I had the distinct honor of serving as the 2019 American College of Surgeons (ACS) Traveling Fellow to Japan. It was a tremendous professional opportunity to share ideas with my Japanese colleagues, which I anticipate will deepen the collaboration between surgeons in our two countries to advance treatment of low-lying rectal cancers and other complex pelvic floor pathology.
Cancer Institute Hospital of the Japanese Foundation for Cancer Research
It was cherry blossom season when I arrived in Tokyo, with the city covered in pink petals.
I spent several remarkable days there, observing operations and sharing insights with surgeons and residents from the Cancer Institute Hospital of the Japanese Foundation for Cancer Research (CIH JFCR), the first and largest hospital in Japan to specialize in cancer care. Since it opened in 1934, the hospital has grown from 29 to more than 700 beds and is now the leading center for clinical and biological cancer research in Japan.
My host at CIH JFCR was Tsuyoshi Konishi, MD, PhD, associate professor of surgery at JFCR and a respected international expert in lateral lymph node dissection (LLND) for rectal cancer. LLND is a technique that is widely employed in the Japanese surgical community—and one that is much less familiar to Western colorectal surgeons. Western surgeons generally use chemoradiotherapy to treat cancer patients at high risk for lateral lymph node involvement. Japanese surgeons, in contrast, often approach low-lying rectal cancer by combining total mesorectal excision with LLND. A recent randomized controlled trial reported by Prof. Shin Fujita, MD, PhD, and colleagues highlighted the potential utility of this technique in a study that showed decreased local recurrence in the patients offered LLND, which led to my interest in this surgical technique.*
At CIH, I observed several complex low-lying rectal cancer total mesorectal excisions with LLND, which Dr. Konishi was kind enough to book back-to-back to match my itinerary. The procedure requires great technical finesse, a strong understanding of the lateral compartment anatomy, and a meticulous and patiently executed laparoscopic approach. I left Tokyo with great respect for the skill of Japanese surgeons, and Dr. Konishi in particular, who kindly shared an anatomical image with me (see top photo, page 85).
I also left with a renewed appreciation for Japanese sushi, which Dr. Konishi and colleagues—Takashi Akiyoshi, MD, PhD; Tomohiro Yamaguchi, MD, PhD; and Hiromichi Ito, MD, FACS—found time to enjoy with me and my son, despite their busy surgical schedules.
Meeting of the Japan Surgical Society
My next stop was Osaka, where I attended the 119th Meeting of the Japan Surgical Society (JSS), which provided an amazing opportunity to attend presentations on international surgical advances and to share insights and perspectives with my Japanese hosts.
A personal high point was the opportunity to present from the podium the lessons learned by our colorectal surgery group at Massachusetts General Hospital, Boston, in the course of the rollout of a new Enhanced Recovery After Surgery (ERAS) pathway for patients. It is a controversial topic, and spirited debate ensued. Some attendees were shocked by the idea of a 24-hour, inhospital recovery following laparoscopic colectomy. The Japanese tend to recover patients in hospitals for much longer periods, in part because they do not have a system of rehabilitation facilities after surgery or visiting nurses. Many perspectives were shared, and the presentation served as an excellent example of the kind of intellectual cross-fertilization that the Traveling Fellowship is intended to promote. I also took the opportunity to present grand rounds on ERAS during my visits to Tokyo and Kyoto, and the experience was memorable and engaging on each occasion.
In Osaka, I had the opportunity to explore nearby temples, restaurants, and culture on a comprehensive itinerary arranged by the organizers of the meeting. Osaka has been known for centuries as the “kitchen of Japan,” and is known for kuidaore, meaning “ruin oneself by one’s extravagance in food.”
Kyoto University Hospital
I concluded my visit with four days in Kyoto, a beautiful city of haunting and majestic temples. While there, I had the privilege of visiting and observing operations at the Gastrointestinal Surgery Department of Kyoto University Hospita. My hosts were Prof. Yoshiharu Sakai, MD, FACS, and assistant professor Shigeo Hisamori, MD, FACS, who went out of their way to introduce me to their colleagues and to arrange for me to observe a series of masterful laparoscopic operations on difficult and complex cases.
Particularly impressive was a carefully executed D3 lymph node dissection, which junior associate professor Kenji Kawada, MD, performed on a patient with advanced sigmoid cancer, while associate professor Kazutaka Obama, MD, performed a simultaneous resection on a synchronous gastric cancer in the same patient. Colorectal surgeons in the West have been reembracing the idea of D3 dissection, relabeled as “complete mesocolic excision,” but Japanese surgeons remain world experts at properly performed and anatomically detailed lymph node harvests in various gastrointestinal node basins.
Conclusion
I had many memorable evenings in Japan, including a wonderful dinner of Japanese barbeque in Kyoto with Prof. Kyoichi Takaori, MD, PhD, FACS, president of the International Association of Surgeons, Gastroenterologists and Oncologists, and his remarkable wife Terue; and a delightful farewell dinner, hosted by Dr. Hisamori and his colleagues, Shigeru Tsunoda, MD, PhD; Riki Ganeko, MD; and Keiko Kasahara, MD.
I am deeply honored and grateful to each and every individual I met and am deeply humbled by the hospitality shown to me in this ancient and beautiful, yet very modern, country. I look forward to maintaining these friendships and professional relationships for years to come and to sharing among colleagues in the U.S. the surgical approaches, techniques, and perspectives I encountered on this trip.
*Fujita S, Mizusawa J, Kanemitsu Y, et al. Mesorectal excision with or without lateral lymph node dissection for clinical stage II/III lower rectal cancer (JCOG0212): A multicenter, randomized controlled, noninferiority trial. Ann Surg. 2017;266(2):201-207.
