Ralph John Nicholls (born 20 May 1943), FRCS (Eng), EBSQ is a retired British colorectal surgeon, Emeritus Consultant Surgeon at St Mark's Hospital London and Professor of Colorectal Surgery, Imperial College London. R. John Nicholls is best known for his work in the development of ileal pouch surgery. With the introduction of ileal-anal pouch surgery, selected patients with ulcerative colitis and familial adenomatous polyposis (FAP) requiring surgery can be treated by removing the diseased large intestine including the colon and rectum while preserving the anus, thereby avoiding a permanent stoma (ileostomy). This revolutionary operation challenged the conventional procedure used at the time, total procotocolectomy, which included removal of the anal sphincter leaving the patient with an ileostomy for life. The technique of ileal pouch-anal anastomosis (IPAA) surgery, also known as restorative procotocolectomy (RPC) consists of removal of the diseased colon and rectum, immediately followed by the creation of a surgical join (anastomosis) between the small intestine (ileum) above and the anus below. The reservoir function of the rectum lost by its removal was replaced by the surgical construction of a 'new' rectum made from the ileum to form a so-called "ileal pouch". This allowed the patient requiring surgery for ulcerative colitis and some with familial adenomatous polyposis to avoid a permanent ileostomy by enabling the storage of stool in the pouch as would normally occur in the rectum to be followed by defaecation through the anus at the patient's convenience. The drive behind creating and developing ileo-anal pouch surgery was to improve the quality of life for select patients who required surgery for their condition and were medically suitable to undergo the procedure. The decision to undergo the pouch operation was made by the patient based on objective information and their preference between life with a permanent ileostomy or the preservation of defaecation through the anus, in each case with the removal of the disease. The Kock pouch procedure developed by Finnish surgeon Nils Kock first reported in Sweden in 1969 which is a continent ileostomy, was also an attempt to improve the patient's quality of life, but it still required an opening of the bowel onto the abdominal wall, rather than preservation of the normal route of defaecation through the anus as in restorative proctocolectomy.
Career
Training and early appointments Born in Wilby, England, Nicholls attended Felsted School and went on to study medicine at Gonville and Caius College in the University of Cambridge. He completed his clinical training and surgical residency at the London Hospital (known from 1990 as the Royal London Hospital) and became a Fellow of the Royal College of Surgeons in England in 1972. It was at the London Hospital, that Nicholls trained under British surgeon Sir Alan Parks. Parks operated on his first ileo-anal pouch patient in 1976 at the London Hospital and subsequently at St Mark's Hospital where he was also a consultant. Nicholls was his first assistant having spent 1976 carrying out research under Fritz Linder on an Alexander von Humboldt Fellowship in the Department of Surgery at the Heidelberg University in Germany. Nicholls became a Resident Surgical Officer at St Mark's on his return to the UK in 1977. He was also a consultant surgeon to St Thomas' Hospital, London, from 1982 to 1993 when he left to become Dean of St Mark's.
Beginning of ileal pouch surgery
The "straight" ileoanal procedure The ileal pouch-anal anastomosis (IPAA) procedure was an advancement from the "straight" ileoanal anastomosis procedure original described by the German surgeon Nissen in 1934 and resurrected by the Americans Ravitch and Sabiston in 1947. They described the total removal of the colon and rectum with restoration of intestinal continuity by means of a 'straight' ileo-anal anastomosis without any formation of an ileal pouch or reservoir. The procedure resulted for many patients in high frequency and urgency of defaecation day and night which made life difficult.
The Kock reservoir The Kock pouch involved first the removal of the colon, rectum, and anus as treatment of the disease. Next, using the last 45 centimetres of the ileum, the construction of an ileal pouch with a valve designed only to allow drainage of its contents when a catheter was passed through the stoma on the abdominal wall. This allowed many patients to have control over their life by being able to evacuate stool at a time of their choosing.
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