Pasquale Ferraro, MD

I want to thank the Association for the great privilege and honour of being selected the Canadian Traveler for 2012. I had heard and read many great things about the fellowship before embarking on my journey. It is truly a unique learning experience that allows us to gain invaluable insight into academic life. It gives us the opportunity to not only expand our horizons but also to make encounters, share ideas and develop friendships with surgeons abroad who generously give of their time and energy to host travelers. I am particularly grateful to Professors John Dark, Michael Griffin, James Garden, Derek Alderson and Glyn Jamieson. I would also like to thank my mentor Andre Duranceau for supporting my candidacy and my Thoracic Surgery colleagues in Montreal, Jocelyne Martin and Moishe Liberman. I also want to thank Dr. Yves Berthiaume who played a major role in organizing my visit to Japan.

I hope to be a worthy representative of the association for years to come.

My trip was divided into two-three week segments – the first to the UK and Denmark and the second to Japan and Australia.

SYNOPSIS OF VISIT: 

Visit to the UK and Denmark (June 24 – July 14, 2012):  

Newcastle: Freeman Hospital, Royal Victoria Infirmary
Hosts: Prof John Dark, Prof Michael Griffin,
Highlight: Discovering new ex vivo perfusion system (EVLP) for lung grafts
Hosts very gracious and generous with their time

Edinburgh: Royal Infirmary, University of Edinburgh
Hosts: Prof James Garden, Prof William Walker

Highlight:

  • Taking part in impressive graduation ceremony for new diplomats at the
  • Royal College of Surgeons of Edinburgh and being present when Dr. Andre
  • Duranceau is honored by the College

London: Harefield Hospital, Royal Brompton Hospital
Hosts: Dr. Martin Carby, Dr. Eric Lim, Dr. Simon Jordan

Highlight:

  • Giving a lung transplant conference in the STAR center at the Harefield
  • Hospital with over 80 people in attendance 

Birmingham: University of Birmingham, Queen Elizabeth Hospital
Host: Prof Derek Alderson
Highlight: Spending three full days with Derek Alderson at the hospital, in the operating room and visiting the historic sites with he and his family

Copenhagen: Copenhagen University Hospital
Host: Prof Martin Iversen
Highlight: Participating as first assistant in a double lung transplant on cardiopulmonary bypass for a young cystic fibrosis patient from Poland

VISIT TO JAPAN AND AUSTRALIA (October 28 – November 20, 2012):

Tokyo: Tokyo Women’s College University Medical Center in Chiba
Host: Prof Yasuo Sekine
Highlight: Witnessing the structure, organizational skills, discipline and pride of the Japanese physicians (and generally of all members of society)

Sendai: Ishinomaki Red Cross Hospital, Tohoku University Medical Center
Hosts: Prof Satoshi Suzuki, Prof Takashi Kondo
Highlight: Presentation by the Red Cross officials on the great East Japan earthquake and tsunami in 2011. Receiving a bronze medal from the Tohoku Medical Society established in Sendai in 1891.

Kanasawa: Kanazawa Medical University
Host: Prof Tsutomu Sakuma
Highlight: Immersion in Japanese culture by spending weekend in Ryokan and Onsen (traditional Japanese inn and hot springs) 

Melbourne: Royal Melbourne Hospital, The Alfred Hospital
Hosts: Dr. Phillip Antippa, Dr. Silvana Marasco
Highlight: Visiting the largest lung transplant program in Australia, pioneers in donor management and use of marginal lungs

Adelaide: University of Adelaide
Host: Prof Glyn Jamieson
Highlight: Small department of surgery but academically committed and highly productive. Glyn Jamieson a true gentleman. Absolutely beautiful wine country!!

Sydney: St Vincent Hospital
Host: Prof Alan Glanville
Highlight: Impressive array of complex transplant procedures and high risk patients – extensive experience with the use of ECMO before and after transplant


TRAVEL JOURNAL:

Newcastle – June 2012

My wife Claudette, our 16 year old twin sons Alexander and Vincent and I embarked on our journey from Montreal to Newcastle on June 23, 2012.

Upon arrival we quickly got a taste of what authentic British weather is all about with a chilly 15 C, cloud and drizzle. Unfortunately it was much the same for three days but it no doubt added charm and character to our visit in Newcastle. We checked into a great hotel located in front of Newcastle football stadium, a 10 minute walk to the Royal Victoria Infirmary and 20 minute walk for quayside and historic downtown.

After resting for a short while, we ordered room service and settled down in our hotel room to watch the quarter final soccer game (Euro 2012) between England and Italy. There was much excitement and tension throughout the hotel and the city with expectations that England would beat Italy. My suggestion to watch the game in an English pub was overturned by my wife – fortunately. Italy wins in a shootout after having dominated the English side for a good part of the game.

On Monday morning June 25, the first official day of my visit, I take a taxi and make my first acquaintance with a true Newcastler. As with any genuine cabbie, he provides me with his opinion about the failure of the EU economic system, American politics, NHS in England and finally transplantation and gene therapy. Unfortunately I could only understand half of what he was saying. After a 15 minute drive we arrive at Freeman Hospital where I meet Professor John Dark in the Cardiothoracic Center. I am greeted by Linda Fellowes, PA and by Sasha Stanchovich a young thoracic consultant on staff. I’m given a tour of the facilities and OR. I visit the transplant institute in the afternoon – a very impressive ultra-modern center. I meet a number of trainees, nurses and staff along the way and I participate in the afternoon transplant rounds from 4 to 5 pm.

At 5 pm, I deliver my first lecture as the James the IV Traveler: “Perspective on Lung Transplantation: Current Results and Recent Developments.” The conference is well received with a number of questions and comments and an excellent discussion period.

After dinner with Claudette and the boys, we head back to the hotel and look forward to a good night of sleep still feeling the jet lag. At 10:30 however, the mobile phone rings and I hear Professor Dark’s voice “we are getting ready for a transplant – are you interested?” Although I was exhausted, it was an offer I could not refuse. I take a taxi and head back to the hospital for 11:15 to learn that the transplant is delayed. Finally after a two hour wait, Prof Dark decides to delay the transplant because of a long ischemic time and plans to place the lungs on EVLP (ex vivo lung perfusion) to perfuse the lungs and assess function before the transplantation. A unique experience for me!! EVLP is new cutting edge technology we have not yet acquired in Montreal. I scrub in and help the young transplant fellow with the procedure. The lungs show good function and a decision is made to proceed with the transplant at 7 am.

It’s now Tuesday morning and I head back to the hotel at about 5:30, get one hour of sleep and return to the hospital for 8 am. I’m scheduled to give a short lecture to trainees on the use VATS-US (video assisted thoracoscopic surgery – ultra sound) for localizing pulmonary nodules intra operatively.

For my second day, I’m meeting with Professor Michael Griffin Chief of the GI unit at the RVI and proud member of the James the IV Association. I met Prof Griffin and then get a tour of the hospital by a young consultant Dr. Harold Immanuel. We then go to the operating theatre where I watch Prof Griffin perform an Ivor-Lewis esophagectomy. I’m most impressed by Prof Griffin meticulous approach – attention to detail dissection – old school type of surgery. By then I’m almost comatose after getting only one hour of sleep so I head back to the hotel to get some much needed sleep.

We have a wonderful dinner on the Tuesday evening with Prof Griffin and members of his staff. My boys are charmed by Prof Griffin’s kindness and friendliness and wonderful stories about Sunderland football and his younger days as a rugby star!! He describes at great length academic life to the boys.

The following morning, I walk to the RVI and meet Professor Griffin. We go to endo suite and I watch Prof Griffin perform EMR for a patient with Barrett’s esophagus and high grade dysplasia. At 10 am I give a lecture to the GI group and trainees: “Outcome Analysis of Free Jejunal Interposition Following Pharyngolarygectomy and Cervical Oesophagectomy”. The lecture is well received and a great discussion period follows. Three of the trainees from their program present their research projects. We spend the rest of the afternoon visiting the city of Newcastle and its many historic sites.

General impressions : Everyone warm and friendly, very busy, committed to their work, patients and careers, proud surgeons (Prof Dark and Griffin), respected by others, leaders, feared by the trainees, visionary, hospital system model of regionalized heath care

Edinburgh June 2012

We travel day from Newcastle to Edinburgh by train and arrive at Waverley station around 1pm on Thursday June 28. After checking into the hotel I receive a call from Penny Earle, Professor Garden’s assistant. My 3 o’clock meeting with Steven Wigmore has been cancelled because of emergency surgery. We decide to visit historic Edinburgh and walk through to city to the Royal Mile and have great dinner of fish and chips in an old tavern.

On the Friday, I head to the Royal Infirmary where I am met by a young consultant Dr. Peter Lamb and taken to the upper GI MDT meeting. I meet Professor Simon Patterson-Brown and participate in an excellent meeting with surgeons, oncologists, GI, radiologists and pathologists. An interesting mix of complex esophageal and gastric cancer cases is presented. Their approach to oesophageal cancer is very similar to ours in Montreal.

At 9:30 I get a quick tour with Penny Earle and then meet up with Dr. William Walker – a senior consultant in thoracic surgery and pioneer in VATS lobectomies. We spend an hour discussing a variety of issues with respect to oncology, patient management, resident teaching and hospital administration.   At 11:30 I take a taxi to the Royal College – Lister center. I meet with Dr. Lorna Marson a renal transplant surgeon responsible for organizing a session with the trainees in general surgery where I present a lecture on lung transplantation.

I head back to the hotel and pick up Claudette and the boys and return to the Royal College of Surgeons for what was certainly the highlight of our visit to Edinburgh. We were to spend a special afternoon at the Diplomats ceremony for graduates. Dr. Andre Duranceau, my mentor, colleague at the University of Montreal and close friend received an honorary degree from the Royal College of Surgeons of Edinburgh. We are ushered into a beautiful library for a private tea party. There we meet Professor Duncan, treasurer for the College and Prof Michael Griffin. The college is historic, grand and majestic – simply breathtaking. We are invited to take our places in a beautiful hall with the new diplomats, council members, honorary guests, families and VIP. Hanging over the entrance is a huge painting with the portrait of King James the IV.

The Edinburgh Royal College of Surgeons was founded in 1507 with a charter ratified by James the IV – King of Scotland at the time. Along with nearly 100 new graduates, Dr. Duranceau receives an honorary degree from college. After the impressive ceremony we return to the library for afternoon tea where I meet Professor OJ Garden for the first time. We spend some time discussing the James the IV Association. I receive from Professor Garden a beautiful pewter quaich with an engraving, a traditional Scottish bowl used to drink scotch.

We spend a wonderful weekend visiting Edinburgh (castle, city tour, museums …) before heading to London on the Monday

London July 2012

We fly from Edinburgh to Heathrow London on Monday July 2, embark on the Heathrow Express (very impressive) from the airport to Paddington Station in Central London and then taxi from the station to the hotel where we check in, relax and go out for dinner.

On Tuesday, I plan to spend the day at Harefield Hospital. Unfortunately Prof Andre Simon, CVT Surgeon and Director of Lung Transplantation is not available so I meet with Dr. Martin Carby – respirologist and medical director of lung transplantation and Dr. Bart Zych senior surgical fellow. We discuss donor issues, selection criteria, retrieval protocols, DCD donors, EVLP and surgical technique. We then visit wards, step down unit and ICU. The hospital is rather old and decrepit as a former military hospital and TB sanatorium.

At 11:30 I meet and have lunch with Dr. Fabio De Robertis, a young cardiothoracic surgeon. We have a good discussion on specialty training (cardiac vs. thoracic), resident education and the health system in the UK. I then head to the STAR center – their center for simulation and training where I give a conference on lung transplantation. Great turnout with over 80 people in attendance; many questions and a good discussion follow the lecture.

After the conference I head for the OR to observe a lung transplantation – another great opportunity for me. The OR theaters at Harefield are impressive – large, modern looking, well light – great contrast with the rest of the hospital. The transplant is being done on CPB like the majority are done in England and Europe.   Later that afternoon, I meet with the transplant coordinator/nurse consultant Anne McDermott and end my visit with Dr. Carby.

Overall, everyone is friendly, warm and appreciative. However, they had only limited knowledge of the James the IV Association. The transplant program is similar to ours in terms of size and function. Transplants performed by a group of five surgeons, less focused on transplantation and the majority cardiac surgeons.

The Wednesday is set aside for visiting London with the family. Rain and clouds on and off all day and finally sunshine in the afternoon after 8 days of bad weather in the UK!!

On the Thursday, I visit The Royal Brompton Hospital with Mr. Eric Lim at 9:00 am. The hospital is old but impressive, majestic and distinguished looking from the outside, located in the Chelsea area of London – posh, expensive and jet set. Eric Lim is a young thoracic surgeon in practice for only 4 or 5 years and chief of service (has taken over from Professor Peter Goldstraw) with a background in medical epidemiology and statistics. He believes in decision making based on outcomes, literature review and patient’s preference.

We attend MDT video conference with team from Essen (respirologists, oncologists, nurses) that lasts about 30 minutes. We then visit wards, HDU, ICU units and hospital. The inside of hospital rather old with some recently renovated and more modern looking areas. We then go to the outpatient clinic. He has an impressive team (PA Susan Harvey, Nurse consultant/liaison Michael Evans, research nurse Anna Powell). Every patient who comes for surgery is enrolled in research (patient outcomes and satisfaction, tumour markers …). Also keeps comprehensive data base of every patient seen who goes to surgery. After the clinic we go for an enjoyable lunch in Chelsea. We discuss patient issues, training, academic surgery and family issues.

On Friday July 6, I go to the hospital for 7 am and give a lung transplant lecture to trainees in CT surgery and consultants. Conference goes well, only a couple of questions and limited discussion. I then go to the OR where I change and meet up with Mr. Simon Jordan one of the thoracic surgeons who performs two cases of VATS sympathectomy for patient with recurrent ventricular tachycardia.

We spend the rest of the day and Saturday sightseeing and shopping. With the boys, we visit the science museum where they have a fascinating exhibit on the history of medicine and the natural history museum.

Birmingham July 2012

We travel from London to Birmingham by train on Sunday July 8. We are greeted and hosted by Professor Derek Alderson, a former James the IV Traveler. We are very graciously invited to his home for dinner with his wife. First home cooked meal in two weeks – a great pleasure. He and his wife are charming, friendly and they go out of their way to make sure we are comfortable.

On the Monday, I’m picked up at the hotel at 7:45 by Professor Alderson and we drive to the Hospital: The Queen Elizabeth Hospital Birmingham (QEHB). Very impressive, grand, new, modern, state of the art, university academic medical center inaugurated in 2010. New hospital contains 1200 beds, 34 OR, and a special unit for all the British Military personnel (e.g.: casualties from current wars in Afghanistan – amputated, burn patients …). In true British style and tradition, university hospital built next to faculty of medicine and on the university campus.

We get a quick cup of coffee and then go to the OR. On schedule, Dr Alderson has an Ivor Lewis esophagectomy. The abdominal part is done MIS followed by an open right thoracotomy. I get the great privilege to scrub and assist with surgery. Surgery starts at 10 am (not unlike our slow and inefficient system at home). I’m impressed with the ease and confidence with which the procedure is carried out by Dr. Alderson. It is obvious he has extensive experience performing oesophagectomies the open way and in depth knowledge of the anatomy preforming a meticulous lymph node dissection of the celiac axis.

After surgery I’m taken to the education center where I spend the next three hours in excellent company. Dr. Alderson has asked key members of his department to present their research projects:

  1. Role of iron in the carcinogenesis of upper GI and colorectal tumours
  2. Radiotherapy followed by local trans anal endoscopic excision (TEMLA) of early stage rectal cancer
  3. Creating a national research network to develop clinical trials in surgery
  4. Experience with radical resection of retroperitoneal sarcomas
  5. Breast cancer research and trials at the University of Birmingham

I’m very impressed with the quality of the research and the commitment these surgeons have made to their institution and their academic careers. At 4 pm Derek and I have tea and get a chance to relax. At 5 pm, I’m invited to give a lecture on free jejunal flaps. About thirty people in attendance including ENT surgeons and maxillo facial surgeons who have extensive experience doing this procedure in Birmingham. The lecture goes well – a number of excellent questions are asked.

That evening, we have dinner at the Marco Pierre White (MPW) restaurant with the members of the upper GI and sarcoma unit. The restaurant sits on the 25th floor of the Cube Building in downtown Birmingham and provides an extraordinary view. Great atmosphere and feeling of camaraderie!!

On the Tuesday morning, Professor Alderson picks me up at 7:45 at the hotel. We go to the hospital – do rounds on the wards and in the ICU. We then visit the old hospital, the Faculty of Medicine and the University. Most impressive is the beautiful art gallery at the University which showcases pieces from masters from the renaissance and impressionist period.

We then meet up with Claudette and the boys and accompanied by Derek we head out to visit the Castle of Warwick where we spend a wonderful afternoon.

General impression: Great learning experience and very enjoyable. Found memories of our visit in Birmingham. Derek Alderson outstanding individual, surgeon, thinker and scholar. Great representative of the James the IV Association. Well read, cultured, knowledgeable, accomplished athlete and most importantly warm, friendly and sincere!!

Copenhagen July 2012

On Wednesday July 11, we embark on our journey from Birmingham to London and then from London to Copenhagen. We arrive at 5 pm in Copenhagen where we are met by my sister and brother-in-law at the airport. My brother-in-law is originally from the Copenhagen and now lives in Montreal.

On the Thursday morning, I take a taxi and head to the Rigshospitalet – Copenhagen University Hospital where they have an impressive lung transplant program. I’m hosted by Dr. Martin Iversen, Medical Director of the transplant program, who takes me to the cardiothoracic morning conference. There are almost 40 people present (CT surgeons, anesthesiologists, ICU doctors, residents, students and nurses). At 8 o’clock I’m invited to give my lecture on transplantation. I then spend most of the morning with Dr. Iversen visiting the hospital, wards, ICU and OR. I meet his colleague pulmonologist responsible for the pulmonary hypertension clinic – Dr. J Carlson. I also meet a young anesthesiologist-ICU physician involved with the transplant patients Dr. Mikhail Zemtsovski.

The hospital contains 1100 beds, performs on a yearly basis 1600 adult cardiac, 200 pediatric cardiac, 1100 general thoracic procedures and 30 to 35 transplants. They have a bronchoscopy suite which performs 35 to 40 diagnostic bronchoscopy a week (including EUS, EBUS, dilatation, stents, TBB …) all under general anesthesia. They have over 5000 TBB from transplant patients in their pathology tissue bank. They have a major VATS lobectomy program that has performed over 1000 VATS lobectomies over the years.

At noon I leave for the hotel and with my sister and brother-in-law we head for a restaurant called NOMA – ranked the number one restaurant in the world. Needless to say we were not disappointed. That evening we go for a visit in the harbour and on the canal.

The following morning, I head for the hospital for 8 o’clock to meet up with Dr. Iversen. I learn there is a transplant to start around 10 am for a young cystic fibrosis patient from Poland. The two countries have set up a special collaboration to allow the Polish physicians to acquire the necessary expertise to eventually develop their own program at home.

To my great surprise, Professor Daniel Steinbruchel, Chief of the Cardiothoracic Division asks me to scrub and help him with the procedure. The transplant goes very well without any intra operative complications. There are however a number of differences with our transplant technique in Montreal: no retrograde flush, sternotomy, CPB for majority of patients, prolene 4-0 for bronchus, end to end bronchial anastomosis, longer donor bronchus, less dissection of hilum and donor hilum, no solumedrol, retrograde flush of air in atrium without unclamping PA. Post operatively, their center uses an immunosuppression regimen consisting of RATG, delay Cyclosporine, Imuran and Solumedrol – Prednisone.

Very interesting visit to Copenhagen where their transplant program is similar in size to ours. Very warm and friendly welcome. Great collaboration and team work between all physicians. Great relationship with staff and nurses. Regionalized health care well established, 14 randomized trials in cardiac surgery department, PhD training a pre requisite for all recruits in their division of surgery.

We visit the harbour and then go to Tivoli Gardens to visit and have dinner. The following morning Saturday July 14 we fly home.

END OF FIRST HALF OF JAMES THE IV VISIT TO THE UK AND DENMARK …

 


SECOND HALF OF JOURNEY: Japan and Australia

Tokyo October 2012

Sunday October 28, I embark on the second half of my journey with my wife. We have a flight from Montreal to Chicago then from Chicago to Tokyo. We arrive at 3 pm on Monday October 29, take a shuttle to Imperial Hotel in the Ginsa district of Tokyo near the famous Imperial Garden. We settle in, rest for a couple of hours and then head to dinner with Dr. Makoto Sugita. Makoto is a former research fellow who spent three years in Montreal from 1999 to 2002. After his MD-PhD and Thoracic Surgery certificate he obtained an MBA. He is now VP responsible for scientific affairs for Janssen Pharmaceuticals in Tokyo.

On the Tuesday, we spend the day visiting Tokyo – museums, shrines and temples and shopping. We enjoy very traditional sashimi, tempura and sushi and visit Tokyo’s largest fish market (Tsukiji Fish Market) – quite the experience!! We then visit the Asakusa area (Senso-Ji Buddist Temple the largest in Tokyo) and local market.

On the Wednesday, Makoto and I visit Tokyo Women’s College University Medical Center in Chiba. We are hosted by Professor Yasuo Sekine, Chief of the Division of Thoracic Surgery. Dr. Sekine is a former transplant fellow from Toronto. The new hospital is beautiful with state of the art equipment and facilities. I give my first lecture on lung transplantation in Japan to their division of cardiothoracic surgery. That evening we enjoy a fabulous dinner with Dr. Sekine, Makoto and our wives.

Sendai November 2012

On Thursday November 1, we head to the Tokyo train station where we take the bullet train (Shinkansen) to Sendai. Sendai is a large city, capitol of the Miyagi Prefecture, where Tohoku University is located – one of the most renowned Universities in Japan. The city is the site of six different universities and has over 1 million people. From Sendai train station we head to our Hotel – The Westin Sendai. New, modern and breathtaking 50 story building in downtown. From the hotel, a car takes us for an afternoon visit to the Ishinomaki Red Cross Hospital one hour north of Sendai on the Pacific coast. Our host is Professor Satoshi Suzuki, Chief of the Division of Thoracic Surgery.

The Ishinomaki Hospital is a 400 bed facility built in 2006. It is a designated Relief Hospital and Critical Care Center for the Red Cross. We tour the hospital, patient ward, ICU and operating rooms. We then have the privilege of attending a presentation prepared for us by officials from the Japanese Red Cross. A senior official presents in Japanese and simultaneous translation is provided by a younger assistant. They are quite emotional discussing the natural disaster that took the lives of friends and family members.

The great East Japan Earthquake that occurred on Friday March 11, 2011 had a magnitude of 9 on the Richter scale (largest ever in the history of Japan and 4th largest in the world’s history!!). Thirty minutes after the devastating earthquake, a horrific tsunami swept the city of Ishinomaki killing over 3000 people. The hospital was left intact structurally (situated on a hilly part of the city) but without power, water supply or food. It was nonetheless the main relief hospital for the injured and wounded receiving and treating almost 4000 patients in 7 days. Following the hospital visit, we travel through the city to see first-hand the devastation left behind and the impressive rebuilding process undertaken by the city’s people.

In the late afternoon we are driven back to Sendai. After a quick rest and change, we head to Tohoku University Medical Center where our host is Professor Takashi Kondo, Chief of the Department of Thoracic Surgery. The hospital is one of the largest in Japan with 1200 beds and has one of the countries only six lung transplant programs. We are greeted by Dr. Yoshinori Okada who takes us on a tour of the wards and ICU. I then give a transplant conference to 25 faculty members and trainees. The conference is well received with many questions and discussion.

After the conference, we attend a small cocktail and banquet organized in my honour where I’m presented with a certificate and bronze medal from the Tohoku Medical Society established in Sendai in 1891. The experience is impressive and humbling. We are then invited to a small traditional neighbourhood restaurant for a wonderful meal of raw fish and seafood.

Kanasawa November 2012

On the Friday, we head for the airport to travel from Sendai to Kanasawa in the prefecture of Ishikawa. The city has a population of 460,000 and sits on the west coast near the Sea of Japan. A car and chauffeur await us at the airport and take us to our hotel the ANA Crowne Plaza Hotel in the downtown area. Our host is Professor Tsutomu Sakuma, Chairman Department of Surgery, Kanazawa Medical University. That evening I give a transplant conference to 30 thoracic surgeons form the Ishikawa prefecture and nearby cities. The conference is well received with many questions and discussion.

On the Saturday and Sunday we travel to a Ryokan and Onsen in the Yamanaka region and spend one night in an absolutely fabulous traditional Japanese Inn. On the Monday we visit the famous Kenrokuen Garden, the Kanazawa Castle and the Higashi district and Geisha houses

We are very impressed and fascinated with our 8 day say in Japan – culture shock in every sense of the word – very few foreigners outside Tokyo and hard to communicate even in English. Nonetheless, people are very warm, friendly, generous and extraordinarily attentive to our every needs – impressive universities and hospitals – hierarchy still very present and strong in hospital system with very powerful professors.

We prepare to travel from Kanazawa to Tokyo to Shanghai to Melbourne. Unfortunately the flight from Tokyo is rescheduled for November 7 – we thus arrive in Melbourne 24 hours later than planned.

Melbourne November 2012

On Thursday November 8, we check in at the Crown Towers Hotel – a beautiful hotel on the river front (Yarro River) in South Melbourne. We spend the afternoon visiting the sites, Federation Square, bus tour, graffiti. My visit to the Royal Melbourne Hospital is no longer possible – which is a great disappointment.

On the Friday, I make my way to the Alfred Hospital at 7:00 where I meet Dr. Silvana Marasco the interim Director of the Cardiothoracic Surgery Division. I give a conference on lung transplantation with 30 people in attendance (physicians, surgeons, trainees, nurses …). Many questions and a good discussion.   They then hold their weekly MDM for transplantation where several cases are presented.

We then tour the hospital facilities and ICU. The ICU is a state of the art modern facility with 45 beds – very impressive set up. Trauma unit and helipad built right next to the new unit. We then go to the OR where I spend the day. The morning case is a very interesting MIS mitral valve repair while in the afternoon I watch two VATS cases. I also meet Dr. Adam Zimmet and Dr. Jillian Gooyi Cardiothoracic Surgeons in the department of surgery.

In the evening, we attend a dinner conference given by Dr. Todd Denny, form Buffalo NY. Conference deals with advanced VATS resections and pneumonectomies for lung cancer. The conference is interesting – a lot of discussion and some controversy about VATS. We spend evening with Dr. Phillip Antippa, Thoracic Surgeon at the Royal Melbourne. Fascinating individual – dynamic and experienced surgeon – athlete – violin player and director of Royal Melbourne Hospital Doctors’ Orchestra!

The Alfred has a world famous lung transplant program – among the best in the world and busiest program in Australia. Volume of 60 -70 cases a year, productive research program, pioneers in donor management and use of marginal donors …

Adelaide November 2012

On the Saturday November 10, we travel from Melbourne to Adelaide – arrive at 5:30 pm. We’re staying at the Crowne Plaza Hotel. Claudette and I walk around the city and find a fabulous Korean restaurant on Gouger Street near the central market.

On the Sunday, we spend the day with Professor Glyn Jamieson. Glyn is a close personal, long-time friend, collaborator and colleague of Andre Duranceau. He is a pioneer and expert in esophageal surgery. Glyn is also a wine enthusiast and owner of a small winery (Mosquito Hill) in South Australia near Mclaren Vale. We travel through the Adelaide Hills. Beautiful country, breathtaking views and amazing scenery!! We stop for lunch in the country side and spend a memorable day with Glyn and some of his personal friends.

On the Monday, I’m picked up by Prof Jamieson who drops me off at St-Andrew Hospital where I meet up with Dr. Philip Game. St-Andrew is a private hospital in Adelaide of 150 beds equipped with ICU and 8 operating rooms. I get a chance to scrub in and help with an esophagectomy. Dr. Game is assisted by Dr. Andrew Lord. They perform an Ivor Lewis type resection – simultaneous abdominal and thoracic approach. Antero lateral thoracotomy and thoracic dissection, resection of azygos, complete lymph node dissection, thoracic duct ligation. Anastomosis done with EE stapler. Proximal anvil inserted through mouth by anesthesiologist – distal component inserted through site of pyloroplasty …  Surgery is complete skin to skin in 3.5 hours. Impressive team approach – been used for over 20 years – excellent results.

In the afternoon, we visit Cleland Wildlife Park a wonderful animal park and wildlife reserve.

The following day, I find my way to the University of Adelaide Department of Surgery in the Eleanor and Harrald Building on Frome Street only a short walk from the hotel. I meet Professor Jamieson at his office. I learn he’s a music enthusiast and has over 500 music CDs in his office (apparently only a small part of his collection at home). I spend the afternoon meeting and talking to the members of the division: Peter Devitt, Sarah Thompson (fellow Canadian who originally came from Calgary, four years into practice, PhD in sentinel nodes in esophageal cancer patients), Jenny Myers surgical scientist and responsible for the esophageal motility lab at the University of Adelaide. They are world experts in HR manometric studies to investigate motor disorders of the esophagus. They have contributed significantly over the years to the surgical literature on this topic.   At 5 pm, I present a conference to the division of surgery on the use of free jejunal flaps. Good discussion and many questions on the functional outcomes – would be of great interest to do motility studies …

After conference, we have a lovely dinner with the members of the division in a restaurant called Ambrosini’s in downtown Adelaide. This ends a very enjoyable visit to Adelaide. Great city – beautiful wine country – fabulous weather. Small Department of Surgery but academically active and impressive results in clinic and research.

Sydney November 2012

We travel to Sydney on Wednesday November 14 to pursue of visit – last segment before we go back to Montreal. We check into the Radisson Blu Hotel. After checking in and a quick rest we walk to the Sydney Harbour, visit the port and have a nice dinner.

On the Thursday morning, I make my way to the St Vincent Hospital for 8 am. I meet briefly with Professor Alan Glanville who is the Director of the Lung Transplant Program. Their program is the second largest in Australia – performs 40 to 50 transplants on a yearly basis. They do a fair number of high risk patients (e.g.: ECMO, redo …). We meet in the ICU where they have a young 25 year old female patient with fulminant viral pneumonia and acute respiratory failure. She is on ECMO (an Avalon bi caval dual lumen venous canula). I meet with a charming young pulmonologist Dr. Adrian Havryk with whom I spend most of the day. We go to the OR where he has a list of cases to do (bronch, stent, dilatation, TBB for transplant patient and for non-transplant patient with rml lesion, EBUS). The cases are done with anesthesia support (sedation, LMA) in a set up very similar to ours. Great discussion – very friendly and kind as is all the OR staff.

At 1 pm I head back to the hotel. Claudette and I plan to spend the afternoon visiting the sites around the harbour and the rocks (old city). That evening we have dinner at a restaurant called Rockpool on George Street. We have a fabulous dinner – awesome food and great service.

On the Friday morning I head to the hospital for 7:30 am. I give a conference on lung transplantation to their lung transplant program. About 20 people in attendance. Informal atmosphere – questions and discussion during the presentation. After the meeting, Professor Glanville and Dr. Havryk set out with their team of students, registrars and fellows to do rounds. We start in the ICU and then move to the patient ward on the floors. Sense of hierarchy very obvious – professor speaks and the others take notes, write the orders and take care of problems. Many old transplant patients (greater than 10 years post op) with complex problems most related to BOS or chronic immunosuppression e.g. PTLD. There is a great deal of discussion about DSA (donor specific antibodies responsible for AMR – antibody mediated rejection). After rounds I go to the outpatient clinic with Adrian to see transplant patients.

This officially marks the end of my James the IV visit to Japan and Australia …

The weekend is spent relaxing and sightseeing (Bondi beach, Manley beach …)

On Monday November 19 we fly home to Montreal.