2008 James IV Report

Erik D. Skarsgard, MD

Division of Pediatric General Surgery
BC Children�s Hospital and the University of British Columbia

I completed my travel in 2 parts: the first leg was in June/July 2009 to Scandinavia and the UK, and the second was in May 2010 to Japan. I chose these destinations for both general and specific reasons. I was interested in visiting Scandinavia because of the quality of their publicly funded health care system, but also specifically to see how the Scandinavians have managed to do population-based followup studies on children with surgical birth defects�one of my own research interests. My trip to the UK was to see the pediatric surgery unit in Oxford, which I had first visited briefly 5y earlier when I attended a British Association of Paediatric Surgery meeting in Oxford. We had hosted one of the Oxford surgeons, Paul Johnson in Vancouver a few years ago, and I was keen on visiting his research unit, and the National Perinatal Epidemiology Unit, also based in Oxford, which collects observational data on birth defects similar to what we have done in Canada with the Canadian Pediatric Surgery Network. And finally I was keen to visit Great Ormond Street Hospital in London, which is one of the most famous children�s hospitals in the world.

My visit to Japan in the latter half of May 2010 included visits to two pediatric surgical units in Tokyo (Juntendo and National Center for Child Health and Development) and one in Kobe. My trip coincided with the Annual Pacific Association of Pediatric Surgeons meeting (also in Kobe), which I attended along with 2 of our residents over the last 5 days of my visit. Japan has a uniquely high incidence of choledochal cyst, as well as a very high volume of biliary atresia and I was especially interested in their surgical management of these conditions. Another specific focus of my visit was to get a sense of how premature babies are resuscitated and managed in the nurseries of Japan, given the very low incidence of necrotizing enterocolitis (NEC-1% vs about 14% in North America) in a gestationally vulnerable population.

Each centre I visited afforded an opportunity to compare and contrast clinical approaches to simple and complex conditions, to interact with trainees, hear research presentations and generally experience the practice of pediatric surgery in a setting outside of one in which I had worked or trained. This was an extremely valuable experience, both from the perspective of learning a new (or old) way of doing things, but I found it very reassuring to realize that nobody�s centre is perfect. We all face challenges no matter where we work., and it is important that we never lose the energy and enthusiasm to find ways to improve the way we deliver surgical care to children and support their families. The James IV Traveling Fellowship was a tremendous experience, one that has certainly enriched me professionally and personally. I am extremely grateful for having been given this unique opportunity.

June 19/20

Left Vancouver at 5:20pm on flight to Heathrow. Arrived June 20 at 11am London time, then caught flight at around 1pm for Oslo (SAS airlines). Sat in middle of back row between two large and tired men! Arrived in Oslo airport around 4:30pm. Checked bag arrived! Caught express train (flytoget) from airline terminal which arrived in downtown Oslo (National Theater stop) within 45 minutes. Raining lightly on my arrival. Checked into Thon Cecil Hotel. Small but clean and quiet hotel room. Had a quick nap, went out for a bite to eat and then slept 10 hours!

June 21

Up by 8am. Had excellent continental breakfast provided free of charge, then went for a quick walk up and down main street in downtown Oslo (Karl Johans Gate). Went to central station (old bus terminal) and saw the recently opened and magnificent Oslo Opera House. Came back to hotel to meet a Norwegian relative Morten Haugen, who took me on a walking tour of Oslo. Saw parliament buildings, Oslo Cathedral (built in 1697), Law courts, law school, City Hall, National museum, Nobel Peace Prize Centre (Nobels Fredssenter), and walked through the grounds of the Royal Palace. We then got in the car and drove up to Holmenkollen where we saw the ski jump being renovated for the 2011 world championships. We drove to Morten�s home (he and his wife Karin are both partners in the same Oslo law firm) and had a wonderful lunch with Morten, Karin, and Morten�s mother Kari (who was wife to my father Lloyd�s cousin Leif). After a lunch of various types of salmon, salads, cheeses (including brown Norwegian goat cheese) and fruit, we drove to and walked through Frogner Park where we saw the interesting sculpted works of Norway�s greatest sculptor Gustav Vigeland. I was dropped at my hotel at about 5:30. Went for another walk to take pictures. Highlight was my return to the Oslo Opera House. Unfortunately the summer season does not start until next week, so am unable to attend anything there. Back to room to work on my laptop. Had not realized the need for a 220 volt electrical outlet adaptor for travel abroad, but fortunately Morton was able to give me one.

June 22

Up early for continental breakfast at 6:30 am. Received message from my Norwegian host (Professor Raghnild Emblem) that I should meet her at Rikshospital at 11:15. Went out for another walking tour. Walked west to the harbor and could photograph sailing ships as well as large passenger cruise boats coming into Oslo harbor. Saw Akershus Fortress (historic military base) which is under renovation so no tour possible. Took taxi to Rikshospital and met Professor Emblem, who took me for a hospital tour. The Rikshospital is 9 years old and is located to the North of Oslo, easily accessible by tram. The hospital is built on the edge of the forest, so many natural vistas from patients rooms. It is the largest of the Oslo teaching hospitals, and hosts many of the medical school and research buildings (the latter connected by a sky bridge). Saw patients� wards in Barn Kyjnner children�s ward (bottom two floors are pediatrics while surgery has the top floor). Saw a children�s room�there are bunk beds for parents to stay.

Had lunch with Raghnild and discussed some of the challenges of pediatric surgical practice in Norway. Currently, she is involved in discussions with physicians and administrators from other hospitals to decide whether neonatal surgery should be centralized or regionalized. Currently there is some neonatal surgery (including CDH, esophageal atresia) being done locally in the city at the hospital with a large trauma centre (Ulvdaal?), and there are pediatric surgeons in the Northern city of Trondheim. However some of the smaller units without pediatric surgeons in which the pediatricians and neonatologists are arguing that the neonatal cases should stay, even though they may see and treat only one case (eg EA) per year. Raghnild argues (correctly) that decisions regarding location of treatment should be made based on the quality of care provided and measured outcomes, but this data is not easily obtained. We had some discussion about the nature of her practice compared to mine. She does urology (we don� t), and they have good relationships with adult surgical colleagues who help them with laparoscopic surgery. The pediatric surgeons are involved in a randomized trial of laparoscopic vs open hernia repair. They do laparoscopic appendectomies, pylorics, fundoplications. They have not taken on most advanced neonatal laparoscopic cases (TEF�s, choledochal cysts, Kasai procedures) and neither have we. They do not have trauma at their hospital, managed by adult surgeons at the trauma centre. I left the hospital at 2pm, so Ragnhild could attend a meeting on the subject of surgical regionalization. I took the tram back downtown, and went for some more sightseeing. I managed to find a universal adaptor at an electronics store downtown. At 8pm, Ragnhild picked me up and took me out for supper with two colleagues (Hans Skarli, and Kjetl ?). Hans is considered a junior faculty member and is the site director for the laparoscopic hernia trial. He also does research on the psychosocial effects of neonatal surgery on families and has made the interesting observation that a prenatal diagnosis seems to confer an adverse psychosocial affect on parents having a baby with a serious birth defect, compared to those in which a birth defect diagnosis is made after birth. Kjetl is a trainee in his 3rd year. He conducts research on Hirschsprung�s disease (intestinal cells of Cahal). We had a lovely supper at the restaurant overlooking Homenkollen and all of Oslo and the harbor to the south (Frognerseteren Hovedrestaurant).

June 23

Met Ragnhild at 1015 at Rikshospitalet. We had a tour of the OR facilities. The pediatric surgeons have one OR within a general hospital OR. The general surgeons do a combined practice of general surgery and urology. Attended a cystoscopy for antenatally diagnosed ureterocele by Gunnard ? They have large rooms and electronic record keeping in the OR (ie paperless OR). They have laparoscopic carts that move in and out of the OR. There approach to venous access is different than ours. Generally anesthesiologist establishes central access, and then surgeons tunnel the line. There is a move towards more out of OR procedures (ie interventional radiology). OR turnovers are slow, averaging about 30 minutes. They do have dedicated specialty OR nursing, even on call�in other words, pediatric general surgeons can be assured of having a specialty- dedicated nurse for all cases�elective and emergency. Visited the MIS Research suite located in a research building connected by a sky bridge. This is used for both research (animal) and human surgery! No biohazard issues here! The MIS suite has an MRI magnet used for intraoperative navigation. The neurosurgeons use all modalities of intraoperative imaging (MRI and CT) to guide brain tumor treatment, which is often multidisciplinary (surgeon/interventional neuroradiologist). Like us, they do not have a surgical robot. Also visited another adult general surgery room where the expert MIS surgeon was performing a laparoscopic repair of a common hepatic duct injured during lap cholecystectomy (not recognized elsewhere). Met one of the GI surgeons who trained Buz Scudamore in ERCP during his 6 month visit to Norway in 1981. At 1130 we had a lunch meeting with the pediatric surgery faculty (Ragnhild, Kristin, Gunnar, Hans), as well as their research fellow (Kjetl), medical student, head nurse and Kari Wagner who is the anesthesiologist in the PICU with a special interest in CDH. I presented our work with CAPSNet; a network overview and some of the studies we have completed to date. There was an excellent discussion that followed on the value of networks, especially in the Scandinavian countries where the case volumes are relatively small, yet the ability to do long term followup on patients is well established (especially in Finland). We also compared Homenkollenapproaches to preop stabilization of CDH patients, and the role of ECMO in CDH treatment. They run a small ECMO program in Oslo, that is largely maintained by cardiac surgery, however the pediatric surgeons cannulate the CDH patients. Also heard research presentations from medical student (?) on a comparison of psychological function of parents of children undergoing gastrostomy, compared to control parents with healthy children. Interestingly preoperative, vomiting (which is quantified) is predictive of psychological dysfunction in this group of patients. Also heard about Kjetl�s research which looks at the association between Interstitial cells of Cajal and the symptoms of postoperative constipation and soiling in Hirschsprung�s disease patients post-pullthrough. Some discussion on operative technique, where to start mucosectomy, length of cuff. Jack Langer is highly revered in the Scandinavian countries, and is generally perceived as the international authority on Hirschsprung�s disease.

Went back to hotel on tram at about 2pm. Walked around a bit, and then took the Royal Palace tour (with a Norwegian speaking guide!). Kristin picked me up at 7:45 and we drove out to Ragnhild�s home which is on the sea looking directly south out along the Oslo Fjord. The view was spectacular, with boats everywhere, celebrating the beginning of �summer vacation�. I met Ragnhild�s husband who is a general surgeon and master craftsman. He was completing the installation of a new floor in the kitchen (along with Ragnhild�s son-in-law), in preparation for new appliances which would be arriving early the next morning. We had a lovely supper of shrimp, cheeses, bread and fresh vegetables on the back lawn overlooking the sea. Given the location of Oslo in the Northern hemisphere, it is light until 11:45 pm (and then the sun is up again by 3am). After a wonderful meal, I said good bye to Ragnhild, and Kristin drove me back to my hotel by 11pm. What a wonderful visit to a beautiful country with lovely and hospitable inhabitants who are now great friends!

June 24

Up by 6:30 am. After an excellent hotel breakfast, I packed and caught the Express Train (Flytoget) to the Oslo Airport, and caught an 11am flight to Stockholm. Scandinavian travel is so easy compared to North America! Caught a bus to my hotel (Elite Palace Hotel) which is located in a suburb of Stockholm (called Vasastaden), which is quite close to the Karolinska institute, which I visit tomorrow. Caught the Bana-T (subway) to the �Old Town� (Gamla Stan). This is the oldest part of Stockholm, and although quite touristy, definitely give a sense of what the city was like in the 16th and 17th centuries. Took a tour of the Nobel museum and found Michael Smith�s picture. Came back to the hotel, worked out in the gym and then had supper in �The Bishop�s Arms� Restaurant. Looking forward to seeing Bjorn Freckner tomorrow.

Thursday June 25th

Met Bjorn Freckner in the hotel lobby at 720. Bjorn is an internationally known pediatric surgeon who started the first ECMO unit in Scandinavia in 1987. He continues to run a very successful ECMO program at Karolinska that provides neonatal, pediatric and adult ECMO. More to come on ECMO later.

We had a brisk walk from my hotel to Karolinska. Bjorn pointed out that the institute is divided into a medical centre (clinical) and basic science research institute and the two are connected by a catwalk. We went to morning X-ray rounds (held every morning with the pediatric radiologist) and looked at films from last night�s patients. Over a cup of coffee, I met the Bjorn�s faculty, and then Bjorn toured me around the hospital. We started in the ICU and reviewed one baby who is on ECMO: a few week old infant with proven pertussis infection. This has a very poor prognosis due to a severe necrotizing pneumonitis with little chance of significant lung recovery. In our experience these babies cannot survive and it is always a question of how long to continue ECMO support. Indeed Bjorn is meeting with the family today to discuss discontinuation of bypass. We compared ECMO technique differences between our centres. They use a roller pump for neonatal ECMO, while we use a centrifugal pump (which is admittedly less desirable for neonatal ECMO). They use mostly VA ECMO, and always for CDH. The Karolinska program provides ECMO to 60-70 patients per year, about 1/3 are neonatal. They also provided ECMO transport to all of Scandinavia, which means they have a team on call at all times to go out and cannulate and bring back to Karolinska. Interestingly, they have put a number of patients (approximately 12) on two and even 3 ECMO runs with a survival rate comparable to the first run of ECMO (approximately 75%). One significant difference is that neonatal and pediatric cardiac surgery is not done at Karolinska. Rather the pediatric cardiac program is at Uppsala.

After rounds and a complete tour of the hospital I had lunch with Bjorn, Johan Wallander (Administrative Director of Pediatric Surgery), Ole Strand (Surgeon from the Emergency Dept, primarily responsible for burns), and Tina Granholm. I had met Tina previously at an AAP meeting, and at Stanford, during my time there. She spent 7 months working in the Harrison lab in 1997. Over lunch, we all discussed similarities and differences between our administrative and academic structures, and some of the administrative challenges Johan is dealing with in talks with other centers to regionalize (or leave as is) the care of pediatric (and especially neonatal) surgery in Sweden. Currently pediatric surgery is practiced in 4 Swedish Centers: Stockholm (Karolinska), Uppsala, Lund and Gotteburg. There is a proposal on the table to limit care to two centers. As might be expected there is a lot of disagreement as to what to do. Johan is very interested in Vancouver, as his son just returned after living there for several months. The Scandinavians all have a very favorable view of Canada and Canadians. They perceive us to be more like them than Americans!

After lunch, Bjorn toured me through the wet labs in the clinical research facility, which occupies the top two floors of the clinical institute.

Then it was time for my presentations. I gave two talks, one on CAPSNet and the other on our work with fetal gene therapy in small animal models. The talks were well attended (15- 20 persons), particularly in view of the fact that it was the start of summer break, and many people (including Bjorn), were actually coming in during their holidays. After a good discussion, we finished up at about 4pm.

Bjorn and I walked back to my hotel (Bjorn is a big time walker, although he also has a 1250 cc BMW motorcycle!). He waited for me in the lobby while I changed, and then we walked from my hotel to the downtown harbor (a 30 minute brisk walk). We caught a small ferry from the harbor which took us to another island where our restaurant was located. Stockholm harbor is full of islands, literally hundreds which lead out into the Archipelago and into the Baltic sea. After a 30 minute ferry ride, we reached our destination island, where we had a wonderful outdoor supper on the waterfront. Joining us for dinner were Tina, Johan and Jan (who is the head of the clinical pediatric surgery division). The Department of Pediatric Surgery is divided in to a research/education group (headed by Bjorn), an administrative section headed by Johan (who is also the overall director) and Jan who is in charge of the clinical group. After a fantastic meal of Skargen (shrimp salad), cured salmon and coffees, Tina drove Bjorn and Jan and me back and dropped me at the hotel. What a fantastic day, and what great people are the Swedes!

Friday June 26th

Today was a free day. After a nice continental breakfast (a hallmark of all Scandinavian hotels), I caught the metro to city station, and then walked from the downtown core to the harbor where we had caught our ferry last night. I walked along the harbor and crossed a bridge to enter Djurgarden (formerly the Swedish King�s hunting ground in the 17th century), which houses a beautiful park with seawall (called Skansen�which is quite similar to Stanley Park in Vancouver). I also toured the Vasamuset (Vasa museum)which contains the fully restored warship, commissioned by King Gustav to be used to fight the Poles in the Baltic in 1628. Over the respectful protests of the royal marine architect, the ship was (over)built, according the King�s specifications. The ship sailed for 1200 m, before she listed, took on water and sank. She stayed on the bottom for over 300 years. She was discovered and raised in 1966, and due to the brackish (mixture of sea and fresh water) nature of the water in the Stockholm harbor, the wood was perfectly preserved and the restored ship is 95% original. I returned to my hotel, exercised had supper and packed in preparation for my early morning flight to Heathrow tomorrow, where I will meet my wife and daughters, who will join me for the 2nd (UK) week.

Saturday, June 26, 2009

Left Stockholm for London at about 8 am. I met my wife Heather and daughters Alexandra and Katherine who flew in from Vancouver in a flight that arrived about an hour after mine. We traveled to Oxford by bus, and checked into a tasteful Oxford hotel on High Street, the Old Bank. Everyone was tired but after a cup of tea and snacks, we were ready for a walk along High Street. After supper and an early night for my jet-lagged family, we got up the following morning for a walking tour of Oxford which included a number of the Oxford Colleges (including Christchurch and its cathedral) and cathedrals. We had supper again at the Old Bank.

Monday, June 28, 2009

On Monday morming, my host, Professor Paul Johnson picked me up at my hotel, and took me to the new Children�s Hospital in Headington. Until a couple of years ago, the Children�s Hospital was a unit within the original John Radcliffe Hospital but now, along with the Oxford Eye hospital it composes the recently completed west wing. The inpatient ward structure is a bit different from ours, with grouping of inpatients by age, rather than by surgical or medical designation. I spoke to the nurses on the Adolescent unit (which has medical and surgical patients), and although expertise maintenance is a challenge, the nurses enjoy the variety of looking after medical patients one day, and surgical patients the next. We also visited the clinics which are very similar to ours. Although each clinic room has a computer and electronic access to diagnostic services (laboratory and radiology), the hospital has yet to make a transition to a paperless medical record. After a tour of the units and tea, I met several of the other faculty including Mr Hugh Grant, Mr VT Joseph, Miss Rowena Hitchcock, and Miss Kokila Lakoo. Oxford has a geographic catchment population of about 4 million, similar to ours. The faculty has established areas of interest: MIS (Grant), urology, (Hitchcock), oncology (Lakoo). Paul has a significant commitment to research and the clinical islet transplant program, and so is a 50% clinical FTE. I visited the operating rooms, where pediatric surgery is allocated 2 rooms, one of which is an endosuite (Olympus). The department runs 4 slates per week, which is comparable to our room allocation at BCCH. I was surprised to learn that Oxford has only 6 full time pediatric anesthesiologists (we have about 20!). After joining Hugh Grant for a laparoscopic pyloromyotomy, I went over to the MIS skills lab with the MIS fellow who is a surgeon from Egypt spending time in research while he awaits a UK training spot in pediatric surgery. I took the laparoscopic skills test, a timed set of exercises (object transfer, cutting out a pattern, dissecting vessels and clipping them, and suturing with intra and extracorporeal knot tying) which is given to each trainee in pediatric surgery at least twice during their clinical rotation, and is used to validate clinical evaluations in the operating room. He politely said that I obviously have consultant-level laparoscopic skills�although I think he was quite desperate for a data point, and would have said anything to get it! After lunch with Paul and Kokila, I attended the Johnson lab meeting and heard presentations from the research faculty, which consisted of about 8 doctoral fellows, or research students. Paul has divided his pancreatic islet research enterprise into 3 arms: 1) maximizing donor islet yield; 2) optimizing islet allograft function and 3) pancreatic islet developmental biology, and has research faculty with projects in each area. A main thrust of his work is direct translational support of the clinical program. The islet procurement facility at Oxford is one of 2 in the UK, and has transplanted four of its own patients, but also procures whole pancreases and purifies islets for distribution to 6 hospitals in the UK who do human transplants. After listening to excellent talks from Paul�s research faculty, I gave a presentation on fetal gene therapy, which was well received by the audience and prompted a number of excellent questions from his research team. After the lab meeting wrapped up, Paul dropped me back at my hotel, and my wife and daughters and I took a cab to the Cherwell Boat House Restaurant on the bank of the Cherwell River. We had a lovely outdoor table in view of the �Punting Station� (punting is a form of boating in which a pole is used to propel the boat from the river bed), and shared a great meal with Paul, his wife Hillary and daughter Tilly, as well as Mr Grant, Miss Hitchcock and a locum surgeon from GOS.

Tuesday, June 30, 2009

The next morning, Paul picked me up and took me to meet with Dr Marian Knight (an obstetrician and epidemiologist by training, who heads the National Perinatal Epidemiology Unit which is Oxford based), and a few NPEU staff members. I presented our experience with CAPSNet also heard a presentation on the collaborative project recently established between the British Association of Paediatric Surgeons and the NPEU-called BAPS-CASS (congenital anomalies surveillance system). This collaborative began collecting data in 2006 on a different congenital anomaly each year (so far gastroschisis, esophageal atresia and congenital diaphragmatic hernia). Case ascertainment is made after birth, by a system of reporting cards sent out each month to all participating institutions. Reporting is done by surgeons and the dataset is quite limited compared to CAPSNet, however the return of data is fairly complete, and this registry is an excellent example of high impact data collection achieved by surgeons. Dissemination of information is by periodic reports issued by the NPEU. The data collected includes followup outcome data which we all agreed is essential to any birth defects registry or database. We exchanged databases, and agreed that we should look for opportunities to collaborate through a minimum common dataset.

After our meeting with the NPEU, Paul took me to the Oxford Centre for Diabetes, Metabolism and Endocrinology. This is a remarkable centre that integrates clinical care, clinical and translational research in one �3-sided� building. The building is architecturally designed to enable cross-fertilization and synergy between all 3 areas, as well as providing training and career opportunities in clinical medicine and research related to endocrinology and metabolic disease. This building also houses the Diabetes Research and Wellness Foundation (DRWF) Islet Isolation facility and Paul took me through the process of islet isolation from whole pancreas to islets ready for transplant. This is obviously a world class facility, islet transplant facility ideally located within a clinical and research excellence hub for diabetes care. It is no wonder that the Oxford group are among the leaders in the field of Islet transplantion.

Thus ended a marvelous 2 day visit to Oxford. I am very indebted to all of the surgical faculty, but especially to Paul Johnson, for making my visit so memorable.

Wednesday July 1, 2009 (Canada Day!)

My Oxford host, Paul Johnson had hired a private driver (Steve) whose clientele are almost exclusively Oxford professors! Steve toured us through London before dropping us off at our hotel located in Holborn, a few blocks from GOSH and the Institute of Child Health. The trip was not without considerable excitement, as we were stopped by London police officers for taking photographs (from the inside of an unmarked van with tinted windows) of the back of the prime ministers� residence. Unfortunately, none of us in the van saw the armed guards motion us to stop, which prompted a call ahead to an anti- terrorist squad who pulled the van over! The police were very nice, and explained that it wasn�t the fact that we took pictures, rather that we had not obeyed instructions to stop, which got us pulled over. Since the bombings of the London underground, security in London has been very tight, and the policeman explained that they go through this process 50-100 times per day! After a 30 minute stop, we were finally allowed to continue on to our hotel. Needless to say, we did not take many more pictures that day!

Thursday, July 2nd, 2009

The following morning I went to GOSH and joined Mr Paolo De Coppi and Mr David Drake and the entire pediatric surgical team for morning rounds in the NICU. Unfortunately, due to a family emergency, my host Professor Agostino Pierro would be unable to join us during my 2 day visit. Also, Mr Ed Kiely, an internationally renowned pediatric surgeon with expertise in surgical oncology and minimally invasive surgery was away. We reviewed 2 patients with long gap EA and discussed options for treatment. Professor Spitz has had a strong influence with his preference for gastric pull-ups. We also discussed gastroesophageal reflux, and the significant difference in approach between GOSH and my hospital. While we do about 5 Nissen fundoplications per year (almost all laparoscopically), at GOS they do 1-2 laparoscopic Nissens per week! The numbers of cases reflect disease specific referrals by pediatricians, rather than local referrals which likely accounts for the very high number. This is unique feature of GOS compared to pediatric surgical practice in Canada, where we have essentially no competition for cases from within each province (except in Ontario and Quebec). Because there are 6 pediatric centres in London alone, home postal code has little to do with where a child will have surgery in London. GOS does not have an emergency department, so treats very few children with appendicitis. All hepatobiliary cases (biliary atresia and hepatoblastoma) are treated at King�s College. However neuroblastoma cases come from all over London (in fact all over Europe!) to be treated by Mr Ed Kiely. A large number of cases are redo surgeries for conditions like HD and imperforate anus. I then joined the 2 senior registrars in pediatric surgery and the remainder of the clinical house officers for a discussion of several cases which they had prepared and presented to me, including NEC, Hirschsprung�s disease (the only pull through done at GOSH is the Duhamel) and neuroblastoma. After this meeting, I was taken to lunch by Paolo and Simon Eaton. Simon is a biochemist by training, and plays a major administrative role in the pediatric surgery research lab at the University College of London (UCL) Institute of Child Health, which is basically the research facility attached to GOSH. Simon not only oversee most of the translational NEC research, he also runs the clinical trials unit in the Department. He is an excellent example of the research synergy created when a basic scientist is imbedded within a clinical department, and he moves effortlessly between the clinical and research domains. In fact to meet him and talk to him, you would not know that he is not a practicing surgeon!

After lunch, I gave a talk on fetal gene therapy to Mr De Coppi, Dr Eaton and Mr Drake and the entire pediatric research team which consists of 10 trainees (basic science and clinical) who also gave brief presentations of their research. The scope of research in the Pediatric Surgery Department is in two realms: clinical trials and basic science. We heard discussion of several active or planned clinical trials including the currently recruiting lap versus inguinal hernia repair which allows repair of the contralateral side laparoscopically and seeks to answer the question what is the incidence of metachronous contralateral hernia repair after unilateral repair through the groin. Another trial randomizes patients requiring a G-tube to either G-tube alone or G-tube plus fundoplication, while a 3rd trial will look at resection and anastomosis versus stoma for babies >100 g with NEC requiring surgery. I was extremely impressed by the group�s breadth of focus on trials. The basic science focus is in two main areas with the use of amniotic stem cells as a paradigm for tissue replacement therapy with (eg a neodiaphragm in CDH, and an neo-segmental esophagus in long gap EA), and the use of stem cells (or at least cell free media from amniotic stem cells in culture) as a novel experimental therapy for NEC. We had an excellent discussion of all of the research fellows� presentations, which were of uniformly high quality.

The following morning I returned for neonatal ward rounds. On these daily rounds with the NICU staff, surgical patients in the NICU are discussed. I also met Mr Joe Currie who serves as the registrar training director for GOS, and also sits on a committee that regionally allocates registrars for pediatric surgical training throughout the southwest region of the UK. This region includes 10 centres (6 in London, 4 outside London) that are involved in the training of pediatric surgery registrars. Postgraduate surgical training in the UK consists of 2-3 years as a surgical house officer, followed by 6 years of dedicated pediatric surgical training at one of the region training hospitals. It is the norm for a UK pediatric surgical trainee to rotate through several Children�s hospitals the 6 years, which is a contrast to North American training, where one receives their general surgical and the pediatric surgical training within single centres. Registrars in the UK have imposed work hour restrictions. A resident cannot work more than 48 hours per week and not more than 18 consecutively. Work hour restrictions for consultants throughout the EU countries are about to go into effect within the next few months however individual surgeons can �opt out�, and it appears that many/most will.

I had a tour of the operating theaters at GOSH. Unfortunately, none of the surgeons had operative lists during my visit, but I did see the OR facilities, which seemed comparable to our own. One nice feature are the induction rooms which adjoin each operating room, which leads to improved efficiency of OR utilization. I was also reminded by surgeons and OR nurses that we had recruited away a couple of the highly valued �theater sisters� to our hospital.

I had lunch with Mr Drake at the Memorial Garden, a small outdoor cafeteria on the top floor of the hospital which memorializes two hospital employees killed in the subway bombings. Mr Drake is the current president of the British Association of Paediatrics Surgeons. He told me that BAPS has conducted a couple of national audits and has found that the incidence of intussusceptions and pyloric stenosis have decreased substantially over the past 20 years. He also spoke fondly of his surgical experiences in Canada. He came to Vancouver as a medical student, and then a few years later, after completion of general surgical training, to northern Manitoba as a locum general surgeon. After lunch, I again met with the GOS surgical faculty and trainees to give my two final talks on CAPSNet and a presentation on behalf of the Surgical Chiefs of Canada on The Canadian Pediatric Surgical Wait Times Project. There was much discussion after both presentations. The UK has a single wait time of 18 months for all children from decision to operate to operation (for all conditions except cancer) which is closely monitored by the NHS. The surgeons all agree that this system is arbitrary and has been established without input from clinicians. They were impressed by the CPSWT project, and felt that our systematic approach which has used data and expert pediatric surgical opinion to establish wait time benchmarks which are condition-specific, was far more sensible. After the research presentations, Mr De Coppi and Dr Eaton, made a pitch for BCCH participation in a proposed multi-centre clinical trial comparing resection and stoma vs primary anastomosis for perforated NEC. I will take the details of the trial back to Vancouver with me and discuss participation with my group. The opportunity to participate in clinical trials is an important one, and I hope that we may one day design our own clinical trials within Canada using the framework established by CAPSNet. I wrapped up my visit of GOSH with a quick stop at �The Lamb�, a famous pub across the street from the hospital that had come highly recommended by Graham Fraser, a retired pediatric surgeon from BC Children�s Hospital, and one of GOSH more (most?) famous surgical alumni!

While I was visiting GOSH, my wife and daughters had spent the days sightseeing and shopping (an expensive activity in London, and one from which I won�t easily recover!). We went out for a nice supper in the theater district, and then saw the Lion King in the Lyceum Theater. What a wonderful show that was! The following morning, we caught a cab to Heathrow (this time uneventful!) and then arrived in Vancouver after a quick (1 � hour, time change included) flight home.

May 17, 2010: Tokyo, Japan

Arrived at Narita airport at 4pm Sunday after a 10.5 h flight from Vancouver. Caught a shuttle to my hotel and after a shower and bite to eat, was ready for bed.

This morning I was picked up by one of the pediatric surgery trainees and taken to the hospital for surgical rounds. There I met Atsuyuki Yamataka (who goes by �Yama�), Professor and Head of the Department of Pediatric General and Urogenital Surgery, and some other members of his faculty; Tadaharu Okazaki Associate professor, Assistant professors Yoshifumi Kato, Akihiro Shimotakahara and a number of the junior doctors. The Japanese system of training in pediatric surgery is arduous�it can take up to 15 years to obtain the highest level of certification, and many never do achieve that level. After listening to the clinical review of patients and the week�s OR assignments (in Japanese), I gave a talk on the Canadian Pediatric Surgery network. After rounds, I was given a hospital tour by Assistant professor Hiroyuki Koga and Junior surgeon Nana Tanaka. We toured the pediatric ward and saw a number of patients with anorectal malformations and Hirschsprung�s disease. The Japanese have a much higher rate of biliary pathology (choledochal cyst and biliary atresia), and Yama is one of the very few surgeons in the world who has successfully performed a Kasai procedure for biliary atresia laparoscopically. I was surprised to see that many of the patients� medications and IV solutions are prepared right on the ward by nurses and in some cases the junior medical staff. This is in contrast to our hospital where almost every medication and IV comes prepared from our central pharmacy. My hosts told me that this was part of a longstanding practice targeting cost-reduction, and I wondered aloud if it might also represent an error reduction strategy, since it represents one less �hand off� of a clinical task. Juntendo uses an electronic medical record both on the ward and in the OR (anesthetic charting), which is an advance we�ve yet to make completely in Vancouver. After coffee, I joined Yama in the OR where he was performing correction of a penoscrotal hypospadias. Like their UK counterparts, pediatric general surgeons in Japan do all of the pediatric urology. In North America, pediatric urology is a subspecialty of adult urology, and therefore is distinct from pediatric general surgery. This particular operation requires meticulous attention to detail, and watching Yama you quickly realize that he is a highly skilled surgeon. I then dropped into the other pediatric surgical OR where Dr Kato was doing a reoperative resection of a neuroblastoma in the posterior mediastinum. The pediatric surgical rooms, like the ward are distinct within the general hospital, and have dedicated staffing with nursing and pediatric anesthesia.

Next, I was taken on a tour of the research facility where faculty are involved in both clinical and translational research. The department operates a weekly pig lab for laparoscopic training of residents. Surgical education in Japan is long and not everyone reaches the highest level of certification. There is a tendency for residents and junior faculty to work in other hospitals (ie �moonlighting�) to supplement their incomes. Only the most senior faculty have dedicated practices at Juntendo. There is little cross- fertilization of trainees with other institutions. The tendency is that trainees remain at the institution in which they were trained, whereas in North America, I think we encourage residents to move around a bit more.

May 18 was a free day that I used to explore Tokyo a little. I was picked up at the hotel by a tour bus that took us on a half day tour with stops at the Tokyo tower, the Imperial gardens and the old shopping center of Tokyo and home to the oldest temples in Tokyo, Asakusa. I took the train home and after a workout and shower, Koga picked me up and we met Yama and 2 other faculty members at a tempura restaurant for another delicious supper.

After my hospital tour, we went out for lunch to a lovely restaurant in Ginza. Then back to my hotel for a rest and shower and out for a sushi supper.

The next morning, May 19, I took a taxi to the National Center for Child Health and Development which is located in the southwest corner of Tokyo. There I was met by Dr Yoshi Kitano, who along with Dr Tatsua Kuroda heads the Pediatric Surgery group (5 surgeons) at NCCHD. This is the newest children�s hospital in Tokyo, built in 2002 by the government, to serve as one of only 5 specialized high risk maternal /pediatric subspecialty hospitals in Japan. NCCHD is one of the largest children�s hospital in Japan, and the only one in Tokyo with an adjacent high risk obstetrical unit/fetal diagnostic and treatment unit.

There are no low risk maternal deliveries at NCCHD, and approximately 1700 deliveries for high risk maternal conditions or fetal anomalies. Our first stop was the NICU, which I toured with Yoshi and the head of neonatology. We discussed management of CDH. Yoshi has great interest and expertise in antenatally diagnosed CDH, having spent 3 years at CHOP in the mid-90s as a fetal treatment fellow under Scott Adzick. In his MFM unit, all prenatally diagnosed fetuses with CDH undergo MRI scans. They are delivered at term, usually by induced vaginal delivery (obstetricians start inductions in the middle of the night so that the deliveries are more likely to occur during the day. All babies are resuscitated with high frequency oscillatoy ventilation and nitric oxide. Surgery is usually delayed 2 or 3 days (we wait twice as long in Canada), unless postnatal echocardiogram suggests that the pulmonary arteries are unusually small, in which case they operate earlier. The outcomes for CDH at NCCHD are excellent, approximately 80% survival, which is remarkable when one considers that all cases are prenatally diagnosed, which itself is a predictor of increased mortality. We visited the surgical ward, which contains surgical patients from all specialties. Similar to our experience in Canada, surgical nurses at NCCHD must maintain a broad range of skills, since they must be able to look after a broad range of cases. The older surgical patients (adolescents) are cared for together with medical patients on a separate ward. I was very impressed by the electronic medical record system and PACS system (radiology) that the hospital has. Yoshi says that although the hospital is now paperless, he finds that it takes more time to chart, and the system has some significant deficiencies (for example, one cannot insert an illustrative diagram in an operative report).

Next Yoshi took me to meet Professor Hiro Sakai, who is the only fully trained pediatric intensivist in Japan (trained at Hospital for Sick Children, in the late 80s), and currently the Director of Interdisciplinary Medicine at NCCHD, with oversight for postgraduate education at NCCHD. We discussed a number of topics, including ethical decision making in pediatric surgery and challenges facing our respective countries in pediatric education (Dr Sakai is especially interested in pediatric resuscitation scenario simulators). Then we had a lovely lunch in the rooftop cafeteria at NCCHD.

After lunch it was time for rounds. Yoshi had arranged a special rounds attended by 4 of the 5 faculty members and all of the residents. The residents took turns presenting cases to me in English, and we had an excellent discussion of some very complex cases, including 3 children with intestinal dysmotility syndromes, a case of long gap esophageal atresia, and a long segment Hirschsprung�s disease. I did learn of some differences in approach between our respective hospitals: for example at NCCHD they wait approximately 6 weeks (enabled by rectal irrigations performed by the parents) before doing pullthroughs (Soave transanal) for short segment Hirschsprung�s disease, while although we use the same surgical approach, we tend to operate in the newborn period. We also discussed management of long gap esophageal atresia. Yoshi and his faculty discussed their experience with the Kimura lengthening procedure, and I reviewed my own experience with the Foker technique and reversed gastric tube esophageal replacement. After these rounds, I was taken on a tour of the NCCHD Research Institute (linked to the hospital by a sky bridge) by Dr Akihiro Fujino. Aki has been in practice at NCCHD for 3 years, having spent 3 years doing research in the Pediatric Surgical research laboratory of Dr Patricia Donahoe in Boston. Aki�s current translation research interest is in developing an innovative treatment for lymphangioma, and he has been successful in establishing a tissue culture system for human lymphangioma cells, and has characterized some of the cellular differences (surface receptors, extracellular matrix) between lymphangioma cells and normal lymphatic endothelium in cell culture. He also has developed a very interesting animal model of human lymphangioma cells injected into the subcutaneous tissues of mice where they form cystic structures. Aki has been successful in obtaining grant funding and hopes to renew his funding with his experimental work to date along with a multicentre survey of clinical experience with lymphangioma at several of the larger Japanese centres. The latter will hopefully justify renewal of his funding as evidence of the magnitude of the clinical problem which could clearly benefit from a new treatment approach. I thoroughly enjoyed this tour, and am very certain that Aki�s research will significantly change the way we approach lymphangioma in the not so distant future.

At 6 pm, I gave grand rounds on CAPSNet, and was very grateful that faculty and residents were willing to stay until such a late hour to hear me. Dr Kuroda presented me with a certificate, signed by the Dean of the NCCHD, acknowledging my lecture and visit to NCCHD. Finally, Yoshi and I took a taxi to the nearby Shibuya district where Yoshi treated me to a wonderful Udon noodle supper.

On Thursday, May 20, I left Tokyo via Shinkansen train, which I caught from Tokyo station. The train trip from Tokyo to Kobe takes about 3 hours. From the Kobe Shinkansen station, I took a bus to the Portopia hotel where I would stay for the rest of my Japan trip.

As we had arranged in advance, I met my host, Professor Eiji Nishijima, Head of Pediatric Surgery at Kobe University and Kobe Children�s Hospital. Eiji and I had not met before, but I spotted him immediately, as he was holding a copy of a textbook that I had co-wrote a few years ago. Eiji is a very friendly and humble pediatric surgeon who is recognized as an international expert in tracheal reconstructive surgery. He drove me to Kobe Children�s hospital, the only free standing Children�s hospital in the Hyogo prefecturate, which is directly affiliated with Kobe University. Eiji runs a department with 5 faculty surgeons, and is the Director of Surgery- a position which is equivalent to our �Surgeon in Chief� in North America. Eiji introduced me to Professor Takeshi Maruo who is the former Head of the Dept of Obstetrics and Gynecology at Kobe University, and is now Vice-President of Kobe Children�s Hospital. Maruo is very engaging and had many stories of his past trips to Vancouver, where he knows a number of our UBC faculty obstetricians. Eiji, Maruo and I discussed a number of topics including resources and access to care. I was surprised to hear that at Kobe Children�s hospital, children wait on average 6 months for hernia surgery. We discovered that in addition to surgical wait times, Japanese health care faces similar resource constraints to what we experience in Canada, however their solutions are much more practical than ours. I explained that we frequently cancel operations when it looks like our slate will run overtime. The reason is lack of nursing staff beyond a certain time�usually 330 pm. In Japan, they experience the same phenomenon, but never have to cancel a case, because all they do is get another surgeon to stay and act as a scrub nurse! Although I thought this was an ingenious solution, I felt it was likely one that our powerful nursing unions in Canada would not accept! The pediatric surgical group does a total of about 1200 cases per year, of which about 200 are day surgery cases. For day surgery they maintain a separate OR from the inpatient OR which has a very rapid case turnover (10 min). Although the OR runs from only 9am-1pm, the general surgeons can usually get 6-7 hernias done during that time. Otherwise, the pediatric surgery service gets 4 OR blocks per week which fun from 9am to 5pm. Similar to NCCHD in Tokyo, the obstetrical unit at Kobe deals only with high risk pregnancy or prenatal diagnosis, and low risk pregnancy is managed elsewhere in one of several general hospitals in Kobe, by either obstetricians or midwives. After green tea and an interesting comparative discussion of pediatric surgery and obstetrics in Vancouver and Kobe, it was time for lunch. Maruo insisted on taking us for lunch to a nearby restaurant, where we enjoyed pasta, pizza and Kyoto vegetables on a lovely outdoor patio with a view of mountains to the left (north) and the ocean to the right.

After lunch, we went back to the hospital and said goodbye to Maruo, but not before listening to Ave Maria for strength and inspiration to carry us through the afternoon! Eiji took me on a hospital tour. We visited the surgical ward, which cares for all types of surgical patients. Each room is quite small, and without space for a parent to stay overnight with their child. Kobe Children�s is in the process of transitioning to a paperless hospital�Although they use electronic order entry and a PACS system, like us, they maintain paper charts. We next went to the PICU where Eiji maintains a tracheal surgery unit of about 8 beds. Professor Nishijima has the largest experience in Japan with slide tracheoplasty for congenital tracheal stenosis, and has done more than 60 slide tracheoplasties in the past 15 years. Kobe Children�s is a referral centre within Japan for this rare condition, and Eiji gets 5-10 new referrals per year. His results of a 90% survival rate with approximately a third of patients requiring a long term tracheostomy are among the best published anywhere, and Eiji attributes a lot of his success to establishing a tracheal surgery team of surgeons, anesthesiologists and specialized ICU nurses. Currently he has 18 certified ICU nurses on the tracheoplasty team. He presented two tracheoplasty patients who are currently recovering in the ICU, and discussed some of his recent technical refinements, including routine use of aortopexy, with tracheal suspension sutures placed between that back of the aorta and the front of the repaired trachea to combat tracheomalacia which is a significant problem in patients following slide tracheoplasty.

Next we went to the operating room where a child was having an anesthetic for lymph node biopsy and CVL placement for presumed lymphoma. The general surgeons at Kobe Children�s now place most of their tunneled central lines using ultrasound guidance in the OR, and are getting away from performing surgical cut downs; a direction we are moving in as well. I also visited the day surgery operating room, and Eiji showed me the small room where parents may sit to view their child�s surgery, which is simultaneously broadcast from an in light OR camera. I was amazed that such a practice would exist in a country where legal action against surgeons occurs more commonly than in Canada (although much less frequently than in the US), where we do not allow families to watch their child�s surgery, in spite of fairly frequent requests.

By 4pm it was time for a research symposium that Eiji had arranged to coincide with my visit. It was well attended (35 attendees, including two pediatric surgeons who work at another hospital in the prefecture, one of whom, Dr Azusa Zaima, I had met at last year�s CAPS meeting in Halifax), and I led off with a presentation of the Canadian Pediatric Surgery Network. The audience was attentive and I was very grateful to Eiji, who kindly translated key points of my presentation into Japanese. Next, Dr Akiko Yokoi, who is the division head for pediatric general surgery, presented a large series of tracheal stenosis patients with associated cardiovascular anomalies and suggested an algorithmic approach to the patient with tracheal stenosis and an associated cardiovascular anomaly. Finally, at Professor Nishijima�s request, I presented some of the recent work we have done in our small animal model of fetal gene therapy using non-viral vector (modified chitosan). After a stimulating 2 hour meeting with good discussion (almost all in english!), it was time for supper. Professor Nishijima had arranged for the entire pediatric surgery department to host me for a delicious meal of Korean-style barbecue at a local restaurant. This was my first chance to taste Kobe beef (in Kobe, naturally!), and it was delicious. What impressed me even more than the beef however, was the fact that Professor Nishijima makes a point of spending an evening outside of the hospital with his entire surgical team which ranges from some very junior residents just out of medical school to Dr Yokoi, his most senior faculty member, at least once per month. We led off the supper with a self-introduction (in english) by each person, in which we stated our name and the year we graduated from medical school. Professor Nishijima has a strong philosophical conviction that regularly sharing a meal together outside the hospital makes his team function more cohesively in the hospital in the care of patients, and I am sure that he is correct. This was a wonderful meal spent with great friends, and was definitely the highlight among many great experiences of my day at Kobe Children�s Hospital.