 Well, good evening everybody. I'm John Fraser, I'm the Dean of the Faculty of Medical and Health Sciences and it's my very great pleasure to welcome you all here tonight. I know the weather is just awful outside so it's wonderful to see such a great turnout. So I'd like to welcome you all to what is our first of our series of inaugural lectures for 2016. And as I said before it's a real delight to see so many colleagues and friends and family here tonight both from within the university and from outside the university and I believe a number of you have travelled quite some distance to attend tonight. So I'm just going to give you a very brief overview of what inauguration really means. It's a process that's been around for a very long time, the universities. It serves two purposes. One is an expression of the acknowledgement and welcome, a reception for new professors joining the circle of the esteemed colleagues that we refer to as the Professoria. The second and most important is to showcase the subject there and the story of the new professor. Their maiden lecture is a professor at the University of Auckland. The lecture series is one of the highlights of our academic calendar and this year we have three new professors that we'll be presenting over the forthcoming weeks. So academic inauguration dates back to many evil times. It was unashamedly intended to impress the public and the rich benefactors, the need for their continued patronage. Professors were chosen not only for their intellectual capacity but also their financial worthiness. One tradition required the new fellow to host all the colleagues for the duration of the inauguration period. I believe that was the start of academic fees. So today's inauguration lecture means of introducing our most eminent staff. Elevation to the rank of professor is not something we take very lightly. Since for many it represents the pinnacle of one's academic career. The process for selection is long and requires intense scrutiny by other professors who are then also advised by a body of international peers who must confirm that the appointee is indeed considered internationally eminent in the chosen field. I believe inaugural lectures are a wonderful opportunity for colleagues, family and friends to learn about the journey that has led to this academic success. The milestones, the decisions and particularly the mentors who have assisted instead along the way. Tonight is my very great pleasure to introduce Professor Ian Visit. Ian is current for head of the Department of Surgery and a consultant colorectal surgeon at Auckland City Hospital and is also the past president of the Colorectal Surgical Society of Australia and New Zealand. So without further ado it is my great pleasure to invite Professor Brian Parry, former head of the Department of Surgery, to formally introduce Professor Visit. Professor Parry will invite Ian to deliver his inaugural lecture after which Professor Alan Mary, the head of the School of Medicine, will deliver some closing remarks. Right. Kia ora koutou and I use that informal greeting advisedly because although this is a prestigious lecture, it's also a family and friends occasion. So I think that's very appropriate. It's my great privilege to introduce Ian. I need to come clean and express my interest and that he's a much respected colleague of mine. We work together day by day and more than that he's a deep friend as well. Ian was born and raised in the city of Auckland. He attended Auckland Grammar School and some of you may have heard of that. It's a little school just up the road there. He frittered away a lot of his time there. He played rugby for the first 15 and did in 1972. He was captain of their first 15. Also he was a senior athletics champ that year as well and had prefect to boot. He managed to do a little bit of homework because he got a university entrance scholarship and also an ASB scholarship the same year. So he was quite a year in. He studied medicine in this faculty here and was awarded the MBCHB in 1978. He did house surgeon years in Taranaki. He was a surgical registrar there for another couple of years in basic training and then got into the advanced training scheme in Wellington where he was granted the FRACS in 1987. For the next decade he worked as a consultant general surgeon in the Western Regional Hospital in Pokhara, Nepal. And that is an interesting institution that is a synergy between a missionary society and the government. And missionary doctors learn a great deal in those situations. They learn a lot about need. They learn a lot about innovation. Working things out from first principles and the importance of being frugal and smart with the spend because I ain't a lot of money. So in a way it sounds like being part of the university walk-on. On return to New Zealand he was appointed as a lecturer in surgery and a research fellow in the department of surgery and he got his MD awarded in 2001. Then he did fellowship training and professional training in colorectal surgery both in Auckland and Concord in Sydney. Came back, senior lecturer and consultant colorectal surgeon and then he became head of the colorectal unit in 2007 until 2012. He was promoted to associate professor in 2008, not easy. And then in 2011 in a weak moment he accepted the idea of being head of department of the university department of surgery. I don't want to go on too long because we want to hear this from this man but he's done an awful lot. He's a member of the Royal Australasian College of Surgeons. He's an honorary life member of the surgical society of Nepal, the colorectal surgical society of Australia and New Zealand. He was president of from 2012 to 2014. He's in various other sections of colorectal surgery and academic surgery and college and so on. And amongst other things he's chair of the National Valve Cancer Working Group in New Zealand and on various advisory groups to numerous to mention. This man has tuned out a lot of peer reviewed papers over the years. He's got PhD students for Africa, many of who are attending tonight. They should be actually studying but they're here apparently because I know Ian will be looking for them. So trying to draw the strands together folks, Ian for me stands out as a man of high integrity, is an energetic and hardworking person, very generous to his patients, to his colleagues and his students. He's academically bright and very productive and on top of all that I think what stands out is his leadership. A novelist who I'm sure you've never read called David Wallace once said real leaders are people who help us overcome the limitations of our own individual laziness and selfishness and weakness and fear and get us to do better, harder things than we could get ourselves to do on our own. Perfectly summarises Ian in his approach and also the observation made by Tom Peters. Leaders don't make followers, they make leaders and that's what Ian is doing in his career and I think it's a tremendous thing that you've been appointed as professor in this August faculty at university. I now invite you Ian to come forward and give you an all-your-lecture. Professor Don Fraser, Professor Pallamere, Professor Brian Barrow, my very good friend, very generous friend, thank you, my colleagues, friends and family. It's an amazing privilege to be here with you today and one that seems somewhat unreal I have to say. I need to apologise to those of you who thought of a lecture about the start of the movement and now mentionable, it was going to be a commentary about politics in North America. It's actually going to be something of a personal journey in polaroid recall surgery that I've had. And it's all been focused around patients who I have come into contact with and I realised that the treatment that they've had is really not as optimal as it ought to be and that has driven me into looking at ways, different ways of managing conditions that might actually make the lot of the patient better. This institution is my alma mater. I spent six heavy years here as a medical student. I entered the medical school thinking I would become a general practitioner working in a rural community close to the sea where I could go fishing and where I could get plenty of chance to train for this beautiful country that we're in. During my 60 years however, two very important things happened. I met my wife, Joan, my wonderful wife who I married in the fifth year and I was completely challenged by the inequalities in care for patients across the world. All of the inequalities really stood out and along with that the privilege that I had as a person living in New Zealand. And so I was challenged really to think of spending my life in a way that might somehow make some small difference to that. In my sixth year, Joan and I went to Nepal for my elective and you can blame the elective program for a lot of what happened. We spent three months in a small mission hospital in Unpeople looking with an inspirational surgeon from America called Tom Hale. We were absolutely amazed at the beautiful views of the mountains and the hills there and also the plight of the people who were so poor and had so little treatment. I went to Nepal thinking I was going to be a general practitioner and I came out thinking the world needs another surgeon. And so for the next eight years I spent time in Tehranaki and then I went into training to be a general surgeon. At the end of that time my seniors said to me, we've got a job for you. Sinorich is a great place to continue to train. I'm afraid I felt pulled in a different direction. And it all revolves around the word location. This is a word that isn't used very often nowadays. But my autobiography has a PhD in Plastic. It's a word that's used for an occupation that involves service that affects a lifestyle and that's paid less than it's worth. She should know. She's a teacher. So the words of Aristotle rang true. We are taught in the world's needs crossed there lies your vocation. And to be honest there were some other words that struck me as well. They were the words of Jesus Christ. And he said, whatever you did for one of the least of these brothers and sisters of mine, you did for me. So in 1987 with two daughters in tow, we headed to Nepal. At that stage of time we had a population of 17 million. Life expectancy of 51 years. And the government spent less than $2 a head on health. We went with a Christian mission organisation called the International Department of Fellowship. And I was seconded to a government hospital, a western regional hospital. It had 200 beds. It served a population of 3 million. There were 20 doctors on staff, almost all of them in Nepal. And only 55 nurses to manage 200 beds day and night all year. The budget was only half a million US dollars a year. It was a steep learning curve. And the challenges included learning a new language. Trying to work without the resources that I'm being used to. Trying to understand what it was like for a patient to have to buy the medication and all of their disposables. And on top of that there was an endless supply of patients presenting late with advanced disease. I tried to adapt as much as I could. I closed the abdomen, used a fishing line and then published a paper on how to sterilise things using a plastic bag and formulant tablets. I kept patients warm under a special tent which had a hair dryer at the top. And anything that could safely sterilise was. This brings me to the first part of my talk. Patients were starving. And there were two main surgical patients like this. Patients were with gastric aloe destruction. And patients with post-operative small bowel fission. And we'll look at both of these. Gastric aloe destruction occurs from two conditions in the setting of the pool. The first is chronic hip gulf, where the scour encloses off the aloe to the stomach. And the second is gastric cancer, where the cancer does that. Patients present with cogeous vomiting, incredible weight loss, disturbance to their hydration and electrolytes. And even as early as 1936, it was known that these patients, within their lost order weight, don't do well after surgery with a high mortality rate. So I see often just looking after these patients. I rehydrate them. I correct their electrolytes. And I operate on them. There was one or two operations that either removed the lower half of the stomach, as shown in this picture. Or I did a bypass where I brought some bowel up above where it was obstructed and joined it together. That's what I did a pretty good job. But three of the first 14 patients I operated on died. All of them, because they had a complication related to their bowel nutrition. So I thought hard about what we could do. And I added something to the operation. I added a tube that went into the bowel, down the stream from where I joined the stomach to the intestine. And I started feeding them immediately after surgery. The first day they would get a sugary solution. And then from there on, by day two or three, they were getting all the calories that they needed. Here's the results. I looked after another 44 patients who had gastric ablet destruction during my time in the fall. The second group, in terms of age, in terms of pathology, and in terms of operation were pretty well the same. The mortality rate dropped from over 20% to just one patient and 44 to 2%. That didn't mean they didn't get complications higher. And most of these complications would have killed patients if they couldn't feed them at the same time. Patients whose stomach didn't work. And so you couldn't feed them because it wouldn't contract. Patients who leaped and really joined the bowel together and so we couldn't feed them through the stomach. And patients who were vomiting. With the tube that I had placed in there, I could continue to feed them. Because we had a very much younger age. And the patient wasn't quite sure what was going on. So in conclusion, gastric surgery in the malnourished actually has a very high mortality. But I've shown that we can reduce that mortality by a relatively simple procedure which could be done at a time of surgery. And that this would also help to manage the post-operative. The second condition is even more challenging. Use patients with small althistilis. In this situation, we operate on the patient, join the small intestine together. And sometime later that breaks down. The intestinal contents get into the abdominal cavity and leaves out through the abdominal wall. The devastation of this condition was brought under me by a patient called Rukmina. Who was 29 years old when I saw her. This was 1989. She arrived really very sick. So sick with peritonitis. I had a labyrinthine. And I found that she had a condition called necrotizing enteritis. That's a bacterial infection. That causes catching the death of the small bowel. So I removed all the debits and joined the rest of it together. Not surprisingly, some of that fell apart. And this started leaking out onto her abdominal wall. Then at all, some of your relatives has to look after you while you're in hospital. She had all her 12-year-old son who cared for her. This gives you an idea of the extent of the difficulty that we have. I had none of the normal devices that we have in New Zealand that would manage the wound. I had no intravenous feeding that we would use in New Zealand, which contains all the nutrients that you might need. I had no intensive care. Initially I tried to re-operate and close these, but inevitably it broke down and the situation was worse than it had been before. Three months later, after her son had cared for her all the time, she died. I was devastated. Her son was almost as an orphan and some of my friends in New Zealand helped support him. He's now married, two children, and an accountant working in Okra. In 1990 I came back to New Zealand and I talked about this problem with Graham Hill, who was a world expert at that stage. The problems associated with small bowel fissure are dramatic. Patient becomes dehydrated, their electrolytes are all to pot, their skin gets eroded by the auto digestion of the enzyme from the fluid that comes out, they develop an intrapominal infection and over time very quickly become malnourished. It's a really toxic mix and in a situation like Nepal, almost everyone who has a fissure dies. Graham Hill told me about a paper he had just read which had been published out of France where they had done an amazing way of managing these patients using enteral feeding. That's feeding into the intestine and if necessary, re-feeding what had come out into the intestine further downstream. They had a series of 335 patients, 85 of them were managed by enteral feeding, 92 of those patients had to be re-fed in some way into a distal bowel and their overall mortality was 34% even in France. I had some thinking that maybe I can use this technique and so I developed what I call the triple soma technique. Now the triple soma technique involves placing three different tubes. The first tube goes into the stomach. Now you need to have a tube in the stomach so that you can continuously feed these patients. I tried feeding them orally and I wouldn't eat enough. I tried putting a tube down the nose to feed them and it only lasted one or two days and they took it out and wouldn't let you put another one down. So a tube in the stomach was needed and we fed them through that. Secondly, they needed the bowel upstream of where it was leaking brought onto the skin so that any contents that came out didn't cause continued infection inside the abdomen. And thirdly, they needed a tube so that whatever came out could, if necessary, be put back in again with a tube into the bowel further downstream than where the leak was. What do you put down the tube? Well, we could get in from feeding form and from the local shops, so we used that. You could get in, which is purified dairy fat. Some of the patients used that. My favourite was actually buffalo liver. Now buffalo liver can be critical and then mashed and then it can go down the shoe. It's very high in protein. What did these patients come up with? Well, a lot of several different causes. Tuberculosis, neglected hernias, necrotizing enteritis, typhoid, trauma and abscesses. This is a 12-year-old boy who was gawd by a bull and didn't come to hospital for 15 days. He was at death's door. For him, I used this technique. He went home and he came back three months later to look like this. A different boy. Just the same shoe. I operated on him and he made a great recovery. So how do we do? One of the high output festures, which means there was more than 500 girls coming out a day, I had to operate on 11 of them. If I operated within the first 10 days, I could do all of the things I wanted to and five out of six of them survived and he did this to the host. If I operated later than 10 days, four of those, five of those patients actually didn't survive because the intraabdominal cavity was almost obliterated by the information associated with the fistula going on. So it became clear you need to operate early and you need to bring the bowel out onto the skin to prevent the ongoing infection. So the overall mortality for high output fistulas 38% after we introduced this. There were many, there were seven patients with low output fistulas and these were actually pretty easy to treat. They could be fed usually orally. I had to feed two of the tube at all of them survived. So in conclusion, as far as managing small bowel fistula, we could bring the mortality down including the low output to 24% usually what I was doing. We need to operate early if they had an official postoperatively, but if they're going to die, they die uncontrolled sepsis and malnutrition usually. What does this mean globally? Earlier this year I spoke with the President of the East, Western and South African College of Surgeons. He told me that almost every hospital across Africa would have at least one patient with a fistula a year. And the same would be true of Asia. Almost all of those patients die. With a simple treatment like this, many of these patients could actually be saved. The courage to be able to operate on them early enough and deal with the contaminations going on. In 1998, we left Nepal with very mixed feelings, I have to say, and our family moved back here to Auckland. We left behind many of the highly doctors who had been involved in training. This picture at the top shows three surgeons I trained. The one on the left is now Professor Gimmery. He is the Head of Surgery at the Monipal Medical School. The surgeon in the middle died a few years after I left or gastric cancer. The surgeon on the right is Dr Gurum, who is now the Chief Surgeon at Western Regional Hospital and is doing far more surgery than I ever did while I was there. I arrived back in New Zealand and there were two wonderful mentors for me. Ryan Parry was Head of Surgery at that stage and he was willing to offer me a job as a lecturer in the Department of Surgery and Graham Hill offered me a research project and offered to supervise me. They could see potential in me. I had a chance for a second go at life in New Zealand at that stage and Graham Hill introduced me to the challenges of managing rectal cancer, which brought me to the second of my topics, the maintenance. Valve cancer is a major issue in New Zealand. About 3,000 new cases a day goes a year and about 900 of those have rectal cancer. The big problem with rectal cancer is that it is very difficult to remove. It is surrounded by major blood vessels, important nerves, gynecological and urological structures, all within a fixed bony pelvis that doesn't expand. So operating on rectal cancer is like working in the dark down the long hall. And the problem with this, the major problem with rectal cancer at that stage was the cancer coming back in the pelvis after the operation had occurred. There were two new developments in the 1990s. One was by a British surgeon called Berl Heald and he described in a tip that was operating down in the pelvis to remove rectal cancer without cutting into the cancer. The second was the research that came out of Sweden, which showed that if you had radiotherapy patients with rectal cancer before they had their operation, you would reduce the chance of the cancer coming back locally by 50%. The problem was radiotherapy was associated with several side effects, incontinence of urine, incontinence of stool and increased risk of sexual dysfunction. So we were stuck with the situation. How do we best manage these patients? And Graham wanted me to try and find the answer. Graham had already described a technique that he was using which is very similar to that of Berl Heald and he called extra-facial excision of the rectal. So my first task was to find out was there any difference between patients who were treated with extra-facial excision of the rectal and patients who had conventional rectal cancer surgery? So I carried out this study with Glenn Mackay, who has been a junior doctor working with us. This involved 315 rectal cancer patients who had been operated on at least 5 years earlier for over a 60-year period. And we looked at patients who had been treated with extra-facial excision of those who had conventional surgery, particularly looking at what happened in terms of local recurrence. What we found was quite surprising and actually caused by a stir across New Zealand and even into Australia. The dotted line shows the local recurrence rate in the conventional surgery patients. By 5 years, 30% of them had the cancer recurred within the pelvis. In the extra-facial excision group, it was less than 10%. Not only that, but the cancer-free survival was significantly greater in the group that had extra-facial excision, with 73% being cancer-free at 5 years to 62% in the conventional surgery group. There were several things that needed sorting out. There were three eminent groups that have recently published on the anatomy of the area. A group from Germany, a group from New York, and a group from Japan. And all of them thought that the nerves that supply the important structures in the pelvis lay inside the fascia that we were supposed to be removing to try and take the cancer out. So I was tasked with trying to work out what the anatomical claims really were like. Most of the studies that had been published were involved dissection of fixed tissue, which is quite hard and difficult to dissect. So I was going to dissect fresh tissue, and in fact I was going to start by dissecting specimens that were removed. This is a specimen removed for a patient who's had the rectum removed with an extra-facial dissection. The main thing I needed to identify was, does the fascia completely surround the rectum? As the studies prove it, it only covered the posterior back part of the rectum. And were the nerves inside or outside the slag? The first person I had was a young man who had ulcerative colitis who was failing all of the treatment and needed his spores to go on and his rectum removed. And he agreed to me taking his rectum and doing some experiments with us. I got the straight from there, and I took it from Graham. He went off to the office and started dissecting it with the instruments there. Within the next two hours, I made my way down and around the rectum and after fixation, showed that the rectum actually was completely surrounded by the fascia procreate. That's the fascia procreate. And it could be removed like a sock. So that if you stayed outside the fascia procreate, you would remove all of the rectum with supporting the fat and lymphatics and blood vessels. I looked at 13 different specimens. I showed that the fascia procreate was thicker at the back than it was at the front, which means dissecting initially at the back right on where the fascia was thicker made it easier to give it to the right plane. I also showed that the attachments of the fascia procreate on the side, on your left is the fascia procreate and on your right is the rectum. And the two are fused together where the lower part of the rectum meets the upper part of the anus. At that point, if there is a cancer, then there's no leeway with the operation. And this has been the basis of understanding that for very low rectum cancers, we need to actually go even wider to make sure we remove the cancer without cutting into it. This is all very well. The question remained as to how before surgery would we know whether the cancer was going to be completely removed when we operated in the extra fascia plane. In the early 90s, in the early 1990s, on CT and MRI, there was just a line that appeared around the rectum. So in this picture, the black bit and the middle of the rectum, the arrows are pointing at the line which is sitting in the fascia around the rectum. My task was to try and identify whether this line actually represented the fascia procreate. Studies have shown the fascia procreate was only 200 microns thick. And the finest detail or resolution of an MRI at that stage was just one millimetre which is five times bigger than the thickness of the fascia procreate. So we decided on a rather daring experiment. We decided that we would take a cadaver, we would put it through the MRI scanner, we would then, in the MRI rooms, set up an operating theatre, operate on the cadaver, put a marker in the right plane and then put it back into the MRI scanner and see where the marker actually lay. So you might recognise some of the fascias here. This is us waiting after we'd done all that to section. It took a long time, just relatively late at night. This was at Middlemore because they had the best MRI scanner at that stage in 1998. We were waiting. This shows the results. The left is the pre-deception MRI with the white arrows showing this line that we're looking at. On the right is the post-deception. And you can see the very black area with the black arrow here is the marker that we put in place. And we had actually now shown that if we looked at an MRI we were looking at the fascia procreate lining around the rectum where we saw that line. That wasn't enough. We now had to show whether we could tell how far the cancer was away from that line before surgery to help us decide who should get radiotherapy before they actually had their surgery. So the next experiment involved two radiologists, David Huff and Charitha Finando, a pathologist, Kai Chow, who's still working with us. And they went back over the last 40 patients who had a rectal cancer and looked at their pre-operative MRI and reported independently as to how deep that cancer had invaded and whether it was actually approaching on the fascia procreate and rot. And then we compared that with the pathology reports we got from Kai Chow. Here are the results. The picture on the left is a patient with a cancer that is just through the wall of the rectum. And you can see this. You can probably use my pointer even. You can see this is the cancer here. This is coming through the wall, just going through the wall of the rectum slide. And this is the fascia procreate. So the long distance between, on this side, there is a cancer here which is actually invading right out to the fascia procreate. They were able to correctly predict in 38 out of 40 of these patients what the relationship between the cancer and the fascia procreate was at 95% accuracy. So that gave us confidence to use this as the basis for making clinical decisions with patients. This caught on, not just at Auckland Hospital but right across Auckland. And so that 10 years later we were able to look what was happening when we used this. So from North Shore, Auckland Hospital and Middle Hospital we gathered patients who had an MRI scan of the rectal cancer and a decision made on the basis of that as to whether they had radiotherapy or not to try and reduce the cancer and then surgery. What did we find? We found that using this approach the local reconstrate for cancer out to five years was just over 6%. Which was comparable with the very best results in the literature. But only 27% of the patients had to have radiotherapy. So we were confident that using this approach we could select patients appropriately who need radiotherapy and spare the others so they would go straight forward to have their operation. So what were the implications of this? About three quarters of patients can probably be spared having radiotherapy and its complications and that now in the present setting compared with just 15 to 20 years ago the local recurrence rate for rectal cancer in Auckland is actually very low. This brings me to the third of my topics the unmentionable. And the unmentionable is fecal incontinence. This condition is doubly debilitating. The patients have to manage very difficult symptoms themselves and they're also socially isolated. They're socially isolated because most of them are actually too afraid to even talk to their closest friends about the problem they have. They manage it in silence. I think of it actually as the modern day leprosy. These are patients who are always feeling as though they are unqueen. They can't leave home for fear of an accident and so these patients suffer mostly in silence. It's not very common you might say and I had thought the same thing and when we look at the literature the population studies that look at its prevalence very greatly from 0.4% of the population to 19% of the adult population. So we decided to try and find out what it was like in New Zealand. So we set out to perform a New Zealand prevalence study of the community. Avinashama who's here tonight did the study with me. It involved a postal questionnaire sent out to randomly identified individuals from the electoral role. The questionnaire involved a validated fecal incontinence score, a fecal incontinence quality life, evidence about constipation and other demographic data. We started with 2,000 individuals and sent out questionnaires to them. This made the prevalence data for the whole population. We then sent out another 2,200 questionnaires that we had a comparable number of Maori and non-Mauri, so that we could work out how ethnicity also related to this. Here's our very pleased with the number of responses that we had. I think it was amazing that we got almost a 60% response rate for a very sensitive state sent out. The non-Mauri response rate was almost 60% and the Maori response rate was almost 50%. That's what we actually find. Fecal incontinence was much more common than I thought. When we defined fecal incontinence as having at least one episode of either liquid or solid incontinence of stored per month, 12.6% of the adult population in New Zealand said they had it. That's one in eight. Looking at constipation, one in three across the population had this. How did Maori and non-Mauri compare? The Maori prevalence rate is actually 18.2%, significantly higher than non-Mauri, as was their constipation rate. What other risk factors did we identify on multivariate analysis? Social economic status, so those with the lowest socioeconomic status were more likely to have incontinence. Those who had previous operations on the anal canal were more likely to have incontinence, perhaps understandably. And those with diabetes, interestingly, were also much more likely to have fecal incontinence. How many people had ever talked to any health professional about this? Well, only 40%. So the majority of patients with these symptoms had never spoken to anyone who might be able to help them. It's not surprising that it's so difficult for these patients if they're not even able to talk to their health practitioners. The management of fecal incontinence is mostly relatively straightforward. We would take a careful history, we would examine them, there are several investigations we do, including an ultrasound to see whether the muscles are intact, an x-ray to see if the bowel is collapsing down and prolapsing, and often pressure measurements of the anal canal. More than 95% of patients with incontinence can be managed with conservative measures. This usually means adjusting their diet, pelvic floor physiotherapy, optimizing medication and adding something, usually low-paramide to try and make the motion a little firmer so that it's easier to hold on to. About 95% of patients are better with just those measures. Unfortunately, there's a few who aren't. And we, up until recently, had three things we could do. We could stitch, we could hitch, or we could ditch. Stitching, we offered to patients who had a torn sphincter. Now, this happens mostly during a very traumatic childbirth in women. And when that happens, we're able to join the sphincter muscle back together again by stitching it overlapping itself. Some patients have what's called prolapse, where the bowel is collapsing and coming down into and out through that passage. We manage that by hitching the bowel up and fixing it to the sacrum of so-called rectopexy. Patients who couldn't be offered those two, the only other thing we had to offer was a colostomy. That's bringing the bowel out under the skin and putting a bag on. In fact, ditching the rest of the rectum. In the late 1990s and early 2000s, a new treatment was starting to be described and some of the results seemed too good to be true. This involved stimulating some of the sacral nerves as they come out through the bone into the pelvis and randomized controlled trials that appeared in the early 2000s suggested that this could be used on those patients with severe fecal ailments that the only other option would have been a colostomy. By 2009 I was convinced that we ought to start doing that here in New Zealand and we started offering this treatment. This treatment involves having a patient flat on the table on their stomach putting a needle through the sacrum until we identify the nerve as it comes out through the bone, the third sacral nerve and then passing a lead with four electrodes through that needle so that it's lying alongside the nerve and then bringing that out through the skin and attaching it to a stimulator that continuously stimulates those electrodes. We would ask the patients to fill out a diary prior to all of this happening. So this is the baseline diary of the first patient that we managed in this way. The area inside the red box shows the number of episodes of fecal incontinence each day for that week. In this patient there were 12. Once we did the stimulator on this patient this is her first week with the stimulator turned on. There wasn't a single episode of fecal incontinence. I actually didn't believe it. This was better than I could possibly have thought. If they have a good response like this we then go on to implant a stimulator very similar to a pacemaker that's used for the heart and that's placed in the buttock and continuously stimulates the lead. What have our results been like? These are the results we had at the end of last year when we had 74 patients involved. Of the 74 patients there were nine who had no improvement with the trial stimulation and they no longer went on with that. And some of those have gone on to have a colostomy. 88% however did have a response and they all had the stimulator implanted. And of those only six have had secondary failure and had to have the stimulator removed. So in fact 80% of the people who we've put into this have ended up with a successful result with a stimulator. What does a successful result look like? Now this is looking at the patient's number of episodes of fecal incontinence per week and looking at the median number. So the median number of patients prior to having the stimulator was seven episodes per week. The median number at the last follow-up of these patients was one per week. And in fact for 40% of the patients it was zero per week. We looked at their quality of life. This is a group of 15 patients who have a degree in post quality of life and all but one of them had a marked improvement in their quality of life. Now those are just lines on a page actually. Not many people would want to hug their colorectal surgeon but these are the patients who do. They come back to me and they say I've got my life back. I can actually go out now. I can go have a meal much with my friends. So how does this work? Well the short answer is we don't know. The longer answer is we're trying to find out. The third sacral nerve is a very important spot. That nerve does four things that are all important in maintaining continence. It's involved in the motor activity to the pelvic floor and the anal sphincter. It's involved in the sensation of what's happening in the rectum. It's involved in sending signals back to the brain to tell you what's happening and bringing signals back again and we think most importantly it's involved in the autonomic nervous system that involves the contractility of the lower part of the bowel above the rectum. Recently a new tool has been developed which is a high resolution manometer. This gives us the ability to measure the pressure in the bowel every centimeter along its length. What we are now doing is trying to understand what is happening with the contractility of the distal colon and how important is this in maintaining continence and in the effect of sacral nerve stimulation. Here is a closer look at one of these manometers. Every centimeter is a fibre optic receptor that gives us a pressure reading. Nine healthy volunteers bless them agreed to undergo a manometry of the distal colon. It's involved placing the manometer with a colonoscope and then taking an x-ray afterwards. The x-ray you can see on your right shows the manometer going up to about the splenic flexion. And we could measure exactly where the manometer receptors were in terms of the colon. This is a picture of our manometry team getting one of these manometers calibrated. The manometer is clipped in place with the colonoscope. Now you have to pay attention this is a difficult slide. These are the results. The line that's running along goes for four hours and from the top of the blue to the bottom of the blue goes from the upper part of the manometer to the lower part. The colour shows the intensity of the colour shows the pressure at each of those levels. After two hours we gave the subject a meal. The area we're most interested in is the two hours following the meal. And when we look at that up close especially if we look at it with a line diagram you will see what's happening to these pressure waves. The pressure waves are actually moving from lower down up the colon. What's called retrograde contractions and they're very frequent. They're happening about three times a minute and that's called the cyclic activity of the colon. What sorts of activity we were seeing with this? The vast majority of the activity was retrograde going back up the colon and the vast majority of that was cyclic motor patterns. 72 of the 107 were actually retrograde cyclic motor patterns and fewer were anti-grade. I don't know where did these waves start. The anti-grade ones were starting further up the bell and almost none starting at the rectum or just above the rectum. The retrograde ones were almost all starting in the rectum and moving back upwards. What we've shown is that this seems to be a retrograde activity in the distal part of the lower part of the bell that acts a bit like a recto-signoid break and we think it is important in maintaining continents. We are now looking at patients who have got a sacral nerve stimulator inserted and seeing what different programs do to this particular activity. We've enrolled 8 of the 15 patients that we need. Tony Lin is doing that who's with us here tonight. In some ways our research has come full circle. Riyash Veda who's also here tonight from New Plymouth he spent 3 years with me trying to understand another condition that causes starvation around surgery. This is post-operative ileus. This is a failure of the bell to return its activity after an operation and it results in abdominal distention, vomiting, inability to eat and inability to pass a bowel motion. What Riyash has done is to provide a clinically usable definition help us with the conservative management and produce some recommendations on how we might do that. We've carried out a randomized controlled trial of a therapeutic option which actually wasn't as good as we thought it might be and he's produced a risk prediction model that will help us to know who's likely to get ileus and how we might manage them. I'm excited about where we're going from here. This is a picture of our research team at present. There are many things that we're looking at. Tony Milne is continuing the work of Riyash and is about to start a new randomized controlled trial looking at another novel agent that we'll be using to try and actually prevent post-operative ileus. Celia Keane is looking at a different bowel problem that's associated with removal of part or all of the rectum called an anterior resection syndrome. Rebecca Jang is doing a randomized controlled trial that will answer the question whether we really need to give antibiotics to patients who have uncomplicated diverticulitis. Noah Bunkley is actually at the moment in Vanuatu and he's doing some work on global surgery. He has just completed an amazing household survey with random households across Vanuatu and looking at barriers to them getting surgical care. He's doing an honest degree with me this year and it's exciting for me to be involved in some research again in low and middle income countries. Lance Yuang is a junior doctor who's been assisting us in some of our incontent studies and Greg O'Grady is a new associate professor who's in the department and has his fingers in more pies than he has fingers in surgery. But he's co-supervising some of my students and is already an international leader in terms of intestinal motility. There are so many people I need to think. My many collaborators who have worked with me particularly my undergraduate and postgraduate students. Lois Blackwell who has acted as my PA as well as looking after the administration and the whole of the department's surgery. Are you here Lois? Thank you Lois. She keeps me sane some of the time to my colorectal colleagues Brian Perry Aaron Mary, Julian Hayes Rowan Collinson Naga Malmasani and Greg O'Grady. They have many times stepped into the breach where my academic duties have called me away from patients and my patients have done well with that. It's been a privilege working with them. I need to mention the patients because all the way through there have been patients who have been willing to submit themselves to unmentionable investigations to be part of what we're doing and to help us understand things better. And finally to my wonderful family to Peter and Becker to Miriam and Sue to Bex and Mike. Thank you. Thank you for understanding why mine seems to be somewhere else when you're talking to me. It is, usually. And of course to Joe who stood beside me in the strongest possible way supported me and has taken many risks with me. I couldn't have done it without him. So thank you all who've come to hear this tonight. I hope you've enjoyed it. I've enjoyed being able to tell it. Thank you. Thank you for an extraordinary address the starved, the malignant and the unmentionable. I'm sold. If I was a rich member of the local land gentry some hundred years ago you would have my patronage. I'll see you later. At the outset I was really struck by the applause you received before you even started. The respect that you're held in is reflected not only on the number and diversity of the people who have attended, but in that applause which was prolonged at heartfelt. And in your lecture we have seen why that is. We heard from Professor Perry about your intensely practical ability which manifests at school in your sporting achievements. We heard that from Professor Perry, not from you which is characteristic of your modesty. And it's long been... I'm an anaesthetist for those people who don't know that fact and I have spent a lot of my life working with surgeons. And it is my view that the majority of good ones are capable practically and they are usually good sportsmen. There are exceptions, but it is normally the case. What we have seen is how that practical ability translated into the work that you undertook first in Nepal and then later in New Zealand. But it was underpinned by an astute academic honesty that was committed to collecting data on your outcomes. Not all of which were perhaps what you wanted to see. But to then analysing the reasons and coming up again practically with solutions to improve the outcomes of your patients. Professor Perry talked about leaders producing leaders. And we heard about that also both in Nepal how you left behind a legacy of leaders and indeed in New Zealand how you continue to do that. Your work on the micro and thick fashion appropriate is just astonishing and reminded me why I decided not to pursue a general surgical career. Extraordinary difficult. Your description of a silent disease, modern day leprosy was very moving. But I was also struck as a person interested in quality and safety of healthcare and the right way to manage patients. The majority of your patients you manage conservatively with simple, sensible, practical measures. But for the remainder you have introduced a high tech very sophisticated stimulation therapy which has in your words given back the lives to many of those patients. Many people think that researchers can't teach. You might with your stunningly arresting lecture I mean I was just riveted through the whole of it that that's not true because you clearly are a researcher and you clearly can't teach. Many people also think that academics are inhabitants of an ivory tower that deal with esoteric topics that have no use to anybody. Well we've seen how far from the truth that is today and I believe in our faculty and in the School of Medicine in particular you illustrate how untrue that is with the work that you've done and that many of your colleagues in that area do do. If you go back to the thought about the relationship between town and Gaon and the idea that perhaps the Gaon in some way has no relevance to the town well we've seen how wrong it is. We have seen how your intensely practical but rigorously academic work contributes enormously to the lives of the citizens of our town and of the people in Nepal. As you said you have given so many people back their lives here and in Nepal. In our School as in the School of Population Health and School of Medical Science we are tasked with producing the future medical workforce of New Zealand and to do that it is critically important that we have people that are not only teachers and academics but are role models. Role models of the kind of doctor that we want in the future in New Zealand and what we've seen today is that you are an incredible role model for our medical students. In fact you're an inspiration for them for all of us and also may I say for me thank you for an incredible inaugural lecture. Thank you all very much for coming tonight. Thank you Professor Perry, Professor Mary for a wonderful opening invitation and a delightful closing remark from Professor Mary but most of all for an outstanding inaugural lecture. I think you've met the highest standards of what we expect from our professors so again like Alan you have my patronage as well. Thank you all for coming tonight.