"Humanization”. Among the many word you can find in a dictionary, the most barbarous has been chosen for the most delicate aim: respect for the rights of patients, also in the healing contexts. As a citizen or, better, a human being. What is important is that the word expresses a topic which involves many aspects of the sanitary world: buildings, organization of services, quality of treatments, and first of all, the relationship among people. In particular between doctor and patient. This complex and often difficult relationship starts from a condition of physical and psychological inferiority of the patient. It is difficult to remain emperor in front of your doctor confessed Hadrian in his Memories, and more difficult is for one of u sto remain a simple man. However this is the core of the question: how to avoid that the naked and suffering body of the patient loose his dignity of human being. That is tom say how to avoid that this relationship between two people become “inumane” both from the point of view of the patient and of the doctor.
Every action, both material (buildings, structures, machinery, economic resources) and non-material (organization, services, professionalism), which aim to “humanize” the relationship doctor-patient need to start from a unique culture, which means the conscience of the equal dignity of doctor and patient as human beings. In other words this means that the doctor must listen and the patient must comunicate. And not only te symptoms of the illness but also the value of his normality. The last of this first fundamental speech can be short, but it is the most important condition for any further speech in the future. Especially in an institute like the National Institute for Tumors, specialized in the research and cure of tumors, i.e. of an illness which attacks not only the body but also the mind, the spirit and the whole life, also of the close people, relatives, friends and colleagues.
This is the reason why, also in the daily problems of a complex “sanitari machine” as the institute is, we have organized many initiatives. These projects, “Disse”, “Prometeo”, “Oltre il buio”, “Salute Donna”... are meeting points among people first, and then among patients and specialists; here people can associate the different life and job experiences for solvine the problems of each one. Obviously the meetings are open to everybody and which need the collaboration of everybody because they involve the right of patients and consequently of the whole community.
The aim of “humanizing” the Institute does not involve only these intitiatives, but it cannot leave aside those already activated and the others which will start soon, making them well-known all over Italy. Only in this way also the other aspects of a more “human” Institute will be realized: from the environmental to the organizative one. And here there is the list of the projects which are going to become element of “humanization” at the Institute: the renewal of the general surgery and of the pediatric one with the new hall and the new didactic area; the completion of the second floor of block 1, the beginning of works at the Cascina Rosa and in the new building for the research laboratories, the new telematic net and the development of more advanced informatic procedures for diagnosis and administration.
Gianni Locatelli
Special commissioner
SAVING SURGERY OF COLON RECTUM
The participation of about 1000 surgeons, from Italy and from abroad, participation of some of te most well-known international specialists has decreed the success of the 4th International Symposium of conservative surgery for colon-rectal tumors, held in Milan from 20 November to 12 December 2000. The concress has been organized by A.R.E.C.O., Association for the European Research in Oncological Surgery, and it was chaired by dr. Ermanno Leo, director of the colon-rectal surgery unit at the National Institute for Tumors in Milan and president of A.R.E.C.O.
“Conservative surgery of rectum” declares dr. Leo at Informazioni-INT, “began at the Saint Antoine hospital in Paris at the beginning of the ‘90s, with dr Rolland Parc. But it is the Institute for Tumors in Milan, with its 400 patients operated according to the new techinque, the hospital with the greatest case histories: moreover here the surgery has been developed. Thanks to the results otained – not only for the preservation of the intestinal and reproductive functions, but also for the decreased number of relapses – the surgery method developed here in Milan is nowadays at the centre of world oncology. At the Symposium we have presented the results of our experience and we have focused, with the help of experts from aborad, on the problems connected with the surgicla technique: without any fear of being contradicted, we can adfirm that the colo-anal anastomosis (this is the name of the new operation) is a technique which has demonstrated it can improve both the quality of life and the survival percentage of patients”.
Moreover it is important to remember that, in the Western world, the intestine tumor is the second one in both sexes: it is preceded by the lung one in men and by the breast one ine women. In Italy there are about 35,000 cases a year of intestine tumor, and there is a great regional difference: indeed the tumor-registers state that the risk of suffering from colon-rectal cancer in Triest is twice bigger than in Ragusa. However only a minimum part of intestine tumors afflicts the last part of the rectum: in Italy they are about 3-4,000 cases a year, to which conservative surgery could be applied if there were enough specialistic centres. “My object”, declares dr. Leo, “is to get this target in the next 5 years.
Among the many experts who took part in the Congress in Milan there were R. J. Heald (England), F. Lazorthes (France), H. T. Lynch (USA), Y. Moriya (Japan), J. Nicholss (England), H. Nelson (USA), F. Scow-Choen (Singapore), W. J. Temple (Canada). Also dr. José G. Guillem from the Memorial Sloan Kettering in New York, one of the greatest international authorities in the field of oncological surgery, was present thanks to the audio-teleconference.
Like all the medical innovations, conservative surgery of the rectum was not born from nothing. At the beginning of the ‘80s, its pioneer was the English surgeon, Sir Alan Parks, who however did not obtained the sowished results. Later the same technique was studied by te French school: Franc Lazhortes, Claude Huguet and, above all, Rolland Parc. “Currently” observes Ermanno Leo, “we can say that the most well-known result is the abandonment of the traditional colostomy. I.e., in the past the last part of the intestine was removed together with the tumor and an artificial anus was created. This method, the only one known till few years ago, obliged patients to live the rest of their lives with the humiliating artificial anus. The colo-anal anastomosis eliminates this unpleasant disease, but, to obtain this result a simple reconstruction of the removed organ is not enough”.
Indeed the core of the new surgery consists in the creation of a new ampolla - with the remaining part of the rectum – which is then connected to the anus: in this way the last part of the intestine is very similar to the natural one. “But in order to guarantee the normal functions” adds Ermanno Leo “it is neccessary to leave intact all the muscles and nerves which control the anal sphincter and defecation. In a large number of cases this result has been possible”.
However it is neccessary to make a “selective” surgery which eleiminates the whole tumor but guarantee the normal intestinal functions. It is an operation more delicate and complex than traditional ones, which is made in two steps. In the first one (4-5 hours instead of the 2 of the traditional surgery) the surgeon removes the tumor and the last part of the rectum where the cancer can form again, and then he reconstruct the artificial ampolla. This part of the surgery end with the application of a temporary artificial anus, which the patient will use for about two months, while the reconstructed part of the intestine and the anal duct set together without risks of infection. In the second step (which lasts about 1 hour) the surgeon closes the artificial anus. After that in the 10-15% of patients intestinal functions can be still irregular: usually a pharmacological therapy based on astringents and lactic ferments and some physiotherapy can eliminate all the problems.
Carrying for the quality of life of the patients, conservative colon-rectal surgery saves also the nerves which control the sexual functions in the man. “Some times ago”, remembers dr. Leo, “the l’European Journal of Surgery Oncology quoted the first gratifying results obtained by the team here at the Institute for Tumors. In the last years, thanks to new diagnostic instruments which allow us to locate more clearly the nerves, we have been able to improve these results”. This is another important goal: traditional surgery seriously compromized male sexuality and in particuar erection, but nowadays it is not so. These are the results which justify the name of conservative surgery for the new technique: indeed it is one of the most modern technique of oncological surgery, the one which reduces mutilations to the maximum. This philosophy has lead, for example, to the abandonment, where it is possible, to the total removal of the breast in case of tumor and the practice of quadrantectomy, or to the reduction of amputation in case of osteosarcoma.
But this is not all. It is neccessary to point out that, besides the results obtained in terms of preservation and qualità of life, the new technique has also improved the therapeutic efficiency of surgery. According to the data obtained from the case histories of the Institute, five years after the operation, relapses have decreased from 35-40% to about 8,5%. This is due to the new morphological and biological knowledges of the rectum tumor. It has been demonstrated that the adipose tissue which surrounds the last part of the intestine (the mesorectum) is not an inert tissue with simple control and support functions. On the contrary the mesorectum can contain a certain number of neoplasic cells from the ampolla. “This is the reason why”, underlines Ermanno Leo, “its removal, together with the close lymph nodes, is essensial in the new surgical method. The reduction of relapses is certainly a consequence of this new approach to surgery”.
On the contrary the roles of chemio and radioherapy as complementary treatments of surgery still have to be cleared. Currently a large number of patients undergo chemio and radioherapy bifore or after the operation. Some of them, however, do not give response to treatments. “This date”, observes dr. Leo “suggests to criticize the great use of these therapies, and of radiotherapy in particular. Probably it would be more useful to focus on histological and immunologic tests to select cases which can benefit radio and chemiotherapy and to see, in each case, which treatments are the most useful”. In Milan people discussed these topics too: their development is left to next studies and to the discussion among specialists.
COLON-RECTAL SURGERY MASTER
During the International Symposium hold on last Novembre-December, the institution of a Master on colon-rectal surgery, entrusted by Umberto Veronesi, minister of te public welfare has been announcedcolondECEante il Simposio Internazionale del novembre-dicembre scorso è stata annunciata la nascita del Master di chirurgia colorettale, affidato dal Ministro, to Ermanno Leo’s operative unit at the Institute for Tumors in Milan. “It is the first course of this kind” observes Leo, “activated in Italy. We have asked for the Master for two main reasons. First of all we need to increase the number of wards in Italy dedicated to this branch of oncology. Indeed, besides the Insitute for Tumors, there are very few operative units dedicated exclusively to colon rectal surgery, and the same happens in amny European countries too. The lack of wards can explain the survival gap between American and European data: 5 years after the operation American data are better than European ones”.
Secondly there is a great demand, from Italy as well as from abroad, for learning the technique of conservative surgery and all the correlated knowledges. Learnign teh new method is not easy and it requires, as any surgical technique, a direct experience and not only theoretical lessons. If courses will be attended by many people, the Institute for Tumors can say that it has “exported” all over Italy its surgery technique, and patients will certainly take advantage of it.
The Master will be organized twice a year at the Operative Unit of the Institute run by dr. Leo and it will last two months. There will be periodic videoconferences with dr. Jeffrey Milsom from the Mount Sinai Hospital in New York and with dr. Nicolò de Manzini from Strasbourg. The first corse began on 5 February 2001: participants were 10, but applications were more than 70.
PARTICIPANTS’ OPINION
“About three years ago, I was at the National Institute for Tumors in Milan, at the surgery unit run by Ermanno Leo. Now the Master has offered me the opportunity for a refresher corse which allows me to improve also my technical skills”. These are the words of dr. Giovanni Piazza, from Palermo, one of the 10 surgeons who partecipate at the first corse of colon-rectal surgery organized by dr. Leo’s operative unit. As all the Master, this too, is reserved to doctors expert in the field: dr Piazza, indeed, works at the Oncological Surgery department at Palermo university, directed by Mario Latteri.
“Since some years”, says dr. Piazza, “at our centre we make, with good result, the conservative surgery of the rectum, using the same technique of the Institute for Tumors. Regarding the course, I am so satisfied that I asked to remain in Milan 3 months instead of 2, as regulations stated”.
Dr. Herbert Dal Corso is specialized in the treatment of lower intestine pathologies too. He works at the S.ta Croce and Carlo hospital in Cuneo and he improved his technique at the St. Mark in London. “At the Master I have not learnt new things. If so”, continues dr. Dal Corso, “this would have been an accusation to my professionalism. But I had the possibilità of dealing with a worldwide well-known team as the one run by dr. Leo is. Only such meetings can really allow the creation of a commor surgical culture. This creates a continuous exchange among the doctors who deals wih colon-rectal surgery, improving the methods and techniques for facing an illness from prevention to care”.
Much appreciated have been also videoconferences which are made daily during the theoretical part of the corse with some of the most well-known foreign surgeons, “What is very new in the technology used in Milan”, underlines dr. Dal Corso, “is the fact that the videoconferenze is made on the internet: this allows people from home to partecipate directly to the discussion, from the internet site of the Institute for Tumors”.
An idea on which the participants to the Master mainly focused on is the incapacity of the so-called general surgery for facing the colon-rectal tumors in a satisfying way. “Data demonstrates the neccessity for structures specialized in this pathology”, said many doctors, “ We do not have to forget that in colon-rectal tumors surgery is more important than che mio- and radio-therapy”. This is why we can say that the Master leaded by dr. Ermanno Leo is not only useful but also neccessary.
