The Association of Coloproctology of Great Britain and Ireland
The Association of Coloproctology of Great Britain and Ireland
The Association of Coloproctology of Great Britain and Ireland
Introduction
Why now ?Professional and political developments in medical training, including the creation of the Postgraduate Medical Education and
Training Board, make it necessary for this Association to define the knowledge base and competencies that constitute Colon
and Rectal Surgery. The Association’s primary motivation is the protection of patient health and welfare, through the
development and maintenance of high standards in the specialty of Colon and Rectal Surgery. To this end the syllabus is
intended to guide the practice of established Surgeons and to inform trainees and training bodies engaged in the acquisition
and the provision of Colon and Rectal Surgical training.
This first version (v1.1) of the ACPGB&I SYLLABUS has been largely based on the Core Curriculum of the American Board
of Colon and Rectal Surgery. While the subject matter of Colon and Rectal Surgery is universal, an attempt has been made
in drafting this version (v1.1), to emphasise those aspects of our specialty which are most relevant to practice in Great Britain
However, it is recognised that syllabus development is a dynamic and evolutionary process and future
considered modification will be required, as determined by the membership of this Association expressed through the
To assist trainees and trainers the contents have been designated to define the knowledge and competence expected of a
trainee completing appropriate training in colon and rectal surgery to BST, HST (General) and SPECIALIST levels, as follows:-
BSTKnowledge and technique expected of a basic surgical trainee at the MRCS examinationHSTIn addition to the knowledge and technique expected of a basic surgical trainee at the MRCS examination - the additional knowledge and technique expected of a higher surgical trainee with a specialty interest other than Colorectal Surgery at the ICB examination and on award of the CCST in General SurgerySPECIALISTIn addition to the knowledge and technique expected of both a basic surgical trainee at the MRCS examination and expected of a higher surgical trainee with a specialty interest other than Colorectal Surgery at the ICB examination - the additional knowledge and technique, expected of a higher surgical trainee with a declared specialisation in Colorectal Surgery at the ICB examination and on appointment as a Consultant with an interest in Colorectal Surgery.
Paul Finan, Jim Hill, Peter Lee, John Nicholls, Ian MacLennan, Peter Sagar, Nigel Scott, Barry Taylor, Graham Williams
The Association of Coloproctology of Great Britain and Ireland
Contents
Crohn’s Disease Other Inflammatory Conditions
Dynamic ProctographyMagnetic Resonance Imaging
Anus and Anal Small Intestine, Colon and Rectum
Anorectal MalformationsOther Paediatric Disorders
The Association of Coloproctology of Great Britain and Ireland
BENIGN ANORECTAL GOAL: Following the completion of appropriate colon and rectal surgery training,Trainees will be competent with the diagnosis and medical and surgical treatment of benign anorectal diseases.
A. Trainees in colon and rectal surgery will be able to do the following:
1. Describe proposed aetiologies of internal and external haemorrhoids.
2. Describe the anatomical distinctions between internal and external haemorrhoids.
3. Describe the classifications for internal haemorrhoids.
4. Describe the signs and symptoms of the following:
5. Describe the indications, contraindications, and complications of nonoperative management of haemorrhoids.
6. Describe the indications, contraindications, and complications of the following:
7. Describe two of the following techniques:
8. Describe indications, contraindications, and complications of the following:
9. Describe the operative technique for the following:
10. Describe the signs, symptoms, and treatment of complications resulting from OPD management, including the
11. Describe the treatment of complications resulting from haemorrhoidectomy:
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12. Describe modifications of therapy with the following special considerations:
A. Trainees in colon and rectal surgery will be able to do the following:
1. Describe the proposed aetiologies of anal fissure.
2. Describe the anatomical location of a classic anal fissure.
3. Describe the signs and symptoms of anal fissure.
4. Describe the indications, contraindications, and complications of non-operative management of an anal fissure.
5. Describe the indications, contraindications, and complications of the following:
7. Describe the preoperative and postoperative care of the following:
Treatment of abscess/fistula associated with fissure
8. Describe the treatment of complications resulting from operative procedures, including the following:
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A. Trainees in colon and rectal surgery will be able to do the following:
1. Describe the origin of cryptoglandular abscess and fistula.
2. Differentiate cryptoglandular abscess and fistula from other causes.
3. Describe the classification of anorectal cryptoglandular abscess- based on anatomical spaces.
4. Describe Parks classification of anal fistula.
5. Describe techniques designed to elucidate pathological anatomy:
Goodsall’s rule and digital examination
7. Describe the preoperative and postoperative care of, and the appropriate
procedure for, the treatment of anorectal abscess based on anatomical spaces.
8. Describe the natural history of surgically-treated anal abscess, including the risk of fistula formation.
9. Describe the operative strategy for anal fistula based on sphincter involvement/location.
10. Describe the following procedures for anal fistula:
11. Describe alternative treatment options for anal fistula:
12. Describe the complications resulting from abscess/fistula surgery:
13. Describe modifications of therapy for the following special considerations:
Necrotising fasciitis/Fournier’s gangrene
14. Discuss classification, preoperative evaluation, and treatment of rectovaginal fistula, based on the following:
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15. Discuss the preoperative and postoperative care of and timing of surgery for
rectovaginal fistula secondary to obstetrical injury (to include secondary incontinence),
16. Discuss treatment of rectourethral fistula, based on the following:
A. Trainees in colon and rectal surgery will be able to do the following:
1. Describe the pathophysiology of hidradenitis suppurativa.
2. Describe the symptoms and signs of hidradenitis suppurativa.
3. Describe the medical management of hidradenitis suppurativa.
4. Describe the surgical management of hidradenitis suppurativa.
A. Trainees in colon and rectal surgery will be able to do the following:
1. Describe the pathophysiology of pilonidal disease.
2. Describe the symptoms and signs of pilonidal disease.
3. Describe the surgical management of pilonidal disease.
A. Trainees in colon and rectal surgery will be able to do the following:
2. Describe the nonoperative management.
3. Describe the operative management of anal stenosis:
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A. Trainees in colon and rectal surgery will be able to do the following:
1. Describe the pharmacology of, adverse events and administration of the following local anaesthetic agents:
A. Trainees in colon and rectal surgery will be able to do the following:
1. Describe the clinical presentation of pruritus ani.
2. Describe the aetiology, medical management, and surgical management
of pruritus ani according to the following classifications:
A. Trainees in colon and rectal surgery will be able to do the following:
1. Describe the aetiology, diagnosis, and treatment of colorectal manifestations of the following:
2. Describe the aetiology and diagnosis of condylomata acuminata.
3. Describe the influence of human papillomavirus (HPV) serotypes
on the subsequent development of cancer.
4. Describe the medical/surgical treatment options for condylomata acuminata.
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BENIGN COLON GOAL: Following the completion of a training in colon and rectal surgery, trainees will be competent in the appropriate diagnosis and treatment of benign colon diseases. DIVERTICULAR DISEASE
A. Trainees will be able to do the following:
1. Describe the aetiologies of colonic diverticular disease
2. Describe the incidence and epidemiology of colonic diverticular disease.
A. Trainees will be able to do the following:
1. Describe and recognise the clinical patterns (including right sided diverticular disease),
presenting symptoms, physical findings, and natural history of colonic diverticular disease.
2. Describe appropriate diagnostic studies and their sequence in the evaluation of
both acute and chronic colonic diverticular disease.
3. List possible complications and classification of diverticular disease including the following:
4. Describe the Hinchey classification of complicated diverticular disease
A. Trainees will be able to do the following:
1. Discuss the medical and dietary management of colonic diverticular disease.
2. Describe the appropriate medical management for acute diverticulitis including the criteria
for inpatient versus outpatient care.
3. Discuss the preoperative assessment and the indications for surgery, surgical procedures,
and complications for acute diverticulitis.
4. Describe the appropriate surgical procedures including CT guided drainage for the
5. Describe the surgical procedures for dealing with complications (fistula, stricture,
recurrent episodes) of acute diverticulitis.
6. Describe the techniques for an appropriate resection for diverticular disease
including the extent of resection, use of ureteral stents, and indications for diversion.
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7. Describe patient selection and the techniques for appropriate reversal of Hartmann’s
procedure including the use of ureteral stents, and indications for diversion. VOLVULUS
A. Trainees will able to do the following:
1. Describe the aetiologies of volvulus of the colon.
2. Discuss the incidence and epidemiology of volvulus of the colon.
A. Trainees will be able to do the following:
1. Describe and recognise the clinical patterns, presenting symptoms, physical findings,
and natural history of colonic volvulus based upon its site.
2. Describe appropriate diagnostic studies and their findings and sequence in the evaluation
of colonic volvulus based upon its site.
3. List possible complications of colonic volvulus including the following:
A. Trainees will be able to do the following:
1. Discuss the role of endoscopy and decompression in the treatment of colonic volvulus based upon its site.
2. Describe appropriate procedures for colonic volvulus based upon its site and indication for surgery
RECTAL BLEEDING
A. Trainees will be able to do the following:
1. List the possible aetiologies of lower GI bleeding.
2. Describe the appropriate evaluation of the patient based upon the patient’s age and other medical conditions.
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MASSIVE LOWER GASTROINTESTINAL (GI) BLEEDING
A. Trainees will be able to do the following
1. Assess haemodynamic stability and outline a resuscitation plan.
2. List the possible aetiologies of massive lower GI bleeding.
3. Outline an algorithm for the evaluation of lower GI bleeding including:
On Table Colonoscopy with Antegrade Lavage
4. Compare and contrast the utility, specificity, and sensitivity of colonoscopy, angiography,
and radio-isotope scintigraphy in evaluation of lower GI bleeding.
A. Trainees will be able to do the following:
1. Describe the angiographic treatment of lower GI bleeding
2. Describe endoscopic treatment of lower GI bleeding including coagulation, injection
3. Describe the indications for surgery, appropriate surgical procedures, and their possible
complications based upon cause, location, patient age, and medical condition.
A. Trainees will be able to do the following:
1. Describe the evaluation and management of postoperative lower GI bleeding.
2. Describe the intraoperative evaluation and management of persistent massive lower
GI bleeding without an identified site.
3. Describe the evaluation of recurrent lower GI bleeding, including use of enteroscopy,
exploratory laparotomy, and intraoperative endoscopy.
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VASCULAR MALFORMATIONS
A. Trainees will be able to do the following:
1. Discuss the aetiologies of angiodysplasia.
2. Describe the clinical presentation and endoscopic findings of angiodysplasia.
3. Discuss indications for intervention, and the operative and nonoperative
A. Trainees will be able to do the following:
1. Discuss the classification of haemangiomas, clinical presentations, and predominant GI sites.
2. Describe radiologic and endoscopic evaluation of patients with hemangiomas.
3. Describe operative and nonoperative management based upon location. ENDOMETRIOSIS
A. Trainees will be able to do the following:
1. Discuss the pathophysiology of endometriosis.
2. Describe the clinical presentation and endoscopic and laparoscopic findings of endometriosis.
3. Discuss indications for intervention and the operative and nonoperative management of endometriosis. COLORECTAL TRAUMA
A. Trainees will be able to do the following:
1. Compare and contrast the use and limitations of the following imaging and diagnostic
tests in the evaluation of blunt abdominal trauma:
2. Discuss the criteria for the following in the evaluation of penetrating abdominal trauma:
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3. Describe the appropriate surgical management of colon trauma in the context of the severity
of associated injuries and stability of medical condition, including the following:
4. Describe the management, both operative and non-operative, of colonic trauma due to:
A. Trainees will be able to do the following:
1. Identify clinical situations requiring evaluation for rectal trauma.
2. Describe methods for diagnosis of rectal trauma and associated injuries.
3. Describe aspects of the surgical management of rectal trauma, including the following:
A. Trainees will be able to do the following:
1. Describe the classification, the evaluation and treatment of obstetrical anal injury.
2. Describe the evaluation and treatment of traumatic anal injuries including the role of the following:
FOREIGN BODIES
A. Trainees will be able to do the following:
1. Describe the evaluation of patients with rectal foreign bodies.
2. Describe various methods of extraction of foreign bodies and indications for surgery.
3. Discuss the postextraction evaluation, indications for inpatient observation, and
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COLORECTAL NEOPLASIA GOAL: Following completion of a training in colon and rectal surgery,Trainees will be competent in the appropriate diagnosis, evaluation, and management of neoplastic diseases of the small bowel, colon, rectum, and anus.
Epidemiology of Colorectal Cancer and Polyps
A. Trainees will be able to discuss epidemiology of Colorectal cancer and polyps including incidence andprevalence, influence of socioeconomic, racial and geographic factors:
A. Trainees will be able to discuss the following aetiological factors in Colorectal Neoplasia:
Categorise adenomas into low risk, intermediate and high risk and discuss screening procedures.
4. Susceptibility to colorectal cancer (CRC)
Genetic pathways for colorectal carcinogenesis
Personal Past History (CRC, Polyps, Other Cancers)
5. Hereditary nonpolyposis colorectal cancer (HNPCC)
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Genetic basis (Genotype/Phenotype correlation)
A. Trainees will be able to list current screening strategies for the following:
A. Trainees will be able to do the following:
1. Describe the clinical signs and symptoms of patients presenting with colorectal cancer.
2. Describe the distribution of CRC within the colon.
A. Trainees will be able to discuss the following:
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5. The significance of extent of disease including patterns of spread :
Detection and management of synchronous lesions
A. Trainees in colon and rectal surgery will be able to do the following:
1. Describe the management of malignant change within an adenomatous polyp
2. Describe the indications and contraindications, operative technique, pre- and
postoperative care, outcomes and the complications of colon cancer
3 Describe the following operations in the management of Colon cancer:
Extended resections to include total abdominal colectomy
Stomas/mucous fistula/Hartmann’s procedure
4. Discuss special considerations in the operative management of Colon cancer:
5. Discuss the rationale and indications for the use of adjuvant chemotherapy.
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A.Trainees will be able to do the following:
1. Describe the indications and contraindications, operative technique, pre- and postoperative care, complications and
outcomes of rectal cancer and the following operations in its management:
Local therapy
- Transanal endoscopic microsurgery (TEM)
Sphincter-sparing resections
- High Anterior resection (above the peritoneal reflexion)
- Low-anterior resection (below the peritoneal reflexion)
- Coloanal anastomosis with or without colonic J pouch
Abdominoperineal resection Pelvic exenteration
2. Discuss the evolution of sphincter sparing surgery.
3. Discuss the use of current preoperative staging techniques and the role of:-
4. Discuss the rationale and indications for the use of adjuvant chemoradiotherapy.
VIII. The Detection and Treatment of Recurrent and Metachronous Colon
A.Trainees will be able to discuss the following:
3. Risks and detection of metachronous lesions
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4. Treatment of recurrent Colorectal cancer
A.Trainees will be able to outline a pain-management program for patients with intractable pain.
Miscellaneous Malignant Lesions of the Colon and Rectum
A. Trainees will be able to discuss the clinical presentation, assess prognostic factors, and outline the appropriate management of the following conditions:
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ANAL NEOPLASIA
A. Trainees will be able to discuss the following anatomical, etiologic, and epidemiologic features:
1. The significance of the anatomical distinction between the anal margin and the anal canal tumours.
2. The differential lymphatic drainage of the anal canal and margin
3. The histological transition of the anal canal
4. The aetiology, pathogenesis, diagnosis, and management of lesions of the anal canal to include the following:
9. Staging classification of anal neoplasia
A. Trainees will be able to discuss the histology, biology, and treatment of anal canal malignancies including
Adenocarcinoma (including anal gland & within fistulae)
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A. Trainees will be able to discuss the histology, biology, and treatment of anal margin malignancies including
Clinical features - including Giant verrucous Tumour (Buschke-Löwenstein)
5. Giant verrucous Tumour (Buschke-Löwenstein)
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PRESACRAL LESION
A. Trainees will be able to discuss the clinical presentations, differential diagnoses, diagnostic evaluation, and
treatment (including pre- and postoperative care, complications, and operative techniques) for thefollowing:
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INFLAMMATORY BOWEL DISEASE GOAL: Following the completion of a colon and rectal surgery training, trainees will be competent in the appropriate management of patients with inflammatory intestinal conditions.
A. Trainees will be able to discuss the initial description of Crohn’s disease and how this became recognisedas different from ulcerative colitis.
A. Trainees will be able to do the following:
1. Discuss the contribution of genetics and immune function to the development of
2. Discuss the possible influence of infectious agents, psychological issues and environmental
factors including diet, smoking, and medication (eg, birth control pills).
A. Trainees will be able to compare and contrast the epidemiologic features of Crohn’s disease and ulcerative
colitis including age and gender distribution, prevalence, risk, and ethnic and geographic variations.
A. Trainees will be able to do the following:
1. Describe, recognise, and compare the clinical pattern, presenting symptoms, physical
findings, and natural history of ulcerative colitis and Crohn’s disease.
2. List criteria for severity of disease as defined by the Crohn’s disease activity index (CDAI)
3. Describe the extraintestinal manifestations of IBD including the following:
Primary sclerosing cholangitis and bile duct carcinoma
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A. Trainees will be able to do the following:
1. Describe and compare the endoscopic, radiographic, and laboratory findings
of ulcerative colitis and Crohn’s disease.
2. Describe the distinguishing histologic characteristics of ulcerative colitis and Crohn’s disease
3. Describe and define the entity of indeterminate colitis.
4. Describe the differential diagnosis of Inflammatory Bowel Disease.
5. Outline a diagnostic assessment for inflammatory bowel disease to exclude other colitides.
Reproduction and Inflammatory Bowel Disease
1. The interaction of inflammatory bowel disease and pregnancy
2. The impact of inflammatory bowel disease on fertility
3. Drug therapy, investigations and surgery during pregnancy
ULCERATIVE COLITIS
A. Trainees will be able to do the following:
1. Identify the mechanism of action, indication, appropriate dosage, side effects, and toxicity
of the following drugs used for the treatment of ulcerative colitis:
2. Discuss the presentation and describe the initial management:
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Describe the logical progression of the joint management of a patient unresponsive to
4. Explain the role of nutritional support in the management of ulcerative colitis.
A. Trainees will be able to discuss the risk of carcinoma as a function of the extent and duration of disease,recommended surveillance, interpretation of biopsy results, and the significance of dysplasia.
A. Trainees will be able to describe the following:
1. Describe the indications for surgery for ulcerative colitis including:
Complications of extraintestinal manifestations
2. Describe the indications and contraindications, operative technique, postoperative care,
functional results, and complications of the following operations for ulcerative colitis:
Total proctocolectomy (TPC) with ileostomy
TPC with ileal pouch anal anastomosis (IPAA) (double staple versus mucosectomy)
- With ileostomy and rectal preservation (stump/mucous fistula)
3. Demonstrate an understanding of the operative management of indeterminate colitis
A. Trainees will be able to do the following:
1. Recognise and describe the management of the following conditions associated with the ileoanal pouch anal
Anastomotic/pouch vaginal and perineal fistula
2. Describe the appropriate follow-up for retained rectum after Total abdominal colectomy with
ileorectal anastomosis or rectal stump preservation.
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CROHN’S DISEASE
A. Trainees will be able to do the following:
1. Identify the mechanism of action, indication, appropriate dosage, side effects, and toxicity of the following drugs used
2. Describe the initial medical management specific to the site of involvement in a patient with Crohn’s disease.
3. Describe the logical progression in the medical management of a patient unresponsive to initial treatment.
4. Discuss the role of nutritional support and therapy in the management of Crohn’s disease.
A.Trainees will be able to do the following:
1. Discuss the risk of large-and-small bowel carcinoma as a function of extent and duration of disease.
2. Describe the recommended surveillance of the colon, interpretation of biopsy results,
A. Trainees will be able to recognise and outline the management of the following complications of
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A.Trainees will be able to do the following:
1. Describe the indications for surgery for Crohn’s disease including:
Complications refractory to or not amenable to medical therapy
Complications of extraintestinal manifestations or of medications
2. Describe the indications and contraindications, operative technique, postoperative care,
functional results, risk of recurrence, and complications of the following operations for Crohn’s disease:
- With ileostomy and rectal preservation (stump/mucous fistula)
A. Trainees must be able to recognise and discuss the management of the following manifestations of
OTHER INFLAMMATORY CONDITIONS
A.Trainees will be able to do the following:
1. Describe the vascular anatomy of the colon.
Describe the aetiologies and pathogenesis of acute colonic ischemia.
3. Describe the clinical presentation of ischaemic colitis
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4. Discuss the natural history, diagnosis, and management of ischaemic colitis.
5. Discuss the diagnosis and management of ischaemic colitis after abdominal aortic aneurysm repair.
A.Trainees will be able to do the following:
1. Describe the vascular anatomy of the colon.
2. Describe the risk factors for and susceptibility to injury from radiotherapy.
3. Describe the mechanism of acute and chronic radiation injury.
4. Describe the microscopic findings of radiation injury.
5. Discuss the evaluation, diagnosis, and management of complications of radiotherapy including the following:
6. Demonstrate an understanding of surgical options for radiotherapy injuries.
7. Describe local therapy for radiation proctitis:
A. Trainees will be able to do the following:
1. Discuss the aetiology, clinical presentation, evaluation, and therapeutic options for the following:
A. Trainees will be able to do the following:
1. Describe the epidemiology, aetiology, pathogenesis, presentation, laboratory and endoscopic evaluation, medical
management (including medication dosage), and indications for surgery for clostridium difficile colitis.
2. In the management of suspected infectious colitis the trainee will be able to discuss:
The role of stool culture, testing for ova, cysts and parasites and hot stool sample for amoebiasis
The role of lower GI endoscopy with biopsy for histological evaluation and culture
The role of serology in the detection of amoebiais and strongyloidiasis
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Infectious colitis as a precipitating factor for inflammatory bowel disease
3. In the management of diarrhoea in the immunocompromised patient including HIV the trainee will be able to discuss
the role of biopsy of perianal lesions, and the importance of requesting stool culture and staining for cryptosporidia,
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GOAL: Following the completion of a training in colon and rectal surgery,Trainees will be competent in the appropriate management and knowledgeable of all of the causes of all intestinal stomas.
A. Trainees will be able to do the following:
3. Discuss types of stomas (loop, end, end loop, double barrel) in relation to indications for stomas.
A. Trainees will be able to do the following:
1. Discuss an ostomy with patients, with particular emphasis on psychosocial issues, life style,
diet, sexual function, reproduction, and physical activity.
2. Discuss ostomy expectations with patients regarding function and anticipated output along
with precautions for fluid and electrolyte balance, depending upon the type of stoma involved.
3. Demonstrate proper siting and marking techniques for all stoma placement, including such
considerations as scars, the umbilicus, skin creases, belt and clothing and positioning
(standing, sitting, and supine positions).
4. Explain the role that the stoma nurse will play in pre- and postoperative care, teaching, and counseling.
A. Trainees will be able to do the following:
1. Describe stoma construction in a step-wise fashion to include:
Construction of a colostomy, including placement through the rectus sheath
Proper preparation of the skin and subcutaneous tissue
Options for positioning and/or fixation of the mesentery
Intraperitoneal versus extraperitoneal delivery
2. Describe in a step-by-step process the creation of an ileostomy, including those items mentioned
above, as well as proper maturation of a Brooke ileostomy.
3. Discuss the appropriate process of preparation for stoma closure in the case of temporary faecal
Care of the postoperative stoma site wound
4. Given these specific intraoperative complicating features, discuss appropriate management of the following:
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A. Trainees will be able to do the following:
1. Describe the normal postoperative course for colostomy function.
2. Describe the normal postoperative course for ileostomy function.
3. Describe the signs symptoms and management for the following complications that occur in the
A. Trainees will be able to do the following:
1. Describe the features of high-output ileostomy.
2. Describe appropriate evaluation and management of high-output ileostomy.
3 Recognise parastomal skin irritation of significance, list a differential diagnosis, and make
recommendations for appropriate management.
4. Discuss the management of ileostomy prolapse.
5. Discuss the management of colostomy prolapse.
6. List alternatives for the management of parastomal hernia including a discussion of the risks and
9. Recognise various skin conditions associated with ileostomy and colostomy, and provide a management
Development of fistula associated with inflammatory bowel disease
10. Describe the presenting feature of ileostomy food obstruction.
11. Describe a management approach for ileostomy food obstruction.
A. Trainees will be able to do the following:
1. Describe stoma appliances, and explain appropriate selection.
2. Describe early postoperative management of conventional stomas.
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3. List various skin barriers and accessory products available for the management of stomas.
4. Describe stoma irrigation with reference to the following:
5. Describe appropriate management and appliance options for a retracted stoma.
6. Describe dietary considerations for patients with an ileostomy or a colostomy, including the following:
A. Trainees will be able to do the following:
1. Characterise the physiologic changes associated with the following:
2. Describe normal ileostomy function including:
Changes that occur in output with postoperative adaptation
3. Discuss causes of high-output stomas.
4. List a differential diagnosis of high-output stoma.
5. Discuss appropriate management of the following:
A. Trainees will be able to do the following:
1. Identify critical patient-education issues related to the following:
Potential complications that may require evaluation
Anticipated changes to occur during the healing process
Instructions regarding symptoms that would necessitate a call to the physician HST
2. Identify sources of support including patient associations.
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4. Describe the effects of medication on stoma output and the peristomal skin.
5. Describe the possible effects that a stoma may have on medication dosage and absorption.
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FUNCTIONAL DISORDERS GOAL: Following the completion of a colon and rectal surgery training,Trainees will be competent in the management of patients with faecal incontinence, chronic constipation, rectal prolapse, and other functional disorders of the pelvic floor. FAECAL INCONTINENCE
A. Trainees will be able to classify the various types of incontinence and cite their incidences and explain their
A. Trainees will be able to do the following:
1. Take a directed history to differentiate types of incontinence.
2. Perform a physical examination to differentiate types of incontinence.
3. List anatomical, neurological, dermatological, and endoscopic findings that differentiate various
4. Identify and interpret anorectal physiology tests in the knowledge of the patient’s history and
5. Describe normal and abnormal findings in imaging studies (eg EAU) that are used in the evaluation
of incontinence and discuss the role of MR scanning.
6. Describe a scoring system for faecal incontinence.
A. Trainees will be able to do the following:
1. Outline a nonoperative bowel management plan incorporating the following elements:
2. Describe the indications, uses and results of biofeedback in the management of incontinence.
3. Discuss a treatment plan for a patient with faecal incontinence including any possible side effects.
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A. Trainees will be able to do the following:
1. Appropriately select patients for operative management consistent with physical and laboratory findings.
2. Select the type of operative repair based on the physical and laboratory findings.
3. Describe the indications for, and techniques used in the following procedures together with
their most frequent complications and the expected functional results:
Muscle transpositions (gluteus and gracilis with or without stimulation)
Artificial bowel sphincter and encirclement procedures
4. Select patients for temporary and permanent faecal diversion.
Discuss the concept of antegrade continent enema conduits. RECTAL PROLAPSE
A. Trainees will be able to do the following:
1. Describe the incidence and epidemiology of rectal prolapse.
2. Describe the pathophysiology and associated anatomical findings of rectal prolapse together with
its clinical presentation including functional disturbances and physical findings.
3. Differentiate between mucosal prolapse, prolapsing internal haemorrhoids, and rectal prolapse
and describe the physical findings associated with rectal prolapse.
4. Describe the condition known as internal intussusception, together with its radiological
findings and identify the treatment options.
5. Discuss the significance of constipation and incontinence in the management of rectal prolapse.
6. Outline the appropriate management of incarcerated and strangulated rectal prolapse.
7. Compare and contrast the perineal and abdominal surgical options for rectal prolapse including
the indications for each approach based on physical examination and laboratory results, complications,
recurrence rate, and expected functional results of each procedure.
8. Describe the operative techniques of the following procedures:
- Abdominal rectopexy with or without resection
9. Describe the evaluation and management of a patient with recurrent rectal prolapse.
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SOLITARY RECTAL ULCER
A. Trainees will be able to do the following:
1. Describe the clinical presentation, endoscopic and histological findings in a patient with
2. Describe the associated pelvic floor disorders and medical/surgical treatment options in
a patient with solitary rectal ulcer. CONSTIPATION
A. Trainees will be able to do the following:
1. Describe normal colonic physiology (including gut hormones and peptides) and the
2. Define constipation and describe its epidemeology
3. Classify types and causes of constipation and outline differential diagnoses in a patient with constipation.
4. Take a directed history for a patient with constipation and perform a directed physical examination.
5. Outline a treatment plan for a patient with constipation based on the interpretation of
endoscopic, radiologic, and anorectal physiologic tests for the evaluation of constipation, including :
6. Identify the different types of laxatives and describe the indications, contraindications, modes of action,
7. Identify melanosis coli on endoscopy and discuss its significance.
8. Discuss a treatment program for a patient with constipation that may include the following:
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A. Trainees will be able to do the following:
1. Describe the diagnostic criteria for anismus (nonrelaxing puborectalis syndrome).
2. Describe the roles of the following in the management of anismus, including the indications,
complications, and expected outcomes of each:
3. Describe the diagnostic criteria and treatment options for short segment/adult Hirschsprung’s disease
4. Describe the clinical presentation of symptomatic rectocoele.
5. Discuss the indications, techniques, complications, and expected results of surgical procedures
used in the management of symptomatic rectocoele.
6. Describe the diagnostic criteria for enterocoele and sigmoidocoele along with non-operative and
operative treatment options including complications and expected outcomes.
A. Trainees will be able to do the following:
1. Describe the role in colonic inertia for total abdominal colectomy (TAC), including indications,
complications, and expected results.
2. Describe appropriate evaluation and management of a patient with recurrent constipation following TAC.
3. List common causative factors for colonic pseudo-obstruction.
4. Describe the appropriate evaluation of a patient with suspected colonic pseudo-obstruction.
5. Describe the medical and surgical management of a patient with colonic pseudo-obstruction.
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MISCELLANEOUS
A. Trainees will be able to do the following:
1. List the diagnostic criteria for irritable bowel syndrome and outline a medical treatment program
A. Trainees will be able to do the following:
1. Outline a differential diagnosis for rectal pain to include the following:
2. Discuss the management of rectal/pelvic pain, including the role of the following:
Psychiatric or psychological treatment SPEC
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ANATOMY/ EMBRYOLOGY GOAL: Following the completion of appropriate colon and rectal surgery training,Trainees will be aware of the normal anatomy and embryology of the anus, rectum, colon and small bowel.
A. Trainees will be able to identify, describe, and discuss the significance of the following anatomical features
8. Pudendal artery as blood supply to anal canal
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B. Trainees will be able to identify, describe, and discuss the significance of the following anatomical features
1. Anatomical versus surgical extent of rectum
Systemic venous drainage (via internal iliac)
Portal venous drainage (via inferior mesenteric)
Innervation of the rectum & pelvic viscera
C. Trainees will be able to identify, describe, and discuss the significance of the following anatomical features
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D. Trainees will be able to identify, describe, and discuss the significance of the following anatomical features
E. Trainees will be able to identify, describe, and discuss the significance of the following anatomical features
A. Trainees will be able to identify, describe, and discuss the significance of the following anatomical features:
2. Anatomical relationships of colonic segments
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B. Trainees will be able to identify, describe, and discuss the significance of the following anatomical features
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EMBRYOLOGY
A. Trainees will be able to discuss the normal and pathologic embryologic development of the anus
B. Trainees will be able to describe the following congenital malformations:
A. Trainees will be able to discuss the normal and pathologic embryologic development of the colon
and small bowel with respect to the following:
B. Trainees will be able to describe the following congenital malformations:
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ENDOSCOPY GOAL: Following the completion of appropriate training in colon and rectal surgery, trainees will be competent in the selection and preparation of patients (including obtaining informed consent) for and performance of, and the prevention and management of complications of, endoscopy of the colon, rectum, and anus.
A. Trainees will be able to do the following:
6. Describe the prevention and management of complications
7. Describe two of the three following procedures with complications and their management:
A. Trainees will be able to do the following
6. Describe the prevention and management of complications.
7 Describe the technique of rectal biopsy and the management of complications of rectal biopsy
A. Trainees will be able to do the following:
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6. Describe the prevention and management of complications.
7. Describe mucosal biopsy and discuss the complications and management of biopsy through
8. Describe snare excision and discuss the complications and management of snare excision
9. Discuss diathermy therapy and safety in endoscopic practice
A. Trainees will be able to do the following:
6. Describe the prevention and management of complications.
7. Describe the technique of biopsy and discuss the management of complications of biopsy
A. Trainees will be able to do the following
6. Describe the prevention and management of complications.
7. Describe mucosal biopsy and discuss the complications and management of biopsy
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8. Describe snare excision and discuss the complications and management of snare excision
9. Discuss the use of CO2 insufflation during colonoscopy
A. Trainees will describe patient preparation and its side effects for each of the following procedures:
A. Trainees will describe instrument set up and use for the following examinations:
A. Trainees will be able to do the following:
1. Describe appropriate monitoring for sedation.
2. Describe appropriate discharge instructions following conscious sedation.
3. Describe the indications for general anaesthesia for endoscopy.
4. Describe the various drugs used for sedation and explain the following:
A. Trainees will be able to do the following:
1. State the indications for antibiotic prophylaxis including appropriate antibiotics and dosage.
2. Describe the preparation and management of patients on anticoagulants, hypoglycaemic drugs.
3. Describe the preparation and performance of endoscopy through a stoma.
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A. Trainees will be familiar with and be able to discuss the following:
1. Describe the indications and contraindications for the following procedures:
Describe the technique and management of complications for the following procedures:
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LAPAROSCOPY GOAL: Following the completion of appropriate training in colon and rectal surgery and laparoscopic techniques, trainees will be knowledgeable in the application of laparoscopic procedures to colon and rectal surgery.
A. Trainees will be able to do the following:
1. List and discuss the proposed advantages and disadvantages of laparoscopic colon and rectal surgery.
2. Discuss the equipment and its set up, patient positioning, and instrumentation for the performance
of a laparoscopic colorectal procedure.
3. Discuss the physiologic impact of laparoscopic surgery as it relates to cardiovascular, respiratory,
A. Trainees will be able to do the following:
1. Discuss the indications and contrainidcations for laparascopic management of the following categories
A. Trainees will be able to do the following:
1. Discuss the prevention, identification, and management of general complications occurring during
2. Discuss the prevention, identification, and management of complications occurring during laparoscopic
surgery in relation to specific conditions and procedures.
A. Trainees will be able to do the following:
1. Discuss the equipment setup, patient positioning, port-site placement, instrumentation, and
conduct of the operation for the following procedures:
Diagnositic laparoscopy with or without biopsy, liver biopsy, and lysis of adhesions
2. Discuss the clinical situations and indications for conversion from laparoscopic to open procedures.
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A. Trainees will be able to do the following:
1. Discuss the preoperative and intraoperative methods of identifying the relevant lesion.
2. Discuss the role of ureteral stents for the identification of the ureters during laparscopic surgery.
3. Discuss the role for laparoscopic liver ultrasonography.
4. Discuss alternative methods of laparoscopy (ie, gasless laparoscopy and hand-assisted laparoscopy).
5. Discuss methods of possible prevention of port-site recurrences during laparoscopic surgery for cancer.
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PAEDIATRIC COLORECTAL SURGERY GOAL: Following the completion of appropriate training in colon and rectal surgery, trainees will have a basic understanding of the relevant anatomy, embryology (see relevant section), clinico-pathology and basic details of the surgery likely to be involved.
A. Trainees will be able to describe and discuss the following:
1. The incidence, aetiology, histology, and variations in anatomical distribution
3. Making the diagnosis of Hirschsprung’s disease
Anorectal Malformations (Imperforate Anus)
A. Trainees will be able to discuss and describe the following:
1. The incidence, aetiology, and classification
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A. Trainees will be able to discuss and describe the following disorders in the paediatric population:
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ANORECTAL PHYSIOLOGY GOAL: Following the completion of appropriate training in colon and rectal surgery and anorectal physiology techniques Trainees will be competent and knowledgeable in anorectal physiology and testing.
A. Trainees will be able to do the following:
1. Describe the contribution of the following muscles to continence and normal defaecation:
2. Describe the pharmacology of the neurotransmitters of anal sphincters.
3. Describe the contribution of various muscle fibre types to anal continence
4. Describe and identify the rectoanal inhibitory reflex.
5. Describe normal colonic motility including colonic transit times, patterns of motility,
6. Describe the following factors in the maintenance of normal continence:
A. Trainees will be able to do the following:
1. Describe the equipment, indications, techniques, and interpretation of the following anorectal
physiologic tests in normal and pathologic states:
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ENDOANAL/ENDORECTAL ULTRASOUND GOAL: Following the completion of appropriate training in colon and rectal surgery and endoanal/endorectal ultrasound Trainees will be competent and knowledgeable in listing the indications for, performing, and interpreting ultrasound for key anorectal pathology
A. Trainees will be able to describe the normal ultrasound anatomy of the anal canal and rectal wall.
A. Trainees will be able to do the following:
1. Discuss or describe the technical aspects of using ultrasound:
Transducer frequencies (depth of imaging)
2. List the indications for ultrasound, perform examinations, and interpret the critical findings
in the following conditions as assessed by endoanal ultrasound:
Anal fistula/abscess (peroxide enhancement)
3. List the indications for ultrasound, perform examinations, and interpret the critical findings in the
following conditions as assessed by endorectal ultrasound:
Rectal neoplasms (staging, surveillance, and biopsy)
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RADIOLOGY GOAL: Following the completion of appropriate training in colon and rectal surgery Trainees will be competent and knowledgeable in listing the indications for radiological examinations and in interpreting radiographic findings for key colorectal pathologies.
A. Trainees will be able to do the following:
1. Describe the performance of plain film radiological examinations.
2. List the indications and recognise critical findings in the following conditions relevant to colon and rectal diseases:
Free peritoneal air (chest and abdominal films)
IBD-associated changes (ankylosing spondylitis, sacroileitis)
Retroperitoneal/mediastinal air (chest and abdominal films)
Synergistic infection (subcutaneous, subfascial gas)
Mesenteric infarction (air in biliary tree)
Gardner’s syndrome (mandibular osteoma)
A. Trainees will be able to do the following:
1. Describe the performance of contrast radiographic examinations.
2. List the indications for and recognise the critical findings in the following conditions as seen on barium enema:
Ulcerative colitis (chronic changes, backwash ileitis, stricture)
Crohn’s disease (colitis, recurrence at ileocolic anastomosis)
Ischaemic colitis (thumbprinting, stricture)
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3. Recognise the critical findings in the following conditions as seen in water-soluble contrast radiographic studies:
4. Recognise the critical findings in the following conditions as seen in small bowel contrast studies:
Single contrast, small bowel follow-through
5. List the indications for and describe the performance of endoscopic retrograde cholangiopancreatography
A.Trainees will be able to do the following:
1. Describe the performance of Abdominal Ultrasound
2. List the indications for and recognise critical findings of the following conditions:
A. Trainees will be able to do the following:
1. Describe the performance of computed tomography (CT).
2. List the indications for and recognise critical findings of abdominal CT in the following conditions:
Postoperative intra-abdominal sepsis (leak/abscess)
Diverticulitis (abscess colovesical fistula)
Graft pseudoaneurysm with aortoenteric fistula
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3. List the indications for and recognise the critical findings of pelvic CT in the following conditions:
A. Trainees will be able to do the following:
1. Describe the performance of nuclear medicine scans.
2. List the indications for and recognise the critical findings in the following conditions
4. Indium-labeled white blood cell (WBC) scan
A. Trainees will be able to do the following:
1. Describe the performance of angiography.
2. List the indications for and recognise critical findings on angiographic examinations relevant to
A. Trainees will be able to do the following:
1. Describe the performance of dynamic proctography (DPG).
2. List the indications for and recognise the critical findings in the following conditions as seen on DPG:
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A. Trainees will be able to do the following:
1. Describe the performance of magnetic resonance imaging (MRI) examinations
2. List the indications for and recognise critical findings of MRI examinations in the following conditions:
A. Trainees will be able to do the following:
1. Describe the performance of positron emission tomography (PET) examinations.
2. List the indications for and recognise the critical findings in the following conditions
Evaluation of Deep Vein Thrombosis/Pulmonary Embolism
A. Trainees will be able to list the indications for, describe the performance of, and
recognise the critical findings in the following studies performed in the evaluationof deep vein thrombosis/pulmonary embolism (DVT/PE):
A. Trainees will be able to list the indications for, describe the performance of, and recognise
the critical findings in fistulograms and sinograms performed for the evaluation of chronic perianal suppurative disease.
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PATHOLOGY GOAL: Following the completion of appropriate training in colon and rectal surgery Trainees will be competent to recognise the gross pathological features and understand the significant histopathological features of the following conditions
A. Trainees will recognise the gross and understand the microscopic features of the following
Squamus cells carcinoma-anal canal, anal margin
A. Trainees will recognise the gross and understand the microscopic features of the following conditions ofthe small intestine, colon, and rectum:
Malignant polyp and Haggitt classification
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Mechanisms of spread-direct local, lymphatic, vascular
Familial adenomatous polyposis (including desmoids and upper GI tumours)
Understand the indications and limitations of Frozen Sections and Cytology
Ulcerative colitis (pseudopolyp, stricture, toxic dilatation)
Infectious colitis (amoebic, tubercular, pseudomembranous)
Meckel’s diverticulum with ectopic mucosa
A. Trainees will recognise the gross features of the following miscellaneous conditions:
1. Developmental cysts (epidermoid, dermoid, teratoma)
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GOAL: Following the completion of appropriate training in colon and rectal surgery Trainees will be aware of ethical issues involved in their relationship with their patients and between themselves and their colleagues.
A. Trainees will be able to identify, discuss, and communicate the ethical issues involved in the followingsituations:
Doctors in diagnostic and support services
Applying principles of effective communication
Adapting communication style to the needs of the listener
Using appropriate balance between giving false hope and removal of all hope
4. Addressing ethical issues surrounding death
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When does technology become standard of care?
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SOCIOECONOMICS GOAL: Following completion of appropriate training in colon and rectal surgery trainees will be expected to be able to describe the essential criteria of a colon and rectal service, its continuing assessment and mode of management both from a local and national perspective.
A. Trainees will be able to identify and discuss the resources required for practice as a consultant surgeon
with a specialist interest in colorectal surgery.
3. Radiology (ultrasound, CT, MR, angiography, video proctography, contrast radiology)
B. Trainees will be able to identify and discuss issues relating to consultant practice including:
4. Clinical governance and audit (unit and personal)
5. Requirements for colorectal training unit status
6. Requirements for colorectal cancer unit status
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C. Trainees will be able to identify and discuss integrated multiprofessional patient assessments
4. Joint medical/surgical gastroenterology co-operation
5. Local ethics and research committee schemes
A. Trainees will be able to do the following:
1. Discuss government agencies related to health-care delivery (NICE; CHI; etc)
2. Describe how legislation and government agencies have impact on the practice of medicine.
3. Discuss the roles of national, regional, and local professional medical organisations.
4. Describe the structure and function of the Association of Coloproctology of Great Britain and Ireland
5. Discuss the structure and function of Trust management and Clinical Directorates.
6. Discuss and describe current national trials facilities
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PRESENTATION SKILLS GOAL: Following completion of appropriate training in colon and rectal surgery Trainees will be able to deliver an effective medical presentation
A. Trainees will be able to formulate an appropriate plan for organising a medical presentation including,
but not limited to, the following points:
3. Developing an outline for a presentation
4. Developing effective content with use of the following elements when appropriate:
A. Trainees will demonstrate an understanding of the following aspects of audiovisual development:
Appropriate volume of information on each slide
Appropriate creation of a poster presentation
Describe differences in the preparation of a poster presentation compared to an oral presentation.
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A. Trainees will be able to describe the following elements in the delivery of an effective medical presentation:
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COMPETENCY CODE COMMENT Benign Anorectal Benign Colon
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COMPETENCY CODE COMMENT Colorectal Cancer Inflammatory Bowel Disease
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COMPETENCY CODE COMMENT Functional Disorders
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COMPETENCY CODE COMMENT Endoscopy
Trainees will be able to demonstrate equipment assembly, preparation and performance of the following procedures:-
Laparoscopy
Trainees will be able to demonstrate equipment set up, patient positioning, port-site placement and instrumentation
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COMPETENCY CODE COMMENT Presentation Skills
MEDICAÇÃO USUAL EM PEDIATRIA 1 – Analgésicos Para o uso da medicação analgésica devem ser considerados os requisitos: a) Estabelecimento das características da dor e do quadro clínico associado de modo a possibilitar o diagnóstico preciso da causa e a definição de uma terapêutica específica adequada. b) Estabelecimento de uma hipótese bem fundamentada e planejament
Dr Loh Seong Feei was interviewed by the Straits Times, in “ More S'pore couples turn to IVF ”, by Ms Jessica Jaganathan, 17 Aug 2008, article below and More S'pore couples turn to IVF At least 2,000 women seeking IVF treatment each year, and couples are spending at least $40 million annually on the fertility treatment. Sun, Aug 17, 2008 The Straits Times BY: Jessica Jaganathan MOTHER
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