Jasper Stijns, colorectal surgery fellow at the UZ Leuven in Belgium, reports on his 2019 Japanese Society of Coloproctology (JSCP) Travelling Fellowship.
I was delighted when I received the e-mail from the ESCP Secretariat that they had awarded me the 2019 JSCP Travelling Fellowship. A few weeks before travelling to Japan, ESCP put me in touch with Professor Jun Watanabe from the Yokohama University medical centre. He arranged my entire stay in Japan, the flights and hotels and contacted the centres I would visit during my stay.
The JSCP meeting would take place on the 11 and 12 October so one week after coming home from ESCP 2019 in Vienna, I left for Tokyo from Brussels Airport. I had a twelve hour direct flight to Narita on Sunday evening and I arrived on Monday late afternoon in my hotel in Yokohama. So I went out for a walk in the city centre and took an early rest.
The next day Professor Watanabe picked me up at my hotel to visit his centre. The day started with a robotic TME for a proximal rectal cancer. It was the first surgery I would see in Japan and was very impressed with their attention to detail. By their standards, it was quite an obese patient. Professor Watanabe performed a meticulous dissection of the planes, high ligation of the IMA and IMV and the nerves were beautifully identified with the enhanced 3D vision of the DaVinci Si. I thought that most Japanese surgeons do not usually perform splenic flexure mobilisation because their patients have long sigmoid loops. Prior to dividing proximally they performed an ICG test, something which is already widely implemented in their country, mainly for left sided resections. No neoadjuvant treatment was given so they did not divert. However they do leave a rectal tube through the anastomosis, which they leave in place for five days. Most patients in Japan leave the hospital between 7 and 10 days after TME. The reason for this is that their entire stay is completely funded by their health insurance and patients and surgeons do not feel the pressure (that we do in Europe) for an early discharge. Another reason is that out of hospital care is not as well developed as in Belgium or The Netherlands.
The second procedure of the day was a sigmoid resection for an obstructive tumour. Again, meticulous dissection of the vessels and planes, the use of ICG, laparoscopic resection performed by two surgeons,… This consistently came back in every centre I visited during my stay in Japan. They provide high-quality surgery for their patients in high volume centres.
That evening Professor Watanabe invited me to dinner with his staff. They took me to a traditional Japanese restaurant where they served delicious sukiyaki (beef cooked in soy sauce and sugar) and off course hot sake!
The next day I visited Matsushima hospital. A small clinic with 100 beds but exclusively for proctology. The clinic was founded in 1928 by the grandfather of Dr Matsushima. He is also the owner of another clinic in Yokohama where they perform endoscopy and another clinic in Tokyo.
Dr Matsushima and his colleagues gave me a very warm welcome. In the morning I was able to observe them performing hemorroidectomies, LIFT procedures for peri anal fistulas and an anocutaneous flap for a chronic fissure. All patients were operated in prone jackknife under spinal anesthesia. There was a quick turnover of patients and surgery was performed in two theatres. In between cases, Dr Matsushima saw some patients in the outpatient clinic. He is a really hard worker! All procedures were performed without diathermy. For the haemorrhoids, they combined classical haemorrhoidectomy with rubber band ligation or mucopexy. This way they have a really tailored approach for each haemorrhoidal pillar. Dr Matsushima had a very interesting modification for the LIFT procedure. In addition to the ligation, he also performed a submucosal excision of the crypt, responsible for the fistula. Also the external track was excised op to the external anal sphincter. You could tell by the way the procedures were performed (quick and with bloodless dissection of the planes) that they had an extensive experience. After a classic Japanese lunch, they took me to the other clinic in Yokohama were I was able to follow some colonoscopies. Also here there was a huge turnover with screening colonoscopies every 15 minutes. The endoscopists were happy to show me the use of AI something they use to even speed up their already very short withdrawal time.
The third day Dr Watanabe took me to the Red Cross Hospital where he would proctor his former boss performing TaTME. The case was a distal rectal cancer cT2N1 at 3cm from the anal verge. The abdominal part of the procedure was performed robotically, with bilateral LPLND. The distal part was done with the transanal platform and a manual colo-anal anastomosis was performed. The combination of the robot (with superb high definition 3D view, stable camera and exposure for the LPLND and TME), and transanal approach (single stapled anastomosis, clear visualisation of distal neurovascular bundles, distal resection margin, etc), really brings the best of both approaches together.
In the afternoon I took the train from Yokohama to Tokyo, and the Yurikamome to Odiaba, an island in Tokyo bay where the annual JSCP conference would be held. The view on the city centre and on Tokyo bay from the Yurikamome (that takes you over the Rainbow Bridge) is absolutely spectacular. We simply don’t have cities like this in Europe. In the evening I was invited to the pre-conference dinner where the JSCP president gave an inspiring speech. It was a dynamic dinner and I had the opportunity to meet surgeons from all over Asia. They all offered me their business cards in a formal way (I love this tradition!!!).
The JSCP conference took place in the Hilton in Tokyo bay. For being a national meeting, it’s quite a large conference with not only speakers from Japan, but from all over Asia and the rest of the world. Most sessions were in Japanese but there was also an English session, which was well attended. This years theme of the conference was "Kodawari", wich means "show your originality". There were sessions on almost every possible topic in coloproctology: ICG, anastomotic leak, rectal cancer, IBD, proctology,…
I had the honour to present the Leuven results on the use of the Martius flap for complex rectovaginal fistula. Later in the session, past ESCP president Per Nilsson gave his invited lecture on 'Knack and Pitfalls of colorectal surgery'. A truly inspiring lecture! After our lectures we were offered a Certificate of Appreciation. It is a kind gesture and I felt incredibly honoured to receive this! It's a perfect example of the hospitality from our Japanese colleagues.
Unfortunately the second day of the conference was cancelled because of typhoon Hagibis, the strongest typhoon in decades to strike mainland Japan and one of the largest typhoons ever recorded. It caused catastrophic destruction across much of eastern Japan. In the morning I was still able to catch a short Yurikamome ride to the next hotel but the streets of Tokyo were already empty and in the late afternoon the wind and rain picked up. All people were advised to stay indoors. It is amazing how well prepared the city was for this destructive force of nature.
The next two days I had some time to explore Tokyo on my own. I took some long walks around Tokyo, from my hotel on Odaiba to the Tsukiji fish market. I spend the afternoon in and around Ueno park with amazing shrines and temples and the Tokyo national museum. Tokyo tower, Shibuya, the Imperial palace… The city has to much to offer to cover it all in two days but it was enough time get a feel of the place.
The next centre I visited was the Cancer Institute Hospital were I was welcomed by Dr Konishi and his colleagues. I attended the morning meeting where they discussed all colorectal and upper GI cases of the week into detail. After the meeting we went to the OR were one of the fellows performed a laparoscopic right hemicolectomy with D3 lymphadenectomy for a big caecal tumor. They performed a medial to lateral approach and performed a perfect CME along the SMV. In the afternoon they performed a robotic (DaVinci Xi) ISR for an early rectal cancer after ESD. I observed the cases with some other visitors, from China and Taiwan. They were also impressed by the skills of Dr Konishi, who performed a perfect TME, especially the distal part where he used the robot to expose the pelvic floor and dissected into the intersphincteric plane. He performed a pullthrough with manual colo-anal anastomosis. The next day they scheduled a laparoscopic APR with LPLND for a ycT3N3 distal rectal cancer. By then I had seen several surgeons performing the LPLND, using either robot or laparoscopy. It was very interesting to see the difference in details but the patience and preciseness with great attention for the anatomy is something that all Japanese surgeons have in common when they perform this procedure. They finished the procedure by creating an extraperitoneal stoma, as a prevention for parastomal hernia.
My time in Tokyo had come to an end and the next morning I took the Shinkansen from Tokyo station to Osaka. In the afternoon I had some time to walk around the city. The next day I took the train to Osaka University were Dr Uemura gave me a very warm welcome. One of his colleagues showed me around the hospital while he was prepping for surgery. It would be an all day case: a local recurrence of a rectal cancer invading the vagina after an open TME. After a long course of chemoradiotherapy, Dr Uemura performed a laparoscopic adhesiolysis, redo rectal resection, lateral pelvic lymph node disection, hysterectomy and resection of the vagina. He performed a large part of the procedure with a perineal approach, where he sutured a SILS port in the perineum. This way he had a superb vision of the cystovaginal septum and the lateral pelvic sidewall. The connection was made with a two team approach. He used ICG to indentify the ureters which was really usefull during the dissection in the fibrotic and edematous tissue. As most surgeons in Europe wouldn’t even dare to think about perfoming such a case in a minimal invasive way, Dr Uemura taught me that the possibilities of laparoscopic and transanal (or transperineal) surgery are endless. After the surgery it was time to have diner and Dr Uemura took me and one of his residents to a traditional restaurant in Osaka. It was a wonderfull evening.
The last day in Japan, I had the honour that Dr Uemura could find the time (on a Saturday!) to be my personal guide. We took the train to Kyoto where he showed me around. We visited the Ryoanji Temple, the Imperial Palace, the famous Kiyomizudera Temple, the Higashiyama district and of course the Golden Pavillion. We had Tempura for lunch in a very cosy and traditional restaurant. During our trip, we had some great conversations about our training, our common passion for surgery, work-life balance and the differences in our culture. At the end of the day we took the train back to Osaka and we said goodbye. I was very grateful for his pleasant company.
The next day I took the flight back to Belgium were I was happy to see my wife and kids again.
The fellowship was once in a lifetime experience. I was amazed by the hospitality of the Japanese people and I especially would like to thank Professor Watanabe, for organising this unforgettable experience! I also would like to thank my hosts, Dr Matsushima, Dr Konishi and Dr Uemura for giving me a warm welcome in their centre.
I would recommend every young ESCP member to apply for this fellowship. Getting to know another surgical culture will broaden your mind for new approaches, techniques and ideas. I am convinced that this experience will make me a better coloproctologist.
Jasper Stijns MD, FEBS Coloproctology
