Fraser Smith continues his Japan Travelling Fellow's report on his experiences at the National Cancer Centre, and visits to Hakone and Kyoto. View Part 3 here.

The following day I started early with a GI MDT at 7:30am. What was interesting was that all upper and lower GI cases were discussed in this forum. A lot of it was in English. I was pleased to be asked about how I would manage one particular patient with a very early stage and low risk rectal cancer that they were going to perform a low anterior resection on. I said that although what they proposed was an option, there is now increasing data to show that by simply observing such patients or adding chemoradiation one can see similar oncological control for these patients without the morbidity of surgery. I said that I would always aim to discuss all available options and alternative forms of treatment with my patients and let them decide what treatment they ultimately wanted. They seemed interested in this concept. After the MDT I then saw a further ESD procedure in their department of endoscopy which is also world famous. This was for a lesion on a fold in a floppy part of the sigmoid colon. It was really tricky but despite over 1½ hours of difficult dissection, the endoscopist finally removed it. This was a real testament to skill and patience and I gave a small round of applause. I laughed because in her limited English the endoscopist turned around to me and said just two words…”very acrobatic”!!

I then I went for lunch with my host Dr Akiyoshi to a really interesting noodle soup restaurant in the downtown which was really delicious! After that I had a couple of hours of free time so I visited the famous Senso-ji Temple. It was stunningly beautiful and spiritual place. One of the things that I did was put a coin into a box to get my fortune read. I shook a metal pot and pulled out a stick with a number which corresponded with one of 100 drawers that each contained different fortunes - some good… some bad. I couldn’t read the Japanese characters so asked a group of old Japanese ladies to help me. They showed me the drawer (number 85) and looked at my fortune and started clapping. It turned out that I had randomly picked the best possible fortune. I was quite moved actually because part of the fortune (which was written in English) said “The patient will do well”. I hope that this was a metaphysical acknowledgement of my interest in ESD for organ preservation and my talks on my own experiences with “Watch and wait" and organ preservation that I was making in Japan!!

Hakone station
Hakone station

On Friday I travelled to a mountain town called Hakone which my hosts had strongly recommended that I visit whilst in Japan. It is famous as a beauty spot but also as a place to take a hot spring bath as it is a very traditional Japanese thing to do. It was a great time of year to see Hakone as the mountains were carpeted with deep red and auburn autumnal foliage. It had the opportunity to take a sightseeing tour to explore the mountains on a tourist train before arriving at a traditional Hot springs experience amongst the trees and mountains that I had pre-booked. I can see why this is a ritual for Japanese people as it is very cleansing and relaxing for the body and mind. I then returned to Tokyo that night with a nice view of Mount Fiji from the train. I packed my things in preparation for my move to Kyoto.

On Saturday I travelled to Kyoto by bullet train. I have wanted to visit Kyoto for probably about 25 years now after reading the book 'Memoirs of a Geisha'. It was actually prettier than I had expected… and I have basically idolised Kyoto since reading the book! As I had the rest of the weekend to explore I visited many galleries, temples, gardens and really just walked around and explored. Many Japanese people actually come to Kyoto as tourists and hire Kimonos and see the sights. It was really so pretty seeing all of the different colours of people in kimonos with the traditional Japanese buildings as a back-drop. I even saw a Japanese couple who were in traditional dress getting wedding photos taken.

Read Part 4 here >