Des Winter, MD, FRCSI, FRCS

St. Vincent’’s University Hospital, Dublin, Ireland

Is there a more privileged position than to visit colleagues under the banner of the James IV Society? It is hard to detail the excitement and thrill every step brought. There are career changing moments and then there are life defining memories. The James IV Travelling Fellowship was both. I went to so many places it is difficult to detail them all in one report. The theme and common thread was minimal access surgery including the evolving field of natural orifice translumenal surgery (NOTES), flexible endoscopic techniques in mucosal surgery, and innovative endosurgical solutions. This took me to several countries on more than one continent. Alas, my travel plans were delayed not once but twice! This was due to the particularly bad weather that closed airports and then the ash cloud that descended from Iceland shutting down transatlantic and European flight. However, my hosts were most gracious in understanding the problems and in rescheduling.

It may be a surprise to some that I spent some time with a gastroenterologist. However, the future of many surgical procedures will be under videoendoscopic /enhanced reality co-ordination. At the front of the revolution is Chris Thompson at the Brigham and Women’s Hospital, Boston. I had the opportunity of meeting the whole team including the researchers and enjoyed sushi for the first time under their tutelage. We tried out some cutting edge equipment for endoscopic suturing that will come on stream very soon. It was a real treat to see years of research coming to fruition. The visit to the Harvard laboratories and animal facilities was another unexpected highlight. Amazingly, for an Irish man, this was my first time in the famous Boston landmark. If I had my time again I would have explored the city a little more. I was too enthralled with the possibilities for endosurgery to take time out. It was an illuminating experience and I am grateful to Chris and his team for their candour and open discussion of where they/we are going with NOTES.

I met John Hunter in Vienna at the European Surgical Association lunch. A more charming and erudite man would be hard to come by. I was delighted when he accepted my suggestion to visit Portland as I had long been interested in the minimal access approaches they had taken. What a beautiful place Oregon is. Nestled in the hills, OHSU has outgrown its original site such that it has sprawled down hundreds of feet connected by a cable car. Another first for me was the cable car ride down and up between institutions in the professional and informative company of the OHSU staff including Kevin Billingsley (a former James IV traveller). Although I have no love of heights, they entertained me such that it was stimulating not terrifying. My abiding memories having done so was that I would be forever working in an all together more dull campus at home. A highlight of the OHSU experience was seeing minimal access approaches to upper GI surgery including the clever occlusion of the left gastric artery weeks in advance of oesophagectomy. I thoroughly enjoyed meeting the clinical and junior surgical team as well as participating in the tumor board / multidisciplinary meeting. As it is in any center of excellence, it was an honour to share meals with the excellent staff and fellows of OHSU with much stimulating conversation that was food for thought.

A trip to Portland in search of minimal access treats and future concepts would not be complete without meeting Lee Swanstrom of the Legacy Center. I had the pleasure of visiting with him in the small community hospital of Astoria on the northern coastal border with Washington state. What a fabulous backdrop. The drive alone was worth the visit. It was great to see surgery in a community setting not altogether different to that seen in my own country. We had ample time to discuss the present and future of NOTES, natural orifice specimen extraction, and approaches for the propagation of novel concepts and designs. As I suspected, we have many overlapping interests and I look forward to future collaboration.

What an honour it was to be visiting professor in the Cleveland Clinic as part of my James IV travels. I was delighted with the additional accolade. The new chairman of the department of colorectal surgery Feza Remzi was a magnificent host. It is a superb department with diverse characters and talents all under the one roof – a credit to the current staff and the surgical giant that is Vic Fazio, the emeritus Chair/Professor who ran the department for so long. It was terrific to meet with Vic and share his insights during my stay. I also visited the Innovation Center which was an eye-opening experience. This is a wonderful concept for not only stimulating novel concepts and translational ideas but bringing them to fruition with multiple experts in various disciplines in one building. Feza and the Cleveland Clinic staff have led in minimal access intestinal surgery and their gastroenterology colleagues are at the forefront of the NOTES evolution. As a result of this visit we have designed a randomised controlled trial of single port versus traditional laparoscopic colectomy that will span the Atlantic.

I travelled extensively in Europe and Scandinavia, visiting multiple centres, and participating in several symposia on minimally invasive gastrointestinal surgery / NOTES while there. Of note, I visited beautiful Stockholm in May with clear skies and blazing sun. The city was as warm and welcoming as my hosts Torbjorn Holm and Anna Martling. I really enjoyed being at the Karolinska Institute and meeting with the other staff members of the historic centre. Evenings by the water with herring and vodka were immense fun and it was wonderful to be there at the same time as the Canadian James IV Traveller Andy Smith. This was a great introduction to northern hospitality so I had some idea what to expect in visiting Denmark. However, nothing truly prepares one for meeting with the great Dane himself, Sĝren Laurberg. We fell out of the sky and landed in Aarhus sideways in blustery weather. I should not have been surprised to find Aarhus a picturesque place since some of the buildings were designed by famed Danish architects whose furniture became synonymous with style in the 1950’s. An affluent city and university centre, Aarhus bustles with a youthful exuberance echoed by the hospital staff. I was honoured with delivering the Finn Hanberg Sĝrensen Honorary Lecture at their annual surgical meeting. We did have time to enjoy more herring and vodka as well as to remake the acquaintance of my Swedish colleagues who were visiting. The quality of Scandinavian trials and data recording is exemplary and it was immensely useful sharing their thoughts, plans, and insights to shape those of my own. The systematic approach they bring to any clinical scenario is one we should all adopt in the development of new techniques in endosurgery.

No trip to Switzerland is complete without a train journey. Having flown to Zurich, a short walk through the airport leads to the in-built station where my train for Bern left at exactly 14 minutes to the hour. It arrived at the destination to the minute. Extraordinary. And the precision did not stop there. I was warmly welcomed by Daniel Candinas and his colleagues including the personable Ulrich Guller. It is a truly breath-taking scenery that meets you as you look out from the top of the hospital. Mountains and valleys at every turn. I have never seen such a perfect scene from a hospital. The hospital campus includes a state of the art gnotobiotic centre which contrasts with the immense history including Kocher himself. In addition to visiting the clinical facility we had an excellent surgical meeting conducted in English such that I could participate. Among the social delights I enjoyed pasta with freshly sliced truffles that will make my mouth water whenever I think of it.

It would be an incomplete visit to European surgical centres of note without being in the Netherlands in the company of Willem Bemelman. One of nature’s gentlemen, Willem is a consummate politician and clear thinker in surgery. I had the pleasure of being guest at the Dutch Society of Surgery meeting. The meeting was excellent and the resulting minimal access clinical trial that was initiated will have far reaching implications I suspect. The Dutch certainly know how to entertain and it was a thoroughly enjoyable trip. A particular highlight was a NOTES meeting in Rotterdam which was informative, thought provoking, and immensely eye-opening. I even had a little time out to hunt for an aquamarine stone that my wife had been talking about for some time. The huge selection was surpassed only by the professional and hospitable manner of each place I visited before selecting the perfect stone – a welcomed gift to thank my darling wife for her immense patience and understanding. Alas, due to the multitude of young children with which we have been blessed in a short time, she was unable to travel with me.

In keeping with the theme of minimal access, NOTES, and natural orifice specimen extraction, I had the pleasure of participating in the FUSION Summit in Oxford hosted by Neil Mortensen and Ronan Cahill. This was attended by many of the other international whom I would have wished to meet but was limited by time constraints. It is clear that there is a future in these approaches as the technological road unfolds in front of us. Quite where it will take us is as yet unclear. What is certain to me is that I have travelled to meet truly extraordinary physicians and surgeons who are driving us onward on the journey. It has been an honour and humbling experience to have done so under the banner of the James IV Fellowship. I will be grateful to the James IV Society for this opportunity forever. I cannot recommend it enough. My only regret is not being able to visit more centres. However, the experience has given me the resolve to continue my quest in the coming years and I will do so in the spirit of the James IV Society. It dawns on you as you travel that there are common threads that connect us through striving for excellence in patient care. Each of us does what we can with the resources available. Some go further to do the exceptional. Living on a small island has the duality of resource limitations yet endless horizons upon which to dwell. It is inspiring to know there are exceptional surgeons beyond the horizon who dream of doing better.