Report for James IV Association

It is essential before I commence my report that I define the context in which I began the James IV fellowship. I had recently been appointed as the Foundation Chair of Surgery at the Graduate Entry Medical School, University of Limerick in Ireland. As the Foundation Chair it is my responsibility to develop on the platforms previously present in the context of undergraduate and postgraduate surgical education, research and service delivery. My responsibilities relate to the delivery of excellence of standards in relation to health service provision, education at undergraduate and postgraduate surgical levels and research at all levels of the translational process. Thus the James IV was to provide me with the ability to visit some of the most established units worldwide where I could observe the units, see first-hand the clinical facilities and identify the mechanisms by which they merged the delivery of clinical excellence as well as excellence in educational and research settings. This was to be broadly achieved under the terms of robotic assisted surgery. Whilst the fellowship readily succeeded in this regard it quickly became apparent to me that it provided something far more valuable and enduring, and indeed far more valuable and enduring for surgery in Limerick and Ireland in general. The fellowship provided new colleagues in surgery that would remain supportive friends. As such, one cannot put a value on the opportunities that the James IV fellowship generated for me, the Graduate Entry Medical School in University of Limerick and for Irish surgery in general. I thank the James IV Association and to future fellows I would say enjoy passing through the gateway of the James IV fellowship and into the world of surgical support and internationalised collegiality.

The John Hopkins March 7th-9th

This was the first component of the American leg of the fellowship travels. My wife and I arrived into Baltimore and settled into our hotel room quickly before Jonathan Efron (our host and chief of the Ravitch Division at Hopkins) drove me out to his house where his wife had arranged a wonderful meal and several staff (including Jonathan’s brother, Richard Schulick and Malcolm Brock) were scheduled to arrive for an evening meal. Dee caught up on her sleep for an hour before joining us at Jonathan`s house. Jonathan and I used the car journey to catch up on robotic colorectal surgery in general terms in relation to current status and likely future developments. Jonathan was scheduled to chair a session at that week’s SAGES meeting. Dee and I were immediately set at our ease by Jonathan, his wife Jammi Terry and brother, at their house in Owing’s Mills. Two of the dinner guests were also either current (Malcolm Brock) or previous (Richard Schulick) James IV travelling fellows and so it wasn`t long before conversation turned to the wonderful experiences that they had had. It was with regret that we eventually left Jonathan’s home as the memory of the crab soup will always stay with me.
The following day Jonathan brought me on a tour of the new hospital facility at Hopkins. This is an enormous facility and will be quite an awe inspiring place in which clinicians can work and patients be treated. Jonathan was very kind as a host and although he had to leave town for SAGES, he graciously gave me the use of his office for the duration of my visit.
I met Elizabeth Wick who introduced me to Cynthia Sears and we spent a considerable amount of time discussing microbial ecology in general and possible implications in colorectal cancer. Elizabeth and I have subsequently embarked on collaboration and we hope to be submitting some samples from Ieland, to their study soon. Next, Malcolm Brock brought me on a whirlwind tour of what is easily one of the pre-eminent cancer research centres worldwide (the Sidney-Kimmel Institute). We discussed his research, his James IV travels conducted up to that point, and his future plans. Malcolm`s enthousiasm for the world of surgery and surgical research is endless. Following this I was invited to sit in on the gastrointestinal multidisciplinary meeting and was invited to contribute in relation to some of the cases discussed. These were fascinating cases and the discussion was warm and open, the perfect environment for teaching junior staff.There I met a previous student of mine, James Clarke, who I was delighted to see was progressing well at Hopkins.
Liza then brought us to dinner that evening where we met several of the residents and fellows. Without fail, Dr Cameron’s fellow was phoned at a particular time for an update on his patients. The dinner was wonderful as was the discussion – it was fascinating to hear the enthusiasm of the residents and fellows for the surgical program and the teaching they received.
At 6.30 on the Wednesday morning I gave a lecture on colorectal anatomy and the manner in which research needed to re-focus on the importance of surgical anatomy and anatomic surgery. I was quite nervous giving a lecture along those lines in the home and origin of anatomic surgery. Dr Cameron`s knowledge of surgical anatomy was quite astonishing. He immediately focussed in on an area that, to this day, is a source of vexation to colorectal surgeons, i.e. anterior landmarks in the distal rectum. That morning I met and had a long chat with Richard Schulick on virtually every aspect of surgical service delivery to research and education and all levels. I wish Richard every success in his new post. I visited the Halsted room which was a truly emotional experience for me as I had been reading about Halsted ever since commencing training as a medical student. I had also read the recent book devoted to his life experience “Genius on the Edge” and so the occasion became all the more poignant. Halsted was without doubt the father of anatomic surgery and remains an inspirational figure in relation to surgical practice, education and research.
At lunchtime I gave lecture on microbial ecology in inflammatory bowel disease – relating some of the findings that we recently published on the topic and touching on some hypotheses that are currently under very active investigation. The lecture was delivered to the gastrointestinal medical department where I met Ted Bayliss who kindly gave me signed versions of his most recent book on Advanced Therapy in Inflammatory Bowel disease. Although the lecture was completed in 40 minutes he and I continued to discuss inflammatory bowel disease, aetiology and pathology for a further hour. This represented a wonderful opportunity for me to liaise with some of the foremost thinkers in relation to inflammatory bowel disease in North America.
That night both my wife and I were delighted to attend dinner at Julie fleischlag’s house in Falling Water Court in Reisterstown. Julie introduced me to her family and guests that evening. The house and surroundings were absolutely wonderful and although Dee and I knew very few people we were immediately set at our ease by Julie`s family.
The following day Dee and I took the train to New York. We had initially planned on flying back to New York but Dr Cameron recommended that we take the scenic and most efficient route, which brought us directly into central downtown New York. The scenary was beautiful as we journeyed up from Baltimore to New York.

Memorial Sloan-Kettering March 9 – 14

I was hosted by Dr Gareth Nash in MSK. I am very grateful to Gareth for having developed such a busy schedule. On the first day I met with Dr Murray Brennan. We spoke about many things in what was the first of many conversations we were to have over the coming days. My abiding memory however is Murray`s enthusiasm to embrace foreign students in MSK. Additionally we spoke about research on perioperative tumor growth that I conducted for my PhD. Within a few minutes had worked out the protocol for an experiment whereby one might definitely determine whether the perioperative period adversely affects minimal residual disease. This was a question that had taxed me for some time and I recall feeling utterly overwhelmed at his pervasive and methodological approach to the question. Words cannot express my gratitude to Murray for embracing our medical students on subsequent electives. Again, this is a testament to the spirit of the James IV Association and is reflected in the fact that Murray and MSK have already hosted our students.
Lunch was spent with two of the surgical fellows. This was very enjoyable and we discussed their intensive training program as well as their academic and clinical duties during the fellowship. The Monday schedule was very busy involving meetings set up with Yulio Garcia-Aguilar, Larissa Temple and culminating in my attending the Colorectal MDT Conference at 5 pm. Yulio and I discussed biomarkers and in particular his recent findings in relation to rectal cancer. The conversation with Larissa centred on methods for outcome prediction and outcomes measurement in general. I was quite exhausted with travel and meetings at that point but the cases discussed were truly fascinating and I thank the CRS faculty for involving me in the discussions. The MDT topics covered included mesothelial cysts, metastatic anal SCC, recurrent rectal cancer, HNPCC and many other topics. I was delighted to meet with Kelly Garrett again who had been a fellow trainee at the Cleveland clinic in Ohio. Whilst the topics covered were varied it struck me that as colorectal surgeons we are all faced with answering similar questions in relation to the diseases we deal with (i.e. does one resect the rectum in a patient with HPNCC, the timing of diverticular resections, the difficulties presented by early stage rectal and colon cancer as well as cancer detected in fully resected polyps).
That evening I was invited to dinner at L`Absinthe 227 E 67th street with Murray Brennan, Marty Weiser, Gareth Nash and Philip Paty. Whilst the conversation was initially focused on surgical topics it wasn`t long before we branched out to discuss everything from golfing along the coastline of Ireland to developing vineyards in New Zealand. The food and wine were wonderful and we all peeled off replete at around 10 pm that evening. Dr Brennan again emphasised the importance of sending our trainees and medical students to MSK and I eagerly thanked him.
The following morning I met Ron De Matteo to whom I`m also very grateful for taking time in his busy schedule to discuss numerous aspects of surgical oncology and related research. Ron was very kind to set up additional meetings which combined to generate a phenomenal experience for me at MSK. For example, I was welcomed on Friday at the sarcoma MDT by Dr Sam Singer with whom I discussed forging research links. Dr Singer very graciously suggested that we might liaise with him in relation to having Irish trainee surgeons join his research team. We discussed bioinformatics and the application of computational biology to the resolution of major questions in surgical oncology.
On Tuesday I was brought across to Cornell to meet Jeff Milsom who kindly introduced me to several staff and we set up to meet for dinner that evening. I again met Kelly Garrett, a colleague of mine from the Cleveland Clinic, who also warmly welcomed me. Kelly was scrubbed up supervising one of their fellows doing a laparoscopic splenic flexure mobilisation. I briefly met with Fabrizio Michelassi who was scrubbed in what seemed like a challenging Crohn`s disease case. I then had some time to catch my breath for the afternoon before meeting with Dee and I met with Jeff Milsom and his wonderful wife. Dee and I would like to thank them heartily for their hosting us at a wonderful meal in a Japanese restaurant in NY. Being Irish we are used to somewhat savoury food that is quite straight forward – the food in this restaurant was traditional Japanese and was remarkable for its color and taste (and moving parts). Jeff`s enthusiasm for eclectic foods is nothing short of astonishing. Jeff is a true pioneer of surgery and it was wonderful to hear him recount the stories behind his evolving techniques in laparoscopic colorectal surgery in the early 90’s.
On Wednesday I gave lecture entitled “Mining transcriptomic profiles in colorectal cancer – Consensus Profile Generation” at the Surgical Oncology Conference. During this lecture I detailed our efforts to capture the potential inherent in gene expression repositories and develop classifiers through integrative approaches to different bioinformatic platforms. This sparked an interested debate after, which was chaired by Ron di Matteo. On Thursday evening Ron and Yulio further hosted me at a dinner. This was a wonderful meal during which the conversation covered a vast array of topics surgical and non-surgical. I think the conversation must have touched on every continent and every department of surgery through all our three connections. Robotic surgery was again a topic of healthy debate and Yulio described his positive experiences with this in the City of Hope hospital in Los Angeles. Again both Ron and Yulio pledged to support Irish surgical trainees and undergraduate medical students.
Most of my time at MSK was spent in discussion with my host Gareth. We discussed robotic colorectal surgery and a manuscript that we had recently collaborated on and were scheduled to present in poster format at the forthcoming ASCRS. Gareth described a clinical trial he had established on cases with pseudomyxoma peritonei and we discussed us accumulating cases to contribute to his trial in Ireland. In addition we chatted long about Gareth`s strong Irish connections and it transpired that we had several links in common. In particular Gareth`s father was well known to people of west Limerick, from which my mother in law is from.
Gareth and I discussed establishing stronger links with surgery in University of Limerick and with Ireland in General. They have recently developed a surgical fellowship program in colorectal surgery for which we hope to have several Irish trainees contribute in the future. In addition Gareth again very graciously stressed the support that MSK would give in respect of Irish trainees at all levels of under and postgraduate surgical education.
The trip to MSK and Cornell were wonderful, extremely busy and highly informative at clinical, educational, research and administrative levels. In particular I would like to thank Gareth for his support and understanding during a time that was difficult for my wife as she had to return urgently to Ireland.

Milan – European Institute of Oncology, 12/4 – 15/4, 2012

Unfortunately my visit to the European Institute of Oncology, where I was hosted by Fabrizio Luca had to be quite short. Despite this Fabrizio packed an enormous volume into this short interval (including about five expessos). I delivered a Grand Rounds lecture as the first event in my itinerary. The lecture covered topics related to colonic anatomy and in particular our recent improved understanding of mesocolic anatomy. The discussion after was interested and varied and touched on several aspects of surgical anatomy. It is particularly interesting to note that one of the earliest correct drawings of the mesocolon was generated by Leonardo DaVinci himself. Next, Fabrizio brought me on a tour of the Institute and we discussed forging links through fellowship programs. We developed a plan for Irish trainees at differing stages to spend some time at the European Institute of Oncology in Milan. We next visited the theatre and I briefly observed robotic urologic surgery. It struck me that robotic facilities could be readily incorporated in any operating room environment, with minimal overall operational disruption. Following this we returned to Fabrizio’s office to further discuss robotic surgery in the colorectal context and potential benefits. We followed a recent recording of one of Fabrizio’s operations, demonstrating the incredible fidelity with which the robotic set-up renders the three dimensional intraperitoneal environment.

Edinburgh visit Sep 12 – Sep 15, 2012

My wife Deirdre came to Edinburgh with me. This was the first occasion on which she was able to travel with me for the duration of the trip. Our accommodation was arranged for in the hotel Missoni by Professor James Garden. This hotel is centrally located just off the Royal Mile and near the top part by Edinburgh Castle – the hotel was wonderful (complementary internet and room snacks etc.), and the centrality meant that Dee could attack all the various shops on the Royal Mile and around (not sure whether that was good or bad for the credit card).
After arriving on the 12th I went directly to the Western General Hospital where I was met by Hugh Paterson. We shared a sandwich and coffee and had some very broad discussions related to a range of topics ranging from laparoscopic surgery to the referendum being planned for Scotland in 2014. It transpired that Hugh was a close friend of a colleague of mine from my surgical training years (Mr Tom Murphy) – both had worked together as research fellows in Harvard (very small world indeed!). Hugh then brought me on a tour to the theatre complex and described their catchment area – the number of consultant colorectal surgeons and the typical daily workload within their unit. I was fascinated to see that they also adopt a week on emergencies in which the consultant in question takes a break from elective work to concentrate on the emergencies for that week. This is a system that we practice in Limerick. Whilst it is great to be able to take a break out of elective clinical work for a period, the week can be quite mentally demanding dealing with various emergency and semi- emergency type situations. We discussed in detail the pros and cons of that system including the fact that by the time the Thursday comes around at the end of the week one can be quite exhausted with the emergency cases (not so much because of the operating which is of course the fun component) but rather through the relentless decision making requirements during the week.
Hugh then introduced me to Graham Wilson who was just finishing a complicated diverticular case in which he had done an oncologic resection for a male patient who had obstructed. We discussed various aspects of the case and then walked through the hospital viewing the facilities of the Western general Hospital. It wasn`t long before we sat down to a coffee and discussion that also broadened to include training, educating trainees, undergraduate and postgraduates. We discussed the political and financial system in Scotland and Ireland and the implications that everything was having for training the surgeons of the future. We also discussed screening systems and the now increasing pick up of adenocarcinomas within polyps. Increasingly, we are in a position whereby we are increasingly faced with the question as to what to do in cases where a cancer has been detected in a polyp that, to all intents and purposes, has been fully resected. This is a problem that is developing momentum across continents worldwide. We then discussed some of the emergency cases that Graham was currently dealing with including the case of managing a patient with a complex laparostomy wound and techniques required. Graham described and then demonstrated the technique of the sandwich Opsite© for managing laparoscopy wounds – he was kind enough to let me observe and make suggestions in relation to a case that he was expertly managing at the time.
I then left for the city centre and met up with Dee following which we immediately left for dinner with James Garden, Ken Fearon, Rowan Parks, Steve Wigmore and their wives in The Honours. Dee and I were struck by the warmth and welcome that we received from the group and we were immediately put at our ease by James. The conversation, discussion, wine and food then flowed as we spent the next three hours discussing all manner of topics from boating on the Lochs of Scotland, to Wine, to the history of Edinburgh, surgery in general and surgical education. The evening was wonderful not least because of the warmth and hospitality of our host.
The following morning I was met by Malcolm Dunlop at the MRC Human Genetics building and we went immediately to the cancer MDT. The cases discussed (all 37 of them!) covered the full range of the colorectal cancer spectrum. My attention was beginning to wane at the thirtieth case and I was enormously impressed by the efficiency with which the group got through the cases being discussed. We then went for a well-deserved coffee and mental reboot with James and again we discussed the difficulties in decision making that polyps detected cancers were presenting. Next we then went to the MRC unit and spent the remainder of the morning there in lengthy discussion related to the molecular genetics of colorectal cancer in general. This was an absolutely enthralling experience for me as Malcolm described their discoveries in this field and how these discoveries were aiding in probing the major questions at the heart of cancer generation. Malcolm gave me a tour of the laboratory facility. I walked around wide-eyed at looking at rooms jammed packed with PCR machines, Biobank facilities and so forth. Whilst it was exhilarating it was also daunting as I was reminded of the task ahead of me at home in Surgery at the Graduate Entry Medical School in the University of Limerick.
Malcolm introduced me to all members of the Colon Cancer Genetics Group with whom I had lengthy discussions in relation to numerous aspects of colon cancer genetics. Ruth Wilson (SOCCS and COGS Study coordinator) very kindly demonstrated the massive database that she manually curates and demonstrated the strengths of Access as well as helping in avoidance of pitfalls. Li-Yin Ooi described her findings in respect of her techniques at ex vivo cultures. Lina Zgaga described their findings in relation to vitamin D and we discussed Bayesian approaches to statistics (which I must admit to still being confused about). Farhat Din brought me through her wonderful findings in respect of the molecular interaction between numerous aspiring related intracellular pathways and mTor.
I then had a further lunch and lengthy discussion with Malcolm and Susan Farrington during which I quickly found my knowledge of gwas screening glaringly lacking. We had a lengthy debate in relation to classification approaches, association studies and other aspects of the molecular biology of colon cancer. I described one of the research programs that we are currently engaged in developing (of course emphasising how embryonic we were in terms of the overall stage and context in surgery in Limerick). Malcolm then freed me up for the remainder of the afternoon with a view to meeting for dinner that evening in the Bon Vivant in Thistle Street. This meant that I could spend some time in preparing my lecture for that Friday afternoon.
Dinner was wonderful. It was attended by Malcolm Dunlop, Chinnah Reddy, Farhat Din and James Anderson. Dee was quickly made comfortable by the group and the conversation, wine and food flowed all night. James and I discussed the wonders of sailing. Malcolm kept bringing the conversation around to cycling. Everybody kept veering away from cycling. Hugh discussed camping in a VW throughout Scotland, my wife`s now dead set on driving around Scotland next year (Thanks Hugh!). I was delighted to hear that Sammy had also completed the Cleveland Clinic Colorectal Fellowhsip and had the tattoo.   This gave us volumes to talk about and discuss.   Even more incredible was the fact that Chinnah Reddy had been in the same school and class as a close friend of mine in Cleveland (Ravi Kiran).
Fortunately Malcolm gave me the Friday morning off which was timely as there was an element of recovery involved. I then caught up with Malcolm in his clinic late that morning where I sat in on some interesting cases. These again led to further interesting discussions and it soon became clear to me (as was the case when I visited MSK) that we share the same questions in relation to clinical cancer related dilemmas throughout the world.
On Friday morning I met Professor Ken Fearon and we had an enjoyable and lengthy conversation regarding ERAS and the achievements associated with that program. Professor Fearon’s achievements in relation to cancer cachexia and sarcopenia are phenomenal and are of direct interest to me in respect of the relationship between perioperative events and long term survival related outcomes. We discussed the intriguing possibility of perioperative events (that could in turn be beneficially modulated in the ERAS context) having a bearing on long-term outcome in terms of survival etc. Ken introduced me to the ERAS nurse coordinator who demonstrated the database utilised to link ERAS associated hospitals and collate data. This was extremely impressive and provided me with several ideas with respect to the GUI programs that we are developing locally – we discussed the possibility of the gastrointestinal surgical unit in Limerick joining the ERAS group.
I was then privileged to be able to deliver a lecture on “Overhauling colorectal anatomy – 100 years on” in which I discussed out findings with respect to mesocolic anatomy, radiology, pathology and oncology. I must say that I was quite nervous given the accomplishments of the individuals in the audience. But the lecture was very well received and prompted a lot of discussion afterwards.
It was with a sense of sadness that I Left the Western General Hospital given the warmth and reception that I received from Malcolm and all in the unit.

Leeds October 8-10 Oct 2012

The trip to Leeds was coordinated with Professor David Jayne and Amanda Smith. This was enormously educational on several fronts and I`m enormously indebted to David for the efforts he made during what is an extremely busy clinical and academic schedule.
I arrived into a frosty and fresh Leeds-Bradford airport on the 8/10/12 and met a surgical colleague called Harish Kapoor. This was very fortuitous as we had many years to catch up on which we dully did over a beautiful indian meal in Leeds. During this conversation topics centered on the surgical history of Leeds and the recent reconfiguration-type events that occurred between Leeds General Infirmary and St James` Hospital. Harish made me feel very much at home from the very outset and this set the tone for the entire visit.
David collected me on the following morning with Danielo – their newly appointed Associate Professor of surgery. We immediately went to the CTRU on the University of Leeds campus where I spent much of the morning. David introduced me to Professor Julie Brown who is the director of the CRTU and who proceeded to give me a detailed account of the requirements needed to conduct trials such as CLASSIC and many others which they are involved in. This information is crucially important to us in University of Limerick where we are in the earliest phase of establishing an infrastructure to conduct surgical clinical trials. We spoke in detail on clinical trials, stability of process in trial design, the required central infrastructure in CRTU`s. We discussed the core components of a CRTU team and the financial mechanisms required to generate self-sustaining programs. In addition we discussed IT systems, data management systems. We discussed the mentorship programs that are run from the CRTU. I am also enormously indebted to Prof Browne for solidifying my thoughts in relation to the importance of a surgical CRTU in Ireland.
I next vet Vick Napp, the operations director of the CRTU and the conversation was similarly enormously informative. The conversation centered on the concept of trial management and the development of related skill sets. Vicky went into detail on SOPs and the key qualities associated,
i.e. clarity, conciseness and guidance. This is particular relevant to us in University of Limerick where we emphasis an overlap between surgical device-related innovation and in clinical trials. Again we spoke about infrastructural requirement and we discussed the requirements for teaching modules whereby individuals could be educated in the skill sets required in populating a surgical CRTU core team. My general feelings are that surgical research is heading in the medtech direction and possibly away from early pipeline intracellular molecular biology. In that context the conversation with Vicky was enormously informative and provided me with much need information in relation to clinical trials involving new health technologies.
Vicky introduced me to Helen Marshall, the principal statistician, who provided a very detailed insight into the statistical pitfalls associated with device related trials and mechanism by which these can be overcome. Helen talked about trial bias; difficulties associated with levels of blinding in device related trials and contextualised her comments in relation to the CLASICC and ROLARR trials. I then met and spoke with the senior trial manager Catherine Lowe and Julie Croft (the senior Trial coordinator). Unfortunately conversations had run over time and we had a few minutes only for this discussion but again the points were highly informative. Both described mechanisms involved in multi-site research, mechanisms of developing engagement and enhancing recruitment and the indemnity related problems sometimes associated with multi-site clinical trials.
I then left University of Leeds Campus and travelled to St. James Hospital where I met Professor Finan. Professor Finan demonstrated the databases that both he and Eva Morris have developed and interpreted in relation to outcomes in colon and rectal cancer surgery. We discussed mortality and morbidity rates, the benefits of identifying groups/trusts that may be outside the 95% percentile (this could be on either side) and we discussed the relationship between volume and outcome. Professor Finan had previously visited Ireland on a number of occasions and we spoke about the strong links that exist between Irish and English colorectal surgery. The conversation then turned to discussions on stoma reversal rates and the usage of these as a quality proxy. I then had a break period for an hour during which I prepared the lecture which I had been invited to deliver to the Department of Colorectal Surgery that evening.
Prior to delivering the lecture in question I met Nicholas West and we spent two hours discussing mutual interests centered on the mesocolon. Nick gave me a broad overview of the studies they had conducted and the collaborations that they were involved in. Nick also gave me a brief tour of level 9 of the LIMM building showing me the projection system they have in place for the virtual pathology repository that they have developed and made open access. I was fascinated by the data that Nick presented which truly affirms the group’s preeminent position in relation to mesocolic lymphadenectomy and outcomes in colon cancer. We then discussed many of the findings that our group recently had in relation to mesocolic anatomy, histology, radiology and three dimensional modelling. This conversation was fascinating but regretfully had to stop in order for me to get over to the John Goligher Colorectal Surgical Unit to deliver my lecture.
It goes without saying that I was quite nervous presenting to such an established group and in particular a group with such a detailed understanding of the relevance of mesocolic lymphadenectomy in general. The lecture detailed the discrepancy that exists between that which we are taught from classic anatomy and embryology and that which we do operatively. The lecture then proceeded to detail how our studies attempted to address this imbalance. I descried how our anatomic findings during total mesocolectomy led to advances in three dimensional modelling of the mesocolon and to further opportunities in relation to a more informative colorectal surgical nomenclature. I spoke in relation to opportunities relating to radiologic appraisals of the mesocolon and finished commenting on how we can reappraise intraperitoneal disease in terms of mesocolic descriptors. The lecture was well attended by upper and lower GI surgeons from the group and was followed by a warm and detailed discussion in relation to several of the questions raised. In particular we discussed high ligation on the right side, as well as the usage of the vascular stump of the ileocolic as a quality proxy.
At that point David and I left and rather than me have a break to catch my breadth for an hour we went straight to Leeds General Infirmary and thereafter into the city centre for dinner. At Leeds General Infirmary David showed me the famous bust of Berkeley Moynihan and we proceeded to dinner at Gaucho`s steakhouse in Leeds city centre. That evening we discussed what seems like innumerable surgical topics ranging from surgical education to clinical practice in general. We spoke about the difficulties of maintaining work/life balances in situations where one has an academic post and has an extremily busy clinical practice. At that point I had spent one day in Leeds and was quite amazed at the amount which the schedule had included.
The following morning David arranged a tour of the Welcome Trust Brenner building. This building is on campus on St James` Hospital site and as such represents an incredible opportunity for merging clinical and early pipeline basic research. At the end of the tour I realised that it is essential to have such a facility available at such close proximity. When coupled with the CRTU facility for conducting later phase clinical trials this represented the ideal balance between early pipeline research and late phase clinical trial. The combination is truly a translational force of significance. Again, the benefits of seeing this first hand are enormous to me as chair of surgery at a young medical school which is currently finding its feet in respect of translational processes and research and as such the experience provided here was invaluable. We then proceeded to the medical engineering building where we were met by Prof Anne Neville at the department of Mechanical Engineering. Prof Neville brought me on a tour fo the mechanical engineering building giving me a snap-shot of what seemed like innumerable different projects all with a clinico-surgical emphasis. It seemed to me that David had generated capacities at all levels of the translational process in medical device generation and in the biosciences.
We then returned to theatre where David commenced a robotic take-down of a colovaginal fistula in a patient with recurrent bouts of diverticulitis. This was the culmination of the tour for me and was fitting in so far as it clearly demonstrated the technical versatility of robotic assisted surgery. It was with sadness that I turned to finally leave, bid farewell to David and St.James` Hospital and return to Ireland after having had such a wonderful and informative trip.

Report from Cleveland visit Oct 31st-Nov 3rd 2012

The final leg of my James IV Travelling involved returning to the Cleveland clinic and to my colleagues there in the department of colorectal surgery. I had completed my fellowship there in 2009-10 and I was delighted to be hosted by Dr Feza Remzi who has always been a close friend and support.
I arrived in Cleveland having flown through or around hurricane Sandy on the 31st Oct. Having spent 18 hours Travelling I was quite exhausted and was delighted to find that transport had also been arranged to the Hotel Continental where I was staying. The wind was howling as we drove from the airport and I was astonished to hear that the freeway and airport had been closed due to the hurricane that Monday. Much of Cleveland (over 100,000 households) was out of power and was coping with significant infrastructural damage.
That night I met Awad Jarrar who is a research fellow with Mathew Kalady and doing some excellent research in relation to the effects of chemo radiotherapy rectal cancer. Awad is completing a PhD supervised jointly through the Cleveland Clinic and University of Limerick. We had dinner which was very pleasant, and more importantly, allowed us some time to catch up.
The following morning the first thing I did was to walk around the clinic to remind myself of the wonderful year I had there training. I met Dr Mathew Kalady for dinner at the North Coast cafe which was very enjoyable as we caught up on the past two years and developments in colorectal surgery in relation to service delivery, research themes and various other topics. After dinner it was down to work and we discussed ongoing collaborations as well as developing further research based collaborations for the coming year.
I then met Dr Victor Fazio in his office on the tenth floor and he introduced me to his administrative support. Dr Fazio had been a phenomenal mentor to me during my training. We discussed colorectal surgery in general and toured the clinic finishing up in the library. Fortunately there were several books on sale at the time for a great deal and I made use of the opportunity to purchase several. I had some time in the afternoon which I used to prepare the lecture that I was invited to deliver at the residents day the following day. That night I was hosted by Dr Fazio and his wife Carolyn at Table  45. We had a wonderful meal and conversation touching on an enormous range of topics including everything from children to maritime warfare and foreign travel.
The following day was truly incredible. The venue was the Tudor Hotel on Carnegie which I was told had significant history associated with it. The occasion was the Resident’s Day hosted by the Department of Colorectal Surgery at the Cleveland Clinic. It was attended by general surgical residents from all over North America. All CORS staff attended and thus it was the perfect opportunity to meet with staff who had trained me as a fellow and many of whom have become friend as well as colleagues.

I met Jeremy Lipman (currently working at Case Western), Jamie Ogilvie (working at Minnesota), Megan Costedio (staff in the Cleveland clinic), each of whom had also been a fellow during my year there. It was an emotional re-union for me as people were now established in successful careers and we had much to discuss. I was delighted to meet John Byrn who was a fellow the year prior to me, and who, along with Eoghan Condon, had come out to Cleveland Airport to collect me and my family when we first arrived there in August 2009.

Other staff I met included Ian Lavery, David Dietz, Jon Vogel, Mazarat Zusthi and Brooke Gurland. I also met Dr Feza Remzi for the first time in several months. This was an emotional reunion for me as Dr Remzi has always been a great support and close family friend.

I met Dr Ian Lavery who I regard as having had the single greatest influence on my technique in colorectal and general surgery. He is widely held as a true master and I was, not surprisingly, extremily nervous delivering a lecture that evening, that focussed on colorectal anatomy as it relates to technique. Regretfully, we had very little time to talk due to the itinerary but I was moved when Dr Lavery presented me an embossed picture of Drs Rupert Turnbull, Sir Ernest Hughes and John Goligher (three giants of colorectal surgery), as they sat together in a unique moment during a meeting in the early 70’s.

I also met Marlene Bambrick who was Dr Ian Lavery’s nurse practitioner and who I also regard as one of my technical mentors at the clinic – Marlene would always help me with technique when I needed it and words cannot express my gratitude for that. The day was so packed with meetings and activities that I didn’t get an opportunity to talk with Marlene and catch up on events over the past two years. That’s something I regret and hopefully will be able to correct in the future. I was also delighted to meet Katherina Allen who had coordinated the logistics of my trip. During the day we were able to catch up briefly regarding children and events in general.

I also met Yulio Garcia-Aguilar whom I had met previously that year in MSK. Dr Aguilar delivered two truly tremendous lectures during the day. The first was an update on the current status of staging in rectal cancer whilst the second was an update on the current status of the management of stage four colorectal cancer. Each was a true master class on the topic and prompted excellent open discussion after from the floor and panel.

These reflected the quality of the presentations that day. Virtually every colorectal topic was covered including difficult diverticular disease, early and late stage rectal cancer, rectal prolapse. Each topic was covered in incredible detail and truly represented a master lass in colorectal surgery. The emphasis was on cases for which the managament was not clear cut and thus the discussion that followed was energetic and enthusiastic. Sitting back and listening to the discussion and the lectures its struck me that American residents are incredibly lucky indeed to have such an opportunity available to them.

I delivered an invited lecture as the Distinguished Alumnus and this marked a great milestone in my career to date. Returning to Cleveland and being awarded the distinguished Alumnus award was a true priviledge and honor. There were no questions immediately after but there was considerable debate during the dinner that evening. This represented the culmination of my experience in the James IV travelling fellowship and it was entirely fitting that my travelling should finish with this honor.

The day’s procedings culminated in a meal at the hotel. The guest speaker was the retired journalist Ted Henry (WEWS Channel 5 News Anchor), who delivered what should be described as an inspirational lecture. The sentiments expressed were too numerous to detail here but will remain with me. That evening Dr Remzi and I took an opportunity to meet for an hour to catch up on everything that we had done over the last year and to discuss plans for the future. We toured around the clinic, meeting the nursing and administrative staff that I worked with two years prior. My one regret was that we did this at about 10 pm at night and unfortunately I was unable to catch up with people such as Jake, Ken, Mellisa, Bonnie and the many others that used support us as fellows when I was working there.

I was delighted to see that Dr Remzi continues to develop a remarkable department at the Department of Colorectal Surgery, The Digestive Diseases Institute, Cleveland. The following day was again packed with meetings, goodbyes and more meetings prior to my returning to Ireland.

In summary:

The opportunities afforded me by the James IV Travelling Fellowship cannot be adequately depicted in words. Whilst the knowledge I obtained from a surgical technical viewpoint is vast, it pales in comparison to the friendships that both myself and my wife Deirdre have developed and will continue to nurture in the coming years.

I would like to thank the James IV Association. Words cannot express the gratitude that I would like to convey. Similarly, words will never adequately capture the scale of the benefits that our students of surgery in Limerick (Ireland) will obtain through the relationships developed on this fellowship.