James IV traveling fellowship 2022-23

Dung Nguyen

April 2022

CANADA

Mcmaster university & hamilton health sciences

The COVID19 pandemic has affected all our lives across the globe. It seemed so long ago that I had travelled abroad. My travel plans for James IV were delayed for 2 years due to the pandemic. Needless to say, I was excited to resume global travels. I am a plastic and reconstructive microsurgeon. The goal of my fellowship was to learn how breast reconstruction and lymphedema are being managed across the world and to establish opportunities for collaboration.

My first visit was to McMaster University in Hamilton, Ontario. I landed in Toronto at 3pm and was picked up by the limousine service to take me to where I would be staying at The Barracks Inn. Immediately, I was taken in by the Inn’s timeless, understated elegant décor and warm Ancaster hospitality. Shortly after, I was greeted by my host, Dr. Susan Reid, Professor of Surgery and Immediate-Past Chair of the Department of Surgery at McMaster University. We went to dinner at Ancaster Mill, a creekside restaurant overlooking the falls! The delicious food was a perfect complement to the beautiful scenery and wonderful company. Dr. Reid gave me an overview of Hamilton and the itinerary for the week. I was excited for the busy week ahead. I was back at the Inn at 9pm. By then, I was struggling to stay awake and was ready for good sleep.

The following morning, I was taken to the Juravinski Hospital & Cancer Center where I observed Drs. Chris Coroneos and Ronen Avram performed a delayed-immediate tissue expander to free DIEP flap reconstruction. I saw an effective way to dissect a perforator flap using a monopolar bovie! I had an animated discussion with the surgeons on the differences between the US and Canadian healthcare. Canadians have quicker access to emergency care and do not have to pay for copays and deductibles, but they pay much higher taxes and have limited access and longer wait times to see specialists. In fact, lymphedema surgery is currently not an approved covered benefit. One of the plastic surgeons is trained in lymphatic surgery but has not been able to offer treatment to the patients. This became an area of interest of mine to better understand the barriers and ways that our institutions can collaborate to advocate for better access to healthcare.

That evening, I had another stimulating discussion at dinner with Dr. Reid and two other fantastic women surgeons, Dr. Lua Eiriksson and Dr. Clare Reade, who are trailblazers for changes within their institution to improve work-life balance conditions for women physicians. It was such a wonderful evening and we truly enjoyed ourselves. The conversations were motivating, inspiring, and uplifting. The food at Victoria’s Restaurant was delicious and the atmosphere so relaxing. It was incredible to talk about ideas for research, advances in patient care, international work, leadership and mentorship, the challenges and sacrifices of being a surgeon and raising a family and so on. It was a perfect way to end the first day!

I spent the second day with the residents at McMaster University. I gave a lecture to the residents on breast reconstruction and then went over case discussions. I was impressed by the thoughtful questions from the residents! Dr. Reid then gave me a tour of the University and history of the medical school and the world-famous problem-based learning model. I was impressed by the rich history and beautiful architecture. This was followed by a walk along the Hamilton Waterfront Trail where one overlook Lake Ontario and can see the old steel plant in the distance. In the afternoon, I had the opportunity to visit Synaptive Medical in Toronto. I met with the CEO and got to tour their manufacturing plant and played with their latest version of the 3D exoscope! We had dinner at a fantastic Italian restaurant in downtown before I headed back to Hamilton.

The highlight my third day was giving Grand Rounds to the Division of Plastic & Reconstructive Surgery on “Surgical Advances in Lymphedema Prevention and Treatment”. Lymphedema treatment and prevention is currently not offered in Hamilton, there was interests from within the Plastics Division as well as from vascular surgeons and oncologists to know more about current research and advancement in the field. After Grand Rounds, I returned to the OR at Juravinski Hospital to observe a combined oncoplastic reduction case and additional breast cases. I had an engaging discussion with the breast surgeon, Dr. Nicole Hodgson, on her approaches to nipple sparing mastectomy and axillary lymph node dissection. The day concluded with a nice dinner with the Plastic Surgery faculty and residents.

The next two days was partly spent in the operating room and meeting key administrators. I had the opportunity to meet with Neil Johnson, Vice President, Oncology & Regional VP of Ontario Health for HNHBB Regional Cancer Program. It was great to share our personal journeys and shared pharmacy heritage. He gave me an overview of the Ontario cancer system. We recognized that despite the differences in healthcare systems, we share a lot of similar health constraints and access issues across the border. We concluded our exchange with an invitation to keep in touch and a desire to build future research and education collaboration. I also met Dr. Jonathan Sussman, professor of oncology and Chair of the Department of Oncology at McMaster University. I gained new perspectives on the application of radiation therapy in the treatment of breast cancer. He was interested to know about my experience with lymphaticovenous bypass for prevention of lymphedema after ALND. I find these conversations very stimulating and refreshing!

On my last day, Dr. Reid took me to see Niagra Falls and gave me a car-ride tour of Niagara-on-the-Lake. Niagra Falls is as impressive and majestic as what I have read. Niagara-on-the-Lake is such a lovely town in Southern Ontario with lush wineries that rival Napa Valley, streets that are tree-lined and flower-filled and has the charms of an old town with historical buildings and fine foods. We ended the evening at dinner with the breast and plastics colleagues. I had a wonderful time in during this trip! The inspiring conversations and the friendships I have established are invaluable!

SEPTEMBER 2022

LONDON

IMPERIAL COLLEGE LONDON

My next stop was at the Imperial College London. My sponsor was Professor Ara Darzi, Baron Darzi of Denham, and the Paul Hamlyn Chair of Surgery at the Imperial College London, the Royal Marsden Hospital, and the Institute of Cancer Research. My host was breast surgical oncologist, Daniel Leff. It was such an honor for me to meet Professor Darzi and learned about his inspiring medical and political career and his passion in global health and innovation. I was grateful for his invaluable advice on career growth and development.

Upon arrival at the Charing Cross Hospital, Dr. Leff introduced me to his breast colleague, Dr. Michael Boland, and the plastic surgery team, including Drs. Simon Wood, Frank Henry, and Georgina Williams. On my first day, I observed a HoloLens-Assisted DIEP flap for breast reconstruction. Dr. Henry introduced me to the HoloLens which is a holographic augmented reality imaging technology to map out the perforators for DIEP flap harvest. At our institution, we use 3D models of the perforators to plan our flap dissection, so it was very interesting for me to see another way of using 3D technology to guide surgical dissection. I also saw an oncoplastic surgery by the breast team and had an engaging discussion about the timing of radiation therapy and shared our experience and thoughts about the pros and cons of radiation therapy before or after mastectomy on oncologic and aesthetic outcomes.

During my visit, I saw many great cases, including nipple sparing mastectomy and immediate direct-to-implant reconstruction with mesh by Dr. Hogben. I was impressed by how proficient the breast surgical oncologists are at performing oncoplastic surgery, including local perforator flap for lumpectomy reconstruction.

For my Grand Rounds, I gave a talk on our novel technique of breast reconstruction using the omentum fat-augmented free flap which generated a lot of great discussion and interests. I also learned that we share a common interest in lymphedema prevention surgery. Dr. Paul Thiruchelvam shared their preliminary data on the LYMPHA procedure, and we saw an opportunity to collaborate!

A major attraction during my visit was the tour of the Hamlyn Center and Institute of Global Health Innovation. The center is an impressive facility that focuses on technological innovation in imaging, sensing, and robotics with a strong emphasis on clinical translation to address global health challenges. I had the privilege of meeting the staff of the Hamlyn center and learning about the exciting projects that are underway including Mammobot and imaging technology to visualize cancer intraoperatively. The integrated and comprehensive research laboratories and teaching facilities were just amazing to see! It was great to end my visit on such a high note!

LONDON breast meeting 2022

Before leaving London, I attended the London Breast Meeting where I spoke on lymphedema and breast reconstruction panels and met up with colleagues from around the world. I also witnessed the historical moment when the country learned about the passing of Queen Elizabeth II. Within hours, the entire country was in mourning. Some of us took a break from the conference to pay our respects to the Queen at Buckingham Palace.

Austria

whitlinger lymphedema clinic

Before returning to the States, I visited the Wittlinger Lymphedema Clinic in Austria. The clinic has been in existence for more than 50 years and is internationally known as Europe’s center for excellence in holistic lymphedema management. It is a facility that offers comprehensive conservative lymphedema management where patients check in for 2-3 weeks at a time and receive complete medical workup, daily physiotherapy, aquatic exercise, nutrition consultation, garment fitting, and skin/nail treatments. It is also the founding site of the famous Vodder technique of manual lymphatic drainage. I got to experience the treatments as a patient for 3 days and saw the effectiveness of good conservative therapy. Inspired by what I saw, we are adopting some of their treatment approaches in a program that is tailored for patients undergoing surgery to maximize volume reduction after surgery.

March 2023

Malaysia

university of malaya kuala lumpur

My last destination was Asia where I visited Professor April Camilla Roslani, Dean of the Faculty of Medicine, and the Department of Surgery at the University of Malaya. I was excited to meet Dr. Roslani, a woman leader and pioneer who is leading the largest colorectal cancer treatment center in the country and who has paved the way to improve working conditions for women in medicine and advancing surgical standards within her country. It was enlightening to get her perspective and advice on mentorship and leadership development.

At the hospital, I saw complex breast and lower extremity reconstruction with free tissue transfer by plastic surgeons using loupe microsurgery. Just as in London, the breast surgeons are very proficient at doing implant-based reconstruction and pedicled flaps, including TRAM flap.

Dr. Hoong gave me a tour of the Breast Cancer Resource Center. She shared her vision of developing an integrated Breast Oncoplastic Curriculum Module to train future breast surgeons in providing basic reconstructive procedures to increase patients’ access to breast reconstruction.

I attended radiology rounds and breast and plastic clinics during my visit. I learned that access to lymphedema treatment is still limited in Malaysia. For Grand Rounds, I gave a lecture on lymphedema management to the residents and faculty. We discussed about our lymphedema prevention clinical trial at Stanford and had discussions on how to offer a similar service to breast cancer patients there.

Lecture on Lymphedema Management

During my visit, I also learned about the Silent Mentor Program, a voluntary body donation program for medication education, training, and research. I was fascinated to learn about the origin of the program in Taiwan and how it was adopted in Malaysia. It is a very interesting program that merges professional medical training with humanistic appreciation in a way that teaches students to respect and show gratitude to the body donor who becomes their silent mentor.

Of course, one cannot leave Malaysia without appreciating its delicious cuisine! Malaysian food, as I learned, is a melting pot of different ethnic foods. It is highly varied in flavors with unique blend of Chinese, Indian, Thai, and even a hint of European influence!

VIETNAM

medical mission trip in hue

Finally, from Malaysia I flew to Hue, Vietnam where I wrapped up the year of traveling with a medical mission trip with ReSurge International to teach and provide breast reconstruction and lymphedema surgeries. There, I also had the opportunity to share my travel experience with local surgeons.

Overall, my James IV travelling fellowship has been extremely rewarding, educational and eye-opening. I appreciate seeing how breast reconstruction and lymphedema are being managed across the globe. I have made many new colleagues and friends and am excited to continue to cultivate these relationships and nurture opportunities for collaboration.

Part I: July 5-21, 2019

Tokyo, Japan

With 126 million inhabitants Japan; the city of Tokyo has a population of about 10 million.  The Japanese population is slowly decreasing but the incidence of gastric cancer is still high.  The most important underlying risk factor is H. Pylori infection but infection rates are trending down. Screening for gastric cancer is done but not in an organised fashion and this is not formally coordinated by the government as we know for example from breast or colorectal cancer. Many Japanese people, however, do get an endoscopy when they are around 40 years old. There are many private and public endoscopy centres with easy access. Hence, early gastric (and oesophageal) cancer is relatively often detected. The treatment of these cancers is according to the Japanese guidelines.

During my first week of the fellowship, I visited the Cancer Institute Hospital in Tokyo. The Cancer Institute foundation was founded in 1927 and the present hospital in East Tokyo was build approximately 15 yrs ago. It is a modern centre with 700 beds. Medical director Professor Sano was my host together with Dr. Kumagai. I very much enjoyed the team discussions where also difficult cases were discussed and expertise sought from all specialists. All patients that will be operated the following week and patients that already had their operation were discussed. In the latter group, pathological specimens and intraoperative pictures were discussed for quality control. Surgeons are trained to become more or less “organ specialists”. Gastric cancer is taken care of by gastric cancer surgeons and oesophageal cancer is treated by another team. There were 16 registrars, actively involved in the care for patients. The Cancer Institute performs about

400-500 gastrectomies per year. Minimally invasive techniques for early stages, locally advanced cancers are operated with an open technique. State of the art 3D laparoscopy and robotic surgery is available and being used. I had the privilege to attend many operations and noticed the standardized techniques, precise lymph node dissections and handling of the specimens.

I also visited the department of Gastrointestinal and general surgery of Keio University Hospital in Tokyo. Prof Kitagawa was my host. I observed a minimally invasive oesophagectomy. I noticed the differences in surgical approach with Europe. In Japan mainly squamous cell carcinomas are treated as opposed to adenocarcinoma in the West. The dissection is more in the upper mediastinum and neck (3rd field) in Japan to achieve a complete nodal clearance. I also watched some laparoscopic gastrectomies with D2 nodal dissection. Hence, I gained a deep insight into the intra-thoracic and upper abdominal lymph node stations, its anatomical boundaries and the dissection techniques. It was very nice to see how skilled the Japanese surgeons and I learned some tips and tricks that I can use in my operations back in the Netherlands. Besides observing surgeries, I was also involved in clinical conferences and discussions on research projects. surgery.

In both hospitals, I gave a presentation on the national surgical training program of the Netherlands and on surgical research. It was a great opportunity to share my views on this to trainees and surgeons in both centres. Both teams kept me busy but I had some time in the weekend to explore the city of Tokyo: wonderful parks, beautiful modern buildings modern and lots of heritage. The museums were splendid and of course the food like nowhere else. At the end of my week, I felt that one week was a bit short but I managed to get a deeper understanding of the Japanese approach on the diagnosis and treatment of oesophagogastric cancer. Furthermore, I made friends and plans for collaboration on future research projects. After my visit, I now have a better understanding of the scientific papers and reports from Asia: their preferred surgical approaches and perioperative management that are among the best in the world.

Brisbane, Australia

My second week was at the Princess Alexandra (PA) Hospital in Brisbane, Australia. The Brisbane population is almost 2 million. Previous James IV travelling fellow, Professor Andrew Barbour, was my host. During my stay I had the privilege to also meet with the other members of the Upper GI team: David Gotley, Mark Smithers and Iain Thomson. Besides their expertise in benign and malignant disease of the upper GI tract, melanoma and sarcomas are other interests of the group. It was surprising to hear that almost 1 in 15 Australians are diagnosed with a melanoma and in people over 70 years this is 1 in 8. During my stay, I attended the multidisciplinary team discussions and a research meeting. It was nice to see the infrastructure of the hospital and a beautiful research centre next to it.  This stimulates translational research. Just a few months after my visit a Dutch medical student will start a collaborative project at the PA with Andrew Barbour. I also had the privilege to observe a few operations, i.e. an oesophagectomy and a few gastrectomies. The difference in patient’s BMI between Japan and Australia was striking. Apart from a different patient population, it was interesting to experience the two paradigms on the treatment of oesophagogastric cancer. Whereas in Australia and Europe/US neoadjuvant chemotherapy or chemoradiation followed by surgery is the standard approach, in Japan surgery is the first-line treatment by many and adjuvant treatment (chemotherapy) is often given in advanced cancers.

Apart from visiting the PA, I also followed Dr. Barbour in a Private hospital he works at. Laparoscopic fundoplications are being performed at a high number and at the highest level of expertise. The group has a database that includes more than a thousand patients after a fundoplication.

Brisbane is a lovely city and my hosts organised nice dinners and social events. The hospitality was great! At the end of my two weeks of travelling, I met with my three children in Adelaide, South Australia to have a three-week holiday together. In Adelaide, I met with friends when I was a senior registrar at Flinders University during the years 2006-2008.

Part II: November 9-23, 2019

Seattle, USA

I visited the Virginia Mason Medical Center in Seattle in November 2019. Dr. Don Low and his team (Dr Kuppusamy and Dr Hubka and the research fellow Dr Puccetti), a thoracic surgeon, was my host. An important aim of my visit was to see their clinical pathway for patients with oesophageal cancer. Dr Low and his team have published many papers on this and have inspired many centres around the world with his enhanced recovery after surgery. I had a chance to speak to many caregivers and stakeholders including intensivists, anesthesiologists, nurses and dieticians and see how the culture in the hospital of getting patients mobilised and discharged early without adverse events. I had the privilege to observe some beautiful operations. I managed to see some interesting approaches, tips and tricks that I will take back home. One of them is the use of a paravertebral analgesia that can easily be placed by the surgeon during thoracotomy/thoracoscopy. The advantage is that under vision the catheter is placed in the right place by the surgeon. This eliminates the use of an epidural that takes time and may have more systemic effects.

Dr. Low is also the initiator of the Esophageal Complications Consensus Group (ECCG). The ECCG started as a group of enthusiastic high-volume centres on oesophagectomy from all around the world. The ECCG managed to reach consensus on a core outcome set of complications and their definitions. At present over 10.000 patients have been registered in an international web-based database. My visit to Seattle gave me the great opportunity to also discuss new developments and adaptions of the database and share my views with the group. By the way, Seattle has some places where they brew very nice beers and Dr Low and his team took me out to discuss science over a pint of Northwestern IPAs.

New York, USA

Next and last on my schedule was Memorial Sloan Kettering Cancer Center (MSKCC). Dr. Vivian Strong was my host. She is a gastric cancer specialist surgeon of the Gastric and Mixed Tumors section of the department of surgery. She is supported by a great team of specialists and a wonderful infrastructure at MSKCC. The main goal of this visit was to see and experience how one of the largest cancer centres in the world manage cancer patients and to attend the multidisciplinary discussions and surgical meetings (teaching, morbidity/mortality and research). I had the privilege to meet some of the world prominent surgeons. Observing a robotic gastrectomy was very helpful in order to help to expand my own experience with robotic surgery that is limited to thoracoscopic robotic oesophagectomy. In between cases and patients at the clinic, there was time to exchange ideas and views related to the diagnosis and treatment of gastric cancer. It was a great honour to speak on Wednesday morning at the fellows teaching session on laparoscopic and open gastrectomy. This was followed by a stimulating discussion. We also had a chance to sit down together and discuss future collaborations on research. But besides the time I spend at MSKCC there was also time for exploring New York and see many museums, famous buildings and lovely places in the city.

Read an article HERE from UC San Diego School of Medicine on Jason Sicklick’s recent travels.

‘After two weeks of travel, conferences, meals with colleagues and conversation, I am reflecting on new collaborations that have developed and lifelong friends that are sure to evolve. I have experienced two different forms of nationalized health care, each with their benefits and challenges, including an anesthesiologists strike on my last day in Italy. With so much communication done virtually these days, this trip is a wonderful reminder of the joys and true benefits of face to face learning and collaboration.’