Gaetano Gallo from the Department of Medical and Surgical Sciences, University of Catanzaro in Italy, reports on his 2018 Japanese Society of Coloproctology (JSCP) Travelling Fellowship.
When I received the news that I had been awarded the 2018 JSCP Travelling Fellowship I was excited and thrilled. I had never visited Japan and knew it would be a lifetime adventure!
JSCP gave me a special guide, Dr Mamoru Uemura, a previous JSCP European travelling fellow and his collaboration has been simply perfect! Dr Uemura is a young and very skilled colorectal surgeon who works at the Osaka National Hospital and organized my entire Fellowship. I want to thank him for his friendly support that permitted me to really enjoy my time in Japan.
My fellowship began on 4 November.
The first day of my fellowship, I met Dr. Tsukamoto, a laparoscopic colorectal surgeon, who welcomed me very warmly at the main entrance of the National Cancer Center, a high-volume colorectal cancer center.
After an interesting visit to the Department of Surgery ended with a meeting with the staff we went to the operating room where I attended three engaging and didactic procedures. Thankfully, during the whole operating session I had the chance to interact with the surgeons.
They began with a restorative proctocolectomy for familial adenomatous polyposis with ileoanal-J-Pouch anastomosis and after the second procedure (i.e. laparoscopic sigmoidectomy for diverticulitis) we took time for a break, going for lunch in a special sushi restaurant!
Last, but not least they performed a right hemicolectomy with complete mesocolic excision. In fact, the CME technique was introduced in the West in 2008, but Japanese, Chinese, Korean and Taiwanese surgeons have been using D3 lymphadenectomy resections for colon cancer for decades. Then my dinner was at one of the most popular tourist spot restaurants in Tokyo, a dream place for all lovers of Quentin Tarantino's films, i.e. "Gonpachi”, where in one of the most famous scenes of the movie Kill Bill was shot.
On the morning of 7 November, I visited the Japanese Foundation for Cancer Research (established in 1908 as the first Japanese institute for cancer). Here the hospitality was provided by Dr. Akiyoshi, who after a tour of the facility accompanied me with his staff into the OR where I could see a TransAnal Total Mesorectal Excision (TaTME) for a recurrent tumor of the low rectum (previously removed with an en bloc endoscopic submucosal dissection). The diet of the Japanese population (that has a low BMI) is clearly different from the European one, so the indications and the advantages of the surgical technique could be different. Dr. Akiyoshi performed a perfect TATME with a double team. Afterwards, I was invited by Dr. Akiyoshi and his staff for dinner and I could try the classic Japanese barbecue (“yakiniku”). It was a funny and friendly evening with a useful exchange of ideas and considerations.
The next day I moved to the Keio Plaza Hotel in Tokyo, where it would be held the 73rd meeting of the Japan Society of Coloproctology. I took a guided tour of Tokyo and immersed myself into Japanese culture (Tokyo Tower, Tea Ceremony, Imperial Palace, and a cruise crossing the Sumida River and arriving in Asakusa, the oldest district of the city with the beautiful Sensoji temple, built in the 7th century). After the interesting pre-conference meeting I joined the inaugural ceremony where finally I met the President of JSCP as well as the scientific and organising secretariat. On Friday morning (9 November) the Congress started with several interesting reports of the JSCP experts and a brilliant Lecture by Prof. Carlo Ratto about new technologies for the treatment of hemorrhoids, anal fistulas and fecal incontinence. The day ended with a presidential dinner for the international guests in an evocative setting. Really unforgettable! On the last day of the conference (Saturday) I gave my lecture on microRNAs profiles in stool of patients with colorectal cancer or precancerous lesions detected by Next-generation Sequencing (NGS), then I rapidly prepared my suitcases to move with a very fast Bullet Train (Shinkansen) to Kyoto!
On Sunday morning I met Dr. Uemura for a one-day tour of Kyoto. I am really impressed by the beauty of all the places I visited but one I will never forget is the Temple of the Golden Pavilion or "Kinkaku-ji" at Zen Buddhist temple.
The following day, I went to the Kyoto University Hospital where I was again warmly welcomed by Dr. Hida. The day was extremely interesting because I had the opportunity to discuss Pelvic Side-Wall Lymph Node dissection for Rectal Cancer with a friendly and savant PhD, Dr. Tomoaki Okada who gave me a beautiful drawing of surgical anatomy that he made during our discussion.
In the OR I saw a robotic APR with inguino-iliac / obturator lymph node dissection performed by Prof. Sakai. The presence of a PhD dedicated to the anatomy of the pelvic-side wall allows a significant contribution to the surgeon during the procedure. In fact, before surgery, the position of the lymph-node was carefully evaluated with a Power-Point presentation by Dr. Okada. I believe we should keep in mind this kind of organization.
The next day, early in the morning, I took a train to reach my last destination, Osaka.
As soon as I arrived, I met Dr. Uemura at the Osaka National Hospital and after a quick presentation I joined the OR to see a Laparoscopic APR for a low rectal cancer with pelvic-side wall lymph node dissection (Japanese surgeons are really masters in this technique!).
I was fascinated by the technical abilities of Dr. Uemura whom I discussed with throughout all the procedures regarding communication with the patient and about the pros and cons of the different oncological procedures for rectal cancer. We had an interesting discussion regarding anterior resection syndrome, the complex, frequent functional disorder that 30-80% patients undergoing a low or very low anterior resection will complain of.
The last two days I spent my time in the OR observing procedures performed by the Colorectal Surgery team.
Before leaving Japan, I visited Nara. I was impressed by the Todaiji Temple, constructed in 752 as the head Buddhist temple in Japan that was so important at that time that the capital moved from Nara to Nagaoka in 784 in order to lowe the temple's influence on government affairs.
On the last evening, perfectly in line with the Japanese hospitality and kindness, a farewell dinner was organized with all the staff of the Department of Surgery. After this dinner it would have been impossible to leave Japan without a little sadness.
In conclusion, I strongly recommend the JSCP Traveling fellowship to all young colorectal surgeons.
It is a unique experience, allowing to visit several referral centers in a short period and making this fellowship truly educational. The lymphadenectomy performed in all rectal cancers is really a surgical approach almost unknown in Europe, part of a different surgical culture, and I think it should be considered also in western countries. I lived in an environment full of hospitality and culture, but above all I have had the opportunity to know many new friends and this is for a young surgeon as I am as important as attending a perfect surgical operation.
Gaetano Gallo, MD
Department of Medical and Surgical Sciences
University of Catanzaro, Catanzaro, Italy
ESCP Japan Travelling Fellow 2018