well as most tertiary hospitals and medical centers. The Philippine General Hospital (PGH) is located in the heart of Manila, and it is the largest government hospital administered by the University of the Philippines. It is also the largest training hospital, and this is where colorectal surgery or coloproctology draws its roots. Medical education is largely patterned after the American system; consequently, colorectal surgery has also followed most American practices and has strong ties to surgical societies in the US.
Coloproctology diseases and operations
Colorectal cancer is the third most common cancer in the Philippines and the fourth leading cause of cancer death, according to a 2015 census estimate. In the PGH and other tertiary government centers, we usually manage advanced cases of colon and rectal cancer, as most patients do not consult early due to various reasons such as financial constraints, access to medical care, or poor awareness about disease. The PGH traditionally receives patients from all over the country; some patients even travel from the far north or south. With the development of more tertiary centers with available expertise, it is ideal that these patients are treated where they are. However, majority of the indigent patients are seen at the government hospitals, and a large portion of them come in obstruction or in sepsis, which also explains the high number of emergency operations. Also important to note that being a tropical country, the Philippines encounters endemic infective diseases such as tuberculosis. Gastrointestinal tuberculosis is a one of the common causes of acute surgical abdomen and obstruction.
One of the significant milestones in the practice of rectal surgery in particular is the adoption of total mesorectal excision (TME) as proposed by Professor Bill Heald. Two Filipino colorectal surgeons took the initiative to learn the principles and techniques from Prof. Heald himself in the United Kingdom in the late 1990s. Since then, they have been the pioneers in teaching fellow Filipino surgeons and surgical trainees about TME. This is now standard practice and required competency in colorectal training. Several research studies conducted in Filipino patients also echo the experience worldwide.
Majority of operations are still undertaken in the traditional open approach, but since the advent of minimally-invasive surgery, there has been a steady increase in the laparoscopic or robotic approaches. There are two robots in two private centers at present, which are being utilized for colorectal procedures also.
As for anorectal diseases, the country has been up-to-date with technological advances for hemorrhoids and anal fistulas, such as hemorrhoidal artery ligation techniques and video-assisted anal fistula treatment. Specifically for fistulas, there is ongoing collaboration with other southeast Asian nations, most notable of which is Thailand with the experience of Professor Arun Rojanasakul, the originator of the Ligation of Intersphincteric Fistula Tract or LIFT technique.
There has also been increasing interest in the management of pelvic floor and physiologic disorders, as is the trend all over the world. Admittedly, we have been lagging in this area, but there are now efforts to strengthen capabilities to diagnose and treat this special group of patients. Several hospitals offer endorectal and endoanal ultrasonography and recently the PGH and The Medical City have acquired anorectal manometry and biofeedback machines. Videodefecography is currently not available in the country; in lieu of that, transperineal pelvic floor ultrasonography may be offered, but there is limited experience as of now. Endeavors to set up specialized pelvic floor centers are in progress.
In the PGH, there are about 1,500 colon, rectal, and anal operations performed every year, more than half of which are done as emergent cases. Endoscopic procedures number around 200-300 annually. With the rise of the TME era and the advances in neoadjuvant and adjuvant treatment, the multidisciplinary team (MDT) approach was first developed in the two government training institutions, PGH and Jose R. Reyes Memorial Medical Center. Since then, MDT management has become the norm for colorectal cancer cases.
Coloproctology society
In 1936, the Philippine College of Surgeons was organized. In 1969, nine colorectal surgeons, who undertook training in coloproctology abroad, organized the Philippine Society of Colon and Rectal Surgeons (PSCRS), and was previously called “Samahan Pilipino ng mga Siruhani ng Isaw at Bitukamtuwid.” In March 8, 1969, the first inauguration and oath – taking of the officers of the PSCRS were held at the Manila Hilton. Dr. Porfirio M. Recio was the first President, also acknowledged to be the Father of Colon and Rectal Surgery in the Philippines. Dr. Recio finished general surgical training at the PGH and then went on for further training in M.S. Proctology in Temple University in the United States. He then became a fellow of the American Society of Colon and Rectal Surgeons (ASCRS). He co-authored the book Surgical Anatomy of the Colon, Rectum, and Anal Canal with distinguished surgeon Harry E. Bacon. Another Filipino colorectal surgeon Teodoro P. Nuguid also contributed to the said book.
The following are the objectives of the PSCRS:
- Maintain the highest standards of surgical practice
- Promote the advancement of the science and art of surgery of the colon and anorectum
- Maintain a high standard of education and training in this subspecialty
- Foster a programme of research
- Safeguard the professional interests and welfare of its Fellows
- Assist in health care programs of national agencies
- Cultivate among its Fellows the spirit of collegiality and brotherhood
In 1982, the first Residency training program in Colon and Rectal Surgery in the Philippines was started in the University of the Philippines – Philippine General Hospital by Dr. Carlos M. Magsanoc (Section Chief) and Dr. Romeo R. Gutierrez. In 2001, a second training program was launched at the Jose R. Reyes Memorial Medical Center. At present, there are seven Colorectal Surgery training programs in the Philippines: UP – Philippine General Hospital, Jose R. Reyes Memorial Medical Center, Southern Philippines Medical Center, The Medical City, Quirino Memorial Medical Center, Rizal Medical Center, and St. Luke’s Medical Center – Quezon City. The creation of more training programs was a result of the projected need to serve the increasing population of the Philippines in the different geographical regions.
In 1992, the Board of Colon and Rectal Surgery was created to be the examining arm of the PSCRS. Its mission is to maintain the highest standards in the practice of colon and rectal surgery in the Philippines.
The PSCRS will be celebrating 50 years of existence in 2019, with our tenth Annual Congress and Scientific Meeting. Every year since the first meeting in 2009, the sessions have become more comprehensive and they have provided the general and colorectal surgery audience the most recent advances and studies on essential colon, rectum, and anus topics.
With its rich history, and with the infusion of fresh and dynamic members, the PSCRS is expected to grow even further, strengthening its leadership role in the development of colon and rectal surgery in the Philippines.
Jeryl Anne Silvia Reyes
The Medical City/Philippine General Hospital
References
- http://www.pscrs.org
- Limson AA, Danguilan JLJ, Gutierrez RR, de Jesus RS, Crisostomo AC, Roxas AM. Surgery in the Philippines. Arch Surg. 1999;134(3):323–327. doi:10.1001/archsurg.134.3.323
- Annual Reports of Division of Colon and Rectal Surgery (GS2), Department of Surgery, Philippine General Hospital
