2008 James IV Association of Surgeons Travelling fellows report

Stephen J Wigmore

LEG 1

CANADA

TORONTO

USA

PORTLAND OREGON HEALTH SCIENCES INSTITUTE
SAN FRANCISCO UNIVERSITY OF CALIFORNIA SAN FRANCISCO
NEW YORK MEMORIAL SLOAN KETTERING CANCER CENTER

My James IV travelling fellowship began in Toronto at the American Transplant Congress. I had never previously been to this congress and it was a fantastic opportunity to hear some of the leading clinicians and scientists talk about their subjects. The highlight of the congress for me was a session on T regulatory cells which featured the combined talents of Alexander Rudensky Washington University and Ethan Shevack NIH Bethesda. This session was extremely helpful to my research as my lab is developing an interest in this field and the interface between Treg cells and Kupffer cells in regulating liver injury. The ATC was also a wonderful opportunity to meet transplant surgeons from around the world in both an academic and a social setting.

Portland Oregon, OHSU

My visit to Portland was hosted by John Hunter, Chief of Surgery at OHSU, who also very kindly lodged me in his house. I had never been to Portland before and it is a beautiful city. The construction of OHSU had clearly presented some ? challenges being on the side of a hill above the town but the setting for the hospital was quite stunning with some creative thinking linking the main campus to newer outpatient clinics by means of a cable car. I had very interesting discussions with John Hunter, Scott Naugler, Assistant Professor of Gastroenterology and attended a morbidity and mortality meeting. The following day I attended a hepatic care conference and this was particularly interesting because of the discussions surrounding treatment of hepatocellular carcinoma which is attracting a great deal of debate in the United Kingdom. After this conference Kristian Enestvedt, one of the surgery residents, took me on a tour of the OHSU campus. This included a cable car ride to the clinics by the Williamette River. Kristian spoke with the sureness of an accomplished surgical trainee and made me wish that I had brought my fishing rod with tales of steelhead lurking in crystal clear streams. I went into the operating rooms to watch Kevin Billingsley performing surgery although circumstances had required a change to the scheduled list and the exciting case had become less so. I was shown some of the other operating rooms and spent a very pleasant lunch with Kevin Billingsley. We shared discussions over the difficulties of time management for clinical academics - a perennial problem which seemingly has no geographical boundaries. I was astonished to hear that in Portland it was more difficult to get an appointment with an expert mountain bike fitter than with an expert liver surgeon, but perhaps that is how things should be. I spent a great afternoon with Susan Orloff who showed me around various other parts of the campus and also the views over towards Mount St Helens etc. I gave my presentation on liver volume and function to a very charitable audience of surgeons, physicians and students and answered a few questions. On my second night I visited Susan Orloff and her husband Bob Hart on their house on the Willamette River and watched the sun go down over Portland with a glass of whisky (not bourbon!) from the deck.

San Francisco, UCSF

My visit to San Francisco was designed to serve two purposes. Firstly to get an opportunity to visit the new Chief of General Surgery, Hobart Harris, who I had worked with in the laboratories at UCSF General Hospital during a sabbatical research visit in 2000. The second purpose was to get first hand information from the UCSF transplant team on the current thinking on criteria for transplantation in patients with primary hepatocellular carcinoma from the UCSF team who have published widely on this subject. I was able to attend the ward rounds with Ryo Hirose and Nathan Bass, which was an excellent experience from the perspective of seeing a range of fascinating and sometimes problematic patients and differences in judgement and intervention from my own practice. I was able to go into theatre and see the back table dissection for a liver transplant and pancreas transplant. Interestingly the organs looked in terrible condition (steatosis) and I was relieved when the biopsy confirmed my suspicions that they were unusable because of 70% steatosis and steatohepatitis. We had an interesting discussion over the pressures on transplantation from the shortage of organ donors and again very similar pressures exist in the USA and UK. I also had an opportunity to meet with Christopher Freise and discussed pancreas transplantation with him.

I joined Hobart Harris in the operating room and watched a number of operations with him, which was a great experience. It is always interesting to see how the dynamics work in operating theatres with different surgeons and nurses and even different healthcare systems. A day with Hobart also confirmed all that we hear about the problems with obesity in the USA as massive patients were wheeled in for a variety of procedures, sadly none of which involved a lap band! Hobart took me out for dinner to one of the great sushi restaurants in Sunset that I used to frequent when I visited previously.

My trip to San Francisco coincided with the wedding celebrations of Brendan Visser, currently working at Stanford, who spent a fellowship in our department in Edinburgh. So it was quite a surprise to find myself in a bar with my colleagues Ernest Hidalgo, Hugh Patterson and Lorraine Kirkpatrick and former colleague Mark Taylor from Belfast, Northern Ireland celebrating Brendan�s last night of freedom(?).

New York, MSKCC

I then flew to New York to visit the Memorial Sloan Kettering Cancer Center where I was hosted by Murray Brennan. As we drove through the New York traffic my mind was cast back to one of the many times that Murray visited Edinburgh and I demonstrated why men cannot do more than one thing at a time by nearly rear- ending the car in front as I tried to give Murray a guided tour of the city. Thankfully Murray did not return the favour and had arranged a private car so I arrived safely in the Upper East Side. I had grown up as a surgeon being inspired by many things but not least the constant stream of visitors from the Memorial Sloan Kettering and so I was very excited about meeting the team and visiting the hospital.

Murray Brennan very kindly put me up in his apartment near the hospital which was a very welcome break from hotels. I had the Sunday to explore New York and headed off with great intentions to the Museum of Modern Art. As it happened I got swept along by a Puerto Rican Carnival and ended up at the wrong end of town. There was no possibility of crossing the carnival and so I took the Staten Island ferry to see the sights. This was a great experience and I toured various landmarks in NY such as the Chrysler building and Empire State and had lunch in a very typical diner. I even had a haircut although I am not sure whether the immigrant who cut my hair was a trained barber or whether he was just minding the shop while his boss went for lunch. The following day I had an early morning breakfast meeting with Yuman Fong and then headed over to the MSKCC to meet the residents and give my presentation. The MSKCC residents were a breath of fresh air and were clearly a highly skilled and very committed group of individuals. Mike House, the Chief Resident, showed me around and made sure everything was just so and his successor Stephen Katz and Rebecca Gladdy were equally helpful. I then attended the surgical grand rounds and listened to an excellent presentation from Bill Jarnagin, Chief of the HPB Service, on preoperative haemodilution and autotransfusion in liver surgery. After this I crossed the road to the New York Presbyterian hospital to visit Fabrizio Michelassi, the Chief of Surgery. After a very interesting conversation he introduced me to David Leeser, one of the New York Presbyterian renal transplant surgeons. David also held a position in the US Army and had been heavily involved in operations in Iraq in recent years and so it was interesting to hear about his activities both civilian and military. Performing over 300 kidney transplants per annum, the NY Presbyterian Hospital must have one of the largest programmes in the world.

I returned to MSKCC to have lunch with the fellows and conversation moved to academic training of clinical surgeons and the differences and similarities between the UK and USA. After lunch I met up with Ron DeMatteo, who I had met a number of times before. Ron is Vice Chair of Surgery and has a significant research interest which, like my own, focuses on basic science research which has relevance to liver surgery. 2007-8 was a highly productive year for Ron and it was great to have the opportunity to go through his research in detail and look for areas of potential collaboration. In the afternoon I had an opportunity to visit the Guggenheim Museum and Central Park. I returned in the evening to have dinner with the fellows, who made a number of clinical presentations and asked a lot of very difficult questions!

I spent the following day in the operating room with Murray Brennan, who was doing a pancreaticoduodenectomy. During the course of this I also had the opportunity to watch Yuman Fong doing some liver resections and Mike D� Angelica, who was also resecting neuroendocrine metastases. It was interesting to see a different way of doing things and the similarities and differences. At MSKCC there are no anaesthetic rooms (I presume because of space) and so patients are put to sleep in the operating room itself. This was a difference in practice from my own hospital where space is not an issue and it is interesting to speculate which system allows best efficiency as the use of an anaesthetic room allows potentially rapid turn around time between cases. The electronic data recording system in use at MSKCC was very impressive and something which my own hospital could definitely learn from. There, clicking on various preset screens populated various forms generating an operation note, part of the discharge summary and also performing the function of billing, all with no paper. That evening I had a delightful dinner at a traditional Italian restaurant with Murray Brennan, Bill Jarnagin, Yuman Fong and Ron DeMatteo.

The following day I had breakfast at the General Surgical Conference and listened to the cases presented and then went on to meet Leslie Blumgart, who was in excellent form having just returned from an overseas trip which combined a bit of work with a vacation. I watched some further cases in the operating room and then met up with Mike D�Angelica, who is one of the more recent recruits to MSKCC and clearly also a very talented individual. I then attended the GMT conference and the fellows conference before bidding farewell to my excellent host Murray Brennan and to New York.

LEG 2

Melbourne and Adelaide

For the second leg of my James IV travelling fellowship I took my family, wife Lynne, sons Forbes aged 12 and Murray aged 9 and daughter Camilla aged 4 and we visited Australia. We flew on the new Airbus A380 giant plane from London to Singapore which was actually a good travel experience, very smooth despite our reservations. We arrived in Melbourne after 21 hours of travelling and were met at the airport by Ben Thomson, a surgeon at the Peter Macallum Cancer Center in Melbourne who had spent two years working in Edinburgh and had become a great friend. We stayed in a furnished appartment in the district of Kew which was close enough to the centre of Melbourne to make travel easy but far enough out to be leafy and green. We met up with Ben Thomson�s family and the kids had a good opportunity to unwind, including a swim in the local pool and brunch. Unfortunately by 4pm we were all struggling to stay awake and despite our best intentions we were all asleep by 6pm. We all awoke at 2am and it took several days to adjust to a complete reversal in time zones. On the Saturday we met up with Simon Banting and his wife, another surgeon at the Peter Macallum Cancer Center who had also worked in Edinburgh in the distant past and had a barbecue. We visited Healdsville Wildlife Park on the Sunday which gave the kids the opportunity to acquaint themselves with the Australian flora and fauna. On the Monday I visited the Peter Macallum Cancer Center which was a fascinating experience. I had the opportunity to listen to a presentation from Rod Hicks who leads a world class group investigating neuroendocrine cancer and who have expertise in imaging and treatment using radiolabelled probes. They have developed novel PET imaging reagents and this facility was particularly interesting, combining basic science and biochemistry with clinical application and therapeutics. I also met up with Wayne Phillips who leads a basic science surgical laboratory looking at Barret�s oesophagus and oesophageal carcinogenesis using a novel transplanted decellularized trachea model in the mouse, which can be reseeded with cells to create a neo-oesophagus and which can then be subjected to experimental stimuli. I was intrigued to know whether this technology could also be used to create a bile duct since there is a dearth of experimental models involving bile ducts. I also heard presentations on the phosphatidyl inositol 3 kinase pathway, which I have done some work on myself. I also heard a presentation from Ben Thomson�s research fellow, Charles, who is investigating the effect of weight loss on liver steatosis. This has obvious relevance as obesity is also a major problem in Australia as well as the USA. I had a very interesting chat with Professor Rob Thomas, the Head of Surgical Oncology, about regional politics in the province of Victoria and health economics. We were sorry to leave Melbourne and headed off in a hired car along the Great Ocean Road in the general direction of Adelaide. During this trip we met echidna, emus and kangaroos at close quarters and stopped at Port Campbell and Robe.

Flinders Medical Centre Adelaide

We arrived in Adelaide and were met by Mark Brooke Smith, who kindly showed us around Adelaide and gave us a traditional Australian barbecue. I visited Flinders Medical Centre and was hosted by Rob Padbury, the Director of Surgery, who I had met previously in Edinburgh and in Italy. I visited the wards with John Chen, Director of Transplantation, and enjoyed a long conversation about the difficulties of running a transplant service over huge distances and with poor donor rates. In spite of the small size of the South Australian programme, rather like Scotland the surgeons have devised strategies to obtain the maximum benefit from the organs that they are offered and produce excellent results. I attended the liver transplant MDT meeting, which again was interesting because of the similarities and contrasts with my own practice. I had the opportunity to discuss image transmission between retrieval team and implanting center with the transplant co-ordinator Libby John and also met a number of hepatologists, one of whom had recently been part of our Edinburgh team.

I explored the various departments of Flinders Medical Centres with a number of enthusiastic guides and was very impressed by the facilities on offer. I attended the Hepatobiliary MDT meeting and saw a number of interesting and challenging cases presented. Rob Padbury hosted my family at a wonderful dinner at his house and we particularly enjoyed the tour around Australia through a wine glass as Rob shared the delights of his cellar with us.

Again we were sorry to leave Adelaide as we headed to Western Australia to my aunt and her family to spend Christmas and New Year.

My James IV travelling fellowship was a wonderful opportunity to experience surgery in the USA and Australia and to meet and see old friends and new in their own environment. I am tremendously grateful to the James IV Association for this opportunity to be a traveller and my family and I have felt the warmth that the association generates as we have travelled around.