I am very grateful and humbled to have been selected as the 2013 American College of Surgeons (ACS) Japan Traveling Fellow. For me, Japan has always been a land of intrigue. My first exposure to its culture was at the age of 14 when I began karate lessons. As a lanky and awkward “geek” growing up at a time when Vietnamese-Americans were generally equated with the “boat people,” I had a hard time understanding and reconciling the differences between Eastern and Western cultures. The lessons of hard work, humility, and academic excellence, as inculcated by my parents, were more often than not challenged by friends, who thought I needed to be more athletic, outgoing, and “normal.” Karate was my solace; it instilled in me a sense of confidence, discipline, and focus. It taught me the “Bushido” way (Way of the Warrior-Knight), which stresses frugality, loyalty, martial arts mastery, and honor. I dreamed of one day visiting this island nation to better understand its rich history and traditions.
Conversely, I was also exposed in my youth to another side of Japan—a darker side, the side that had once invaded my native land, Vietnam. My parents told me stories about the horrible acts that the Japanese soldiers committed against their Asian brethren.
As a naturalized American citizen, I also had conflicting feelings over the bitter history that had inextricably bound Vietnam, Japan, and the U.S. together. Japan had fought Vietnam; Vietnam had fought the U.S.; and the U.S. had fought Japan. Adding to my perplexity was the fact that Vietnam was engaged in a civil war. My father had taken up arms against his own relatives and had battle scars to show for it—all because they had held a different political philosophy.
I spent most of my early adult life trying to reconcile these mixed feelings, although I knew deep down that they had to have some meaning. I once read a quote, “Pressure makes diamonds, friction makes pearls,” and wondered, “When will I see the pearls?” I have searched for meaning, for these pearls.
I recalled a mantra that a business professor once imparted, “For a leader to be successful, he or she must either hire his or her weaknesses or work on them.” I thought about my weaknesses and decided to work on them. Although I had confidence as a surgical oncologist in my ability to care for patients with myriad tumors, I also realized my limitations in managing patients with hepatocellular carcinoma and cirrhosis. Thus, I resolved to take advantage of the opportunity so that I could learn as much as possible about the Japanese approaches to hepatopancreato-biliary diseases, with the goal of incorporating the surgical pearls into my practice and improving care for my patients.
In my ignorance, I thought that as a Vietnamese, it would be easy to learn Japanese. How wrong I was! After downloading an app onto my iPad, I spent an enormous amount of time trying to learn Japanese. Unfortunately, age must have played a factor as my retention rate was quite low. I resigned to learning just some basic phraseology.
Toru Ikegami, MD, PhD, an associate professor in the division of transplant service at Kyushu University, in Fukuoka, helped me organize my trip. He gave me a list of universities to consider visiting and then made the necessary arrangements.
Tokyo University Hospital
Having arrived early, I spent a day exploring the city before visiting Tokyo University Hospital. At first blush, Tokyo is really no different than any big U.S. city. It has skyscrapers, hotels, shopping malls, and major chain stores, such as McDonald’s and 7-Eleven. However, there are some noticeable differences: the cars and streets are much smaller; the driver’s seat is on the right, and people drive on the left side of the street. The Japanese people are very quiet, soft-spoken, and courteous. Public trash cans are sparsely available, yet the streets are very clean. Bowing is common, and repeated bowing is a sign of respect and sincerity.
Cell phones are prohibited on subways, and it is considered uncouth to eat and walk at the same time. The Japanese people are very accommodating. I must have stopped countless pedestrians to ask for directions, and they were eager to help. Some even walked me to my destination.
At Tokyo University Hospital, my hosts were assistant professors Yoshihiro Sakamoto, MD, PhD, and Takemura Nobuyuki, MD, PhD, both from the division of hepato-biliary-pancreatic (HPB) surgery. That morning, I attended a division conference, during which a variety of HPB cases were presented and discussed.
I saw several interesting cases at Tokyo University. Because most international visitors are only allowed to observe but not scrub in on a case, I decided to go from room to room to see the different operations that were occurring concurrently. I witnessed a nearly bloodless right posterior hepatectomy that was completed with only a Kelly clamp, 4-0 sutures, and the Covidien small jaw ligasure. I developed a greater appreciation of the Glissonian approach to liver resection so as to reduce bleeding and preserve as much liver parenchyma as possible. I also saw a distal pancreatectomy and a Whipple procedure. The surgeons were meticulous, and I found their surgical skills impressive.
I learned that Tokyo University was unique in that surgeons there occasionally perform two-stage Whipple operations. To avoid a pancreaticojejunostomy leak, the surgeons prefer to perform a delayed pancreaticojejunostomy anastomoses at a later operation for selected patients. I also learned that because Tokyo University is a public hospital, it has limited resources. For example, it uses sutures rather than stapling devices for most cases.
Drs. Sakamoto and Nobuyuki and I had an in-depth conversation on the role of adjuvant and neoadjuvant therapy for patients with pancreatic adenocarcinoma. The two surgeons told me about their successful use of S-1 in patients with pancreatic cancer. S-1 is a novel oral fluorouracil antitumor drug that inhibits dihydropyrimidine dehydrogenase (DPD) and has been used in Japan but not in the U.S. for patients with pancreatic cancer. An article on the success of S-1 was recently published in the Journal of Clinical Oncology.*
Dr. Sakamoto, Dr. Nobuyuki, other surgical colleagues, and I ate a sushi lunch under a cherry tree. Drs. Sakamoto and Nobuyuki also treated me to a traditional Japanese dinner at a nearby restaurant. I gorged on the delicious food and drank plenty of saki and learned to say kanpai (pronounced kampai), or “cheers,” when toasting.
My hosts at Jikei University were Katsuhiko Yanaga, MD, PhD, FACS, professor of surgery; chief, division of digestive surgery; and President of the Japan Chapter of the ACS, and Takeyuki Misawa, MD, associate professor and vice-director of the hepato-biliary-pancreatic surgery service (see photos, page 79 and this page). At 8:00 am, I was led into a room full of residents, students, and faculty for a conference. A table at the head of the room was reserved for the chair of surgery and division chiefs. Residents also had seats, but medical students, who had just begun their school year, were relegated to standing at the side of the room.
After the conference, we went to the operating room, where I observed a laparoscopic left lateral segmentectomy. Unlike Tokyo University, Jikei University Hospital is a private hospital and, as such, its surgeons have access to a broader range of equipment/instruments, including tissue links, CUSA, and endovascular staplers.
That evening, I gave a lecture, Should All Patients With Resectable Pancreatic Cancer Undergo Neoadjuvant Therapy? I also briefly discussed our laboratory work on oncolytic virus and was pleasantly surprised that Jikei University also has a surgical fellow who is researching this subject. We had a lively discussion and exchanged ideas during the meeting. After the lecture, Drs. Yanaga and Misawa took me to dinner where we were joined by Kazuhiko Yoshida, professor of surgery, vice-president, and chief of surgery at Jikei University School of Medicine; Hiroaki Shiba, MD, PhD, an assistant professor, and Koichiro Haruki, MD, a surgical fellow.
I discovered that Japanese and American surgeons have many things in common. Like many of us in the U.S., Japanese surgeons often do not leave their office before 9:00 pm and begrudge how little time they spend with their families.
During my visit to Jikei University, I saw Dr. Shiba perform a Whipple procedure on a 65-year-old woman. I was intrigued by how he performed a pancreatojejunostomy anastomoses. I was unfamiliar with the technique and later learned that Dr. Misawa developed it and taught it to Dr. Shiba. I encouraged Dr. Misawa to publish an article on this procedure for the benefit of the surgical world.
Japan Surgical Society Congress
The following day, I flew to Fukuoka to attend the 113th Annual Congress of the Japan Surgical Society. It was an incredible experience. At the meeting, I was joined by approximately 16 other traveling fellows from different corners of the world, including China, Germany, Spain, Korea, and India. Yoshihiko Maehara, MD, PhD, professor and chairman, department of surgery, Kyushu University and Congress Chairman of the Society, and his colleagues were marvelous hosts. We attended an elaborate reception and each of us received a certificate to commemorate the occasion.
I attended a lecture by ACS President A. Brent Eastman, MD, FACS, on the American College of Surgeons: The Next Hundred Years. His thoughtful and insightful talk was well-attended and well-received.
I gave a presentation on adjuvant versus neoadjuvant therapy for pancreatic cancer. Similar to our annual meetings, the Japan Surgical Congress involved numerous concurrent sessions. Although most of the sessions were conducted in Japanese, I was able to learn something, especially at those programs that included a video segment. I saw an interesting video that showed how the ligamentum teres was harvested and used as a patch for a narrowed hepatic vein following a hepatectomy. Other equally fascinating videos showed the authors’ approaches to non-anatomic liver resection.
In the evening, we enjoyed dinner at a well-known local sushi restaurant, where we saw the owner prepare our meals from a large, freshly caught tuna. Later we had our pictures taken with two geishas, and I had my picture taken with Dr. Eastman, and his lovely wife, Sarita (see photo).
By the end of the evening, the traveling fellows each received a traditional Japanese fan. On the way home, I felt an overwhelming sense of excitement that I was so fortunate to have had this opportunity of a lifetime.
Kyushu University was my last stop. On my first day there, Satoshi Ida, MD, PhD, assistant professor, department of surgery and molecular targeting therapy, took me and other visiting fellows—Ulrich Bork, MD, a surgeon and research fellow at University Hospital of Heidelberg, Germany, and Sunil Kumar, MD, assistant professor at All India Institute of Medical Sciences, New Delhi—to the campus. At the university, Dr. Ida ushered us into a conference room, where I met Toru Ikegami, MD, PhD, associate professor of the liver transplant service, and Dr. Maehara (see photos). I attended the department’s morning conference with the medical students and residents.
At the morning conference, Dr. Maehara reviewed all of the surgical cases that were to be done that and the following day. I saw a variety of operations, such as minimally invasive esophagectomy, liver resection for cholangiocarcinoma, laparoscopic abdominoperineal resection, and living-related donor liver transplantation. I learned that most transplants in Japan involve living-related, rather than cadaveric, donors, largely due to cultural beliefs and the scarcity of cadaveric donors in Japan. The night before I departed for the U.S., the faculty at Kyushu treated Dr. Bork, Dr. Kumar, and me to dinner at an exquisite traditional Japanese restaurant.
The Japanese surgical education system is organized in an interesting way. After graduating from high school, a student spends six years in medical school; two years are spent learning the liberal arts, and the remaining four years are focused on medicine. Surgeons undergo six years in residency, three of which are spent at a different hospital. The first two years are focused on internal medicine, the next three are centered on surgery at a different hospital, and the last year is at one’s own institution. To pursue postgraduate studies, the student spends another four years pursuing a PhD. Once all of these stages are completed, the student may begin his or her faculty appointment.
There are four levels of faculty positions: (1) assistant professor, (2) lecturer, (3) associate professor, and (4) professor. Progressing to the next level is dependent almost entirely on the judgment of the surgeon’s professor(s) and chair.
Interestingly, a surgical mortality is handled by the local police and may entail an extensive investigation. Some surgeons I met at the congress thought that such a system had hampered them from tackling some of the more complex cases.
The trip was not all work. I did find time for exploring and enjoying Japan’s breath-taking natural beauty. In Tokyo, I went to the famous Asakusa market. On the weekend, I took the Shinkansen (bullet train) from Tokyo to Kyoto and spent a day visiting the many different historic sites such as Nijo Castle, Kyoto Imperial Palace, Kiyomizudera Temple, and the Garden of Kinkakuji Temple (Golden Temple). I visited a friend, Atsushi Shimizu, MD, from Jichi Medical University, and spent a day at Nikko National Park.
I also went to Hiroshima, and visited the Peace Memorial Park, the resurrected Hiroshima Castle, Hiroshima Atomic Dome, Hiroshima National Peace Memorial Hall for the Atomic Bomb Victims, and Torii Gate at Miyajima Island or Shrine Island. The area was so peaceful, serene, and full of life that it is hard to fathom the devastation that occurred almost 70 years ago. The Peace Memorial Park is a sobering reminder of our species’ frailties.
Some final thoughts
In 2009, I had an opportunity to go to Vietnam to teach a surgical course to medical students. I learned a great deal about the complex relationship between Japan, Vietnam, and the U.S. Over the years, Vietnam has worked to modernize its society, and both the U.S. and Japan have become two of the country’s largest investors. I marveled at the gigantic bridge, built with the help of Japan and America, that connects the Vietnamese people, who previously had to travel by small river boat to go from one land mass to another.
I also admired my elderly father’s unrelenting effort to reconnect with his past as he painstakingly walked for miles, going door to door, searching for lost relatives. It was an emotional sight to witness the endless tears streaming down my father’s and relatives’ faces as they finally found and embraced each other. Such inspiring moments lifted my spirit and taught me that people of all stripes are generally good and that, as horrible as war is, nations and people do learn to work together to achieve a common goal. Today, America, Vietnam, and Japan have forged some of the strongest bonds in the world.
The ACS Traveling Fellowship to Japan was an opportunity of a lifetime for me to not only acquire more surgical knowledge that will translate to better care for my patients, but also to discover inner peace and tranquility. I have found the “diamonds” and “pearls” and gained a greater appreciation of the complex world in which we all live. For this, I am forever indebted to the International Relations Committee of the ACS for selecting me to represent our great and distinguished organization.
*Ueno H, Ioka T, Ikeda M, Ohkawa S, Yanagimoto H, Boku N, Fukutomi A. Randomized phase III study of gemcitabine plus S-1, S-1 alone, or gemcitabine alone in patients with locally advanced and metastatic pancreatic cancer in Japan and Tawain: GEST study. J Clin Oncol. 2013;31:1640-1648.