Samson Tou reports on the experience he gained in rectal cancer surgery during his fellowship in Korea. His trip included the International Colorectal Research Summit and visits to different tertiary referral centres in Seoul.

It is a privilege to be selected as the recipient of the 2017 ESCP Korean Travelling Fellow. I read with much interest the fantastic experience from the previous recipient Edgar Furnee, of his fellowship in Seoul in 2016. As a substantive colorectal consultant for nearly five years, my primary interest is minimally invasive rectal cancer surgery. The jury is still out as to which is the best approach for rectal cancer treatment. I have been performing robotic procedures for the last three years and I was aware of the significant advancements of robotic colorectal surgery in South Korea. The city of Seoul is often considered a 'Mecca' for robotic colorectal surgery. There were other aspects of surgery I was keen to explore, this was coloanal handsewn anastomosis for very low rectal cancer, a practice that is not routinely performed in the UK.

My fellowship was very well organised by the KSCP secretariat, Professor Ji Yeon Kim and ESCP secretariat Vanessa Wise. My Itinerary was packed, started with a two-day conference (International Colorectal Research Summit) over the weekend, followed by a week of a daily visit to different tertiary referral centres in Seoul.

The conference was organised by Professors Seong Taek Oh, Woo Yong Lee and Suk Hwan Lee. I was very impressed with the high-quality presentations and video surgeries during the conference. The presentations were in English and where discussions were said in Korean, highly professional interpreters familiar with medical terminologies provided simultaneous interpreting from Korean to English. The conference covered the whole spectrum of colorectal diseases. The surgeons in Korea are very knowledgeable with chemotherapy evidence and trials. Subsequently, I realised most surgeons do provide chemotherapy treatment for patients.

Conference programmeFormal mealShopping mall

Apart from the Korean speakers, there were invited speakers including Faheez Mohamed whom I have had previous correspondence with through a referral to Basingstoke. He gave a talk on cytoreductive surgery with HIPEC in the UK. Takashi Akiyoshi, who presented the pelvic lymph node dissection after neoadjuvant chemoradiation. His video on laparoscopic lateral lymph node dissection was a masterclass. There was a session on Korea-Lithuania joint symposium in which a group of Lithuania surgeons, led by Professor Samalavicius, presented their experience. A session on new technique and instruments for ESD, Professor Hiroshi Kashida showing his technique of ESD with high definition video, to almost like an art with his advanced technique. My presentation was on the impact of the learning curve on robotic rectal cancer surgery.

During the Summit, I met Professor Seon-Hahn Kim, a world renowned laparoscopic and robotic surgeon. My visit to his unit didn’t work out in 2012 due to timing. This trip allowed me to finally visit Korea University, where Professor Kim works. He told me he had two robotic rectal cases during the last two days of my visit including a coloanal anastomosis. I was overjoyed; it was the most eye-opening and humbling experience for me to see Professor Kim using some of the most advanced surgical techniques.

During the whole trip, I was staying in the Gangnam-gu area, next to the world largest underground shopping mall. I was treated to some of the local cuisines including Korean BBQ, and also to a more formal meal in the Lotte Tower, which is the 5th tallest building in the world. I took some time out from the busy schedule to visit some local attractions, such as Insadong, a 700-metre-long street famous for traditional Korean crafts.

Meal at busy restaurantMeal at low table

The following week I visited Severance Hospital (Professors NK Kim and KY Lee), Seoul National University Hospital (Professors KJ Park and SY Jeong), Samsung Medical Centre (Professor HC Kim) and the Korea University Anam Hospital (Professor SH Kim, two days). Patients in South Korea are willing to travel to another city to receive their treatment. Geographically the country itself is not big. A vast number of patients with colorectal cancers are being treated in tertiary centres in Seoul. Consequently, the specialists are also centralised and these hospitals have a high volume of cases. For example, in Samsung Medical Centre, they see approximately 2,000 colorectal cancers per annum.

Severance HospitalSurgerySurgeons

During the week, I observed four robotic rectal surgeries. A young male patient who had locally advanced rectal cancer with enlarged lateral lymph node received a long course chemoradiation. Post-op restaging still showed prominent lateral lymph node. He underwent robotic low anterior resection and lateral lymph node dissection. Another male patient had low rectal cancer was operated with the Xi platform. The third case was a patient who had obstructed upper rectal cancer and had a stent inserted few days before his operation. The upper rectal cancer was bulky, and I think it is in this situation where the robotic platform provides a precise dissection. The last robotic case was a male patient who had a very low rectal cancer, required a coloanal anastomosis. In my training in the UK, most of this group of patients would have undergone abdominoperineal resection. However, some patients are stoma averse, and it is in this situation where coloanal anastomosis may be useful. Professor Kim was very honest with regards to the success rates for the types of surgeries and that in some cases patients would have to accept that the functional outcomes may not always be perfect. I was making notes while watching these operations as I found them very useful for my own practice. In fact, I did modify some port placements and techniques after I returned to the UK. I was impressed with the teamwork from the anaesthetists, scrub nurses, assistants and the fellows. It does highlight the importance of the same team performing high volume surgeries regularly, making the whole process more efficient.

Apart from the robotic cases, I have seen several complete mesocolic excision (CME) for right hemicolectomies, both open and laparoscopic. CME is the standard approach for right hemicolectomies in this part of the world and using 3D image allows accurate dissection.

I am at a stage in my practice and career whereby spending time observing and talking to experts have enabled me to improve my work, my knowledge and skills, and this trip has certainly fulfilled this. It has also allowed me to have an insight into the work ethics and culture of the Korea healthcare system. I am very grateful that ESCP and KSCP have facilitated this learning and life changing training opportunity for me.

Samson Tou, Consultant Colorectal Surgeon
Royal Derby Hospital, UK
2017 ESCP/KSCP Travelling Fellow

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