I was delighted and honored to be chosen as the European Society of Coloproctology (ESCP) travelling fellow to Japan in November 2015. Dr Eiji Shinto (National Defense Medical College) welcomed me on my arrival; he had been the Japanese Society of Coloproctology (JSCP) travelling fellow to the ESCP meeting in 2014. Dr Shinto had kindly arranged all aspects of my trip, including which units I would visit.
My first day in Tokyo was a national holiday and Dr Shinto took me on a sight seeing trip of Tokyo where we visited the Sensoji temple, followed by the Tokyo Sky tree, which is the tallest building in Tokyo. The views from the top were breathtaking. After the Sky tree we took a river cruise down the Sumida river. Although November it was a beautiful sunny day and we enjoyed a cold beer whilst watching the city of Tokyo sail by.
My first experience of Japanese surgery came at the Tokyo Cancer Institute. I was welcomed to the department by Dr Takashi Akayoshi. During my three days visiting the Tokyo Cancer Institute I was lucky enough to watch some incredible laparoscopic colorectal resections performed, including an en bloc laparoscopic lateral pelvic node dissection. Dr Akayoshi has published a number of research papers on laparoscopic lateral pelvic lymph node dissection and it was fascinating to discuss these with him. This was an area that I was particularly keen to observe in Japan, as this is not routinely performed in the United Kingdom. Amazingly, 95% of colorectal resections are performed laparoscopically in the Tokyo Cancer Institute with the team performing over 1000 cancer resections a year. I would be lying if I said my trip was all work and no play because every unit I visited arranged evening hospitality for me. In Tokyo I was treated to trips to a Japanese pub and a Sushi restaurant with Dr Akayoshi, his colleagues and the residents. It was highly enjoyable to discuss the differences between UK and Japanese surgical training with some of the residents. I was amazed to learn that they do not usually leave work until 10pm and work on Saturday and Sunday as a routine.
My traveling fellowship then moved on to the Shizuoka Cancer Centre, which sits at the base of Mount Fuji. The cancer centre is a relatively new unit but already enjoys an international reputation. I was welcomed to the centre by Dr Yusuke Kinugasa who heads the colorectal division and the chief resident Dr. Numata. Dr. Kinugasa has published widely on robotically assisted rectal cancer surgery. It was incredible to learn that he has performed over 400 robotic rectal cancer resections in 4 years. Dr Kinugasa and his team made me feel extremely welcome. Coming from a unit that does not have a Robot I was fascinated to watch three robotic rectal cancer resections performed by Dr Kinguasa during my visit. The Shizuoka Cancer Centre is a training centre for robotic surgery. Consequently one of their systems has a training console, which gives the trainee an identical view on the console to the operating surgeon. I was fortunate enough to observe the whole of a rectal excision with bilateral lateral pelvic lymph node dissection through the console. This experience has convinced me that there are some potential benefits of robotic rectal cancer surgery; the 3D views and the clarity of vision low down in the pelvis did appear to make low rectal dissection and lateral node dissection easier than by conventional laparoscopic or open surgery. Dr. Kinguasa’s familiarity and technical skill made robotic rectal cancer surgery look easy which I suspect was primarily down to his expertise of the technique.
In the evenings I was treated to delightful meals with Dr Kinguasa and his team. It was fascinating to discuss the differences in healthcare systems. With such a high usage of minimally invasive surgery and few stomas I was surprised to hear that the length of stay is usually at least 7 days. However, further discussion explained that the hospital income is maximized if a patient stays for a week rather than a shorter period of time.
From Shizuoka I moved to Nagoya and attendance at the 70th JSCP meeting. On my first evening I was welcomed at the Congress dinner, it was wonderful to meet Professor Hase and the President of the JSCP Professor Maeda. This was followed by a specially arranged ESCP fellowship drinks reception. I was fascinated to meet retired Japanese surgeons who still attend the annual meeting well into their 80’s. It was fascinating to talk to some who had been contemporaries of Professor John Goligher. On the first day of Congress I delivered my presentation on the Swansea experience of pelvic exenteration for primary rectal cancer. It was a great honour to receive a certificate and gift to mark my presentation. The congress appeared very well attended and I was told there were over 2000 surgeons present. It was interesting to attend different sessions to understand differences in colorectal practice between Western and Eastern practice. In the evening I had the privilege of an invite to the President Maeda’s diner and had a memorable meal with a superb selection of wines to accompany each course.
From Nagoya, I moved to my last destination at Kyoto University Hospital, where Professor Sakai welcomed me. At Kyoto I was fortunate to observe another laparoscopic lateral node dissection performed at the same time as a laparoscopic colo-anal anastomosis. Professor Sakai demonstrated a number of fascinating adjuncts to his surgery; he used fluorescence to check both the vascularity of the bowel used for anastomosis and also to check that all lymphatic tissue has been removed from the lateral node dissection. In the evening I was taken to diner by Professor Sakai and his team to an okonomiyaki (Japanese pancake) restaurant. The okonomiyaki were delicious and we had a terrific evening discussing differences between UK and Japanese healthcare funding. I was also lucky enough to enjoy a day’s sight seeing in Kyoto and visited some beautiful temples and sampled the shopping in Kyoto.
During this fellowship I have been lucky enough to watch some amazing minimally invasive surgery performed by masters of their craft. This was my first trip to Japan but I doubt it will be my last. I have made many wonderful friendships and enjoyed terrific hospitality coupled with fascinating discussions over diner at each centre I visited and at the annual congress. I would like to conclude by thanking Dr Eiji Shinto for the time, effort and care he put into organization of my travelling fellowship and also that the Japanese Society of Coloproctology for making this travelling fellowship possible – Arigatōgozaimasu.
Martyn Evans, Consultant Colorectal Surgeon
Morriston Hospital, Swansea, United Kingdom