Report to James IV Society of Surgeons

Professor David Watson

December 9, 2006 to January 23, 2007

The James IV Travelling Fellowship provided a unique opportunity (and excuse!) to take 6 weeks out of my usual clinical and academic practice, to spend time with surgeons in Europe and North America, to see their approaches to disease management first hand, and understand other approaches to the surgical management of Upper GI disease, to interact and share research and clinical ideas, and to develop links between my Department at Flinders University in South Australia, and the centres visited during the period of travel.

• Department of Surgery, Ben Gurion University of the Negev, Beer Sheva Israel
• Department of Surgery, Paracelsus Private Medical University, Salzburg, Austria
Department of Surgery, Royal Victoria Infirmary, Newcastle-on-Tyne, UK
• Department of Surgery, Royal Hallamshire Hospital, Sheffield, UK
• Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA

1. Enhance links with leading oesophago-gastric surgery units in Austria, UK and USA
2. Gain a better understanding of alternative clinical and surgical treatment strategies for the management of oesophageal and gastric cancer
3. Enhance collaborative research opportunities in oesophageal cancer and endoscopic management of gastro-oesophageal reflux

Dec 9-10 - Adelaide to Vienna, Austria
Dec 11-13 - Vienna, Austria
Dec 13-15-Israel
Dec 16 - Israel to Salzburg
Dec 17-23 Salzburg, Austria
Dec 24 - Salzburg to London
Dec 25 - 26 - London
Dec 27 - Jan 4 - Newcastle, UK
Jan 5 - 7 - Sheffield, UK
Jan 8 - 9 - Manchester, UK to Portland, USA
Jan 10 - 17 - Portland, Oregon, USA
Jan 18 - 20 - San Francisco, USA
Jan 21 - 23 - San Francisco to Adelaide

Israel

As I was already in Europe, the James IV Travelling Fellowship (which funded my travel to Austria) provided a convenient opportunity for a short side-trip to Israel to visit Dr Avi Shapira, a trauma and gastrointestinal surgeon from Ben Gurion University of the Negev, Beer Sheva Israel, and Medigus Ltd, a small company also based in Beer Sheva. I have been collaborating with this group for 3 years, to progress the development of a new technique for endoscopic anterior partial fundoplication. Initial clinical trials have commenced in my unit at Flinders Medical Centre in South Australia. The short visit (2 days) provided an opportunity to meet with Dr Shapira and his colleagues, to progress instrument design modification, and to plan for a larger clinical trial which will be conducted in collaboration with other surgical units in Europe, UK and USA

Salzburg, Austria

I spent over a week in the Department of Surgery, at the Paracelsus Private Medical University, in Salzburg, Austria. During this time I was a guest of Professor Hubert Stein and his Department. Professor Stein previously worked with Professor Ruediger Siewert in Munich, and he moved to Salzburg approximately 2 years ago, to head the Department of Surgery in Salzburg. Professor Stein's clinical interests align closely with my interests - oesophageal and gastric cancer, Barrett's oesophagus and surgery for gastro-oesophageal reflux. He heads a large department which now undertakes a significant volume of clinical work relevant to this area. His department also undertakes clinical research relevant to these diseases. During my time in Salzburg, I had the opportunity to participate in all of the clinical activities - wards rounds, operating lists, and clinical meetings. Highlights were the opportunity to scrub in and assist with en bloc oesophagectomy and D2 gastrectomy procedures. These are procedures which are not routinely performed in Australia, and it was valuable to see the surgical techniques applied in this Department. Recently, Australian oesophageal surgeons have been invited to participate in randomised trials run by the Medical Research Council (MRC) of the UK. A requirement of the protocol for these trials is that surgeons must adhere to a defined en bloc oesophagectomy technique. Hence, the opportunity to see first hand the particular techniques applied in Salzburg provided a valuable opportunity to consider aspects relevant to standardisation of surgical technique for these and future trials in Australia.

An additional, but significant opportunity was provided by participating in the multi- disciplinary team meeting (MDT) which was held in Salzburg, with participation from surgeons, medical oncologists, radiotherapists, pathologists and radiologists. MDT's have been largely run on an ad hoc basis in many Australian institutions (including mine), and this provided an opportunity to better appreciate both the value of these meetings and the organization required to coordinate this approach to the management of oesophageal and gastric cancer. In Salzburg I had opportunities for considerable informal interaction with Professor Stein, other consultant staff in his department, and surgical trainees. During the visit I delivered a lecture to the Department of Surgery's "grand round" entitled; "Evidence based anti-reflux surgery". As Professor Stein is also collaborating with the development of the endoscopic fundoplication device developed in Israel, I also had an excellent opportunity to discuss plans for clinical trials in endoscopic fundoplication.

Newcastle, UK

I spent over a week in the Department of Surgery, at the Royal Victoria Infirmary, in Newcastle, UK. Here I was a guest of Professor Michael Griffin and his Department. Professor Griffin's interests are oesophageal and gastric cancer. He heads the Northern Oesophago-gastric Unit, which is one of the largest units in the UK which specialises in Upper GI cancer, and his department undertakes clinical research which is relevant to this area.

My time in Newcastle provided a further opportunity to spend time in one of the UK's leading units for the management of oesophageal and gastric cancer. In particular, Professor Griffin has been one of the leading protagonists for centralisation of the management of oesophageal and gastric cancer into specialist units in the UK. It is likely that the management of these diseases in Australia will head in this direction. For this reason I was keen to see and understand how this unit organises its work. I had the opportunity to spend time with the surgeons, trainees and nurse practitioners working on this unit, as well as spend time in the operating theatre for surgery for oesophageal and gastric cancer. I also had the opportunity to participate in all the other clinical activities - wards rounds, and clinical meetings. As with my time in Salzburg, I was able to scrub in and assist with en bloc oesophagectomy and D2 gastrectomy procedures. This also provided an opportunity to consider and progress ideas for the standardisation of surgical techniques for collaborative clinical trials between Australia and the UK.

In addition, I was able to spend time in the endoscopy unit when patients were undergoing endoscopic ultrasound staging of gastric and oesophageal cancers. My unit is the only unit in Australia in which endoscopic ultrasound is performed by surgeons, and the Newcastle visit provided an opportunity compare and consolidate techniques in a similar environment.

I also had the opportunity to participate in the multi-disciplinary team meeting (MDT) which was held in Newcastle. The Newcastle approach to this is a potential model for the process which I would like to introduce into my own institution. I had the opportunity for considerable informal interaction with Professor Griffin, other consultant staff in his department, senior surgical trainees (2 who are spending time in Australia in 2007/8), and research fellows. The opportunity to spend a significant amount of time with the oesophageal nurse practitioners and to understand their role was particularly valuable as my unit is in the process of setting up a similar role. The Newcastle experience has provided a template to develop this further.

During the visit I delivered a lecture to the Department of Surgery's weekly meeting entitled; "Fundoplication without incisions?". I also participated in a research forum, during which the research fellows presented updates on their current research projects.

Sheffield, UK

Following Newcastle, I had 2 working days with Dr Roger Ackroyd, in the Department of Surgery at the Royal Hallamshire Hospital, Sheffield, UK. I previously worked in this department in 1993, and this was an opportunity to cement ongoing links between Sheffield and my Department in Adelaide, and to progress several collaborative clinical trials in the areas of Barrett's oesophagus ablation, oesophageal cancer surgery and laparoscopic fundoplication. I spent one day in the public hospital, meeting with various staff and one in a nearby private hospital. During the day at the public hospital, I again assisted in an oesophagectomy. At the private hospital, I had the opportunity to view laparoscopic bariatric surgery, in particular laparoscopic gastric bypass. The latter is a procedure we have been undertaking in Adelaide, although until recently we have had limited opportunities to compare surgical techniques with other surgeons. This day has provided many useful insights which should improve the surgical techniques applied on my unit in Adelaide.

Portland, Oregon, USA

After a 36 hour delay, and rescheduled flights, due to the original scheduled flight from Manchester to the USA not departing I arrived in Portland, Oregon! Here I spent time in the Department of Surgery, at the Oregon Health Sciences University Hospital as a guest of Professor John Hunter, Associate Professor Blair Jobe and other members of the Department of Surgery. This Department's interests are oesophageal and gastric cancer, laparoscopic techniques for benign oesophageal disease, and biomarkers for oesophageal and gastric cancer. Professor Hunter is one of the leading academic Upper GI and laparoscopic surgeons in the USA. His interests in anti-reflux surgery and laparoscopic hiatus hernia surgery complement the interests of my department, and the opportunity to engage with members of his Department on an informal basis was very productive. In addition, this visit provided an opportunity to see how an academic institution in the USA organises clinical care, as there are considerable differences between Australia and USA at this level, due to different funding models and regulatory environments.

I spent time with the surgeons, trainees, and medical students working on Professor Hunter's unit, and I was able to spend time in the operating theatre for surgery for oesophageal cancer and gastro-oesophageal reflux. Professor Hunter's unit, like mine, is undertaking laparoscopic oesophagectomy. Hence, the interchange of ideas during the operative cases was valuable. I also participated in other clinical activities such as wards rounds, and clinical meetings. In my "spare time", I wrote an editorial (at Professor Hunter's request) for the World Journal of Surgery. Professor Hunter is the Editor-in-Chief of this journal.

During the visit I led a 60 minute interactive session at the weekly combined meeting between the Departments of Surgery and Gastroenterology. This entailed the presentation of 2 difficult cases of oesophageal surgical disease, during which there were opportunities for a lively and interactive discussion.

Summary

The James IV travelling fellowship provided an excellent opportunity to explore how surgeons in different parts of the world manage oesophageal and gastric cancer - at least one oesophagectomy was undertaken in every centre I visited. This has allowed me to consolidate ideas which will aid the reorganisation of oesophageal and gastric cancer services in my hospital and region. Additional opportunities were provided by time spent in the endoscopic ultrasound unit in Newcastle, and with laparoscopic gastric bypass procedures in Sheffield.

The links made and consolidated in Salzburg, Newcastle, Sheffield, Portland and Israel have consolidated and developed relationships which should lead to collaborative endeavours in the areas of surgical and endoscopic treatment of gastro- oesophageal reflux and oesophageal cancer trials. I also expected that these links will facilitate the interchange of trainees between my hospital and the centres in the UK and USA.

Social aspects

I travelled with my family (wife and 3 children - aged 17, 15, and 7). This made a 6 1/2 week period of travel possible. I would certainly recommend taking the family to any future travellers. In Austria, Sheffield and Portland this provided opportunities for interaction with the families of my hosts, and it provided a unique experience for my family, and provided opportunities to develop what I hope will be long lasting friendships. Whilst I was in the UK, my wife and children took the opportunity to visit relatives in Dublin, Ireland, whilst I spent time in Newcastle. Travelling with my family for the extended period of time added great value to the opportunity provided by the Fellowship.

Final thoughts

The James IV Travelling Fellowship provided a unique opportunity for travel, and to take part in the day to day activities of leading surgical units in England, USA and Austria. I was overwhelmed by the hospitality shown to me, and to my family in all the places we visited, and I greatly appreciate the opportunity given to me by the James IV Association of Surgeons, in awarding this Fellowship to me.