It was my great privilege to have been chosen as the ESCP/JSCP travelling fellow to Japan in 2013. The fellowship allowed me to fulfil a long-lasting ambition which I had nurtured since many years after listening to the tales of my mentor Prof Bob Steele’s visit to Japan. My main aims of this fellowship were to specifically observe and expand my learning of sphincter preservation rectal surgery, to experience the technical advances in minimally invasive surgery particularly reduced port surgery, and to interact with academic clinicians and scientists in Japan. With the help of my host Dr Masaaki Ito, Director, National Cancer Centre – East, Kashiwa and with the assistance of his able secretary Mrs Noriko Okada we put together an itinerary which allowed me to visit three cancer centres (National Cancer Centre – East, Kyoto University Hospital, and Osaka University Hospital) in three different cities during my two week visit. This also allowed me to experience the different cultural aspects of Japan.
National Cancer Centre-East, Kashiwa
I flew to Tokyo from London on the 8th November 2013 and an hour’s comfortable train journey from Narita took me to Kashiwa. Despite it being a Saturday, Dr Ito kindly met me in the hotel in the evening where we had dinner together. He took time to brief me about the Japanese culture and I had my first tutorial of Japanese language. When we finished the meal I was able to politely thank him in Japanese “arrigato gozaimas” and was ready to greet his team on Monday with “ohaio” and “konichiwa”. Sunday was meant to be a relaxing day but I woke up to my first ever experience of an earthquake that shook eastern Japan, including the capital Tokyo with a magnitude of 5.5. Thankfully there were no damages particularly any Tsunamis.
My first four days in the “National Cancer Centre-East hospital” hosted by Dr Ito, Dr Saito and their wonderful team was very educational. Every morning during the car journey from the hotel to hospital, Dr Ito carefully laid out the plans for the day. Each morning started off with a unit meeting where the junior team members presented and updated the progress of all the cases to Dr Saito and Dr Ito. Although the meeting was conducted in Japanese, Dr Ito took time to explain the relevant cases to me in English and asked for my views. On the first day Dr Ito also gave me a tour of the hospital including the wards, theatres, endoscopy suites, and also the research facilities, and introduced me to many of his clinical, nursing and research colleagues. After the unit meeting, I accompanied Dr Ito in his ward rounds at the end of which he briefed me about the theatre cases. The electronic patient records were all integrated with the necessary pathology and radiology information, and were user-friendly.
I was extremely lucky that during these four days at NCC-East, I was able to observe many laparoscopic pelvic dissections including two cases of inter-sphincteric resections all done very elegantly by Dr Ito. Clearly, he is an accomplished laparoscopic pelvic cancer surgeon who has developed a reputation and tertiary level practice in laparoscopic sphincter preservation and his experience was clearly visible in how he handled these difficult cases. Keeping with the Japanese tradition, the lymph nodal clearance in all the cases were standardised and meticulous. I also observed laparoscopic and open lateral pelvic node dissections, and Dr Saito’s open surgery for recurrent pelvic cancer with external iliac artery resection and reconstruction. The well laid out structure for training the juniors in this busy (average 14 – 16 new cancer referrals/week) but young cancer unit was very visible and Dr Ito led from the front and took particular pride in this. It was fascinating to see how much it meant for a Japanese surgical trainee to be allowed to carry out a “lateral pelvic lymph node dissection” and the training skills and patience of Dr’s Ito and Saito was evident. It was very gratifying to see the high work ethos of the junior members of the team and I saw many junior staff members catching short naps in their desks in the intern’s room. It was obvious the “European working time directive” and the “48-hour week” are yet to reach the Japanese surgical shores. The majority of our discussions revolved around the similarities and differences in dealing with rectal cancer patients. It is clear that the Japanese practice is predominantly surgery driven with radical lymph node clearance, ultra-low restorative surgery, fewer defunctioning stoma’s, and less use of radiotherapy perhaps influenced by Japanese history. However, this may be beginning to change with the new generation. The multi-disciplinary team meeting which I attended at NCC-East was also very much surgeon led. I was able to share our own units experience with sphincter preservation surgery and delivered a lecture on Professor Williams’ pioneering work on “anterior perineal plane” approach for low rectal surgery and the continuing work we are doing here at the “St Bartholomew’s and The Royal London Hospital” in London.
JSCP annual meeting, Tokyo
From Kashiwa I travelled by train to Tokyo for the JSCP meeting. A very well attended meeting mostly conducted in Japanese but the English sections were also popular with the Japanese surgeons. The ESCP travelling fellowship lecture on sphincter preservation surgery which I delivered at the meeting was chaired by Professor Takayuki Akasu and I’m grateful for the support of Prof Ronan O’ Connell, President of ESCP for his support during the lecture. With such a predominant “inter-sphincteric resection” practice in Japan, the anterior perineal plane approach raised several interesting questions and remarks from the Japanese and South Korean audience. Professor Kazuo Hase, Chairman of International Committee, JSCP was a gracious host indeed and introduced me to many senior Japanese and South Korean surgeons at the welcome reception.
The remaining part of my fellowship time was spent between the units of Kyoto University and Osaka University. Professor Sakai hosted my time in Kyoto and I observed him performing laparoscopic left colonic resection and an ultra-low anterior resection. There seems to be much less reliance on defunctioning the ultra-low anastomoses and Prof Sakai’s unit routinely performs intra-operative fluorescent imaging to establish the adequacy of bowel perfusion prior to reconstruction, a clinical translation from their own basic research.
The last leg of my fellowship was spent with Dr Ichiro Takemasa and his team at Osaka University hospital. Here I was exposed to a feast of high-class single port advanced colorectal surgery by this pioneering master surgeon. His personal cumulative experience of single port cancer resections is well above 400 cases and I watched him do a range of left and right colonic resections including perhaps the first ever single-port neo-vaginal reconstruction using sigmoid colon for Rokitansky-Mayer-Küster-Hauser syndrome.
All the three units I visited practiced subtle variations in technique (e.g. intra-operative flexible endoscopic evaluation of anastomotic integrity in Osaka) and used innovative, novel surgical devices designed and manufactured in-house in Japan, many of which were new to my practice here in the UK. This exposure has definitely inspired me in my “medical device research portfolio”.
I took some time off to visit and experience the rich Japanese culture and cuisine and was in time to see the vibrant “autumn leaves (koyo)” in Kyoto. The visit to Ginkakuji, the Zen temple and the peaceful walk along the “philosopher’s path” along Kyoto’s eastern mountains of Higashiyama were memorable. The majestic beauty of “Mount Fuji” from the air is etched in my memory just like the most generous Japanese hospitality and respect for others which I experienced throughout my trip.
I left Japan having learned a lot about my own speciality, furthering my own clinical practice and having met some incredible professionals whom I’m proud to call my friends. This visit has allowed me to expand my professional network particularly my academic links just as the volcanic eruptions off the coast of Nishinoshima, in the Ogasawara chain of islands on the 21st of November 2013 helped Japan expand its territory when I was leaving Japan.
I wish to express my deepest gratitude to my principal host, Dr Masaaki Ito (Director NCC-East, Kashiwa), Professor Yoshiharu Sakai (Kyoto University) and Dr Ichiro Takemasa (Osaka University) for their kindness and wonderful hospitality. I also thank the many junior surgeons particularly Dr Kowano Shingo, NCC-East for his kindness, help and his most humble attitude. Mrs Noriko Okada’s secretarial skills and careful planning and detailed itinerary made my time in Japan effortless and trouble free despite my very limited Japanese vocabulary of some ten words. Finally, I thank both the ESCP and JSCP for this incredible opportunity creating the most inspirational exchange visit and am very privileged to have been the ambassador between European/UK colorectal surgery and our Japanese counterparts. I am sure ESCP’s endeavour to establish similar visiting fellowships between Europe and South Korea will be yet another addition to the many opportunities for young surgeons like me in the future. I wish all my Japanese friends a heartfelt “hajimimaste”
Mohamed A Thaha
Senior Lecturer in Colorectal Surgery
Barts and The London School of Medicine & Dentistry
Queen Mary University of London