Lorenzo Ferri, MD, PhD

 

Imperial College and Royal Marsden Hospital, London:

The first leg of my trip started with a short jaunt across the Atlantic to London with my family in tow. My wife Alison, and two children Chiara (11) and Luca (8) were excited to join me for the first two weeks of the traveling fellowship. We landed in Heathrow on a cloudy Saturday morning to be welcomed by my uncle, David Iron, a computer engineer, working ironically for a Montreal based IT company but having set his  sights on  a restarting lunar  exploration (lunarmissionone.com).  We spent  the first two days in the UK at his and my aunt’s, author/blogger Alexandra  Campbell (themiddlesizedgarden.co.uk), house in Faversham, a beautiful town in Kent. We were fortunate to have timed our visit with a medieval town festival celebrating the 800th anniversary of the Magna Carta, a 1281 copy of which Faversham possesses in the town archives. Our children enjoyed attending “knight school” replete with archery and axe throwing, the latter a skill I wish I had honed at an early age that might have served me well on some of my meetings with hospital administrators.

We took the Sunday evening train to London to prepare for my visit to Imperial College the following day. Nisha Patel and Karen Kerr had prepared a busy and exciting schedule for me over three days. Monday morning I met with Professor George Hanna, the director of Upper GI Surgery at Saint James hospital. I was scheduled to meet him in his office immediately prior to a benign esophageal operation that he was to perform. Thankfully anesthesiologist across the Globe share a common core value of procrastination, as it afforded us over two hours of excellent discussion in Professor Hanna’s office on several aspects of the management of malignant upper GI disease prior to he being called back to the operating theatre. I was impressed with his program’s research initiative of bringing Mass Spectrometry to the bedside to aid in clinical decision making, and entirely novel paradigm using metabolomics to impact patient care. Indeed later in the day I had lunch with one of his research fellows, Mazar and Karen Kerr, to discuss the projects in more detail, in which employs investigating the efficiency of volatile organic compounds in exhaled breath to differentiate patients with esophago-­‐gastric cancer from non-­‐ malignant conditions. With professor Hanna we discussed several potential research collaborations including the management of oligo-­‐metastatic disease in gastric cancer as well as the outcomes of high lymph node burden esophageal cancer. Over the next two days I met a number of research associates, fellows, and residents exploring numerous aspects of the very impressive academic surgical juggernaut that is the Imperial College Department of Surgery. I saw various complementary aspects of simulated and virtual surgical wards and operating suites all designed to enhance training of the next generation of surgeons.   What I found particularly impressive was the close collaboration between the physical sciences (particularly engineering and chemistry) and surgery in several of the projects I witnessed, including prototypes of next generation robotics and the use of metabolomics (termed “metabonomics” at Imperial College) to aid in the diagnosis and treatment of  patients with malignancy. The department of surgery employs several mass spectrometers in translational research at the clinical interface unlike any I am   aware across the globe. Two projects currently underway struck me as particularly genius.  He first is an electro-­‐cautery knife coupled to Mass Spec to provide real-­‐time MS analysis of volatile organic compounds as the surgeon cuts through tissue, say a liver or breast containing a cancer. The team has identified a panel of VOCs in the resulting smoke that indicates malignant tissue, providing immediate feedback that the surgeon may be too close to the tumour margin. Another project close to my heart was one in which Both George Hanna, and another future host on my James IVth travels, Jesper Lagergern of the Karolinska Institute, were co-­‐ investigators. This study involved a novel non-­‐ invasive diagnostic test for gastro-­‐esophageal adenocarcinoma based on MS analysis of exhaled breath.  The following day I spent the morning at the Royal Marsden Hospital, with Shanu Rasheed, a colorectal surgeon with Imperial College affiliation, as my guide through the clinical workings of the famous cancer centre. I had a long discussion with David Cunningham, a world-­‐renowned Upper GI oncologist who has authored many of the practice-­‐changing studies on gastric and esophageal carcinoma (e.g. MAGIC trial). It was exhilarating to meet and discuss with someone with whom I share a common opinion regarding the treatment of gasto-­‐esophageal adenocarcinoma and upon whose work I based my own trials investigating novel neoadjuvant chemotherapy regimens for this disease.

My final day, I gave a talk to the department of surgery on the evolving approach to neo-­‐adjuvant therapy for esophageal carcinomas. After my presentation I spent time talking with the world renown Italian esophageal surgeon Giovanni Zaninotto, who has cross appointments at Imperial and the University of Venice.  He has since appointed me as associate editor of the journal Diseases of the Esophagus. My visit concluded with having tea with Sir Ara Darzai’s in his office in which we discussed the challenges of running an academic surgical program, he offered important advice that I’m certain to heed.

Trinity College, Dublin Ireland

With family in town, we next travelled from London to Limerick to spend the weekend on the west coast of Ireland (Dingle Peninsula) and drove to Dublin for Monday. My visit to Trinity College was organized by my host John Reynolds, a world-­‐renowned esophageal surgeon.  Professor Reynolds has built a remarkably comprehensive upper GI cancer program with not only an innovative clinical structure managing all aspect of this disease, but also strong clinical, translational, and fundamental research closely enmeshed within the hospital. The tradition of internationally recognized esophageal cancer management runs deep at Trinity College, indeed it was at this institution where Dr Watson and colleagues completed the first positive neo-­‐adjuvant trial in esophageal adenocarcinoma published in the NEJM in 1996, and heralded the era of this approach for esophageal cancer. I spent the first day with Dr Reynolds and his team and witnessed surgery for several benign and malignant upper GI diseases, including a Laparoscopic Heller myotomy by Dr Reynold’s colleague. In speaking to John about achalasia I was impressed by the number of patients in whom they are able to avoid an operation with an aggressive approach with pneumatic dilation. Learning of their success employing pneumatic dilation in most patients with Achalasia, it may me reflect on the current, and I think misplaced, zeal in endoscopic myotomies (POEMs). If the Trinity College success with pneumatic dilation was universal, I feel that POEMs would have a very limited appeal in the management of Achalasia.

I spent the following day with Dr Reynolds and his bench/translational research group including the scientific director, Dr Jacintha O’Sullivan. After giving a talk on my benchwork research titled “Post-­‐operative complication and cancer recurrence: Dissecting the role of neutrophils in the metastatic process”, I was fortunate to spend the rest of the morning listening to numerous presentations from graduate students in the gastric and esophageal research group. I was greatly impressed with the outstanding quality of the research, as well as the innovative translational approach that Drs Reynolds and O’Sullivan have adopted, particularly their use of human tissue. Indeed I have borrowed their tissue culture technique to obtain conditioned media from human peritoneum for a new research program I am starting on peritoneal metastasis. Following the morning research session, Drs Reynolds and O’Sullivan invited me to visit with them the remarkable Trinity College main campus in the centre of Dublin.

The following morning I was filled with a mild sense of trepidation, as I walking into the Saint James Hospital of Trinity, a personal Lion’s Den considering I was about to give a talk on the merits of neoadjuvant chemotherapy, without radiotherapy, for esophago-­‐gastric adenocarcinoma to the oncology group that started the entire paradigm of neoadjuvant chemo-­‐radiotherapy for this disease.  I was surprised, and relieved, to see that Irish demeanor is far more civil than what I have endured at other centers  with a divergent opinion after giving a similar talk (I think I saw the boiling cauldrons of tar and feathers outside the lecture hall at MD Anderson a couple of years ago…). Indeed, although my talk at Trinity College titled “Refining Neoadjuvant Therapies for Esophageal Adenocarcinoma: En bloc Resection, Radiotherapy, Both or Neither?” did not yield any immediate converts to chemotherapy alone as a neo-­‐ adjuvant treatment, it was well received and generated a lot of interesting discussion. Furthermore, I was encouraged to hear that Dr Reynolds has enough clinical equipoise in this topic to have written and started the neo-­‐ AEGIS trial, in which neo-­‐adjuvant chemotherapy  (MAGIC regimen) will be compared to chemo-­‐radiotherapy (CROSS regimen).  He has already enrolled over  50  patients  in  Ireland,  and  has  recruited  numerous  centres  across  the  UK  to help reach the planned 700 patients. Afterwards, we discussed the challenges of standardizing the surgical therapy in these large multi-­‐institutional trials, particularly the potential confounding influence that en-­‐bloc esophagectomies may pose. I am greatly indebted to Dr Reynolds for his remarkable hospitality and I look forward to inviting him to McGill as a Visiting Professor in the near future.

Karolinska Institute, Stockholm Sweden

 After a week in Ireland, my family and I travelled to Stockholm to visit the prestigious Karolinska Institute. I planned my trip to the Karolinska so as to visit both the clinical epidemiology research group in esophageal cancer run by the husband and wife team of Jesper and Pernilla Lagergren as well as the very active clinical program lead by Magnus Nilsson at the Huddinge Hospital. My first day was spent with Magnus Nilsson, at the Karolinska Institute affiliated Huddinge Hospital approximately 10 km south of the downtown core. Magnus runs an outstanding Upper GI surgical division that includes not only stomach and esophagus, but also a very strong hepato-­‐pancreatico-­‐biliary service.  I attended the daily morning rounds for the service, to which all attending surgeons and trainees are present. All patients are discussed in detail, as well as the upcoming cases for the day. I was impressed that the Huddinge hospital is able to maintain these rounds given everyone’s very busy schedules, but recognize the importance of all surgeons reviewing cases together so that silos do not develop. It is a way that the Karolinska affiliated hospital is able to maintain communication and standards, both operative and peri-­‐operative, amongst all surgeons.  As the division is currently embarking on a revision of their peri-­‐operative guidelines and pathways for a number of upper GI cancer cases, was asked to talk on the Montreal General Hospital experience with enhanced recovery for esophageal cancer, a topic on which we have published extensively. After rounds, I joined Magnus in the operating theatre for a laparoscopic subtotal gastrectomy.  His approach has evolved over the past couple of years, largely due to the influence of a fellow from Japan, and uses a “4-­‐ hand” approach popularized in Tokyo in which two surgeons can operate simultaneously. I found this quite interesting and I have since adopted this technique, to the delight of my trainees. In between cases, Dr Nilsson and I talked in his office – under the gaze of an Alfred Nobel bust – on all things esophageal.  He had just completed analyzing the data from a Scandinavian trial for which he is PI comparing neoadjuvant chemotherapy to chemo-­‐radiotherapy for esophageal carcinoma, a topic true to my heart.  I look forward to the published manuscript, as it will help move the field forward, in addition to the other trial on this topic currently underway run by one of my earlier James IVth hosts – John Reynolds. At the completion of the day of operating – I sat with Dr Nilsson and his team to go over several video’s of operative procedures – including their prone approach for minimally invasive esophagectomy, a technique I plan to try in Montreal.

The following day I visited the remarkable Upper GI Cancer research group based at the Karolinska Institute’s downtown campus. This group of clinical epidemiologists is directed by the esophageal surgeon Dr Lagergren and is, without a doubt, the strongest and most productive clinical research program on upper GI cancer in the World. Dr Lagergren and his wife, Dr. Pernilla Lagergren, form a complementary research team with over 30 research assistants, associates, and students. They have access to one of the most comprehensive and complete National cancer registries, and have used it to publish on the pathogenesis of esophageal cancer, and outcomes of treatment thereof, in the leading medical journals including NEJM and JAMA. The two Dr Lagergens are able to perform clinical research on a National scale I though only possible at the single institution level.  I was most impressed with a current study in which every single patient whom has survived esophageal cancer for more than 5 years in the entire country of Sweden is visited by a trained research nurse to complete a focused quality of life questionnaire, nutritional assessment, and objective determinant of caretaker burden. The scope of the studies they are able to undertake at a National level is truly breathtaking. I look forwaed to collaborating with the Lagergren’s in the future. After a pleasant weekend in Sweden, my family returned home to Montreal as I continued  on with the next stop of my James IV traveling fellowship to Scotland and Northern England.

University of Edinburgh, Scotland

I arrived on a Monday afternoon and had some free time to visit Edinburgh and work on my next talk. That evening I was picked up at my hotel by the extremely hospitable and gregarious James Garden – chief of surgery at the Royal Infirmary of the University of Edinburgh. We were joined by several other upper GI surgeons -­‐ including the director of esophageal surgery at the Royal Infirmary – Mr. Simon Patterson Brown. Dinner was held at the New Club – a remarkable supper club with an outstanding view of the Edinburgh Castle, a view I took advantage of whilst drinking a superb Highland Park scotch recommended by my host James Garden.   The following day I spent meeting several members of the Upper GI surgery team starting with Ward Rounds accompanying Richard “Skip” Skipworth. We took the opportunity to discuss perioperative management of esophagectomy patients and compare the enhanced recovery clinical care pathways that we each use. This was followed by visiting the operative theatre with Skip in which he was performing an open Ivor Lewis (or Lewis Tanner) esophagectomy.

The University of Edinburgh Esophageal Cancer program is one of the UKs largest -­‐ and this was evident by the remarkable skill with which Dr Skipworth performed   the procedure. Throughout the day, I met with several other members of the department of Surgery including Steve Wigmore, Ewan Harrison, and Robert O’Neill. I was struck by the dynamic and innovative nature of the research being performed  at the Royal Infirmary, clearly a very strong academic unit and a leader in the UK. Mr O’Neill and I discussed the possibility of continuing collaborative efforts into the proteomic and metabolomic features of esophageal cancer   progression.

I finished my visit at the Royal Infirmary with a talk on the Endoscopic Management of Early Esophageal Malignancy. This presentation on the ablative and endoscopic resectional techniques was well received by the oncologists and endoscopists in attendance – indeed I had referred to a recent manuscript from their group that mirrors our experience at McGill.

The day concluded with a dinner at the Odine Restaurant with Drs Garden, Harrison, and Rowan Parks – a colorectal surgeon and next years’ James IVth Traveller. This seafood dinner was amongst the best I have had in recent memory and clearly  altered my opinion of Scottish cuisine mired in images of lumpy haggis.  The following day I spent visiting the Edinburgh Castle where I spotted some attire in  the Great Hall built by James IVth I may find useful at my next meeting with the McGill University Health Centre Hospital Administrators (see photo below). I next walked down the hill to Holyroodhouse Palace – the Queen’s official home in Scotland. I fortunately timed my trip by chance with the official visit of the Queen and was able to witness the pomp and circumstance in full display as she hosted Edinburgh’s leading citizens to a garden party.

Surprisingly, I did not see Professor Garden in presence, but it is possible I did not recognize him in his party hat.  Joking aside, I must formally thank Dr Garden for his incredible hospitality during my stay in Edinburgh, he went beyond the call of duty and the Quaich – a traditional Scottish drinking vessel for scotch -­‐ I received from him sits prominently on my desk. I have since tried the Highland Park in it, however it probably is best suited as a decorative memento of my trip to the University of Edinburgh. I concluded my very productive Edinburgh trip by boarding a train to Newcastle upon Tyne in Northern England.

 

Newcastle-­‐upon-­‐Tyne, England

For esophageal surgeons in the UK, Mike Griffin’s program at the Royal Victoria Infirmary of the University of Newcastle is the mecca. Over the past 25 years, Professor Griffin has built a remarkable and comprehensive Esophageal Cancer program covering the entire region of Northern England – the area of the World with the highest incidence of esophageal adenocarcinoma. In my estimation, this is likely one of the strongest esophageal program anywhere, on par with what John Wong, Tom DeMeester, and Rudiger Seiwert had built a bit a decade or two earlier in Hong Kong, Los Angeles, and Munich respectively.  Mike runs all aspects of the esophageal cancer program, from stage 1 – 4 and from diagnosis to death -­‐ hopefully with a long interval in between! I was fortunate to have visiting at the same time Marc van Berge Henegouwen and Suzanne Gisbertz, two surgeons from the Amsterdam Medical Center – a leading European esophageal cancer hospital. The presence of these two experienced surgeons with whom I conversed significantly, greatly enhanced my visit. The day began in the operating theatre with one of Dr Griffin’s colleagues, Arul Immanuel, performing an en bloc Ivor Lewis esophagectomy. I learned a lot of small technical details from the operation, and was intrigued by the circular stapling anastomotic technique that he and Mike have adopted and I plan to try this at home. This was followed by several cases of interventional gastroscopy performed by Professor Griffin – this gave us the opportunity to discuss the varying management options of Barrett’s esophagus and high-­‐grade dysplasia whilst he performed two cases of endosopic mucosal resection. The afternoon was rounded out with a series of research presentation by Dr Griffin’s group as well as my own talk on enhanced recovery after esophagectomy.  I was struck by the impressive breadth of Professor Griffin’s clinical research and the direct clinical applicability of the results – he himself gave a talk on vascular supply of the gastric conduit that was extremely informative. Despite my personal experience of approximately 500 esophagectomies, I found out that there was much more to learn on vascular anatomy of the  stomach.

The  following  morning  we  had  several  other  research  presentations, including  a  profoundly  interesting  one  in  which  Professor  Griffin  discussed  the public outreach and education program that he has instituted to increase the public awareness of esophageal cancer in Northern England. He has recruited the help of a mascot – the “esopha-­‐Goose” -­‐ to get the word across to the general public that esophageal cancer is a real health issue.  This is accompanied by a comprehensive   public campaign including lectures, posters, and even beer glass coasters in pubs! This was truly inspiring, and I believe that we should adopt much of what he has started in North America. We completed our visit with the Upper GI Multidisciplinary Meeting which is run across several sites in Northern England by videoconference. This was a completely exhaustive (and exhausting!) 3 hour meeting going over every active patient with esophageal cancer that the team manages. This final meeting concluded the European portion of my James IVth travelling fellowship. I returned home for a few weeks to tend to my own patients with esophageal cancer prior to embarking on the second leg of the fellowship to California and China.

University of Southern California, Los Angeles, United States

I took the opportunity of the James IVth to visit an esophageal surgery centre built       by an icon in the field.   Although Tom DeMeester has been retired for several years,   the USC division of thoracic surgery has continued his legacy in excellence in esophageal disease under the leadership of Jeffrey Hagen. My first day at the USC – Keck School of medicine started with the research rounds in which the members of      the division and research fellows discuss the projects under investigations.   I met     three members of the team, Drs Jeffrey Hagen, Daniel Oh, and Tom’s son Steven DeMeester.  I gave a talk titled “– The Influence of en-­‐bloc resection on neoadjuvant therapies in esophageal adenocarcinoma “  which  prompted  an  extensive  discussion into the value of radiotherapy in these circumstances as well as the overreaching    impact on the CROSS trial, despite its recognized shortcomings for adenocarcinoma histology.   I then accompanied Jeff Hagen and Daniel Oh to the operating theatre   where they performed two robotic cases with the latest generation Xi machine.   The   first was a robotic lobectomy for a growing lesion in the right lower lobe. As my exposure to the robot is essentially non-­‐existent at my own institution due to financial constraints of a single payer system, I was intrigued by the application and cost-­‐effectiveness of this technology for a procedure I would have done by VATS back home.  I was greatly impressed with the ability Jeff Hagen was able to control  what  amounted  to  a  rather  significant  injury  to  the  pulmonary  artery  using  the robot as well as multiple clips passed by the excellent bedside assistance of Daniel Oh. For the second case, Daniel Oh performed a robotic enucleation of a 3 cm mid-­‐esophageal leiomyoma. The visual optics of the procedure was truly illuminating, and I was impressed by the diligence and patience of Dr. Oh as he carefully dissected the tumour off of the mucosa millimeter by millimeter with remarkable skill.

The second day I spent with Steven DeMeester which started in the endoscopy suite.  I attended  three  gastroscopies, one of which was for Barrett’s esophagus where I was overblown by the significant personnel support endoscopists enjoy at USC. Steven then took me to visit LA County hospital which is a short walk from the private USC-­‐Keck Medical Centre. After reviewing inpatient cases with the residents, we talked quite a bit about the differing access to medical care depending on insurance coverage status in California. Coming from a single payer system with comprehensive medical coverage, this was quite an eye-­‐opener for me.

This afforded us the opportunity to discuss differences in management approach for this disease. His father built an impressive center for the study of esophageal disease with close collaboration between general and esophageal surgeons. For a generation of academic surgeon, USC was the epicenter of esophagology. Although there has been a split between the two specialties since DeMeester senior’s retirement, one can still witness the greatness that USC has held in the esophageal world. I was impressed walking along the halls seeing picture of past fellows, many of whom have since built internationally recognized careers in esophageal disease, most pertinent of which is coincidently my host at my final stop of the James IVth Travelling Fellowship, Simon Law of the University of Hong Kong.

University of Hong Kong and Shenzhen Hospital, China

It was with great pleasure and anticipation that I returned to the University of Hong Kong. I trained here in 2004 under the tutelage of John Wong, and could think of no greater honour than return as a James IVth Travelling Fellow. This department of surgery is widely regarded as one of the “musts” on the James IVth tour, and I fondly remember attending a dinner in 2004 as a lowly clinical fellow in honour of a James IV traveller from Wisconsin. I arrived at my hotel after a long plane ride from Sothern California with just 45 minutes to freshen prior to being picked up in a car by my previous mentor John Wong. We travelled to the Hong Kong Country Club in Aberdeen where we met another figure instrumental to my training at HKU, Simon Law and his wife Sharon. The following day started with the weekly department of surgery research rounds. These rounds showcase the research being performed by trainees of all levels across all divisions of the department.  Three presentations  were given: one from plastic surgery highlighting the use of inguinal lymph node free graft transfers to the axilla to treat post-­‐surgical lymphedema; another from the colorectal surgery division exploring microRNA profiles from colon cancer patient tissue as a predictor of response to chemotherapy; and finally a randomized trial exploring the utility of gum chewing in the context of an enhanced recovery pathway for colorectal cancer. Each talk was well prepared and presented in a professional manner. The rounds were presided by Simon Law, and insightful and helpful questions and comments into the research methods or presentation style were posed by CM Lo, the current chairman of surgery, and John Wong.  These 90-­‐minute rounds were followed by visiting the Surgical Research Laboratories with Dr Nikki Lee where we discussed several translational research projects in which we could collaborate. I returned to the Queen Mary Hospital to spend the rest of the day in the endoscopy suite with Daniel Tong, one of the Esophageal and Gastric surgery division consultants.  Daniel  performed several interventional gastroscopy cases including two ablation procedures for dysplasia and one particularly complex case comprising a broncho-­‐ esophageal fistula several months following an esophagectomy. We commiserated together  our  shared  experiences  with  this  devastating  complication  and  discussed the ideal treatment options. I followed this experience giving a talk on my research titled “Post-­‐operative complications and cancer recurrence: What can surgeons do to improve outcomes”.   It was particularly moving for me to give this talk at the Queen Mary Hospital, because it was precisely in this building that John Wong challenged me to explore this concept almost 12 years ago.   With his push, I continued this line of research moving from a single institutional review from the esophagectomy experience at HKU, to population based studies, to a 10 year translational and fundamental research career exploring the deleterious oncologic consequences of post surgical complications. Because of this I owe much of my academic success to John Wong’s initial investment in me.

Later in the same evening I was picked up at the hotel by CM Lo, the current chair of surgery for a dinner at the Aberdeen Marina Club.  We had dinner with Alan Sihoe, the head of thoracic surgery at the University of Hong Kong and a Canadian to boot. I discussed with CM the challenges of maintaining an academic unit in the present day in which scholarly activity is not valued by most health care systems. Dr Sihoe had come to the University of Hong Kong from its heated rival Chinese University of Hong Kong only in 2008, well after I had trained at the Queen Mary Hospital. He had been Anthony Yim’s partner for several years, a true pioneer in minimally invasive lobectomy. Indeed I had spent a couple of days with Dr Yim during my time at the Queen Mary Hospital in 2004, which allowed me to start one of Canada’s first VATS lobectomy programs when I returned to Montreal. Alan and I compared notes regarding our approaches to minimally invasive resection of the lung.

The next day I attended an operation by Simon Law and Daniel Tong for a woman     with a mid esophageal squamous cell carcinoma.  The University of Hong Kong  surgical approach had changed significantly. Simon has adopted an entirely minimally invasive approach, yet maintaining the en-­‐bloc resection principles that I learned when I trained there under him and John Wong. Although my technique has  also evolved to a minimally invasive approach, I learned a great deal from watching Simon and Daniel, particularly their approach in the abdomen. Following the     operation Simon and his wife Sharon hosted Daniel Tong and myself to a dinner at      the venerable Hong Kong Jockey  Club.

During my fellowship at the Queen Mary Hospital I became friends with several of the  trainees,  Joe  Fan  was  amongst  the  ones  who  welcomed  me  the  most  with  his kind demeanor and unrelenting humour.  Joe was a third year resident when I left in   2004 and he has since become a colorectal surgeon and the main local administrator charged with helping CM Lo build an academic surgical unit at the University of Hong Kong-­‐Shenzhen Hospital just across the border.  The Shenzhen regional authority  built  a  massive  hospital  4  years  ago  and  approached  the  University  of Hong Kong to staff and run the medical program to ensure that the stringent quality standards equal those at the Queen Mary Hospital. Many university surgeons at the University of Hong Kong travel the 45-­‐60 minutes from Central HK to the Shenzhen hospital once or twice a week to operate and mentor the local surgeons.   With CM Lo’s guidance, Joe Fan has built the surgical services at the hospital from scratch to      fill  the  bricks  and  mortar  provided  by  the  Shenzhen  government.   The  enormity  of this  venture  cannot  be  underestimated,  both  literally  and  figuratively.   This hospital is absolutely massive and was built to help manage the health care of one of China’s largest cities, a sprawling metropolis bordering HK of over 10 million people and the world’s fastest growing city.  This city was a hamlet of only 50,000 people less than 30 years ago. Although at 2000 beds, The University of Hong Kong-­‐Shenzhen Hospital is considered a mid sized hospital in China, the enormous footprint and physical layout  of the facility is breathtaking. More of a convention center or airport than hospital,  Joe actually has a bicycle in his office to help him get around in a timely fashion. I was particularly impressed with the “presidential suite”, a 5000 square meter wing of the hospital built for senior Communist party members should they fall ill. The government provided just the structure, and Joe Fan was charged with filling this vacuous space with personnel and equipment so as to provide surgical care equal to the high standards of the Queen Mary Hospital in Hong Kong. After our tour of the hospital, in which I had more exercise walking around this massive complex that I had in the previous couple of years, Joe and I talked about the interesting but complicated intersecting private and public health care systems that exist in China over lunch at an upscale adjacent mall that would not look out of place in Phoenix, Arizona.

The Hong Kong visit concluded my travelling fellowship and I returned to Montreal and a desk piled high with papers, and more than a couple administrative headaches, that accumulated in my absence. I am greatly indebted to the James IVth Association of Surgeons for supporting what has been the highlight of my academic career and allowed me to meet and cement great friendships with the esophageal community across the globe. I am certain that this experience will lead to many future collaborative research and teaching endeavors, indeed I have already had more than one trainee from the centers I visited contact me concerning coming to McGill for sub-­‐specialty clinical and research training.