2016 Traveling Fellow to Japan reports on visits to hepatobiliary centers

Dr. Anaya (fourth from left) in a Japanese restaurant with junior faculty and resident/fellows from the University of Tokyo, divisions of hepato, pancreato, biliary surgery and organ transplantation

Dr. Anaya (fourth from left) in a Japanese restaurant with junior faculty and resident/fellows from the University of Tokyo, divisions of hepato, pancreato, biliary surgery and organ transplantation

Dr. Anaya (front row, center) and Professor Kokudo (front row, second from left) with faculty and trainees after he delivered the invited lecture at the University of Tokyo

Dr. Anaya (front row, center) and Professor Kokudo (front row, second from left) with faculty and trainees after he delivered the invited lecture at the University of Tokyo

Dr. Anaya with Professor Kokudo during the presidential dinner, JSS 116th Annual Congress

Dr. Anaya with Professor Kokudo during the presidential dinner, JSS 116th Annual Congress

Professor Mori and a surgical trainee from Osaka hosting Drs. Anaya (rear, second from left) and Balch (front row, center), along with several European surgeons in Osaka

Professor Mori and a surgical trainee from Osaka hosting Drs. Anaya (rear, second from left) and Balch (front row, center), along with several European surgeons in Osaka

Dr. Anaya and Professor Nagino at a Japanese restaurant in Nagoya

Dr. Anaya and Professor Nagino at a Japanese restaurant in Nagoya

I recently returned from Japan after visiting different hepato-pancreato-biliary (HPB) centers and attending the 116th Annual Congress of the Japan Surgical Society. It was truly an outstanding experience, and I am grateful to the American College of Surgeons (ACS) International Relations Committee for selecting me for the 2016 Traveling Fellowship to Japan. As a surgical oncologist with a focus on HPB surgery, I have had an interest in visiting some of the leading centers for liver surgery in Japan, and this visit exceeded my expectations.

University of Tokyo

My host at the University of Tokyo Hospital was Prof. Norihiro Kokudo, MD, PhD, FACS, chairman, hepato-biliary-pancreatic surgery division and the artificial organ and transplantation division, department of surgery. My visit was organized by Junichi Arita, MD, PhD, an HPB surgeon and associate professor, University of Tokyo.

Prior to my arrival I was assigned a “buddy” to guide me through the planned activities and events and facilitate any inquiry or interests I had. My buddy was Akihiko Ichida, MD, PhD, an assistant professor who had recently completed the hepatobiliary fellowship and a doctorate in clinical research. I had discussed with Dr. Arita specific interests for my visit, and he and Dr. Ichida ensured that I would accomplish all of my goals during this short visit.

I engaged in a number of academic and clinical activities while visiting. I first met with Professor Kokudo, and we discussed common interests as well as technical and general surgical approaches to different clinical scenarios typically considered controversial in the field. I learned about the structure of the institution’s academic program and its gradual development. Professor Kokudo was very forthcoming, sharing specifics of this process and providing input derived from his personal experiences. Subsequently, I was invited to join him in the operating room (OR) to observe an extended right hepatectomy plus caudate lobectomy with bile duct resection for colorectal metastasis, which he performed with Dr. Arita. For the most part, the surgical approaches and techniques they used are similar to those used in the U.S., although specific details about the procedure were unique to their center, including the use of contrast ultrasound and the processing of the specimen; residents and fellows performed the marking, cutting, and preparation of the specimen/slides. It was a great experience, and the case went smoothly and was completed almost effortlessly by Professor Kokudo.

The first night of my visit, junior faculty and residents/fellows invited me to a dinner during which we discussed the intricacies of HPB training and building academic careers in surgery. The trainees’ commitment to scientific training was impressive. All of them were pursuing doctorates as they were completing a busy fellowship in HPB surgery.

I also attended their preoperative conference, which was presented in English to facilitate understanding by visiting surgeons. Special attention was placed on liver anatomy and surgical planning. I attended the tumor board meeting, which included participation by faculty and trainees in other specialties.

On my last day, I gave a lecture to the HPB division on the role of regionalization of care for hepatobiliary malignancies. The attendees raised questions regarding the similarities and differences between the health care systems in Japan and the U.S. Japan has a universal health care system; however, care for HPB malignancies is not regionalized and can take place in essentially any hospital with the necessary infrastructure. I found this interesting, particularly in a setting with a number of high-volume leading liver centers.

During my stay in Tokyo, I had the opportunity to tour key landmarks in the city, including the oldest Buddhist temple—Sensoji in the Asakusa district, the Imperial Palace, and Tokyo’s Skytree. I was fascinated by Tokyo’s history, organization, and people. I was particularly impressed by the city’s transportation system and the warmth of its people.

My stay in Tokyo and visit to the University of Tokyo Hospital was truly a remarkable experience, and I am grateful to Professor Kokudo, Drs. Arita and Ichida, and all the staff in the division for their hospitality.

The 116th Annual Congress of the Japan Surgical Society

After my stay in Tokyo I traveled via Shinkansen (bullet train) for approximately two hours to Osaka, the second largest city in Japan and host city of the 116th Annual Congress of the Japan Surgical Society (JSS). The congress is the largest and oldest surgical meeting in Japan, typically attended by more than 10,000 people. The meeting was well organized, with a number of sessions presented in English. Close to 50 guests from different parts of the world and approximately 15 other traveling fellows attended the meeting. We all participated in a ceremony during which we received a certificate from the JSS in recognition of our visit.

I gave an oral presentation on Establishment of a Regional Network to Improve Quality of Care and Outcomes for Hepatocellular Carcinoma, which was well received, and attended invited lectures by Charles M. Balch, MD, FACS, director, Clinical Research Network, and professor of surgery, Johns Hopkins Medicine, Baltimore, MD, on The Future of Surgical Oncology, and by ACS President-Elect Courtney M. Townsend, MD, FACS, titled The American College of Surgeons Enters Its Second Century: Its Role in Quality and Education.

I attended a number of networking events, including the presidential dinner, hosted by Professor Kokudo, President of the JSS, and Prof. Yoshiki Sawa, MD, PhD, chairman, department of cardiovascular surgery, Osaka University, and president of the 116th JSS Annual Congress. This wonderful dinner took place on the rooftop of the tallest building in Osaka, with a spectacular view of the city.

I had the opportunity to meet Prof. Masaki Mori, MD, PhD, FACS, chairman, department of gastroenterologic surgery, Osaka University. David Shibata, MD, FACS, chairman, department of surgery, University of Tennessee Health Science Center, Memphis, and 2010 awardee of the ACS Traveling Fellowship to Japan, helped connect us as I was planning my visit. Dr. Mori invited visitors from Europe and me to visit his department and to a dinner where we had the opportunity to learn about his trajectory and legacy in academic surgery and to discuss ongoing research projects with one of his surgical trainees.

Osaka University Graduate School of Medicine

During my stay in Osaka, I visited Osaka University Hospital and spent time with Hidetoshi Eguchi, MD, PhD, associate professor and chief, HPB surgery, department of gastroenterological surgery.

Dr. Eguchi and I discussed the different training pathways to becoming an HPB surgeon in Japan, and the structure of the section. Especially impressive was the number of surgeons and trainees (nearly 60) pursuing research degrees at the university and within Professor Mori’s department and research lab. After discussing the research structure and setup, I toured the research facilities of the department and then met with other visitors to observe a laparoscopic distal pancreatectomy.

Subsequently, visiting fellows were invited to attend presentations on specific research projects in colorectal surgery and to review video presentations of innovative approaches to surgery for colorectal diseases. We discussed the different surgical approaches and treatment strategies used in Japan, the U.S., and Europe. The residents/fellows were enthusiastic, and it was a great way to end our visit. I am grateful to Professor Mori, Dr. Eguchi, and their faculty and staff for their hospitality.

Nagoya University Graduate School of Medicine

Next, I traveled to Nagoya, located between Osaka and Tokyo. This experience was one of the highlights of my trip to Japan. My host was Prof. Masato Nagino, MD, PhD, chairman, division of surgical oncology, first department of surgery, Nagoya University, a unique institution. Approximately 100–120 liver operations are performed annually, of which close to 80 are performed to treat hilar cholangiocarcinoma, making Nagoya University the world leader in the management of this disease. I engaged in a number of clinical and academic activities that encompassed the entire perioperative period, allowing me to gather details about the university’s clinical management of this disease.

I attended a preoperative conference presented by residents and fellows. Japanese was spoken at the conference, but given the extensive and meticulous attention placed on the anatomy and surgical planning, I understood the issues of each case presented and the surgical approaches and plans discussed. Preoperative imaging included 3-D reconstruction of the liver, portal vein, hepatic artery, and bile ducts for complex cases, which also is common practice in the U.S. They prepared a “surgical planning card” for each patient that contained all relevant information, 3-D reconstruction images, and, most importantly, a final picture drawn by the residents, in which each reconstruction image was superimposed and the surgical plan was finalized, with rare deviation from this preoperative diagram. This provided an accurate, detailed projection of the surgical plans that helped the trainees become more knowledgeable and proficient in liver surgical anatomy.

The next day I observed an extended liver resection with bile duct resection and portal vein resection/reconstruction in an elderly female presenting with hilar cholangiocarcinoma. The case went smoothly, and the skillful dissection reflected the team’s proficiency and experience with these complex operations. Following the operation, we went through some video recordings of similar procedures, including hepato-pancreato-duodenectomies (among the largest series in the world), and discussed their surgical approach and in many cases, details regarding techniques developed by their group. I also participated in surgical rounds during their non-surgical day and observed some crucial differences between postoperative management in their system and that of the U.S. The key difference is the prolonged length of stay following surgery in Japan, with patients returning home essentially only after a full recovery and back to their preoperative baseline (approximately 30 days in most cases).

I spent the last afternoon in Nagoya discussing difficult cases and surgical approaches with Professor Nagino. He took me on a tour of the hospital, including the wards and intensive care unit, and introduced me to the chief of interventional gastroenterology, with whom we had interesting discussions regarding preoperative biliary decompression.

I cannot say enough good things about the hospitality of the surgeons, staff, and that of Professor Nagino, and I am extremely grateful to him for inviting me and for taking the time to make my visit productive.

My traveling fellowship to Japan was an amazing experience, and I am so appreciative of the College providing me with this opportunity. This award resulted in important scientific exchanges, and I have no doubt that it has opened the doors to future collaborations and friendships with a number of exceptional colleagues and surgeons and scientists.

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