James IV Traveling Fellowship Report 2007

Prof. Ronnie T.P. Poon

Department of Surgery
The University of Hong Kong
Queen Mary Hospital
102 Pokfulam Road
Hong Kong
China

E-mail: [email protected]

Part A � United States and Canada

My James IV Traveling Fellowship was divided into 2 blocks, the first block in the United States and Canada in April-May 2007, and the second block in Europe in December 2007.

American Surgical Association Meeting, Colorado Springs, Colorado, USA April 25-28, 2007

I started my James IV traveling on 25th April 2007 flying from Hong Kong via Los Angeles to Colorado Springs to attend the 127th Annual Scientific Meeting of the American Surgical Association, which is the most prestigious surgical association in the USA. The meeting was held at a historical hotel in Colorado Springs, the Broadmoor. In the opening of the meeting on 26th April, 2007, I was introduced as one of the international guests of the meeting. The Scientific Session started after a Presidential Address by the new President of the Association, Prof. Jay Grosfeld. I presented a paper entitled �External Drainage of Pancreatic Duct with a Stent to Reduce Leakage Rate of Pancreaticojejunostomy after Pancreaticoduodenectomy: A Prospective Randomized Trial� in the meeting. Our randomized controlled trial showed that the use of an external pancreatic duct stent across the pancreaticojejunostomy significantly reduced pancreatic leakage rate after pancreaticoduodenectomy. Prof. Keith Lillemoe from Indiana University was invited to discuss the paper, followed by questions from other well-known heaptobiliary and pancreatic surgeons including Prof. Steven Strasberg from Washington University School of Medicine at St Louis and Prof. William Traverso from University of Washington at Seattle. The discussion in the meeting was of very high scientific standard, with well constructed comments and questions from the discussants. The high-quality papers in different specialties of surgery presented in the meeting provided a chance for me to keep updated of development in the broader aspects of general surgery.

The day ended with a dinner with Prof. John Wong, Prof. Keith Lillemoe and Mrs. Lillemoe, Prof. Frank Spencer (a past President of American Surgical Association), Prof. Ronald Fairman of University of Pennsylvania at Philadelphia and Prof. James May of University of Sydney in an elegant restaurant in the Broadmoor.

On April 27, I attended another day of scientific paper presentations. In addition to the scientific papers, there was an interesting Forum Discussion on the shortage of surgical manpower and problems of training of surgical residents in the USA, which in many ways are similar to the problems we face in Hong Kong. In the evening, I attended the Annual Reception and Dinner of the American Surgical Association. On April 28, I attended the last section of scientific papers, including one paper from University of California at Los Angeles on expansion of criteria for liver transplantation for hepatocellular carcinoma, which is my area of research interest. The meeting closed at noon and I flew to San Francisco in the afternoon to start my visit to Stanford University. On the way to airport, I met Dr. Anton Bilchik, Director of Gastrointestinal Oncology of the John Wayne Cancer Institute. We had common interest in ablative therapy of liver cancer and we discussed our research projects in this area.

Stanford University, San Francisco, April 29 � May 3, 2007 (Hosts: Prof. Thomas Krummel, Prof. Jeffry Norton and Prof. Samuel So)

Since there were no academic activities on Sunday, I took half a day touring around the main campus of Stanford University, visiting some of the historical buildings of the world-renowned University and a fine art museum. This provided a break for me after three intense days of scientific sessions in the American Surgical Association meeting. The day finished with a dinner with Prof. Jeffry Norton, Chief of General Surgery of Stanford University and a member of the James IV Association of Surgeons. Prof. Norton gave me a good idea of the history and recent development of Department of Surgery of Stanford University.

In the early morning of April 30, 2007, Prof. Norton picked me up from the hotel to attend the surgical morbidity and mortality meeting. This was followed by case presentations by residents. I also had a chance to understand the resident training program in Stanford University. Then the chief resident, Dr. Russel Woo, took me for a short tour of the Medical Center site. Dr. John Morten, Director of Minimally Invasive GI Surgery, took me for a lunch in hospital cafeteria and we exchanged ideas about outcome research and also the implication of hepatosteatosis on hepatocarcinogenesis, a topic of common interest to us. In the afternoon, I went to the operating room to observe a case of laparoscopic gastric bypass surgery for obesity by Dr. Morten. I do not perform such operation in my practice but it was impressive to observe how Dr. Morten performed laparoscopic surgery in morbidly obese patients. I also observed Prof. Norton performing a Whipple�s operation on a patient with a large pancreatic head neuroendocrine tumor requiring resection of a long segment of superior mesenteric vein and reconstruction using superficial femoral vein. I ended my day in the hospital by meeting Dr. Ronald Dalman, Director of Vascular Surgery, who had visited our Department as a speaker in the Surgical Forum last year. He briefed me on his vascular program and research activity. At night, I had a sushi and sashimi dinner with Prof. Sam So, Director of Asian Liver Cancer Center, in a Japanese restaurant. Prof. Sam So was a graduate of the University of Hong Kong and had on-going collaboration with our group on basic research on liver cancer.

On May 1, 2007, I gave a lecture entitled �Current Advances and Controversies in the Surgical Management of Hepatocellular Carcinoma� in the Surgical Grand Round in the morning. I then attended a tumor board meeting with Prof. Sam So. In the afternoon, I met Dr. Brenden Visser of the Veteran Affairs Hospital, which is another hospital affiliated with Stanford University. Dr. Visser is a young hepatobiliary surgeon who had just joined the Faculty after one year of fellowship in Prof. James Garden�s unit in Edinburgh. We discussed the management of several cases of hepatocellular carcinoma in patients with severe cirrhosis related to hepatitis C virus infection, which is a common problem among the Veterans in the USA. We also discussed the difference in hepatobiliary and pancreatic surgery practice in USA and the rest of the world. In the USA, liver surgery, pancreatic surgery and liver transplantation are often performed by surgeons of different background of training, making it difficult to have comprehensive training in all aspects for young hepatobiliary and pancreatic surgeons. Dr. Visser expressed interest to visit Queen Mary Hospital for a short period in the near future to further widen his overseas experience in hepatobiliary and pancreatic surgery. In the evening, Dr. Visser took me to watch a baseball game in the Baseball Park in San Francisco. We were joined by another hepatobiliary surgeon, Dr. Carlos Covera, from the University of San Francisco. I was impressed by the large crowd and the vibrating atmosphere in the Baseball Park. This gave me a good taste of American culture in addition to the traditional hot dog and chips in a baseball park.

On May 2, 2007, I spent the day with Prof. Sam So observing his operation in the morning, and touring his research laboratory in the afternoon. The operation was an open radiofrequency ablation of colorectal liver metastasis. I was introduced to a new radiofrequency ablation device called In-circle, which is a bipolar radiofrequency electrode capable of creating a large sphere of ablation in much shorter time compared with existing radiofrequency ablation devices. We discussed the possibility of conducting a trial of radiofrequency ablation using this new device in hepatocellular carcinoma patients. I also met Prof. Michael Longaker, also a James IV Traveler. Prof. Longaker is a plastic surgeon with research focus on tissue engineering and regeneration, and he told me that his group has recently published two papers in Nature - certainly an extraordinary achievement for a surgeon-scientist. In the evening, Prof. Sam So took me to the Santa Cruz Mountain for sight-seeing and visit of Thomas Fogarty winery and vineyard. Dr. Fogarty is well-known for his invention of Fogarty balloon catheter for extraction of thrombus in vessels, but he is also well-known locally for brewing fine wine in the Bay area of San Francisco. My visit to Stanford was concluded with a nice group dinner at an elegant restaurant with Prof. Thomas Krummel, Mrs. Krummel, Prof. Jeffry Norton and Prof. Sam So.

In the past year, our Department has sent a breast surgeon and a vascular surgeon to Stanford for Fellowship training. We also have on-going collaborative research in molecular biology of liver and gastric cancers. The visit gave me a more thorough impression of the clinical and research activities of the Stanford Department of Surgery and allowed me to establish new friendship with several researchers.

University of Toronto, Toronto, May 4 � 8, 2007 (Host: Prof. Richard Reznick, Prof. Robin Mcleod)

I arrived at Toronto in the evening of May 3, 2007. Prof. Richard Reznick called my hotel room to inform me that his father just passed away the day before and he would not be able to see me while I was in Toronto, but he had made all the arrangements for me to meet other clinical staff and basic scientists in University of Toronto.

My activity in University of Toronto started with attendance of the Gallie Day on May 4, 2007. Gallie Day was a day of annual research presentation by residents of the Department of Surgery. The Department had a surgeon-scientist training programme, with 39 residents pursuing active basic or clinical research as part of postgraduate study in the Department. The presentations in the Gallie Day ranged from basic science on developmental biology, trauma physiology and cancer biology to clinical research on surgical outcomes, reflecting the successful research training programme of the Department and the diverse research interest within the Department.

After the Gallie Day research meeting, I met Prof. Chi-Chung Hui, the Head of Development Biology Research Institute of the University of Toronto who graduated from the University of Hong Kong. He has developed a strong interest in studies of signaling pathways based on knock-out and transgenic mice. He is an Honorary Professor of the University of Hong Kong and he has active research collaboration on developmental biology with the Division of Pediatric Surgery in my Department. We discussed the potential of collaboration in my cancer research using the mice models generated in his laboratory, as several signaling pathways of development are also involved in carcinogenesis and tumor progression. I toured his laboratory and was impressed by his active collaboration with basic researchers in the Department of Surgery, which was housed in the same laboratory floor.

In the evening, I was driven by Prof. Robin Richards, Vice Chair of Clinical Surgery, to the Grand Liberty for the Gallie Day dinner, in which several awards to residents and Faculty members with outstanding performance in teaching and research was delivered. I was impressed by the way the Department encouraged residents to perform research, which contributed to the academic success of the Department. I spent May 5, 2007 Saturday with Dr. Alice Wei, her husband and two kids in her country home. Dr. Wei was Assistant Professor specialized in hepatobiliary and pancreatic surgery. She spent a year as a clinical fellow in our Division in 2003 and wrote a paper under my supervision on risk factors of extended hepatectomy that was published in British Journal of Surgery. I was glad to see that she had developed an active practice since she returned to Toronto, and she found the training she had received at Queen Mary Hospital useful to her career.

On May 6, 2007 Sunday, Prof. Steven Gallinger took me out to have lunch in the revolving restaurant at the top of CN Tower, Canada�s National Tower and the World�s tallest Building. Prof. Gallinger, a hepatobiliary and pancreatic surgeon, was a James IV Traveler in 2004. We were joined by other hepatobiliary surgeons of the University of Toronto, including Dr. Carol Swallows, Dr. Sean Cleary, Dr. Ian McGilvray and Dr. George Zogopoulos. We talked about our research interest and I was impressed by their involvement in basic research. Dr. Swallow recently published a paper in Nature Genetics on a gene that plays an important role in carcinogenesis of hepatocellular carcinoma. We discussed the possibility of collaboration on basic research.

On May 7, 2007, I started with a meeting with Prof. Ben Almen, Vice Chair of Research of Department of Surgery. We are in a similar position in our respective department as I am the Chairman of Research Committee responsible for supervision of research activities of the Department. We exchanged view on how to encourage young residents to do basic research, and how to integrate basic scientists and clinical researchers. I was impressed by the strong collaboration between Department of Surgery and preclinical basic science departments in University of Toronto in joint research programmes like developmental biology and cancer research. After meeting Prof. Almen, I then visited the Surgical Skills Centre at Mount Sinai Hospital. I had a tour of the Centre with Dr. Helen MacRae, the Director of the Centre. When I was visiting, there was a skills class for the surgical clerkship medical students. Their residents also had a curriculum of a training session once a week in the Surgical Skills Centre on different surgical techniques such as bowel anastomosis. There was also active research on surgical skills training.

After the visit to Surgical Skills Centre, I met Prof. Bernard Langer, previous Department Chairman and a member of the James IV Association of Surgeons, and Prof. Robin Mcleod, a James IV Traveler in 1999, for lunch in a restaurant nearby the hospital. Both of them had been visitors of our Department in Hong Kong. In the afternoon, I visited the laboratory of Prof. Steven Gallinger, and in the evening, I attended the journal club of residents chaired by Prof. Mcleod. The journal review was part of the �Evidence-based Review in Surgery� program jointly run by Canadian Association of Surgeons and American College of Surgeons. Prof. Mcleod was involved in the initiation of this program and she showed me the website in which all the reviews of papers in different subspecialties of surgery were posted in the website. The materials would be useful for surgical trainees in Hong Kong as critical appraisal of literature papers is part of the examination for surgical fellowship at the end of resident training. After the journal club, I followed Prof. Mcleod in a late evening ward round to see her patients.

In the morning of May 8, 2007, I met Prof. MingYao Liu, Prof. of Surgery and Director of International Research Relations of the Medical School of University of Toronto. He briefed me on various streams of clinician-researcher programme in the medical school, including a MD-PhD programme at the medical student level and a resident-Master/PhD programme at the resident level. We also discussed potential exchange of graduate students and postdoctoral fellows. I then met Dr. Nikki Woods, Director of Surgical Education at the Wilson Centre of Surgical Education. We discussed assessment of education performance of Faculty members and I was shown an online assessment system of their Department through which residents and medical students could evaluate the teaching of the teachers and give scores in several areas of performance. We also discussed the importance of teaching in promotion of Faculty members. In the afternoon, I toured the animal research laboratory of the Sick Children�s Hospital with Prof. Cho Pang, who had active research on organ preservation, wound healing and tissue reconstruction. Then I traveled to Sunnybrook Health Science Centre, which is another major teaching hospital of the University of Toronto apart from the Toronto General Hospital, Mount Sinai Hospital, Princess Margaret Hospital and Sick Children�s Hospital. I met two basic scientists, Prof. Robert Kerbel and Prof. Jorges Filmus, who had previous collaboration with me in basic cancer research. Prof. Kerbel is a world renowned scientist on tumor angiogenesis and antiangiogenic therapy, and Prof. Filmus is studying a novel tumor marker of hepatocellular carcinoma. We exchanged an update of our current research work and discussed how to further enhance our collaboration. I toured their laboratory and was joined by Dr. Terence Tang, a former PhD student of the University of Hong Kong under my supervision who graduated two years ago. Dr. Tang moved to Toronto after graduation to work under Prof. Kerbel as postdoctoral fellow. I had a dinner with him in the China Town and kept him updated of the current development of our Laboratory in Hong Kong. This pleasant gathering with my previous PhD student brought to an end of my visit to the University of Toronto.

The visit of the Department of Surgery of the University of Toronto gave me the impression that this is one of the surgical departments in the world with the highest number of surgeon-scientists and with the most active basic research programme. The Department has a large number of Faculty members working in several different teaching hospitals with diverse research interest and close collaboration with basic scientists. Their surgeon-scientist training programme is certainly a possible model for future development in my Department. I was able to meet several investigators who share with me common research interest, and this is likely to enhance future collaboration in my basic and clinical research.

Mayo Clinic, Rochester, MN, May 9-14, 2007 (Hosts: Prof. Michael Sarr, Prof. David Nagorney)

I traveled to Rochester via Chicago on May 9, 2007. The next day, Prof. Michael Sarr picked me up from the hotel to the Mayo Clinic. I first met Prof. Gregory Gores, Chairman of the Department of Gastroenterology and Hepatology. Prof. Gores is an internationally renowned researcher on hepatobiliary cancers, and he runs an active basic research programme studying molecular biology of cholangiocarcinoma. We discussed our research interests, and he also briefed me on the liver transplantation programme and neoadjuvant chemoirradiation protocol for cholangiocarcinoma in Mayo Clinic. Mayo Clinic probably has the largest experience in the world in liver transplantation for cholangiocarcinoma, with numerous publications in this area. Then I toured the Simulation Centre with Dr. Kellie Mathis, a 3rd year resident doing research on surgical simulation. The Simulation Centre is well equipped with different facilities for surgical skills practice, and also has simulations for different clinical setting such as intensive care unit, operating room and recovery room in which medical students and residents could learn in a simulated clinical environment for both skills and decision making.

In the afternoon, I met Dr. Florencia Que, a hepatobiliary surgeon with also interest in bariatric surgery. She briefed me on the hepatobiliary and pancreatic service in Mayo Clinic. I then met Dr. Charles Rosen, Director of Adult Liver Transplantation. Mayo Clinic performed about 100 liver transplants a year, majority being deceased donor transplantation. Dr. Rosen took me to see the transplant clinic, transplant ward and the intensive care unit. He also introduced to me a few transplant hepatologists who work with him. Unlike the programme in my Department, there is heavy involvement of hepatologists in the perioperative and long-term care of liver transplant patients. Similarly, the hepatologists also work closely with hepatobiliary surgeons in management of hepatobiliary malignancies. I finished the day by meeting Dr. Lewis Roberts, a hepatologist with strong interest in basic research on hepatocellular carcinoma.

In the morning of May 11, 2007 Friday, Dr. Jayleen Gram, a year 4 resident, took me to the St. Marys Hospital to observe Dr. Que�s operations. I watched Dr. Que performing a laparoscopic banding for obesity, the first ever laparoscopic banding operation I have ever seen, although it is a very common operation in the United States. In the operating room, I was joined by another visitor of the Department from Japan, Dr. Takeo Fukagawa. Dr. Fukagawa is the Chief of Division of Gastric Surgery at the National Cancer Centre Hospital of Tokyo and he was spending three months visiting several centers in the United States. We exchanged our experience in visiting different centers so far. I then met Prof. John Donohue at the Mayo Clinic Building. Prof. Donohue was a James IV Traveler 12 years ago and he visited the Department of Surgery at the University of Hong Kong as part of his itinerary. I briefed him the recent situation at our Department.

At noon, I delivered a lecture entitled �Recent Advances and Controversies in the treatment of Hepatocellular Carcinoma� in the Combined Pancreas-Hepatobiliary Group Conference in the Dubai Lecture Hall. The conference was a joint meeting between the hepatobiliary surgeons and gastroenterologists and hepatologists. There was intense discussion on several controversies regarding the role of resection, ablation and transplantation for hepatocellular carcinoma.

After the lecture, a hepatobiliary surgical fellow Dr. Thomas Schnelldorfer guided me a tour of historic sites at Mayo Campus. We visited the Plummer Building, the oldest existing building of the old Mayo Clinic, and I was given a good account of the history of Mayo Clinic, which was established more than a century ago by two general surgeons, William J. and Charles H. Mayo. I toured the old library of Mayo Clinic and the original office of the Mayo brothers, seeing some of the oldest surgical instruments used for treatment of haemorrhoids and other common surgical problems in the old days. In line with the spirit of the James IV Traveling Fellowship nowadays, the Mayo brother traveled frequently to different parts of the world to bring innovative ideas into their practice, while they preached their own ideas to surgeons in the rest of the world at the same time. The Mayo brothers also put strong emphasis on research on innovations in surgery. After the tour of historic sites, I met Dr. David Farley, the Chairman of General Surgery Education Program. He briefed me on the resident training programme of Mayo Clinic, which had the second largest number of residents in the USA, with more than 70 residents a year.

On May 12, 2007, Prof. Michael Sarr invited me to a house barbecue dinner at his home with her wife Barbara, Dr. and Mrs. Donohue, Dr. and Mrs. Kendrick, Dr. and Mrs. Fukagawa and also two surgical fellows Dr. Thomas Schnelldorfer and Dr. Kaye Reid-Lombardo. On May 13, 2007, Prof. Sarr hosted another dinner in a restaurant where I met a visiting surgeon from Boston and several fellows working in the laboratory of Prof. Sarr in the study of gastrointestinal mobility. It was interesting to note that the fellows came from different countries including Germany, Pakistan and Mexico. We talked about research and surgery in different countries. I gave a lecture to the residents and staff of the Department of Surgery on �Impact of Radiofrequency Ablation on Management of Liver Cancer� on May 14, 2007,. Then I attended the morbidity and mortality meeting, followed by a meeting with Prof. David Nagorney, who helped to arrange my itinerary in my visit. We discussed about the importance of fostering younger generation to do research in hepatobiliary surgery, and we also discussed potential collaboration on research and clinical trials. I finished my visit of Mayo Clinic by meeting Dr. Vijay Shah, a hepatologist with interest in studying endothelial cell biology and portal hypertension. Dr. Shah is an associate editor of the journal �Hepatology�, and I knew him through my e-mail communications with him as a reviewer for papers submitted to the journal. We discussed our areas of research interest and potential collaboration in basic research on liver cancer in the future.

The visit to Mayo Clinic gave me a different impression from the previous institutions that I visited as Mayo Clinic is a private institution. I was impressed by the way private surgical practice can be integrated with research and teaching in the Clinic, and the close collaboration between surgeons and clinicians from other specialties in multidisciplinary management of patients.

World Conference on Interventional Oncology, Washington DC, May 14-18, 2007

My North American part of James IV Traveling ended in Washington DC where I attended the World Conference on Interventional Oncology as invited Faculty and presented three lectures on �Combined Resection and Ablation for Liver Cancer�, �Traditional and Evolving Surgical Therapies for Hepatocellular Carcinoma� and �Management of Hepatocellular Carcinoma: Hong Kong Perspective�. I also moderated a panel for case discussion on management of hepatocellular carcinoma. The Conference was organized by a group of surgeons and interventional radiologists with interest in developing a new discipline of interventional oncology along with medical, surgical and radiation oncology.

Part B � Europe

Hopital Beaujon, University of Paris VII, Paris, 11th to 16th December 2007 (Host: Prof. Jacques Belghiti)

I started my European part of traveling on 10th December 2007. I arrived at Paris in the early morning of 11th Dec 2007 and was picked up by a research fellow working under Prof. Belghiti, Dr. Guido Dillo from Italy. After unloading my luggage in the hotel, I immediately went to the hospital to attend the morning round of the residents, followed by a morning meeting of the Department to discuss the management of the inpatients. The round and the meeting gave me a good idea of the surgical practice in Prof. Belghiti�s Department, which is completely dedicated to hepatobiliary and pancreatic surgery. I arrived at the hospital in time to observe the 100th liver transplantation of the year performed by Prof. Belghiti - a deceased donor transplantation using a marginal graft for a patient with hepatocellular carcinoma. There was problem with major bleeding from a tear of middle hepatic vein-IVC junction during the operation but Prof. Belghiti showed his vast experience in handling such a difficult situation by controlling the bleeding in a calm manner. In the evening, I gave a lecture entitled �Current Status of Ablative Therapies for Hepatocellular Carcinoma� in the combined liver meeting of surgeons, hepatologists and radiologists of the hospital. The lecture stimulated a lot of discussions and sharing of experience, especially in relation to the role of surgical approach of radiofrequency ablation versus percutaneous approach. Then Prof. Olivier Farges and Dr. Guido Dillo took me out for a nice dinner in an elegant Italian restaurant. Prof. Farges has a special interest in resident training and we discussed a multi-center randomized trial on the usefulness of simulated laparoscopic training he was conducting.

On 12th December 2007, I started by joining the morning meeting, followed by observation of an interesting case of removal of a duodenal polyp in the third part of the duodenum. In the evening, I took the Metro to the centre of Paris to see the famous �Avenue des Champs Elysees� and �Arc de Triomphe�. This was my first time sightseeing in Paris, and I was amazed by the beauty of �Avenue des Champs Elysees� with Christmas lightings alongside the Avenue. Then I took to Metro to an area known as Vavin to visit the home of Prof. Belghiti and his wife, whom I have met before in conferences. Prof. Belghiti took me to a historical Brasserie called �La Copola� for dinner. According to Prof. Belghiti, this is the best known Brasserie in Paris with a history dated back to 1930s. We had a nice dinner with French white wine, and we discussed some of the recent developments in liver surgery and liver transplantation.

On 13th December, I observed a difficult case of resection of a large left lobe hepatocellular carcinoma performed by Prof. Belghiti. Prof. Belghiti demonstrated the use of hanging maneuver, which he first described in the literature several years ago, in this case of left trisectionectomy. The operation was difficult because of the huge tumor, and Prof. Belghiti demonstrated the use of intermittent Pringle maneuver and infrahepatic IVC clamping to reduce bleeding during the liver transection. I also observed a case of pancreaticoduodenectomy for pancreatic adenocarcinoma. Afterwards, I gave a lecture on �Prevention of Pancreatic Leakage after Pancreaticoduodenectomy� in the surgical meeting of the Department, and discussed with Prof. Belghiti and Prof. Sauvanet regarding the management of pancreatic stump after Whipple�s operation. I also gave opinions on the management of cases of hepatocellular carcinoma, chronic pancreatitis and intraductal papillary mucinous neoplasm presented in the meeting.

On 14th December, I attended the operation session of Prof. Belghiti again. It surprised me that Prof. Belghiti was operating almost every day, amidst his busy schedules in administrative meetings and teaching. The operation was a right hepatectomy for a large right lobe hepatocellular carcinoma very close to middle hepatic vein, again a difficult case. Prof. Belghiti demonstrated to me again the use of hanging maneuver, which he combined with the anterior approach of resection advocated by my unit. The hanging maneuver appeared to be particularly useful in anterior approach for right lobe tumor, as it did not only make the transaction easier by elevating the transaction plane, but more importantly it reduced bleeding from the branches of middle hepatic vein. Prof. Belghiti demonstrated to me that there was no bleeding from these branches after cutting open because of the good control provided by the hanging maneuver. Intermittent Pringle maneuver and continuous infrahepatic IVC clamping was employed again to reduce bleeding during transection, and Prof. Belghiti managed to resect the large right lobe tumor with preservation of middle hepatic vein. The case was illustrative of the usefulness of hanging maneuver, which I would consider using in future cases of anterior approach resection for large right lobe tumor. I also observed a case of laparoscopic left lateral segmentectomy for a liver adenoma in the operating theatre next door. The operation was performed successfully using bipolar diathermy and ultrasonic dissection, without the aid of new technologies such as Ligasure or Harmonic Scalpel that I commonly use. To me, this demonstrated that surgeon�s technique was probably more important than technological advances even in laparoscopic liver resection.

On 15th December, I met Prof. Belghiti in the hospital at noon and he took me to see the patients who had been operated this week, and all were recovering well. After a quick lunch with sandwich, we started a tour of the famous sites in Paris. It was a sunny Saturday and the weather was perfect for sight-seeing. We spent the afternoon in a leisure drive in Prof. Belghiti�s car from one place the other, and I was impressed by so many old but well preserved architectures in Paris. I visited Tour Eiffel, Palais de Chaillot, Palais Bourbon, Place de la Concorde, Cologne Vendome, Madeleine, Opera, Hotel de Ville, Cathedrale Notre-Dame and Eglise du Dome, where lies the tomb of Napoleon. I then went to Prof. Belghiti�s home for a tea before we strolled along the streets around his living area to give me have a good feel of typical streets and houses in Paris. We also visited Saint-Germain Des Pres, a famous church built between 990 and 1014. It was a very relaxing day and for the first time, I felt that I have truly visited Paris. On 16th December, Prof. Belghiti picked me up from hotel and drove me to the airport at noon time to catch a flight to Edinburgh.

Royal Infirmary of Edinburgh, Edinburgh, UK 16th � 20th Dec 2007 (Host: Prof. James Garden)

I arrived at Edinburgh late in the afternoon on 16th Dec 2007 and was picked up from the airport by Prof. Rowan Parks, a previous James IV traveler who has visited my Department two years ago. I had a dinner and Christmas pudding at the home of Prof. Parks with his wife. Then Prof. Parks drove me to the hotel.

I was picked up from the hotel in the early morning of 17th Dec 2007 by Prof. James Garden. After arrival at Royal Infirmary, Prof. Garden showed me around the hospital, the University building and the Queen�s Medical Research Institute. I had a good chat with Prof. Garden in his office regarding the organization of his department and the clinical/research activities in the department. Then I spent the whole morning in the Queen�s Medical Research Institute. I attended the liver research group meeting chaired by Prof. Stuart Forbes. I was interested to find a lot of researchers on stem cells in the group studying the role of stem cells in liver cirrhosis, liver regeneration and liver cancer. The group included a good mix of clinician-scientists (including two surgical residents doing full time PhD) and basic scientists who worked closely on the research projects. Prof. Forbes showed me some of his research data on the role of mesenchymal stem cells in liver fibrosis. We discussed about potential collaboration in laboratory research in the future and also possibility of helping each other in examination of thesis of postgraduate students. Then I had a chance to talk with Prof. Steven Wigmore, a transplant surgeon who recently joined the Department, regarding his research interest. Prof. Wigmore runs a very successful program of translational research related to liver transplantation and liver surgery. He showed me a presentation on a study of ischemic conditioning and reperfusion injury, which demonstrated the role of Kupffer cells in protection of the liver to ischemic injury, and another study on genetic predisposition to liver failure after liver resection. There was apparently a very good integration of surgeon-scientists and basic scientists in the institution, with great success in securing grants and in publications in high-impact factor journals. I had a lunch with Prof. Wigmore in the hospital canteen. In the afternoon, I gave a lecture on ablative therapies for hepatocellular carcinoma, followed by a dinner with Prof. James Garden, Prof. Steven Wigmore, Prof. Rowan Parks and Dr. Mark Duxbury in the Prestonfield House, which is one of the best hotels in Edinburgh.

On 18th Dec 2007, I was picked up by Prof. Garden in the morning and attended the ward round with Prof. Garden and Prof. Parks. After a coffee break, I attended the multidisciplinary meeting of HBP team, in which the radiologist went through several cases of HBP cancer cases, followed by the pathologist reviewing the pathological findings of operated cases in the previous week. The meeting was also attended by the hepatologists and medical oncologists who provided input on the management of patients. In the afternoon, I had free time to explore Edinburgh. I visited the famous Edinburgh Castle and the Royal Mile area. The day was concluded with a very nice dinner with Prof. James Garden, the Dean of medical school Prof. John Savill and a hepatologist Prof. John Iredale in one of the best restaurant in Edinburgh. I had a chance to understand the development of Research Centres and the research training system in the Medical School of the University of Edinburgh. The Dean has been able to promote a very successful culture of collaborative research through the Centres, which is what I have been striving to do but with less success as Deputy Director of Centre for Cancer Research at my own Medical School.

On 19th Dec 2007, I took a train to visit the Royal Infirmary of Glasgow through arrangement made by Prof. Rowan Parks. I had a chance to see the countryside of Scotland in a train ride of about 50 minutes. Dr. Ross Carter, a hepatobiliary and pancreatic consultant surgeon of Royal Infirmary of Glasgow, picked me up in the train station. I started in the hospital by observing endoscopic ultrasound of a few cases of pancreatic cancers performed by Dr. Colin Mckay, another consultant surgeon in the HBP team. Dr. Mckay actually learned the techniques of endoscopic ultrasound at the Prince of Wales Hospital of Hong Kong where he served as an Assistant Professor in 1999-2000. Then I observed a few interesting cases of operation, including thoracoscopic division of splanchnic nerves for pain control in a case of chronic pancreatitis, a case of laparoscopic cysto-gastrotomy for pancreatic pseudocyst and a case of percutaneous necrosectomy for necrotizing pancreatitis. Dr. Carter and his group have led the development of minimally invasive approach in management of necrotizing pancreatitis and they have performed percutaneous necrosectomy for more than 110 cases. Dr. Carter demonstrated to me the techniques of the procedure and also described to me the results of the procedure, which has led to a decrease in operative mortality to about 15% compared with over 20% in their previous experience of open necrosectomy. They have not performed open necrosectomy for the past three years and their experience on percutaneous necrosectomy was truly impressive. After the operation session, Dr. Carter took me to the Intensive Care Unit and the High Dependency Unit to show me a couple of interesting cases, and then he showed me a video of the full procedure of percutaneous necrosectomy.

On 20th Dec 2007, the final day of my visit to Edinburgh, I observed a case of Whipple�s operation performed by a fellow under the supervision of Prof. James Garden. The operation went smoothly until the fellow made a hole in the portal vein while separating the pancreatic neck from the vein. There was massive bleeding and great difficulty in control of bleeding. In the end, a portal vein graft from a cadaveric liver that happened to be available on that day but not suitable for liver transplantation was used to salvage the situation. This is an unusual intraoperative complication of Whipple�s operation that could happen to young surgeons starting to perform the operation, but it was well handled by Prof. James Garden. By the time when the bleeding was controlled and the portal vein graft was put in, I had to leave for airport to catch the flight back to Hong Kong. I subsequently received an e-mail from Prof. Garden that the patient recovered well from the operation.

Conclusions

The James IV Traveling Fellowship has allowed me to visit several renowned surgical centers in North America and Europe, and supported me to attend two important conferences. This experience of spending a few weeks in visiting fellow colleagues in other centers has broadened my view on the surgical practice and research organization, and the warm hospitality I have received from each group of surgeons who I visited has the trips very enjoyable. The traveling fellowship has helped to strengthen the connection that I have already established with some of the centers, and establish some new friendship through sharing of knowledge and experience. I consider the experience one of the best rewards of my academic work and will certainly be one of my most favorite life-time memories.

Acknowledgements

I am deeply grateful to Prof. John Wong and Prof. S.T. Fan for their support in my application for the James IV Travelling Fellowship, and my colleagues in the Division of Hepatobiliary and Pancreatic Surgery for taking care of my clinical duties during the travel. I would also like to thank Prof. Thomas Krummel, Prof. Jeffry Norton, Prof. Samuel So, Prof. Richard Reznick, Prof. Robin Mcleod, Prof. Michael Sarr, Prof. David Nagorney, Prof. Jacques Belghiti and Prof. James Garden for their great hospitality, and their secretaries and junior staff for making smooth arrangement for my visit to the respective centers. Last but not the least, I sincerely thank my wife Roberta for her understanding and support of my wish to do the James IV traveling, and for taking care of our home during my overseas travel for nearly six weeks.