Report of the 2014 ACS Traveling Fellow to Japan

Slide 1

The Golden Temple in Kyoto.

Slide 2

Lymph nodes being harvested by a surgical resident.

Slide 3

Dr. Uemoto (left) presenting Dr. Mullen with a certificate commemorating the JSS meeting in Kyoto.

Slide 4

Dr. Mullen and Dr. Kitagawa.

Slide 5

Dr. Mullen with (from left) a geisha, Dr. Katz, and a surgical resident.

Slide 6

Dr. Mullen with Dr. Kodera (far right), and surgical residents in Nagoya.

Slide 7

Dr. Mullen with his family at the Torii Gate.

It is with great pleasure and tremendous gratitude that I submit this report on my experiences as the 2014 American College of Surgeons (ACS) Traveling Fellow to Japan. As a surgical oncologist specializing in the treatment of gastric cancer, I have long been interested in traveling to Japan to observe and learn from the leading gastric cancer surgeons in the world. As soon as I became aware of this unique fellowship opportunity, I applied, and I am grateful and honored to have been chosen.

With the invaluable assistance of my mentors at the Massachusetts General Hospital (MGH), Boston, especially Kenneth Tanabe, MD, FACS, chief of surgical oncology, as well as my hosts in Japan, I was able to develop an efficient and educational itinerary organized to coincide with the 114th Annual Congress of the Japan Surgical Society (JSS) in Kyoto. With my itinerary in hand and having made a valiant, albeit last-ditch, effort to learn some basic Japanese, I set out for Japan.

Kyoto University

I traveled for nearly 24 hours before arriving at the architectural wonder that is the Kyoto train station. I took the Shinkansen (bullet train) from Tokyo to Kyoto, gazing at the beautiful snow-capped Mt. Fuji to the north as we headed east.

The following morning I arrived at Kyoto University Hospital and met with Prof. Shigeru Tsunoda, MD, PhD, assistant professor of surgery and a colleague of my host in Kyoto, Prof. Hiroshi Okabe, MD, PhD, associate professor of surgery. We attended a meeting at which the surgeons discussed patients to be seen in clinic that day, including a review of the imaging studies with a radiologist. I did not go to clinic, but rather went to the operating room (OR) to observe Professors Okabe and Tsunoda performing a laparoscopic distal gastrectomy, which was specifically planned to match my scheduled time at the hospital.

Unfortunately, international visitors are prohibited from scrubbing on cases, but observing the cases was still educational. Professor Okabe is widely regarded as an accomplished laparoscopic gastric surgeon in Japan. His group performs approximately 90 gastrectomies and 25 minimally invasive esophagectomies annually. It was a pleasure to watch Professor Okabe and his team perform a meticulous, effortless distal gastrectomy and D2 lymphadenectomy. I immediately understood that the outcomes for this procedure in Japan are fantastic because the procedure is so carefully and systematically performed.

As this was my first opportunity to be in an OR outside of the U.S., several observations struck me as notable:

  • OR cases tend to start later in the morning, at 9:30 or 10:00 am.
  • Surgeons at the major university hospitals specialize in one field, such as esophagogastric cancer, and typically do only one major OR case per day.
  • There are fewer ORs—perhaps only 15–20 for a 1,000 bed hospital.
  • Japanese surgeons perform a timeout procedure just as we do in the U.S., and, in fact, a large checklist is posted on the walls of the OR at some centers.
  • Surgeons use linear and circular staplers and energy devices that are similar to those used the U.S., and, at least at the hospitals I visited, there seemed to be no financial pressure to limit the use of disposable instruments.
  • OR cases are almost always done by two faculty members—typically a full or associate professor together with an assistant professor—and the residents usually hold the camera and help close the wounds.
  • Once the gastrectomy specimen is retrieved, an army of residents come to the OR to open the specimen, show it to the operating surgeons, and harvest the regional lymph nodes, node by node, placing them in formalin-filled jars, each labeled with the relevant lymph node station.

In addition to observing several minimally invasive gastrectomies at Kyoto University Hospital, I had the opportunity to attend a multidisciplinary pathology conference and to make rounds with the surgical faculty and house staff. I have long wondered why Japanese surgeons report such long lengths of stay (LOS) in their studies. I learned that this is in part cultural, as Japanese patients expect to stay in the hospital until they feel ready to leave. One obvious benefit of longer inpatient stays is that readmissions to the hospital are so rare that they are considered unthinkable, and any care that leads to readmission is viewed as a failure. I found this quite interesting, especially given how much we discuss efforts to reduce our 16 percent readmission rate for gastrectomy patients at MGH. The other reason for the extended LOS is financial, as most university hospitals in Japan have approximately 1,000 beds, and to maintain their government funding and staffing levels, they must demonstrate as close to full use of their beds as possible. Patients are allowed to stay significantly longer than we might ordinarily allow in the U.S. to ensure that beds are in use.

Outside of the hospital, I had several wonderful social outings, including a traditional sushi dinner with Professor Tsunoda and his wife and children at their house in northern Kyoto and a casual dinner at a local favorite restaurant of Professor Okabe and his team, who were incredibly gracious hosts.

Japan Surgical Society

At the time of my stay in Kyoto, the 114th Annual Congress of the JSS was held at the Kyoto International Conference Center and the Grand Prince Hotel. This meeting is very similar to our ACS Clinical Congress, in that it is the largest and best-attended surgical meeting in Japan each year, with more than 14,000 attendees. Joining me were 15 to 20 other traveling fellows from around the world, including fellows from Germany, India, China, Korea, and Spain. We all attended a luncheon at which we received certificates to commemorate the occasion from Prof. Norihiro Kokudo, MD, PhD, FACS, president of the JSS, and from Prof. Shinji Uemoto, MD, PhD, FACS, congress chairman.

Though most of the program was in Japanese, I was able to attend a few outstanding lectures in English, including the ACS Presidential Lecture by Carlos Pellegrini, MD, FACS, FRCSI(Hon), on Ensuring Quality in Surgical Practice: The ACS Perspective. I also attended an Honorary Member Award Lecture by Jacques Belghiti, MD, on Advances in Liver Surgery: What We Have Learned from Japan. At the International Session on Upper Gastrointestinal Tract Surgery, I presented Predictors of Lymph Node Involvement in T1 Gastric Carcinoma. This talk generated some lively discussion from Prof. Shunji Sano, MD, PhD, and others at the meeting.

I had the honor of attending several formal Japanese kaiseke meals with traditional geisha dancing. At these receptions, I had the fortune of speaking with several notable surgeons from Japan, including Yuko Kitagawa, MD, PhD, FACS, professor and chairman, department of surgery, Keio University, Tokyo, and Kazuhiro Yoshida, MD, PhD, FACS, professor and chairman, department of surgical oncology, Gifu University, as well as Prof. Hong-Jin Kim, MD, PhD, FACS, from South Korea. I also saw some colleagues from the U.S., including Michael Kendrick, MD, FACS, from the Mayo Clinic, Rochester, MN, and Matthew Katz, MD, FACS, from MD Anderson Cancer Center, Houston, TX, both of whom delivered invited lectures at the meeting.

We strolled along the streets of Kyoto in the evening and viewed the famous “sakura,” or cherry trees, which were in full bloom. We were then treated to an after-dinner party at a traditional Japanese teahouse, or ochaya, in the Gion district, and we played drinking games with maiko (apprentice geisha). I also had the opportunity to see some beautiful sights in Kyoto, the former imperial capital of Japan, including Nijo-jo Castle, Kinkaku-ji Temple (Golden Temple), and Ginkaku-ji Temple.

Nagoya University

My next stop was Nagoya University, where my host was Prof. Yasuhiro Kodera, MD, PhD, FACS, chairman, department of surgery (II). Dr. Kodera is a world-renowned surgeon and thought leader in the field of gastric cancer. He arranged several minimally invasive esophageal and gastric cancer operations for me to observe. I also had the opportunity to watch Prof. Masato Nagino, MD, PhD, chairman of the department of surgery (I), perform an extended hepatectomy for a Klatskin tumor. I was particularly impressed by the advance preparation of the surgeons in Japan for their major surgical procedures. Beautiful hand-drawn diagrams of the planned resection with all of the portal venous, arterial, and biliary anatomy carefully detailed were posted on the OR wall, accompanied by three-dimensional computed tomography scans of the liver with the functional remnants outlined for the various possible resections.

In the course of my stay in Nagoya, I also had several long discussions with Professor Kodera regarding neoadjuvant and adjuvant therapy approaches to gastric cancer and the rationale and status of multiple clinical trials for gastric cancer that are being conducted in Japan. Lastly, I had the opportunity to attend a meeting of young surgeons from the community hospitals in Dr. Kodera’s network, where they presented some of their more challenging cases. This meeting occurs at least once every few months and allows Dr. Kodera to learn about the surgical care that is being delivered at the community hospitals in his network in and around Nagoya, as well as the opportunity to spot a young surgeon with promise to recruit back to the academic hospital. Presentations ranged from gastrectomies to colectomies and included excellent video footage.

This meeting with the “community” surgeons stimulated a discussion about surgical training and the promotion process in academic surgery in Japan. Because one of the hats I wear is that of program director of the general surgery residency program at MGH, I have a keen interest in surgical education. Japanese physicians begin their schooling immediately after high school, enrolling in a six-year program, which includes two years of liberal arts education followed by four years of medical school.

Students interested in general surgery then complete a six-year residency program, the first two of which are focused on internal medicine, followed by three years in surgery at other hospitals, followed by a final year in surgery at one’s own institution. Most graduates then pursue postgraduate studies in basic surgical research either in the U.S. or Canada for an additional four years and typically earn a PhD in the process. Many academic surgeons in Japan confided that this is a necessary step for academic success in Japan for two reasons: (1) it is an opportunity for the trainee to learn to speak and write English, and (2) the experience provides a certain “credibility” for the trainee as a legitimate candidate for an academic post.

Nonetheless, an academic job is by no means guaranteed after such a course of study. New surgeons begin their careers in the community hospitals within the network of a major academic center, such as Professor Kodera’s network outside Nagoya University. Perhaps only 10 percent of these community surgeons are recruited to work at the university hospital as assistant professors, based on the judgment of the chairman of surgery. Only the most gifted are promoted to the rank of associate professor, a title often associated with a leadership position, such as chief of a division. Even fewer associate professors are promoted to full professor, a rank typically reserved for department chairs. For example, a large academic medical center like Nagoya University or Keio University in Tokyo might have only three or four full professors on the entire faculty.

Professor Kodera was wonderfully hospitable, and he took a visiting resident from Spain, some of his residents and junior faculty, and me out to dinner on several consecutive nights. We dined on superlative sushi one night, tasty Korean barbecue another, and, believe it or not, one of the finest Italian meals I have ever had.

Keio University

The final stop on my itinerary was Keio University in Tokyo, where Professor Kitagawa was my host. Professor Kitagawa is chairman, department of surgery, Keio University, a world-renowned surgeon specializing in esophagogastric cancers, and is particularly noted for his work in sentinel lymph node (SLN) mapping for early gastric cancers.

On the first morning of my visit, he gave me a tour of the hospital and of his new research facility, including a large animal lab for his translational research program. Professor Kitagawa and his very capable junior partner, Hiroya Takeuchi, MD, PhD, associate professor of surgery, organized several consecutive OR days of complex upper gastrointestinal cases for me to observe, including combined laparo-endoscopic resections of gastrointestinal stromal tumors (GISTS) near the gastroesophageal junction, SLN mapping of early gastric cancers, and laparoscopic distal gastrectomies with D2 lymphadenectomies. I was again impressed by the facility with which they performed these rather complex procedures using three-dimensional laparoscopy. I was amazed by the commitment of their colleagues in gastroenterology, who completed the submucosal tumor dissection and stayed in the OR for the entire six-hour procedure to resect a GIST laparo-endoscopically.

In addition to observing OR cases, I attended a guest lecture on the role of angiogenesis in the progression and metastasis of GI tract cancers and the current status of angiogenesis inhibitors in the treatment of GI tract cancers. Coincidentally, the guest lecturer that evening happened to be my colleague and friend from the MGH, Dan Duda, PhD, a scientist with whom I collaborate on a number of translational research projects in the field of gastric cancer. We all celebrated together that evening with a kaiseki meal accompanied by beer and sake, and we discussed potential future research collaborations between MGH and Keio University.

While in Tokyo, I was joined by my wife and two children, and we made a point of visiting several famous sights, including the Tsukiji Fish Market, the Imperial Palace, Asakusa, and the Hama Rikyu Gardens. We also took an extended weekend trip on the Shinkansen out to Kyoto, where we visited Arashiyama and took a boat cruise down the Hozugawa River, and then on to Hiroshima and its neighboring island, Miyajima. We visited the Peace Memorial Park, the Peace Museum, and the Atomic Dome in Hiroshima. We then took a ferry out to Miyajima Island and viewed its famed Torii Gate—one of the most famous sites in all of Japan.

Final thoughts

I offer my profound thanks to the International Relations Committee of the ACS for selecting me to represent this great organization as the 2014 Traveling Fellow to Japan. I also extend my thanks to the many gracious hosts in Kyoto, Nagoya, and Tokyo, who made my visit so educational and hospitable.

The knowledge and perspective I gained as a result of this fellowship will enable me to offer better care to my patients with gastric cancer, and I anticipate that the research collaborations that I made and plan to foster in the years to come will translate into exciting new treatments for this disease. For those surgeons considering this or another traveling fellowship, I cannot emphasize enough how valuable such a trip abroad can be in one’s own personal and professional development. Indeed, we have much to learn from our surgical colleagues around the world, and establishing both personal and professional connections with them is an honor and a joy.

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