Read Part 2 of our 2017 Japan Travelling Fellow Fraser Smith's experience of endoscopic submucosal dissection and other techniques at the National Cancer Centre and the Cancer Institute of Tokyo.
Monday was my first day in the National Cancer Centre. I had wanted to visit the world-famous endoscopy department to learn more about magnification chromoendoscopy and the technique of endoscopic submucosal dissection (ESD), for which they are renowned world experts. I spent an interesting morning discussing pit pattern recognition, inspecting all of their state-of-the-art equipment, much of which is custom designed with the major manufacturers and trialled there, and discussing the different indications for ESD and reviewing cases with my hosts. In the afternoon saw a difficult colonic ESD where they had to use a technique known as 'tunnelling' to stabilise the scope. They also used a balloon overscope to stabilise it. It was masterful. After this I attended the weekly ESD MDT where the previous cases done were compared with the final pathology and also new cases and the management plan were discussed. What I thought was amazing was that all of the clinical decisions are based on endoscopic features and pit patterns. This is different to the multitude of expensive clinical tests that we order for our own patients during work-up and something from which I feel that we could learn from in my opinion.
The following day I saw more ESDs and discussed more cases with my hosts. It was a great honour and opportunity to be hosted in this institution and to see them in action. I was inspired and can see how we could use ESD and dissection in the submucosal plane far more in our own patients and definitely by being there and being immersed in it, the learning experience was very deep and lasting. I already have a potential research project lined up with them!!
On Wednesday I went to the Cancer Institute of Tokyo where my host Dr Akiyoshi and my friend Dr Konishi worked. It too is a world famous institution and it was only at this point that I realised the true mastery of laparoscopic surgery that is prevalent in Japan. OK, the patients are very slim, but that is only part of the equation. My jaw did literally drop when I watched them in action! I was lucky to see an extended resection for caecal cancer with en bloc excision of Gerota’s fascia and the gonadal vein, full D3 lymphadenectomy with skeletonisation of the ileocolic vein and artery. In the second theatre I saw an anterior resection that was performed beautifully with pinpoint accuracy. I was very interested to hear that only the minority of anterior resections involve splenic flexure mobilisation as apparently the Japanese have long sigmoid colons! I then saw a third anterior resection, this time ultra-low, which was interesting because this patient had recently undergone an ESD for a very low rectal lesion that turned out to have adverse features. Despite the previous excision, the surgical planes were completely untouched (unlike post TEMS). Again the IMA trunk and left colic artery were preserved, the splenic flexure was not mobilised yet there was excellent specimen reach into the pelvis!!
After my day in theatre I then went to the path lab. I had been recommended to do this by one of my colleagues in Liverpool who had also visited Japan. This was very interesting. The specimens are actually initially processed and cut by the surgical residents. Of further interest is that they lay the specimens onto nodal 'maps' and so chart out the number and location of each of the nodes. I also had the opportunity to discuss and see how ESD specimens were handled and processed which was also very interesting because they take serial slices and photograph them and then map out exactly where any cancer is in relation to the mucosal appearances. These, in turn, are then discussed with the endoscopist in Powerpoint format at a weekly meeting as a learning process.
That evening I was asked to give a talk to the department about my experiences with 'watch and wait' and organ preservation for rectal cancer. I was really pleased because although it is not really practiced in Japan there was a very good turn-out for my talk and there seemed to be a lot of interest in what I had to say. After this I went out for sushi with my hosts in a traditional sushi restaurant… and enjoyed more sea urchins!!
