ACS Traveling Fellow to Germany reports on experiences

Dr. Karanicolas (left) and Professor Büchler

Dr. Karanicolas (left) and Professor Büchler

I was honored to be selected as the 2018 American College of Surgeons (ACS) Traveling Fellow to Germany, where I traveled to four cities over a period of three weeks in April 2018. I had not visited Germany previously and spoke only a few words of German, most of which had no application in the medical context. Fortunately, all of the surgeons and colleagues I met in Germany were fluent in English, eager to interact, and tremendously welcoming.

I would like to express my sincerest appreciation to the ACS and the German Surgical Society (GSS) for supporting and hosting this educational exchange. In particular, I am deeply indebted to Profs. Norbert Senninger, MD, PhD, FACS, past-director, general and visceral surgery, Universitätsklinikum Münster; and Tobias Keck, MD, FACS, director and surgeon-in-chief, Universität zu Lübeck, who were instrumental in planning and coordinating my trip.

My educational objectives included clinical, research, and cultural goals. From the clinical perspective, I was primarily interested in learning about the differences in approaches to hepatopancreaticobiliary (HPB) cancers. Surgeons in Germany have a reputation for being technically superb, and I hoped to learn technical tips and pearls that could be applied to my practice. Academically, the Study Center of the GSS has led several innovative, practice-changing clinical trials over the last decade, and I hoped to visit with the leaders of this clinical trials group to learn more about how they achieve success and to build potential collaborations. Finally, from a personal perspective, I thoroughly enjoy traveling to new parts of the world and experiencing different languages, cultures, and food. My wife Emelyn joined me for the second half of the trip, along with our three children Andrew, Matthew, and Grace. I was fortunate to be able to share this amazing experience with my family.

Heidelberg: Universitätsklinikum Heidelberg

My trip began in Heidelberg, a quaint, baroque-style city that is home to Germany’s oldest university and several internationally renowned research facilities. The Universitätsklinikum Heidelberg is a major center for surgical oncology and HPB in particular, with an annual volume of more than 700 pancreatic resections. During my time in Heidelberg, I quickly became accustomed to the daily routine, which flowed with incredible precision and efficiency.

Each day, all of the attending surgeons (Oberärzte) and trainees meet at 7:30 am for a morning report. Within 30 minutes, the team reviews admissions and operations from overnight, discusses active issues on the wards, conducts morbidity and mortality rounds, looks at tumor boards, and participates in occasional visiting presentations. This briefing is followed by rounds in the intensive care unit, a full day of operating, and, finally, a preview of the operative cases planned for the next day. A similar structure is followed at each of the centers I visited. I was particularly impressed by the team-based approach and attention to detail from each team member.

Dr. Karanicolas with Drs. Ulrich (center) and Diener

Dr. Karanicolas with Drs. Ulrich (center) and Diener

My hosts in Heidelberg included chairman and Prof. Dr. med. Markus Büchler, FACS(Hon), and surgical vice-chairman Prof. Dr. med. Alexis Ulrich, MBA, both of who were incredibly welcoming and gracious. I had the opportunity to observe Profs. Büchler, Ulrich, and colleagues perform a range of complex surgical oncology cases, including proctectomies, pancreaticoduodenectomies, hepatectomies, and esophagectomies. There were routinely six or seven concurrent operating rooms focused on complex surgical oncology, with Profs. Büchler and Ulrich rotating between the rooms for critical junctures of each case. This team-based approach allowed the surgeons to frequently operate together and optimize care for their patients while allowing training and standardization of technique within the institution.

One highlight for me was the “artery/uncinate-first” approach to pancreaticoduodenectomy. I had been trained to perform this step at the end of the operation, but in Heidelberg the surgeons routinely perform this early on—particularly in cases of potential vascular involvement, with the goal of optimizing resection margins. Since returning to my clinical practice in Toronto, ON, I have incorporated this modification into my approach to the operation with positive results.

Heidelberg also is the home of the Study Centre of the GSS, led by Prof. Dr. med. Markus Diener. I enjoyed discussing several theoretical and practical aspects of clinical trial design and conduct with Professor Diener over the course of several days, including the challenges of funding clinical trials, building infrastructure, and maintaining effective collaboration.

I took advantage of the beautiful weather during my time in Heidelberg to jog along the River Neckar, hike the Philosopher’s Walk, and explore the Heidelberg Schloss (Castle). On my final evening in Heidelberg, Professors Ulrich and Diener kindly invited me to a steak restaurant, where we chatted about our families and cultural differences between Germany and Canada.

Lübeck: Klinik für Chirurgie Universitätsklinikum Schleswig-Holstein

The next stop on my itinerary was the northern port city of Lübeck. The old part of Lübeck is essentially an island enclosed by the River Trave. The old city is made up nearly exclusively of brick gothic buildings, which have been very well preserved, and the entire old city is now listed by the United Nations Educational, Scientific and Cultural Organization (UNESCO) as a World Heritage Site.

Drs. Keck (left) and Karanicolas

Drs. Keck (left) and Karanicolas

I met Professor Keck at the Klinik für Chirurgie Universitätsklinikum Schleswig-Holstein. I had corresponded with Professor Keck in planning the trip, so I was pleased to be able to meet him and express my appreciation in person. Professor Keck leads a department with a focus on minimally invasive surgical oncology. I had the opportunity to observe a meticulous lymph node dissection during the course of a robotic esophagectomy, in addition to a robotic duodenal resection.

One of the strengths of the Universitätsklinikum Schleswig-Holstein is the extensive biobank housed on hospital grounds that is directly integrated with clinical care. I appreciated the opportunity to visit this state-of-the-art facility and learn about the exciting research the team is leading in the genomics of pancreatic cancer. In addition to translational research, Professor Keck’s team is leading the development of a registry of pancreatic surgery. We discussed the logistics of combining registries across countries and the potential to use registries for prospective clinical trial data collection.

Despite his busy schedule, Prof. Keck and his wife Sinje invited me out to a lovely dinner in the old city of Lübeck. We discussed a wide range of topics including travel, children, and cultural differences between Germany and North America. Professor Keck had traveled to the U.S. as the 2008 ACS Traveling Fellow and previously spent two years in Boston, MA, and had a unique perspective on similarities and differences between our systems.

Dresden: Universitätsklinikum Carl Gustav Carus

After a five-hour train ride I arrived in Dresden, on the River Elbe near the border with the Czech Republic. Dresden was once a cultural, educational, and political center of Europe, but extensive bombing during World War II left much of the city in ruins. Major restoration efforts have returned much of the city to the elegant baroque and rococo architecture that earned the city the nickname of the “Jewel Box.”

Drs. Weitz and Karanicolas

Drs. Weitz and Karanicolas

The Universitätsklinikum Carl Gustav Carus houses another large department of surgery, led by Prof. Dr. med. Jürgen Weitz, MD, MSc. I observed a variety of complex cases performed by Professor Weitz’s skilled team of surgeons, including a robotic esophagectomy, laparoscopic subototal colectomy, and liver resection. Again, the technique was meticulous and a pleasure to observe.

Professor Weitz and I chatted about several similarities, including our training at Memorial Sloan-Kettering Cancer Center, New York, NY, and our passion for skiing. We also talked about differences in clinical care, in particular the emphasis in North America on earlier discharge after surgery and the influence of differing models of reimbursement. We discussed opioid-reducing strategies to postoperative analgesia, other components to enhanced recovery after surgery, and the importance of managing patient expectations.

Some of the team, including Prof. Dr. med. Thilo Welsch, MBA, FACS, and Prof. Dr. med. Sören Torge Mees, FACS, kindly invited me to dinner in a less touristy area of Dresden. We discussed a range of topics, including the differences in training and promotion between Canada, the U.S., and Germany; the advantages and disadvantages of each system; and the fact that none is perfect—but there is room for improvement and collaboration in each.

Berlin: GSS Annual Meeting and Charité–Campus Virchow

The final stop on my journey was Berlin, the site of the Annual GSS meeting. My family met me in Berlin, and we were able to spend some wonderful time together enjoying this amazing, cosmopolitan city. Our family enjoyed a boat tour on the Spree River and dinner with the families of two former fellows from our surgical oncology program in Toronto, PD Dr. Johannes Lauscher, MD, and PD Dr. Mario Müller, MD. It was wonderful to reconnect with these colleagues and hear about their academic and personal pursuits. To our surprise, our five-year-old daughter Grace developed a culinary obsession with currywurst—a Berlin specialty.

I attended the GSS Congress meeting—a large meeting with several concurrent sessions. I was delighted to see PD Dr. Lauscher present some research that he performed during his time with us in fellowship. At the ACS Germany Chapter session, I gave a presentation on The Importance of Trans-Atlantic Scholarships and participated in a lively discussion about further opportunities for collaboration between our countries.

I also visited Charité–Universitätsmedizin Berlin, Europe’s largest university clinic. Charité has a rich history of clinical work and research, with notable professors including Profs. Rudolph Virchow, MD; Robert Koch, MD; and Theodor Billroth, MD. The outstanding work continues today under the supervision of Prof. Dr. med Johann Pratschke, PhD, FACS. The approach at Charité seemed closer to our typical practice in North America, with most surgeons specialized in one or two anatomic areas. I discussed various approaches to hepatic resection with PD Dr. med. Moritz Schmelzle, and observed a robotic-assisted pancreaticoduodenectomy performed by Prof. Dr. med. Marcus Bahra. I was interested in hearing Professor Bahra describe how his experiences with robotic surgery have influenced his approach to open pancreatic surgery.

Drs. Lauscher (back row, far left), Karanicolas (back row, second from left) and Müller (second from right, front row) with their families

Drs. Lauscher (back row, far left), Karanicolas (back row, second from left) and Müller (second from right, front row) with their families

Lasting memories

The ACS Germany Fellowship met and exceeded all of my expectations. I have already incorporated some operative techniques into my surgical practice and am keen to continue modifying them. I believe there is a great opportunity for collaborative research between North America and Europe and am actively pursuing this with several of my new colleagues in Germany. Although our models of care are quite different, the actual clinical care that patients receive is remarkably similar. Both systems have room for improvement, and through exchange programs like this one, presumably we can continue to learn from each other.

I would like to close by again thanking the ACS and GSS for providing this unique educational opportunity. I offer my sincere thanks to the hosts in the cities I visited, and I anticipate they will have the opportunity to visit Toronto so that I can repay their hospitality. It would not have been possible for me to make this trip without the support of my partners and the chairman at Sunnybrook Health Sciences Centre and the University of Toronto to cover my clinical practice. Finally, I am most appreciative that I was able to share this experience with my wife and children, and I thank them for their ongoing love and support.

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