Colin Peirce MRCSI, MD, Specialist Registrar, Department of Colorectal Surgery, St. Vincent’s University Hospital, Dublin:
It was a great honour to be awarded the European Society of Coloproctology Travelling Fellowship to Japan this year.
I was delighted to have the opportunity to represent not only the European Society but also St. Vincent’s University Hospital, Dublin, Ireland, where I am currently completing the final year of my Specialist Registrar program in General and Colorectal Surgery. I had never previously been to Asia let alone Japan before and thus the trip really was a fantastic opportunity for me in both professional and personal terms.
However, the organizational side of things was somewhat daunting at the outset, but with what I can only describe as excellent help from Dr. Shingo Tsujinaka, who himself had been the Japanese Society of Coloproctology Travelling Fellow to Europe in 2013, the itinerary worked out perfectly and made for a truly outstanding two week fellowship. Dr. Tsujinika arranged each of my 3 hospital visits and he was able to visit 2 of the 3 institutions with me also.
Following a brief stop in Shanghai en route to Tokyo to visit a friend and his family from my university days (and play in a seven a side rugby tournament!), the itinerary set out following my arrival in Japan allowed me to visit the National Cancer Centre Hospital, Tokyo, Fujita University Hospital, Nagoya and Kyoto University Hospital, Kyoto. I would also attend the annual meeting of the Japanese Society of Coloproctology in Yokohama between my first and second hospital visits where I would give an invited lecture and meet many of Japan’s, and indeed the world’s, finest colorectal surgeons.
National Cancer Centre Hospital, Tokyo: 4-6 November
The National Cancer Centre in Tokyo is a very impressive building with the world famous Tsukiji fish market nearby. From start to finish, Dr. Kanemitsu (Chief, Colorectal Surgery Division) and his colleagues made me feel very welcome and had very kindly arranged a series of specific surgeries I had requested to see in advance of my arrival if possible. The differences in the approach to rectal cancer between Europe and Japan in terms of the use of radiotherapy and the performing of lateral pelvic sidewall dissection have long been a source of debate. Having never witnessed the latter, I observed with great interest as Dr. Kanemitsu and his team performed a meticulous open operation for a low rectal cancer: full pelvic side wall lymphadenectomy with handsewn coloanal anastomosis and a defunctioning stoma. All pertinent radiological and endoscopic images were on full display, all the latest technology in terms of stapling devices was available and there were many cameras, monitors and indeed steps from which to observe the operation. That evening I was treated to a delicious meal at a nearby traditional Japanese restaurant where we dined on local delights and enjoyed one or two glasses of sake.
On the second day, I watched as Dr. Tsukamoto performed a very impressive robotic assisted low anterior resection. I was especially interested in this robotic operation as currently there isn’t a robotic colorectal surgery program in Ireland. From the set-up of the robot itself, the docking of the robot, the console, the theatre dimensions required – it was all new to me and I was impressed with how smoothly the surgery went from start to finish for what I believe was the 13th colorectal case performed in the institution. I have no doubt that the keynote lecture at next year’s ESCP meeting in Dublin, entitled: ‘Is robotic surgery hype, or the next big thing in colorectal surgery?’ will provide great debate.
On my final day I observed Dr. Kanemitsu and also his colleague Dr. Shida both perform D3 right hemicolectomies. Once again these were an anatomical tour de force and we discussed complete mesocolic excision at length. I could not help but notice that the BMI of Japanese patients is considerably less than that which we are accustomed to at home and certainly made me a little envious! Throughout my visit, Dr. Kanemitsu and I discussed the specific management protocol of rectal cancer in the National Cancer Centre Hospital and we acknowledged the strengths and perceived weaknesses of the respective European and Japanese approaches. He did produce compelling data and with further randomized controlled trials ongoing, I look forward to reviewing the results of these in due course. We agreed that collaboration between both societies, ESCP and JSCP, in terms of future trials and research was of utmost importance and it is something I would hope to get involved in as my career progresses.
Japanese Society of Coloproctology Meeting, Yokohama: 6-8 November
With over 2500 delegates, the 69th Annual Meeting of the Japanese Society of Coloproctology in Yokohama was impressively attended. I was again warmly welcomed at the Reception Dinner where we were all treated to some wonderful pre-dinner piano and violin recital. I met with many surgeons over the course of the evening, from near and far, and it really was made easy for me as all were very accomplished English speakers, whereas my Japanese is unfortunately limited to the bare minimum.
I attended many sessions of the meeting including the popular English speaking sessions where Professor Wexner and Professor Remzi of the Cleveland Clinics in Florida and Ohio respectively delivered state of the art lectures on the management of fecal incontinence and the surgical treatment of inflammatory bowel disease respectively. I delivered my European Society Fellowship paper entitled ‘Sacral nerve stimulation: where is the sense in it all?’ – a paper based on the work I had carried out for my MD thesis under the supervision of Professor P. Ronan O’Connell in University College Dublin and an area in which I have ongoing interest. Professor Kazuo Hase of the National Defense Medical College chaired the session and he very generously gave me some Kami-mon Washi paper Japanese photo frames as a gift. I had very interesting conversations with Professor Maeda (Fujita University Hospital) and Professor Takao (International University of Health and Welfare) regarding the content of my paper and the underlying mechanisms of sacral nerve stimulation and indeed its role (or not) in patients with ‘anterior resection syndrome’.
Undoubtedly one of the highlights of the meeting was the Presidential Dinner, held in a magnificent restaurant on the 65th floor overlooking Yokohama Bay and hosted by the President of the 69th Annual Meeting, Professor Makoto Matsushima. I was honoured to be seated with the President of the JSCP, a number of past presidents and a number of internationally renowned figures.
Fujita University Hospital, Nagoya: 10-12 November
My journey to visit Professor Maeda and his team in Nagoya also provided me with my first opportunity to travel on the shinkansen (bullet train) – certainly a step up in speed from what I was used to at home! Professor Maeda and his wife treated us to a wonderful dinner in a traditional restaurant on arrival and a detailed plan of the itinerary over the days ahead, both in and out of the hospital, was formed. Professor Maeda’s reputation precedes him in Japan and his hospitality was second to none, and I was honoured to enjoy some of his wine collection too! I was very interested to hear of his plans for hosting the annual meeting of the JSCP in Nagoya next year and it certainly sounds like it will be a great meeting as it was in Yokohama.
Fujita University Hospital is the largest hospital in Japan and certainly a very impressive institution. We were kindly collected from the hotel by Dr. Masumori and guided to the Department of Surgery from there. The operating list I attended allowed me to see Professor Maeda perform a transanal excision and also a transvaginal repair of a rectocele. Pelvic floor work has always been an interest of mine and I was especially interested to see Professor Maeda’s retractor he uses for this work – one that he has designed himself. It negates the need for the assistant to have to retract with a Langenbeck (or other such retractor) and allows for great exposure with minimal potential for anything (or anyone) obstructing the operating surgeon’s view. I met the Dean and Professor of the School of Medicine, Professor Takao Tsuji, and was very impressed with the student facilities on the main hospital campus. Robotic surgery is well established at Fujita University Hospital and this is not surprising with the wonderful on-site facility of a robotic training centre, which Assistant Professor Hidetoshi Katsuno gave us a tour of. I observed the urological team training on live tissue with the trainer at one console and the trainee at the other. I also had the chance to use the robotic simulator and I was thankful that experienced robotic surgeons told me it was more difficult than the real thing as I found it more difficult than anticipated.
I would like to make special mention of Professor Maeda and his wife, Yayoko, for their tremendous hospitality. They were insistent on taking time out of their schedules to escort us on a day trip to Takayama as well as visiting the historic Nagoya castle, the city center shopping district, the Tokugawa art museum and the magnificent Toyoda museum. They really made us feel very welcome and I have no doubt that all delegates at next year’s meeting are in for a real treat.
Kyoto University Hospital, Kyoto: 13-15 November
Following another swift trip on the shinkansen, we disembarked in the beautiful city of Kyoto. The taxi journey alone from the Kyoto station to the hotel was a trip full of glimpses of beautiful temples and autumnal leaves. The following morning I enjoyed a lovely walk from the hotel, across the river and onward to Kyoto University Hospital. Dr. Koya Hida and Dr. Takahashi, members of Professor Sakai’s team, greeted me on arrival and guided me around the gastrointestinal ward and theatre complex. I observed Professor Sakai perform a meticulous laparoscopic low anterior resection without defunctioning stoma and with the use of intraoperative fluorescent vascular mapping, as well as a plastic loop placed around the distal colon to allow for a perioperative rectal washout prior to rectal transection. I found the lack of a defunctioning stoma for such a low anastomosis intriguing, with a transanal drain used instead and planned removal of same once the patient begins to defecate in the postoperative period. It was also interesting to hear of a proposed postoperative stay of 10 to 14 days being normal and there seemed to be far less pressure on hospital beds and early discharge of patients than in the Irish Health Service. We discussed the various surgical instruments available to perform such precise laparoscopic work, with Professor Sakai favoring the spatula with diathermy as his main dissecting tool – not something I have any experience with to date.
Professor Sakai and his team treated us to a delicious dinner on the first night – the whole team attended and it was great to see the ease with which they all got on and the camaraderie and collegiality amongst all members of the team, especially after such a long day at work. We also enjoyed another delicious meal with Professor Sakai and his wife the following evening and discussed all aspects of our health services – from university degree, through junior training years, to overseas fellowships, consultancy and beyond.
I was very kindly given a ‘day off’ by Professor Sakai to go and experience and explore Kyoto. We visited the Kinkaku-ji, Ginkaku-ji and Kiyomizu-dera temples, which were truly beautiful and drank from the famous Otowa falls fountain - where the water has been known since ancient days to be spiritual with healing effects. The gardens surrounding the Imperial Palace were also a high point and the different colors of the leaves really were spectacular at that time of year.
Sadly, the two-week fellowship was drawing to a close and once again the bullet train whisked us back to the final destination – Tokyo. Not to miss out being a true ‘tourist’, the Hyatt cocktail bar (famous from the blockbuster movie Lost in Translation) and the Kill Bill Restaurant were visited – these after a lovely walk around the Shinjuku Gyoen National Garden.
Sometimes it’s hard to sum things up in a written report, but I hope it is quite apparent that this was a phenomenal trip for me from start to finish. I was overawed by the hospitality I received and only hope that I can repay it at some point in the future – the ESCP meeting in Dublin next year hopefully being a starting point. I entered each hospital as the travelling fellow to visit the Professor and his team and I left each one with a series of new colleagues and friends – a truly memorable experience.
Each of my visits gave me food for thought in terms of our everyday practice in Ireland and I now feel more than ever that if a surgeon doesn’t strive for advances in their field and doesn’t challenge what is ‘standard’ care, then they are doing themselves and their patients a disservice. Collaboration is an integral part of our chosen field and there is no doubt that we can learn a great deal from the technique and protocols of our peers in different countries and health services.
I would like to pay special thanks to the ESCP for awarding me this very prestigious fellowship opportunity and to the JSCP for allowing me the chance to visit their wonderful country, their very impressive surgical institutions and attend and present at their annual meeting – I am deeply indebted to one and all. I must also make special mention of Dr. Shingo Tsujinaka, a consultant colorectal surgeon himself at Jichi Medical University, Saitama Medical Center. As stated at the outset, Shingo created the itinerary for me from start to finish and was a constant presence and guide throughout my trip and I am very grateful for our friendship. This fellowship is unique and I have no doubt will continue to go from strength to strength over the years ahead, as will the collaboration and collegiality between both societies. It was my great privilege to represent both the ESCP and Ireland on what was my first, but hopefully not last, visit to Japanese shores. To all my Japanese colleagues and friends, as we say in Ireland: ‘Go n-éirí an bóthar leat!’