ACS 2018 Traveling Fellow to Japan reports on experience

Participation in the 2018 American College of Surgeons (ACS) Traveling Fellowship to Japan was a fantastic opportunity to collaborate with surgeons who are at the forefront of advancing the science and ideas related to gastric cancer surgery. The country is an established leader in the screening, staging, and resection of gastric adenocarcinoma, and the lessons I learned regarding the treatment of gastric cancer were as sharp as what I learned about Japan’s culture.

Shizuoka Cancer Center

My experience in Japan began with a visit to Shizuoka Cancer Center, Shizuoka Prefecture, where Prof. Masanori Terashima, MD, FACS, chief, division of gastric surgery, and chair, stomach cancer study group, Japan Clinical Oncology Group, and his colleague Tomoyuki Irino, MD, PhD, welcomed us. At the cancer center, I had the pleasure of observing a proximal gastrectomy with double-flap esophagogastrostomy. Proximal gastrectomy has been largely abandoned in the West due to concerns over disabling reflux and inadequate lymphadenectomy and margins for diffuse type advanced gastric cancer. The novel technique of double-flap reconstruction is an attempt to prevent gastroesophageal reflux and maintain quality of life for patients with early gastric cancer. It was an exquisite laparoscopic operation that incorporated meticulous surgical technique with high-quality three-dimensional imaging and fantastic visualization. The procedure focused on maintaining quality of life after resection and is appropriate for patients with T1 stage malignancy.

This experience led to my first lesson from the traveling fellowship: The treatment of gastric cancer in the U.S. and Japan differs. Early T1 lesions account for approximately half of gastric cancer cases in Japan but constitute 5 percent of my practice in gastric adenocarcinoma at MD Anderson Cancer Center, Houston, TX. In my time observing experts in gastric cancer at centers in Japan, there appear to be differences in incidence, biology, screening, pathologic classification, tumor staging, and treatment compared with the cancer I treat in the U.S.

With Mount Fuji as a backdrop, Shizuoka Cancer Center was a beautiful center to visit and witness a leading-edge laparoscopic surgery performed by Professor Terashima, one of the experts in the field. I also had a chance to tour the facility, and I noted that the call rooms in Japan offer a different perspective on the comfort of a bed (see photo above). As they are diligent students of anatomy and surgical planning, the residents likely do not use the room often. The preparation of trainees in surgery in Japan is inspiring, as shown in the photo on this page, in which a resident has illustrated the vascular anatomy of the liver in preparation for the resection of a cholangiocarcinoma.

Cancer Institute Hospital

I next met with Prof. Takeshi Sano, MD, PhD, FACS (see photo below), deputy hospital director, department director of gastroenterological surgery, and his colleagues Masayuki Watanabe, MD, FACS, and Koshi Kumagai, MD, PhD, at the Cancer Institute Hospital in Tokyo to observe a complex, multi-team operation for a patient with two separate primary cancers involving the esophagus and stomach, requiring total esophagogastrectomy with colonic interposition graft reconstruction. Professor Sano was gracious in giving us a lecture summarizing the Japanese lymph node staging system and providing an update on clinical trials in Japan, which led to lesson number two from the traveling fellowship: We can learn many lessons from Japan that can be incorporated into the treatment for patients in the U.S. Gastric cancer is a rare malignancy in the U.S., not even in the top 10, and we will need to determine how lymph node classification, minimally invasive surgery, and staging procedures translate from the East to the West.

Keio University Hospital

Prof. Yuko Kitagawa, MD, PhD, FACS (see photo below), and his colleagues Hitoshi Tsuda, MD, PhD, and Hirofumi Kawakubo, MD, PhD, met me at my next stop, Keio University Hospital, Tokyo, and allowed me to observe a robotic total gastrectomy and laparoscopic subtotal gastrectomy over two days. Robotic gastrectomy was approved by the national insurance system of Japan just a few days before my arrival and will likely experience a rapid expansion across the country.

My visit to Keio allowed me to achieve one of my main goals of the fellowship—to observe the standard laparoscopic lymph node dissection technique in Japan. It was no surprise that the body habitus of Japanese patients is quite different from U.S. patients, which leads to lesson number three: Caution is needed in performing minimally invasive surgery for patients with gastric adenocarcinoma in the U.S., with a critical emphasis on maintaining the same oncologic principles regarding margin status, tumor manipulation, and lymph node dissection as open surgery. This issue is particularly important for resident and fellow training as more than 400 gastrectomies for cancer are performed at many centers in Japan annually, whereas few centers in the U.S. perform more than 40 a year.

118th Annual Congress of Japan Surgical Society

The Japanese culture of hospitality was alive and well at the Japan Surgical Society (JSS) as I was invited to the opening dinner of the JSS, as well as the presidential dinner where I had the chance to interact with leaders in surgery from not only Japan but around the world. Prof. Takao Ohki, MD, PhD, chairman of the JSS International Committee, was a gracious host, and the traveling fellowship was exceptionally well organized. The lectures at the JSS, many of which were focused on gastric cancer, were fantastic. As another testament to the early diagnosis of gastric cancer in Japan, almost as many patients undergo endoscopic mucosal resection or submucosal dissection (51,000) as undergo gastrectomy (57,000). Metastatic disease is found in a minority of patients (30,000) but with similar dismal outcomes as patients in the U.S. and Europe.

A group of dedicated investigators, including Hironori Ishigami, MD, and Prof. Joji Kitayama, MD, PhD (see photo above), are studying intraperitoneal therapy for disease metastatic to the peritoneum. Their work has manifold potential applications for trials in U.S., and we hope to have started a collaborative relationship that will allow us to exchange science and ideas in the future. My experience at the JSS led me to the fourth and final lesson of my fellowship to Japan: We share the same problem of limited survival in patients with metastatic disease, and international team science will allow us to improve the treatment and prognosis of this dreaded disease.

I will be forever grateful to the ACS and Professors Terashima, Sano, and Kitagawa for a formative experience in gastric cancer. A personal thank you goes out to Naru Ikoma, MD, MS, one of our complex general surgical oncology fellows at MD Anderson, and his family, who welcomed me to Japan and went above and beyond in their hospitality and guidance around the city. As we prepare to host the International Gastric Cancer Congress in Houston in 2021, we hope to reciprocate the generosity of the ACS and hospitality of the host institutions by providing a similarly high-quality collaborative learning experience for gastric cancer.