Interview Joan Martí Ragué

Name: Joan Martí Ragué
Date of birth: 21-09-1943
ID Number: 37592912 X
Address: Gran Via de les Corts Catalanes, 616, 4
08007 Barcelona
Telephone Number: 933.012.357
Degree in Medicine and Surgery from the University of Barcelona, 1966
PhD in Medicine and Surgery by the Autonomous University of Barcelona, 1975
Specialist in General Surgery,1968
Specialist in Traumatology and Orthopaedic Surgery,1969
Specialist in Occupational Medicine,1970
Specialist in Digestive Surgery, 1979

Division Head of the Coloproctology Unit of the Bellvitge Hospital, 1977- 2008
Associate professor of the University of Barcelona, 1990-2008
Head of the General Surgery Unit of the Dr. Martí Ragué Institute, 1994-2008
Head of the General Surgery Unit of the Dr. Martí Ragué– A. Sáenz Institute, 2009 2009.

Associate professor of 12 pre-graduate courses
Accredited tutor of 31 post-graduate courses
Teaching professor of 24 continued education courses
Director of 4 doctoral dissertations

Publication of 55 national original articles
Publication of 1 international review
Publication of 51 international original articles
International publication of 1 book
National publication of 3 books
Publication of 30 national book chapters
Publication and editing of several books on stomas
Editor of 4 national books
Principal investigator in 2 clinical trials
Co-investigator in 19 clinical trials

100 national communications
60 international communications
152 national lectures
75 international lectures
Moderator of several national and international round tables

Transplantation Proceedings
Gastrum
Gut
Internacional Journal Colorrectal Disease
American Institut of Cancer Reserch
American Journal of Gastroenterology
Journal of the National Cancer Institut
American Journal of Surgery
British Journal of Surgery
Colorectal Diseases
Diseases of Colon and Rectum
Journal of the American College of Surgery
Spanish Surgery
Journal of Digestive Diseases

President of the Spanish Association of Coloproctology in 1990
Member of the Spanish Society of Digestive Pathology
Member of the Spanish Society of Surgeons
Member of the Spanish Society of Digestive Pathology
President of the European Council for Coloproctology 1995-1997
Member of the European Council for Coloproctology
Member of the European Society of Coloproctology
Member of the Spanish Society of Coloproctology
Member of the American College of Surgeons

Organizer of the National Meeting of Coloproctology, 1990
Organizer of the Conference of the European Council for Coloproctology, 1995
Organizer of the Annual Meeting of the European Society of Coloproctology, 2003
Coordinator of several courses on stoma

Virgili Award of the Catalan Society of Surgery, 2008

How did you arrive at the decision to specialise in colorectal surgery?

The main problem encountered by general surgery and traumatology during the 1960s and 70s was high morbimortality, resulting from the fact that all surgeons performed all types of surgical procedures. In 1972-73, Dr. Sitges Creus, head of the Department of Surgery of the Prínceps d’Espanya Hospital in Bellvitge, created three functional units: one for liver and pancreas surgery, one for esophagogastric surgery and one for coloproctology, with the aim of reducing morbimortality. On the other hand, it enabled the establishment of ongoing training for professionals to specialise in each area, as well as training for new surgeons.

Colorectal cancer cases are increasing in our country. Why?

This is a difficult question to answer, as there is no single cause but rather a variety of factors affecting this increasing number of cases: type of diet, environment, stress, genetics… What is undeniable is the gradual increase of this pathology and the fact that is still being diagnosed too late..

One of the problems in this field of medicine is diagnostic delay. In your opinion, which is the first symptom that should lead an individual to seek specialised help?

This may not exactly answer the question, but I think that before seeking help over any symptom, there are a series of measures that can be applied to prevent this situation. One group is comprised of patients and family members with a hereditary disease such as familial polyposis of the colon, Lynch syndrome, hereditary non-polyposis colorectal cancer… Early detection tests, such as the faecal occult blood test in patients aged 50 and over, the performance of a colonoscopy on family members of colorectal cancer patients, the detection of family members who are susceptible to developing hereditary cancer via genetic counselling consultations…
As far as the first symptoms go, bleeding or changes in bowel habits are usually delayed symptoms and appear when the cancer has already progressed.

Do you think the time interval between the onset of the first symptom and treatment has improved? Does the decrease of this time period improve prognosis?

In response to the first question, I would say yes, if we compare it with the past century, but this interval is still too long.
In relation to the second question, it is hard to absolutely confirm whether it improves prognosis or not. A shorter interval most certainly does not worsen prognosis, given that in theory the most important thing is the knowledge of the molecular biology of tumours since certain tumours are more aggressive than others even when they pertain to the same staging category. But we must not forget that we are treating people, and the lengthening of the interval between diagnosis and treatment not only entails a physical impact, but also has a psychological effect.

Speaking of treatment, in your opinion, which are the most important advances in colorectal cancer?

The creation of multidisciplinary coloproctology units in which surgeons, digestologists, oncologists, radiotherapists, radiologists, anatomo-pathologists, stomach pathologists and oncopsychologists participate. These committees develop intervention protocols and clinical guidelines with the aim of providing a general overview of the disease and proper treatment, even though these documents have the limitation that professionals do not always know how to apply them to each specific case, since they are sometimes hard to interpret.
This, however, has not been cost-free, since it has led to a loss of the doctor-patient relationship, which to me is essential in our profession’s daily practice.
Other advances have been the variety of drugs now available (chemotherapeutic, monoclonal antibodies, biologic drugs) in the market, new treatment techniques combining chemoradiotherapy with surgery, mainly in the treatment of advanced colorectal cancer, the introduction of the laparoscopic approach which minimizes aggression and which generally facilitates a faster recovery.
Overall, I would say there have been incessant advances and improvements.

Coloproctology as such has not been recognized in our country, but an increasing number of coloproctology units are being established in our hospitals. Does this mean that a colorectal pathology has a better outcome if treated by a specialised surgeon than by a general surgeon?

If we agreed to the contrary, it would mean that my concerns over the past few years regarding my own training and the training of other surgeons in this field would have been pointless; therefore, the answer is YES. The outcome is better if patients are treated by specialists.
However, I think this specialty has been abused, given that in certain general hospitals there should not be specialty units comprised of just one person; and they should be able to decide which colorectal pathology they can take on and which one should be referred to reference hospitals, where it has been proven that pathology volume improves morbimortality.

Some treatments require the construction of a colostomy (a pseudoanus). Given the current situation of this procedure, do you think the patient can lead a normal life? What do you tell patients when you must perform this procedure?

I think current materials work adequately for the patient to lead a normal life. At present the problem revolves around other factors such as: the preparatory information given to the patient by the nursing specialist and the surgeon, which explains what a stoma is, what the surgical procedure consists of, the postoperative management followed and all possible complications the patient may encounter, both in the short term and in the long term; the involvement of family and friends and many other factors that are completely unrelated to the materials used.
Depending on the patient, his/her family, the colorectal pathology that is being treated, etc, the information given will be different. I think it is very important to leave the door to communication open and to achieve good empathy (feeling) with the patient, in order to assuage the information that is provided and make it easier for the patient to accept it.

In terms of prestige, what is your assessment of the quality of Catalan coloproctology?

I think Catalan doctors’ prestige dates back to many years ago, when the first residents were trained at the Sant Pau i Santa Creu Hospital, when nothing remotely similar existed in Spain. This prestige also applied at congresses and courses in which doctors from all over Spain participated. The level has been improving progressively, both in Catalonia and in the rest of Spain. I personally believe that we should be very happy about the quality of Catalan coloproctology, but also not entirely satisfied, given that I think there is still room for improvement. Thank you very much, Dr. Martí. As a coloproctologist surgeon I am grateful for having exercised my profession at a time which has enabled me to share experiences with you and, especially, to have been by your side to learn from complicated cases the solution of which required both technical and scientific quality as well as human quality.