What Is a Colon and Rectal Surgeon?

A colon and rectal surgeon is known by many names, including colorectal surgeon and proctologist, but they all have the same definition.  A colon and rectal surgeon is a licensed physician who specializes in the medical and surgical treatment of conditions that affect the lower digestive tract (i.e. large intestine) (Swierzewski, 2015).  This type of medical specialist has knowledge and education in general surgery as well as specialized knowledge in diseases and disorders of the colon, rectum, and anus.   A colorectal surgeon completes extensive education, training, and clinical experience prior to becoming a practicing physician.

Colon and rectal surgeons specialize in the preoperative, operative, and postoperative care of patients with colorectal disorders. Conditions treated by colon and rectal surgeons include the following: anal abscess, anal fistula, and anal fissure, bowel incontinence, colorectal cancer (e.g., colon cancer, rectal cancer, anal cancer), colorectal polyps, diverticular disease (e.g., diverticulitis), hemorrhoids, inflammatory bowel disease (IBD; e.g., Crohn's disease, ulcerative colitis), irritable bowel syndrome (IBS), pelvic floor dysfunction, and rectal prolapse (rectocele, proctocele) (Swierzewski, 2015). 

Ultrasound, colonoscopy, virtual colonoscopy, and flexible sigmoidoscopy are some of the screening and diagnostic tools a proctologist may use to evaluate a patient and identify the appropriate treatment.  Surgical procedures in this specialized field include open and laparoscopic colorectal surgery (e.g., colon resection, colectomy, polypectomy) and ostomy (e.g., colostomy, ileostomy) (Swierzewski, 2015).  Because they are specialized in surgery, colon and rectal surgeons typically work in hospitals or surgical centers as part of a team of nurses and other physicians and medical care professionals.  They interact and coordinate with internists, general practitioners, radiologists, anesthesiologists, pathologists and gastroenterologists.

A gastroenterologist also treats and diagnoses diseases of the gastrointestinal tract, rectum and anus; however only colon and rectal surgeons perform surgery, gastroenterologists do not.  Many times, both the surgeon and the gastroenterologist work together to provide comprehensive treatment to their patients. 

History of Colon and Rectal Surgery

It was Frederick Salmon founder of St. Mark's Hospital, whose interests in anal fistulas and other diseases of the rectum attracted his successors, William and Herbert Allingham, to create the new specialty of proctology in the mid-1800s (Longo, 2003).  In 1878, Dr. Joseph Matthews, noticing that the patients in his Kentucky practice received little attention for rectal issues, went to study with Dr. William Allingham.  When he returned to Kentucky, Dr. Matthews announced he would see only patients with colon and rectal issues, thus becoming the first proctologist. 

Dr. Matthews later became Professor of Surgery in the Kentucky School of Medicine and in 1883, established the Department of Proctology in the Medical School (Longo, 2003).  In the United Kingdom, surgeons such as Percy Lockhart-Mummery and John Golligher, paved the way for specialization in colon and rectal surgery (Longo, 2003). The establishment of proctology as a specialized medical field led to a few additional practicing proctologists, although colorectal surgery was still performed by general surgeons. 

In 1899, the American Proctologic Society was established in order to further research and provide patients with the best possible colon and rectal care.  This organization became a subsidiary of the American Board of Surgery, and then became an independent society known as the American Board of Proctology in 1949.  As the American Board of Pathology, this organization developed examinations and certification programs in addition to educational programs. 

On April 15, 1961, the Advisory Board for Medical Specialties grated the American Board of Proctology to adopt the name The American Board of Colon and Rectal Surgery (Longo, 2003).  Twenty years later, the American Board of Colon and Rectal Surgery established mandates that required a colon and rectal surgeon to complete a general surgery residency and become board certified in general surgery as eligibility requirements to become a certified colorectal surgeon.

Currently, three areas of colon and rectal disease continue to be studied in order to further advance treatment options for colorectal diseases, disorders and cancers.  Three principal areas that will continue to receive attention and funding in colorectal disease include mechanisms of carcinogenesis and therapy, suppressing inflammation and modulating inflammatory mediators seen in intestinal inflammatory states such as Crohn's disease and ulcerative colitis and finally exploring mechanisms of intestinal motility and dysmotility as seen in irritable bowel syndrome and poor functional results following operations restoring intestinal continuity (Longo, 2003).

Due to the unfortunate increase in colon cancer cases, many research activities continue to determine the genetic makeup of those at high risk.  Stoma and ostomy surgical procedures continue to be improved in order to provide the greatest quality of life possible for the patient. Continued research is essential to identify the etiology of colon, anal, and rectal cancers which will allow for more intensive and accurate treatment options. Genetic and DNA analysis is being researched to determine patients at higher risk to develop colon cancer, however, there is much more to be discovered.      

What does a Colon and Rectal Surgeon Do?

Hemorrhoids are one of the most common gastrointestinal disorders affecting nearly 5 percent of the United States population, with 2.5 million patient physician visits for treatment per year (Longo, 2003).  A hemorrhoid is a swollen vein or group of veins in the region of the anus. Although some patients may find relief with increased fiber intake, topical medications and non-surgical techniques, others require surgical procedures to treat their hemorrhoid disorder.  Surgery may involve removing the inner- or outer-hemorrhoid. 

A variety of factors will determine the appropriate treatment, and non-surgical treatment options are attempted to relive symptoms prior to surgical options in most cases.  The nature, frequency and severity of symptoms, in addition to patient preference determine the decision for surgical intervention. Below are just some of the issues or problems that may be presented to a colon and rectal surgeon.  It should be noted that the list below is not exhaustive. 

Anal fissure is a cut or tear in the lining of the anus, and it is another common condition seen by colon and rectal surgeons.  Symptoms of fissure include pain during and after bowel movements that persists for a certain amount of time and rectal bleeding.  Stool softeners, fiber supplements and warm baths heal nearly 30 percent of fissures (Longo, 2003).  Those that are not healed are considered chronic and may require surgical repair, typically in the form of a surgical anal sphincterotomy. 

Fistula-in-ano and abscess – A fistula-in-ano is an abnormal tract or cavity communication with the rectum or anal cavity by an identifiable internal opening (Longo, 2003).  Crohn’s disease is associated with fistula-in-ano which can be categorized into four types: intersphncteric, transsphincteric, suprasphincteric and extrasphincteric.  In most cases, surgery is required to eliminate the fistula. 

Ulcerative colitis is a condition in which inflammation of the walls of the bowel and formation of ulcers occurs.  Environmental, dietary, and genetic factors may contribute to or cause ulcerative colitis (Longo, 2003).  Surgery is only used to treat this condition in severe cases, after medication and dietary changes have been prescribed. 

Crohn’s disease is a disorder of any portion of the gastrointestinal tract with symptoms including abdominal pain, diarrhea, fever and weight loss.  Obstruction of the gastrointestinal tract is common with Crohn’s disease, as is sepsis due to perforations, and surgery is often necessary to alleviate these issues and improve the patient’s quality of life or for emergency purposes. 

Colon cancer screening - Excluding skin cancers, colorectal cancer is the third most common cancer diagnosed in both men and women in the United States (ACS, 2017).  Current colorectal cancer screening options include fecal occult blood testing, flexible sigmoidoscopy, air-contrast barium enema, fiberoptic colonoscopy, virtual colonoscopy, and stool DNA tests (Longo, 2003).  Screening procedures are typically determined by level of risk based on family history in addition to the results of the initial screening results (such as fecal blood results). 

A colonoscopy is a minimally invasive procedure in which a tube with a camera is inserted into the rectum in order to examine the colon and rectum.  This procedure allows the colon and rectal surgeon to identify polyps or other signs of cancer, and conditions such as Crohn’s disease or ulcerative colitis. 

Rectal and anal cancer – Surgery is typically required in cases of rectal and anal cancer, whether it be for tumor or lymph node removal or other operational procedures.  Magnetic and radiation therapies are frequently used as treatments for anal and rectal cancer patients for detection and to decrease local recurrence. The goals of treatment are cure, local control, sphincter salvage, and avoiding permanent colostomy (Longo, 2003). 

Fecal incontinence remains one of the most devastating conditions, although its exact incidence rate remains unknown.  Women have a higher incident rate of fecal incontinence, and the causes can vary from childbirth, rectal prolapse, pelvic floor denervation to radiation (Longo, 2003).  Passive incontinence relates to losses occurring without patient awareness usually associated with internal sphincter dysfunction and reduced maximum resting anal pressure (Longo, 2003).  Urgent incontinence is the inability to defer defecation and is associated with sphincter dysfunction or strong bowel contractions.

Functional and pelvic floor disorders – These are disorders that are the result of abnormal bowel movement habits (i.e. constipation).  Surgery is required in severe cases when only partial emptying occurs.

Instestinal stomas and ileostomy (ostomy) – In cases of colon cancer or other colon disorder, the stoma is surgically moved to the outer part of the abdomen, and a pouch is attached to catch the drainage that would normally be expressed through bowel movement. 

Anorectal physiological testing - Manometric, electrophysiologic and radiologic techniques used in combination provide important basic information necessary to understand anorectal and pelvic floor disorders (Longo, 2003).  This type of physiological testing evaluates the function of the anorectum, pelvic floor, and anal sphincters by measuring fecal incontinence.   

Practicing Colon and Rectal Surgery

Surgeons with expertise in colon and rectal surgery are often called upon by their medical counterparts to evaluate patients with a variety of functional bowel disorders often manifested by abdominal or pelvic pain, cramping, constipation, diarrhea and incontinence (Longo, 2003).  Because of the specialization colon and rectal surgeons have, they can have a great impact on patients with colon and rectal issues. 

Below is an extensive, although not exhaustive, list of the surgeries a colon and rectal surgeon may perform or participate in as a member of a medical team. 

Types of Surgeries (URMC, 2017)):

Some may wonder why a colon and rectal surgeon chooses this profession.  Others may think this is one of the worst types of medical professional options available.  The truth is, many proctologists choose this profession because they themselves, or a family member or friend, had colon and rectal issues, so they chose to become one to help people like them.  Dedication is required in order to become a licensed colon and rectal surgeon, and the desire to help patients with colon and rectal issues is vital. 

Colon and rectal diseases and cancers can cause extremely painful and uncomfortable symptoms for the patient.  A colon and rectal surgeon may help alleviate the symptoms, and hopefully eliminate the problem depending on the circumstances and severity of the issue.  As seen in the table above, a wide variety of surgeries and procedures may be required of a colorectal surgeon, which is why intensive education and training are needed to become one.

How to Become a Colon and Rectal Surgeon

A colon and rectal surgeon will perform diagnostic testing on patients, administer appropriate treatment plans or surgery, advise patients on managing their conditions, collaborate with other healthcare practitioners, and conduct research on colon and rectal disease in a variety of topics. They also perform a variety of surgical procedures such as repairing fissures, removing pre-cancerous polyps, bowel resections, and treating colon cancer.  Extensive education and training is required to become a licensed colon and rectal surgeon.  An undergraduate (bachelor’s) degree, medical school, internships and residencies are all required for colon and rectal surgeons. 

Typically, an undergraduate degree in science (biology, chemistry, physics) or a pre-medical field is chosen.  The student must then pass the Medical College Admission Test (MCAT) and be accepted into an accredited 4-year medical program.  Intensive education and training in medical school includes anatomy and physiology in addition to clinical training in all major medical disciplines. 

Residency in general surgery is completed after medical school, and it takes 5-6 years to complete in most cases.  An additional 1-2 years of specialized colorectal surgery residency is then required to become a licensed colon and rectal surgeon.  To apply for the American Board of Colon and Rectal Surgery certification, a colorectal surgeon must have a minimum of 14 years of education and training (Health, 2017). 

Popular areas of specialization include minimally invasive surgery, surgical oncology, endocrine surgery, and colon and rectal surgery (Longo, 2003).  Sub-specializations of each specialized category include exposure, training, and experience in areas such as laproscopic morbid obesity surgery, inflammatory bowel disease, minimally invasive parathyroidectomy, soft tissue sarcomas, and pancreatic neuroendocrine tumors (Longo, 2003).  A practicing colon and rectal surgeon uses ultrasound, endoscopy and other surgical procedures involving the abdomen, pelvis and perineum. 

Fellowship training and Board certification

During the last year of residency in the general surgery program, an aspiring colon and rectal surgeon will apply for fellowship training in colon and rectal surgery through the National Residency Matching Program, which matches the request with one of the 40 colon and rectal surgery programs in the United States and Canada.  The fellowship is typically two years in duration, and involves clinical colon and rectal surgery training as well as research opportunities.   

When the fellowship is completed, the future colorectal surgeon may apply for American Board of Colon and Rectal Surgery certification.  To become board certified, a written examination including sections in pathology and radiology must be passed (qualifying examination) and an oral certifying examination will certify the applicant as board certified in colon and rectal surgery (Longo, 2003).  Recertification is then required once every ten years.

The following is a comprehensive list of ABCS requirements for certification as a colon and rectal surgeon (Health, 2017): 

• Undergraduate (e.g., Bachelor of Science) or advanced (e.g., Master’s) degree
• Graduation from an accredited medical school (M.D. or D.O.)
• Completion of at least 5 years of general surgical residency
• Completion of at least 1 year of colon and rectal surgical residency
• Achieved an adequate level of experience in the preoperative, operative, and postoperative management of colorectal disorders
• Successful completion of the written Qualifying examination and the oral Certifying examination (administered by the American Board of Surgery)
• Provide a detailed record of colorectal surgery experience
• Submit recommendations from training program directors
• Successful completion of the written Qualifying examination and the oral Certifying examination (administered by the American Board of Colon and Rectal Surgery)

The oral examination consists of an interview by three teams of successful colorectal surgeons who evaluate the candidate’s knowledge and ability to manage colon and rectal surgical problems.  The three teams together determine if the candidate should be granted certification. Recertification is required every ten years, during which the colorectal surgeon's credentials are reviewed to make sure that he or she has maintained continuing medical education (CME) in the field, actively practices colon and rectal surgery, and is respected by his or her peers (Swierzewski, 2017).  Passing a written examination is also required for re-certification. 

Job Prospects

According to the U.S. Bureau of Labor Statistics, the employment of health diagnosing practitioners such as proctologists will grow by 20 percent between 2012 and 2022 -- 9 percent faster than the average for all jobs (Green, 2014).  Working as a colon and rectal surgeon can be demanding.  Work hours are often long and irregular.  Conversely, it can be a very rewarding profession. A successful proctologist will also have strong analytical skills, good observation and attention to detail, communication and interpersonal skills, empathy and compassion, problem-solving and decision-making skills, high level of physical fitness, and a genuine interest in science and healthcare (Green, 2014). 

While the profession of colon and rectal surgery is demanding mentally, physically and emotionally, it has its rewards.  The 14-year education and training just to become a licensed colorectal surgeon is an accomplishment in itself; however, the benefits to their patient’s quality of life can far outweigh the demands.  In addition, the salary is a significant compensation for the specialized knowledge a colon and rectal surgeon utilizes. 

Although job growth is predicted to increase, the competition for medical school can be intense.  To be accepted, an applicant must stand out from the crowd and demonstrate their knowledge through the application process.  In addition to excellent grades, volunteering in a medical or clinical setting and performing community service are options to consider for impressing the medical school review board.  Colon and rectal surgeons are highly educated in a highly specialized field, but they are highly paid as well. 

Due to the increase in rates of colon cancer and other colon and rectal diseases, the field of colon and rectal surgery will continue to grow, and surgeons with this specialized knowledge will be in high demand.

References

Longo, Walter E. The Specialty of Colon and Rectal Surgery: Its Impact on Patient Care and Role in Academic Medicine.  Yale Journal of Biology and Medicine, 76 (2003), pp. 63-77.

Swierzewski, Stanley J., III, M.D.  Colorectal Surgeon Education and Training, 2015. Retrieved September 11, 2017 from: http://www.healthcommunities.com/colorectal-surgeon/what-is-a-colorectal-surgeon.html

Green, Alison. 18 October, 2014.  How to Become a Proctologist in the US, 18 October, 2014.    Retrieved September 12, 2017 from: http://www.careeraddict.com/become-a-proctologist-in-the-us

URMC – University of Rochester Medical Center.  Colorectal Surgery.  2017.  Retrieved September 11, 2017 from:  https://www.urmc.rochester.edu/surgery/colorectal/procedures.aspx

ACS-American Cancer Society.  Key Statistics for Colorectal Cancer.  2017.  Retrieved September 12, 2017 from: https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html