Kevin G. Billingsley, M.D.

Associate Professor
Chief, Division of Surgical Oncology
Oregon Health and Science
Portland, Oregon

2009 James IVth traveling fellow summary

Introduction

I was enormously honored and gratified to be awarded a James IV traveling fellowship. I am trained as a surgical oncologist, however in recent years I have chosen to focus much of my clinical work in the area of hepatobiliary and pancreatic malignancies. My research centers around clinical trials and outcome studies in hepatobiliary, pancreatic, and colorectal cancer. My administrative work involves division leadership as well as prorgrammatic development within the cancer program at Oregon Health and Science University.

As I planned my itinerary, I found the reports of previous travelers to be enormously helpful. In particular, I reviewed the thoughtful summaries that were filed by Drs. Yuman Fong, C.M. Lo, Selwyn Vickers, Tim Yeatman, and Kevin Bearhns. I am also enormously grateful for the support of my chairman, Dr. John Hunter who not only nominated me for the fellowship but allowed me time away from my duties at Oregon Health and Science University. I am deeply indebted to Dr. Murray Brennan for his support and Dr. O. James Garden for his advice on travels.

My goals were to visit centers in which would provide excellent models for the organization of a multidisciplinary hepatobiliary and pancreatic unit. I also aimed to visit centers where hepatobiliary was practiced with high volume and significant technical expertise.

After some family discussion, my wife and I decided we would do as much of the traveling as possible as a family. As such, my wife and two young children (ages six and three) were with me for all but one week out of the six weeks of travel. Although there were certainly some challenging moments associated with traveling with children this young, this was a truly wonderful family experience and I would commend this approach to other travelers.

Because of my work schedule, my wife’­s work schedule and the set of travel destinations, I elected to perform the travels in two blocks, separated by approximately six months. In February and March, 2007, I traveled to Hong Kong and Australia. In September, 2007, I traveled to Scotland and Paris.

Hong Kong and Australia

February 26, 2007 Hong Kong

We arrived at 0700 at Hong Kong’s sprawling new airport. We were all rather exhausted from the 14 hour flight from Los Angeles. Although one piece of luggage went missing, we were met at the airport by a very nice driver that was sent by the Hong Kong University Dept. of Surgery.

On the ride into Hong Kong proper we marveled at the large number of huge high rises and enormous apartment blocks that cling to the hillsides throughout Hong Kong. These images give new meaning to the idea of population density.

We checked into the Meridien Cyberport Hotel which is on the South side of Hong Kong island, a short distance from Queen Mary Hospital and the University of Hong Kong medical campus. At this point it was about 0930 and we elected just stay up and treat it as another day.

We went out of the hotel and crossed the street to the cyberport arcade. We had a nice Chinese style brunch at a restaurant within this modern shopping complex.

We returned to the hotel and after a quick shower and change. I headed downstairs where I was met by a driver for the short ride up the hill to the hospital complex.

After some searching around I was able to find the operating theatres. Helped by several gracious nurses, I located the change rooms and I changed into the regulation green scrubs with buttons up the front.

I found Dr. CM Lo in OR 2 on the fifth floor. He was taking a transplant fellow through a laparoscopic RFA of a segment 6 HCC in a patient with chronic hep. B. The patient had well compensated cirrhosis, with minimal portal htn. Dr. Lo was using the radionics cooled tip electrode to peform the ablation. A standard laparoscopic ultrasound probe was used. He was careful to hold the duodenum down and away from the ablation site.

After the case we went for coffee. Dr. Lo explained that the majority of their oncology work is hep. B related as the chronic carrier state in Hong Kong is extraordinarily high. They see only 5% hep. C.

We talked about liver transplantation. In Hong Kong for a variety of reasons cadaveric transplantation is unusual. Most transplants are living related. They predominantly use the right liver as a graft. Many of the transplants are still done emergently when patients are deteriorating.

Dr. Lo explained that QM is a public hospital that is funded with an annual budget by the Hong Kong government. Care is provided to eligible Hong Kong citizens for approximately 12$ US a day for care. For example a patient receiving a transplant with a 20 day hospitalization would be charged roughly $240.

The surgical faculty are all on salary. They all have a small number of private patients. Monies from private patients are collected by the divisions and returned to support the division priorities and research efforts.

Dr. Lo explained that the system was quite different a few miles away in China where surgery is essentially a cash and carry enterprise. Many patients travel to China for transplants. If patients have the cash, they can get an organ in China. The source of these organs is not entirely clear. There is little doubt, however, that some of the organs are harvested from criminals that are executed by the Chinese Justice system.

However, many patients return to Hong Kong for management of their post transplant complications. The Chinese have difficulties with graft preservation. As such many grafts develop biliary sclerosis, stricture, and ultimately graft failure that requires treatment with retransplantation.

After a discussion over coffee, we joined his team of a fellow, several registrars and intern for round on the ward. The ward was large unit with several open bays, with approx.6 patients per bay. We discussed a patient with a large extrahepatic bile duct cyst and carolis disease. Patient was treated with a bile duct excision and reconstruction. We saw several patients with graft failure from biliary sclerosis.

We discussed the fact that all of the surgeons in the HPB division were involved in endoscopic work. They do their own ERCP, stenting, stone retrieval etc. The gastroenterologists consult them for these procedures. He explained that this gives them great flexibility in choosing interventions for liver and bile duct pathology and they have no vested interest in any particular procedure as they do them all.

We discussed my primary interest in HPB and Dr. Lo rearranged to the program to allow me to spend more time with his group.

February 27, 2007 Hong Kong

I joined the University of Hong Kong surgical staff this morning. The day begins with a research and x-ray meeting. The entire department gathers at 0730. The resident presents a clinical research study. This particular day it was a review of outcomes following mitral valve repair. The presentation and research methods were analyzed and critiqued in a thoughtful way. Then all divisions present one case with radiographs. It is a very interesting array of pathology.

I toured the hospital with Barbara Chik, HPB transplant fellow. We saw the vascular lab, day surgery center and Jockey Club skills center. This is a multi purpose meeting and training facility. Courses are held for practicing surgeons, trainees, and nurses.

I asked Barbara about transplantation. She explained that patients do routinely go to China for transplants. Organs are harvested from executed criminals. It is not clear how this occurs, but obviously warm ischemia time is a problem. Match is done by blood type alone. Patients then return to Hong Kong and develop diffuse biliary injury related to biliary ischemia. Apparently, by paying more money patients can arrange for shorter ischemic times possibly with in hospital execution.

I met with Dr. John Luk. We spent the morning touning the faculty of medicine building and the two floors of dept. of surgery research space. One floor is predominantly vivarium and animal surgery. The second floor is a collection of spacious wet labs with core facilities. They have an active tissue bank and tissue acquisition program. Specimens are all bar coded. They have a dedicated specimen retrieval technician.

Dr. Luk explained that much of the funding comes from the Hong Kong government. Researcher salaries are paid by the government. They also provide the space. Private donations, and pharma pay for reagents and additional personnel. They don’­t rely on indirects to cover research expenses or grants for faculty or research salaries. Lunch with Dr. Luk at Japanese restaurant.

I returned to the hospital. I observed Dr. Chik perform ERCP and stent placement in transplant patient with DBI.

I joined a ward rounds with B. Chik and S.C. Chan. There were an extensive number of patients, almost all with hep. B related liver disease, and transplant problems.

I then met with Dr. John Wong. He graciously welcomed me and we had a discussion of my interests. Dr. Wong then explained some of the workings of the department to me. I also told me some of the history of the department and we reviewed some of the medals and papers of Dr. G.B. Ong, the founder of the department.

February 28, 2007 Hong Kong

The day started with census conference. This is equivalent to M and M. A variety of cases were presented with thoughtful discussion. One memorable case involved a tracheostomy placed at bedside on the neurosurgery service. This resulted in a posterior tracheal laceration, pneumomediastinum and eventually patient demise. Dr. CM Lo chaired the conference.

We then went to the OT where I watched Dr. Ronnie Poon followed by Dr. Cheung. They were operating on a 49 yo man with a very large right liver HCC. He has Hep B. There appeared to be a left adrenal met. This was not felt to be a contraindication for resection.

The surgeons employed the anterior approach. There were several technical points that were worth remembering. They used a modified anchor incision. They started with an upper midline for exploration and ultrasound. When it appeared resectable they then made a curvilinear right side incision that divided the right costal margin and entered the right chest. They then extended the inicision to the left side. A bookwalter was used for exposure. The then proceeded with chole and hilar dissection. A lot of this was done with bovie. The right hepatic artery was divided and then the right portal vein. This was divided with simple ligation and then suture ligature with 5-0 prolene.

This provided some access to the IVC. The liver was gently lifted up and several short retrohepatic vein branches were divided. As much of the anterior cava as possible was exposed. They then placed stay sutures in the liver for traction. The liver was scored with bovie. Parenchymal division was then carried out with CUSA and multiple mini clips and medium clips. Small vessels were also ligated. This was slow, meticulous and tedious. The CUSA had a bovie attached that was also used to cauterize small vessels.

This was almost bloodless. A third surgeon assisted with suction and exposure. No Pringle maneuver was employed. Hepatic vein branches were controlled with suture ligature. Dissection was eventually cared down on to IVC. The dissection was then carried laterally. Bile duct was divided and oversewn. The right hepatic vein was eventually dissected out and divided with endo GIA stapler. All diaphragmatic attachments were divided and the specimen was removed. I estimate 300-400 cc blood loss.

Of note that University of Hong Kong group has presented data that suggests that survival after reection of HCC is better if the anterior approach is utilized rather than more traditional hepatic mobilization.

I then gave my talk entitled “Evolving multidisciplinary treatment of hepatic colorectal metastases.” This was given to the department. I was introduced by Dr. Poon. The talk was received graciously and there were a number of thoughtful questions.

We then went to dinner at the Aberdeen Marina Club. This club is adjacent to the large and famous floating restaurant complexes in Aberdeen. We were joined by Dr. Wong briefly. The dinner party included Dr. Poon, Dr. CS Lai, Dr. CM Lo, and Dr. John Boey. All are previous James IV fellows. Dr. Lai and Dr. Boey are in the private practice of surgery in Hong Kong. Dr. Lai also has an active practice in Macau where he does a lot of HPB surgery.

March 1, 2007 Hong Kong

The day started with ICU rounds at Queen Mary. These are bedside teaching rounds that are attended by the entire department. The rounds are led by a senior resident. The junior resident presents the case and the relevant radiographs. Other residents are then questioned on the x rays. A general discussion is then held.

Two cases were presented. The first case involved a patient with a prior distal gastrectomy with two esophageal cancers. The operation was staged. In the first procedure a substernal colon interposition was placed. Dr. Wong explained that they preferentially use the right colon based on a midcolic pedicle. This was placed in a retrosternal location. He says the key to the procedure is to open the diapharagm just behind the xiphisternum and then to make an anterior mediastinal passage by dissecting bluntly in the plane just posterior to the sternum. The strap muscles must be divided in the neck. There is no need to resect the head of the clavicle. In a second operation the chest was opened and the esophagus was removed. It had been previously divided in the neck, but it was then divided off the stomach.

The second case involved a patient with a sigmoid primary and three liver mets in the right liver. These were resected with wedge resections.

Following ICU rounds I returned to the hotel and we headed off on a family excursion in Hong Kong. We went into the central district and took the Star ferry across the harbor to Kowloon. We wandered around Kowloon including a visit to the Peninsula hotel, a visit to Kowloon park and lunch at McDonalds. We then returned to Hong Kong island on the Star Ferry. We visited the IFC which is a large mall that includes a major transportation hub. It also encompasses, IFC 1, the tallest building in Hong Kong.

At 5:30 I returned to the hospital for the HPB division meeting led by Dr. Lo. This meeting reviews all potential upcoming cases. We reviewed a number of interesting cases. Dr. Lo made an interesting anatomic and technical point. He suggested that for right hepatectomy, the plan of dissection should travel right along the right side of the middle hepatic vein. There are actually less branches off the vein in this plane than further away. For extended right or if the vein is going to be included the dissection should be carried down the left side of the vein.

We talked about living related donors and the need insure adequate venous drainage of the graft.

I then joined Dr. SC Chan for dinner at the Golden Bull Vietnamese restaurant in the Causeway bay area of Hong Kong. This was located in an enormous shopping center called Times Square.

On the way home we drove to Victoria peak where we took in a fabulous view of Hong Kong Island and Kowloon.

March 2, 2007 Hong Kong

Today we took the day for family touring. We got up and did a few errands and then we traveled by taxi to the Ocean Park amusement park. This has long been popular with Hong Kong families. It is a delightful place set on the steep headlands over the South China Sea.

The entrance of the park is set at a low level, but it is connected by a spectacular tramway to the upper portion of the park. We spent some time on the kiddie rides at the low part of the park. We then rode the tram to the upper area. At the upper portion of the park there were two large aquariums that the children loved. One aquarium had sharks of a variety of species with and undertank tunnel that allowed visitors to walk under the sharks swimming above.

We also rode roller coasters and water slides. One of the roller coasters was quite hair raising as it was constructed out on a cliff side with quite a sheer drop heading down to the sea.

March 3-4, 2007 Hong Kong travel to Melbourne

We got up this morning and were able to take our time over breakfast and then we finished our packing. The van arrived at 11 am to take us to the airport. It was about a 35 -40 minute ride to Hong Kong’­s new airport. The new airport is out on Lantau island. We checked in for our flight to Melbourne. Because of our travel scheduling we are routed through Shanghai to connect to another flight to Melbourne.

The airport in Shanghai is large, concrete and institutional appearing. We passed through abbreviated customs and then on to another terminal where we waited for the flight to Melbourne. We boarded and flew overnight on to Melbourne, arriving at approximately 8 am.

We cleared customs which took some time and then we picked up our rental car from Budget to drive into the city. It is a bit of an experience to drive on the left side of the road. Activating the gear shift lever with the left hand and the turn indicator with the right hand is all very different.

We checked in at the Medina Grand Hotel. Immediately upon check in, my friend, Dr. Bruce Mann met me in the lobby and we all headed to the Melbourne zoo. We had a marvelous time at the Zoo and the children enjoyed the koalas, meerkats, and kangaroos.

March 5, 2007 Melbourne

I spent the day at the Peter MacCallum cancer center. This is essentially the only freestanding multidisciplinary cancer treatment center in Australia. I met first with Prof. Robert Thomas who is the director of surgical oncology at the center. He explained that historically the center focused on medical oncology an radiation oncology. However, in the past 8 years, Dr. Thomas has built the center up as a surgical oncology facility as well. The current operative load includes esophageal surgery, sarcoma, breast, some HPB. He reports that the care is still a bit limited in some regards because they do not have the specialty resources of a larger medical center.

I then met with Dr. Wayne Phillips and Dr. Danielle Greenawalt. Dr. Phillips is on the full time scientific staff. Dr. Greenawalt is an American postdoctoral fellow. They presented extensive microarray work they have done, developing predictors of response to chemoradiation for esophageal cancer and rectal cancer. They have done this work in collaboration with one of the surgical oncology fellows , Dr. Kwong, who is now a surg. Onc. Fellow at MSKCC.

I also met with Lisa Devereaux who runs the tissue bank. They have a single IRB Form that they use for all tissue donation. They acquire tissue and blood from a variety of sources and this is stored in a -80 freezer. They have their own software program for tracking the tissue. Samples are not bar coded but are labeled with a code. Investigators from Australia may apply to gain access to tissue samples.

I met with Dr. Eddie Lau who gave me a tour of the PET centre. Eddie is a radiologist. He explained that most PET in Australia is interpreted by radiologists rather than nuclear medicince physicians.

I then met with Dr. John Zalcberg, who is the director of hematology and medical oncology. Johns focus is GI medical oncology. We discussed a variety of topics related to clinical trials work in GI cancer. We also discussed the unresolved issue of the optimal schedule for preoperative radiation therapy for rectal cancer. He explained that the trans tasman multidisciplinary group is completing a randomized trial of short course preop. Therapy verus extended course chemoradiotherapy.

We then went to a conference room where I gave my talk on multidisc. therapy for hepatic colorectal metastases.

After the talk and some lunch I met with Mr.Ben Thomson, who is a HPB surgeon who trained in Edinburgh. Ben explained that HPB surgery is quite diffuse in Melbourne with approximately 8- 10 surgeons doing HPB work in approx. 10 hospitals. We talked about a variety of technical issues including the use of CUSA for liver transection.

Like the United States, Australia has a problem with obesity and many patients have fatty livers. Ben suggested that his approach to this problem was to put patients on a two week liquid only fast before liver resection. He uses a product called optifast for this. He reports that this clears the liver of a lot of fat and makes the liver much easier to work with. We also discussed the merits of laparoscopic liver resection.

March 7, 2007 Melbourne

Today I spent the day with Professor Chris Christophi and his team at the Austin hospital. This is a large teaching hospital in the northern suburbs of Melbourne. It is affiliated with the University of Melbourne.

Prof. Christophi is the chair of the department and he runs the HPB unit. The unit performs transplants and HPB surgery. A significant volume of their HPB work involves colorectal cancer liver mets. Prof. Christophi picked me up at the hotel and took me out to the Austin hospital.

He explained that Melbourne has two medical universities and general HPB surgery is distributed among 5-6 hospitals in the area although the liver transplants are all done at the Austin.

His unit is responsible for several research labs including a very well funded xenotransplantation program. The labs and investigators do rely on NIH MRC grants for ongoing support.

I met with Dr. V. Muralidharan (Murali) and Dr. Michael Fink. Both are HPB surgeons in the unit. Both surgeons trainined in Australia but they did advanced trained in HPB and transplantation in Birmingham, England. They allowed me to sit in on their audit conference. The department maintains an HPB clinical data base. This has been set up in Microsoft access. The surgeons meet weekly with the data manager and they review all cases for accuracy and they oversee the quality assurance of the data going into the database. The database includes operative details, complications and followup. The trainees in the dept. also participate in the process.

Following this we spent some time discussing interstitial laser ablation of liver lesions. The surgeons in this department have developed a lot of experience with this. A group in Germany led by Vogel is the other group who is doing this. They report they are able to treat lesions close to the bile duct without bile duct injury.

I then gave my colorectal cancer liver met talk. We then had a discussion of appropriate margins at hepatectomy after response to preoperative chemotherapy.

We had a bit more discussion and then I took a taxi back into the city to the hotel.

Prof. Christophi again picked me up at around 7 pm and took me to the Melbourne club for dinner with his team. The Melbourne club is an old time gentlemans club that provides a nice view of life in Melbourne. We were joined by DR. BZ Wang, Dr. Graham Starkey (HPB fellow) Dr. Mehrdad ( who is soon departing for additional training in the US at Mass. General and Hershey) and Dr. Bob Jones who is the main liver transplant surgeon in the unit. Dr. Jones is a new Zealander who has worked all over the world including a stint at Pittsburgh but he has been in Melbourne for a number of years.

We had quite a lively dinner with excellent food, wine and conversation. The meal was topped off with a huge round of stilton cheese. Absolutely delicious.

March 8, 2007 Melbourne

This morning we had a family breakfast. I then went to the Royal Melbourne Hospital where I met Dr. Ramin Shayan. Dr. Shayan is a surgical trainee at the Royal Melbourne who is spending 3 years doing research and getting a Ph. D. His mentor is my sponsor in Melbourne, Dr. Bruce Mann. Ramin’­s work is focusing on the relationship between VEGF and lymphogenesis and lymphatic proliferation and repair. He pointed out that VEGF D has much more general effects and more effects on lymphatics than VEGF A or B which are inhibited by bevacizumab.

Ramin is planning a career in academic surgery. He explained that Australian surgical trainees who are planning academic careers often pursue a Ph. D. in the process of their training. However, the Ph.D. entails no specific course work. A thesis is produced that must be defended before committee at the conclusion of the Ph. D. Most trainees accomplish this in three years.

Ramin toured me around the institution. He showed me the Walter and Eliza Hall institute for biomedical research. This facility is on the Royal Melbourne campus. It was established by donation from the founders but now receives ongoing support from the Australian government. We also visited the Ludwig institute. My understanding is the Ludwig is a global network of cancer research facilities. It has laboratory facilities at medical universities all over the world including Europe, North America, Australia.

We then went on to the department of surgery. The Royal Melbourne is the major teaching hospital for the University of Melbourne school of medicine and is a major site for training surgical residents and registrars. My understanding is that Australian surgical training involves a 2-3 basic training component and 4 years of advanced training in general surgery at which point trainees are eligible to sit for their fellowship examination. At this point most surgeons arrange some additional overseas training in a subspecialty area.

At this point I met with a large group of trainees under the tutelage of Dr. Julie Miller. Dr. Miller is an American trained surgeon on the faculty. She practices trauma surgery primarily and also has an interest in endocrine surgery. We discussed a number on interesting cases involving met. CRC with liver involvement. We talked about the nuances of the evaluation and surgical treatment of this group of patients.

Following this session Ramin took me on a tour of the anatomy labs at Melbourne Univ. We stopped in for a visit with Professor Ian Taylor. Prof. Taylor pioneered the use of pedicle free flaps in reconstructive surgery. He was kind enough to demonstrate a number of his research projects. Much of his work involves the use of lead oxide injection into cadaveric vessels and lymphatics and followed by precise dissection to map the micro anatomy of the vessels and lymphatics. One project under the direction of Dr. Warren Rozen, another surgical trainee, involves a detailed study of the perforating vessels through the rectus abdominis that are used in perforator flaps for breast reconstruction.

After this I then walked back to my downtown hotel. In the evening, my wife and I joined Dr. Mann and Dr. Miller for dinner at the Brasserie, a wonderful restaurant in the casino complex in Melbourne. We were also joined by Dr. Robert Thomas of the Peter MacCallum and his wife, Ibolla. We had a very nice time in this lovely Australian city.

March 12, 2007 Brisbane

This morning, Dr. Jonathan Fawcett of the HPB service at the Princess Alexandra (PA) Hospital picked me up at the hotel and took me to the PA for the day. This is one of Queensland’­s largest hospitals and center for liver transplantation within Queensland.

We joined the team for a ward round. This included Dr. Daryl Wall, one of the other consultants and senior registrar, Andrew Stabler. The team also included, several registrars. The PA has a distinct nursing unit for HPB patients. There is a separate nursing unit for transplant patients. The round included a variety of patients with HPB disease, both benign and malignant as well as some general surgical patients.

Following the ward round, I went off with a meeting with Professor Russell Strong. Professor Strong has retired from active surgical practice, but he maintains an office at PA and he is the medical director for Queenslanders Donate, a government sponored program to foster organ donation in the state of Queensland.

Professor Strong has been one of the pioneers of liver surgery, both in Australia and around the world. We had a wonderful exchange and he shared with me some of his history in liver surgery and transplantation. He explained that when he was a practicing general surgeon in Queensland, there was a virtual epidemic of trauma with liver involvement. Much of this was blunt motor vehicle trauma with drivers sustaining impact on the right side of their bodies incurring massive blunt liver injury. To more successfully manage these patients he began to learn more and more about liver anatomy and surgery. This eventually led him to a practice involving liver resection for tumor and into the field of liver transplantation. He then started Australia’­s first liver transplant program. Professor Strong’­s memories of many specifics of his patients and his career is remarkably detailed. He related several clinical anecdotes from his career (including patient names) to illustrate different points about liver surgery and the progression of his program.

Following my meeting with Professor Strong I went on to the operating theatre with Dr. Andrew Stabler. Andrew was scheduled to operate with Dr. Wall performing a distal pancreatectomy and splenectomy for a small tumor of the midbody of the pancreas. Dr. Wall explained he does not routinely do preoperative laparoscopy. Endoscopic ultrasound is available but not readily obtainable.

He proceeded with right upper quadrant incision that he describes as a jaguar incision. It involves a midline component that extends close to the xiphoid then goes down the midline and extends to the right. The operation was then carried out in a fairly standard fashion. The lesser sac was entered by dividing the omentum off the stomach with ligasure. The pancreas was then dissected over the vessels and divided sharply. The cut edge of the gland including the duct was oversewn with 3-0 prolene. The splenic vein was oversewn at the splenoportal confluence.

Following the operation, Dr. Wall and I discussed some techniques of pancreatic surgery. He indicates that he routinely does a dunking anastomosis for the pancreaticojejunostomy. This involves an inner layer of interrupeted suture that approximates the duct to the mucosa. He then uses two successive sets of interrupted suture from the bowel wall to the pancreatic capsule to invaginate the pancreas. He places a small stent in the pancreatic duct. He also explained that in patients that are compromised and he feels that there is low likelihood of carrying out a secure anastomosis he will treat them with a primary pancreatico cutaneous fistula. The fistulous drainage eventually diminishes and the drain tube is removed at six weeks.

I then meet up with Dr. Fawcett. We had a coffee and a fairly extended discussion about surgical practice, various HPB surgical personalities around the world and differences between Australian and American systems.

March 13, 2007 Brisbane

We spent most of the day relaxing and did some shopping in the afternoon. At 4:30 Jonathan Fawcett picked us up and took us to the home of Dr. David Gotley. David is an UGI surgeon and Queensland University chair of surgery. David and his wife had prepared a marvelous barbecue dinner. We had time for a brief dip in the pool with David and his sons, James and Benjamin. This was delightful fun for my son, Kai, 6 , who was longing for company of other youngsters after so much time with his parents. Other guests included Jonathan Fawcett, his wife, Kate, and John Shinfein, and his wife, Sharon. John is doing an UGI fellowship for the year with David Gotley. He is a surgeon from Newcastle, England.

March 14, 2007 Brisbane

This morning I went to the PA hospital to meet up with Dr. Shinn Yeung, one of the HPB surgeons. Before meeting with Shinn I ran into Prof. Russell Strong in the hall way and we had a chat. I asked him his opinion of laparoscopic liver resection. Prof Strong indicted that he had great enthusiasm for technical innovation,but that we need to keep in mind the fact that margin control and the oncologic integrity of the operation was paramount in many liver resections and these principles must not be sacrificed for a relatively small bit of short term benefit for a laparoscopic procedure.

I then accompanied Shinn to the OT. Shinn trained at PA and then did HPB training with Mr. Myrv Rees in Basingstoke England. The first case was a young woman with a liver lesion in segment 6 with some extension into segment 5. Shinn had decided to approach this laparoscopically. The patient was positioned supine. No lithotomy.

The scope was placed through an umbilical port site. Two 5 mm ports were placed along the right subcostal area and a 12 mm port though the midline in the high epigastrium. The right liver was quite mobile. A non anatomic resection line was demarcated with electrocautery. He then used harmonic scalpel to divide liver parenchyma. The gallbladder was taken off the liver from top down to make additional room for the resection. The remainder of the liver parenchyma was then divided with serial application of the GIA 45 stapler. The cut surface was treated with tisseel. Laparoscopic ultrasound was also used to direct the resection. The specimen was retrieved using an endocatch bag by enlarging the umbilical port site.

We then went to an off campus lunch, and we were joined by Dr. Brian Mead, a colorectal surgeon. Brian also did his residency training in the Princess Alexandra system and did additional training in colorectal surgery with Bill Heald in Basingstoke. We talked about the fact that as most Australian surgeons do some private work and some public work, they are often spread between several hospitals and this compromises their ability to do academic work.

We returned to the hospital and I watched Shinn do an open left lateral sectionecectomy for a primary liver tumor that appeared to be an intrahepatic cholangiocarcinoma. He approached this tumor through a hockey stick incision. The parenchyma was divided with CUSA on amplitude 80%, 3cc/min flow on irrigation, aspiration 100% and tissue select standard. Small vessels were controlled with diathermy and larger pedicles were sutured or clipped.

In a separate room I watched Brian Mead do a laparoscopic sigmoid resection for a small cancer. This tumor was located in the distal sigmoid and was tattooed. The patient was quite thin.

The patient was positioned in lithotomy with the legs relatively low. A standard umbilical port was placed and pneumo was induced. A 12 mm port was placed in the right lower quadrant at the level of the ASIS. This was actually fairly close to midline, avoiding the epigastric vessels. A 5 mm port was placed in the right upper abd. A 5mm port for the assistant was placed in the left mid abdomen. Brian did all of the operating from the right side of the table. The table was planed to the right. The assistant held the camera and provided some lateral traction with the 5 mm port on the left side of the abdomen.

He used harmonic to take down all attachments and mobilize the left colon to the splenic flexure. Dissection was then carried down into the pelvis. Efforts are made to not grasp the colon directly but to grasp pericolonic fat or to sweep and retract the colon gently.

After the colon was completely mobilized, the sigmoid was retracted to the left and the peritoneum on the left side of the sigmoid and prox rectum was opened. Then the space behind the superior rectal artery was opened. Dissection was then carried retrograde to dissect out the inf. Mesenteric arterial pedicle. The inferior mesenteric vein was identified. The IMA pedicle was skeletonized with harmonic and then divided with a GIA vasc. Stapler. The IMV was then dissected out and divided between locking plastic hemoclips.

Dissection is then carried down in to the pelvis to mobilize the proximal rectum. Dissection is carried down on to the rectal wall using harmonic. The rectum is divided with a long linear GI stapler.

At this point a small Rocky Davis type appendectomy incision is made in the right lower quadrant. A wound protector is placed and the colon is brought up through this incision. An appropriate point of proximal division is identified. The purse string clamp is placed and a prolene on a straight needle is passed through the clamp and back the other direction. The bowel is then divided between clamps. A 29 EEA anvil was placed and secured with the pursestring. The bowel was returned to the abdomen and the incision was closed. The EEA was introduced per anus and advanced under laparoscopic visualization. The two ends were then brought together and the anastomosis was completed under direct vision. The anastomosis was tested with insufflation under water. It was then necessary to mobilize a a bit more of the descending colon to take tension off the anastomosis.

I then asked Brian about his approach to right colon tumors. He recommended placing the camera at the umbilicus, then a 5 mm port in the midline supra pubic area, a 5 mm in the leftt lower quadrant and a 5 in the left upper quadrant. He recommended extending the umbilical port for specimen retrieval and anastomosis.

March 14, 2007 Brisbane

This morning I gave grand rounds at the Princess Alexandra hospital. I gave my presentation entitled Evolving Multidisciplinary treatments for colorectal liver metastases. There was a nice turnout from the department of surgery.

Following the talk I spent some additional time visiting with Dr. David Gotley who is planning a trip to the US in the near future. Dr. Shinn Yeung then gave me a ride over to the Wesley hospital.

Dr. Ian Martin and Dr. Nick O’­Rourke are private practice surgeons in Brisbane who do a considerable volume of hepatobiliary surgery and a lot of laparoscopic surgery. Dr. O’­Rourke is doing laparoscopic right hemi hepatectomies. Dr. O Rourke was not available today so I met up with Dr. Martin. He had a lengthy list of hernias, cholecystectomies and lap band procedures. The OR ran like a private hospital in the US with very rapid turnovers and an efficient anesthetic team.

I watched him do a laparoscopic right inguinal hernia repair. An infra umbilical incision was created and a space maker balloon was inserted just behind the rectus muscle and inflated. Two midline 5 mm ports were placed and the inferior epigastric vessels were dissected and the hernia sac was dissected. The sac was eventually divided and twisted and secured with an endo loop. Mesh was then introduced with a slit for the cord structures. The mesh was tacked to the pubic ramus and to the rectus. It was draped around the cord structures. There was a bit of oozing and a small drain was left.

We then went on a ward round and we visited with a man that had a hand assisted left lateral sectionectomy for two colorectal mets in the left lat. Segment. A vertical hand port incision had been placed in the right paramedian position. Additioanal ports were arrayed along the left side of the abdomen. Ian explained that He had taken the left lateral segment inflow close to the umbilical fissure with stapler and then come through the parenchyma , finally taking the left vein.

Ian and I spent some time talking about lap liver resection. He indicated that he thought that left lateral sectionectomy was a very safe and reasonable procedure for a laparoscopic particularly with hand control. He suggested that he thought the indications for lap right hepatectomy were less clear and that there were substantially more hazards for a lap right hepatectomy.

I then watched Ian do a lap chole. A couple of his technical points merit comment. He operated from the right side of the table. He burned through the cystic artery. He does perform routine cholangiography on every case. This takes him about 2 minutes. The gallbladder is delivered through the umbilical port site and a 5 mm camera is placed in the upper midline port for this. A 10-12 port is not used in the upper abdomen. The cholangiography catheter is introduced easily from the right upper quadrant port site.

I then watched a laparoscopic incisional hernia repair. One key point was that the camera was introduced through cut down in the anterior axillary line in the subcostal position. This afforded an excellent view of the abdomen. Two additional working port sites were placed below this laterally. The mesh was secured with two prolene sutures laterally and then with a lot of tacks. He admitted the tacks are painful but they prevent recurrence.

In the midst of his huge elective schedule Ian had to explore a woman with metastatic carcinoid that developed a bowel perforation. As it turned out this was inserted into the schedule. He found that the perforation had entered the sub q but had not perforated into the free peritoneum. He put a drainage tube in the perforation and he debrided the necrotic tissue in the sub cutaneous position.

Following this he took us over to his “rooms” This is his private office consulting space. The rooms consisted of a waiting room and two offices. He rents one of the offices out to an audiologist. He has a single office/exam room combination. He runs the entire practice with a single secretary who answers calls, schedules patients, schedules OR, and answers patient phone calls. He pays someone to come in one day a week to enter clinical data in a data base. I was struck by the fact that this is an efficient practice system and he does not need to pay an elaborate staff to perform authorizations, work with managed care companies and doing coding and billing because of the simplicity of the federal health care coverage and the private coverage.

We went back to the OR where he performed another lightning fast cholecystectomy. Following this, Ian had another hernia and a couple of lap band procedures on the schedule. I decided to go on and head back to the hotel to prepare for my evening talk.

Edinburgh and Paris

Sept 8- Sept. 9 , 2007 Edinburgh

I flew with the family from Portland to Frankfurt. We connected in Frankfurt on Lufthansa to Edinburgh.

The cab driver familiarized us with the city on the way in. The Royal Infirmary had graciously made arrangements to put us up in a serviced apartment. This very functional two bedroom unit was less than a mile from the Royal mile and the attractions of the center city.

We were quite fatigued from travel so we took a brief rest then headed out where we found dinner in an excellent pub.

September 10, 2007 Edinburgh

Professor James Garden graciously collected me at the apartment this am and brought me to the Royal Infirmary. He is the Regius professor of surgery at the University of Edinburgh. We toured the facility and reviewed some of the history of the institution. Joseph Lister was one of the earlier Regius professors.

The HPB unit at Edinburgh does transplantation as well as hepatic, pancreatic and biliary tract work. The unit does approximately 60 transplants a year. We toured the high dependency unit where many of their postop patients go after surgery. The unit is run by intensivists that are almost exclusively anesthesiologists. The transplant unit pays into the ICU pool and relationships are very good.

I then met up with Professor Steve Wigmore. Steve is a liver transplant surgeon who also runs an active basic science research program. I joined him at his weekly research conference. The research program is a collaboration with two hepatologists. The focus is on macrophage biology in the disease liver. Specifically the investigators are targeting the inflammatory mediators involved in fibrogenesis in the diseased liver. They are also looking at stem cells as potential therapy to mediate regression of hepatic fibrosis and repopulation of normal hepatocytes. I was impressed that Steve had a very nice new lab area with abundant space. This is in a research building that is adjacent to the new hospital.

Steve and I then talked some about the technicalities of liver surgery. The Edinburgh group use a cusa for transaction. He reports he routine performs the hanging maneuver for large right liver tumors. He uses a large gently curved pean clamp for this.

I then met up again with James Garden and Rowan Parks, another HPB surgeon. They described the distribution of GI cases in Edinburgh. All of the HPB surgery, and upper GI surgery is done at the royal infirmary. All of the colorectal surgery is done at the Western hospital. Since this specialist program has been introduced outcomes have improved for both urgent colorectal surgery and UGI bilary tract.

We then made plans for the rest of the week. I will be going to Glasgow to meet with the pancreatic unit run by Ross Carter. On Wednesday will going to Dundee for a Scottish HPB care meeting.

Sept. 11, 2007 Edinburgh/Glasgow

Today I traveled by train to Glasgow. Scotland is remarkably compact so it is only 50 minutes by train from Edinburgh to Glasgow. I was meet at the train station by Mr. Ross Carter of the upper GI surgery service at the Glasgow Royal infirmary.

Ross and his colleagues, Colin Mackay and Yoon Dickson perform the majority of the pancreatic surgery in Western Scotland. Their practice includes pancreatic cancer, pancreatitis and a great deal of endoscopy. The surgeons do virtually all of the ERCP, and EUS. Ross also does a significant amount of minimally invasive therapy for pancreatic necrosis. This involves image guided placement of drains in the retroperitoneum and sequential dilation and upsizing of drains to achieve adequate drainage.

Unfortunately the whipple procedure that was on the operative schedule for the day was cancelled because of medical comorbidities. This left Ross and I to talk at significant length about a variety of topics in pancreatic disease.

He shared some interesting and well edited video clips with me. One of the most interesting was of minimally invasive thoracic splanchnicectomy for pain control for pancreatitis and pancreatic cancer. This involves positioning the patient prone and making a small incision into the chest just below the tip of the scapula. A blunt port is placed and pneumo induced. A single lumen ET tube is used. A second working port is placed. The splanchnic branches are identified on the lateral aspect of the vertebral bodies. These are then cauterized with the hook cautery. The procedure is repeated on the contralateral side.

He also shared a nice video of his whipple technique. His pancreatic anastomosis involves a dunking style reconstruction of the end of the gland into the side of the jejunum. The intestine is secured to the back of the gland. The intestine is opened an additional layer of sutures is placed through the capsule of the gland. One or two duct to mucosa sutures are placed. A similar approach is taken to the anterior part of the reconstruction. Long side sutures are placed through the intestine and then up through the gland.

Ross also arranged for me to speak with Francis Regan . Francis is one of the nurse specialists on the UGI team. This group of nurses guides the patients through the continuum of care. Even when they have transitioned to medical oncology care, they remain available for questions and symptom management. This provides care that the patients greatly appreciate and it frees the consultant surgeons for additional clinical duties. Ross emphasized the importance of this group of nurses in his practice.

In between our conversations Ross went off to do several ERCPs. He reports it is typical for him to do 10 ERCP s per clinic session. I was impressed that Ross clearly has enormous facility with ERCP and his ability to do ERCP within the Scottish system gives him the ability to perform the full spectrum of interventions for pancreatic and biliary disease. He explained that ERCP is also done by gastroenterologists, but because all physicians in the system are essentially salaried by the NHS, there are no significant turf battes.

Sept. 12, 2007 Edinburgh

Today my family and I took the train from Edinburgh to Dundee. The Scottish train service is fast, comfortable and convenient. My destination was the Ninewells hospital and the University of Dundee School of Medicine. The Medical School was the site of the annual meeting of the Scottish HPB clinical network.

The Network is an affiliation of the clinicians from throughout Scotland that are involved in the care of HPB patients. This also includes the nurse specialists at each center who are dedicated to the care of this group of patients. The NHS of Scotland has established these clinical networks on a regional basis for virtually all of the major cancer sites including lung, colorectal and breast. The HPB network is relatively new. The more established networks collect data prospectively, audit outcomes and establish clinical pathways and patient referral patterns.

When we arrived in Dundee after a nice train ride, my family and I were able to get a bit of lunch. We then strolled the downtown area some and did some shopping. At this point I left my family who headed off to one of the local museums. I got in a taxi and took the short ride to the Ninewells hospital and the Medical School. The hospital and school are on a sprawling campus in one of the residential areas of Dundee. The department of surgery came to prominence under the direction of Mr. Alfred Cuschieri who was one of the early developers of laparoscopic surgery in the U.K. Cuschieri also established a state of the art surgical skills training center principally for instruction in laparoscopic techniques.

The conference was in one of the large medical school auditoriums. I had been asked to give a talk on HPB clinical care pathways in the United States. There were a series of very interesting presentations. Mr. Colin Mackay, from Glasgow, who I had met the previous day spoke on the role of EUS in pancreatic cancer. He made the point that he felt the primary utility was in evaluation of small lesions, CT negative patients, cystic lesions and biopsy of unresectable disease. He commented that with the improvements in CT scanning, EUS was rarely the determinant of whether he took the patient to the operating room. He did offer the reminder that one of the strengths of EUS was that for a group of patients it was possible to rule out cancer with a high degree of certainty and thus avoid operation.

Dr. Marianne Nicolson from Aberdeen spoke on medical oncology. She commented that Gem Cap was the primary therapy for advanced pancreatic cancer. She reviewed the findings from ESPAC 1 and talked briefly about ESPAC 3 which is designed to compare gemcitabine to 5 — FU in the adjuvant context. She talked about the positive result of the SHARP trial with sorafenib for HCC.

Dr. Dermot Mckeown from Edinburgh reviewed preoperative preparation and assessment for liver surgery. He described the Lee criteria. He reminded the audience of the morbidity of operating on patients on anti platelet therapy and the morbidity of operating in the short term after stent placement. He also reminded us that beta blockers are helpful, but beta blocker withdrawal is particularly bad. I asked him later about low CVP anesthesia. He offered the suggestion that respiratory variability in the CVP is perhaps more meaningful than the absolutely number. He rarely uses specific maneuvers to bring the CVP down.

There was also an interesting talk about Early recovery after liver surgery. This highlighted the importance of early refeeding, ambulation and epidural pain management. They also use a preoperative carbohydrate loading drink.

I then spoke on clinical pathways in the US. I described the well known volume outcome relationship in pancreatic cancer surgery. I also discussed the resistance in the US to the regionalization of pancreatic surgery.

Following the meeting, James Garden, Rowan Parks and myself all returned to Edinburgh by car. It was a lovely drive along the river Tay and through the Scottish countryside back to Edinburgh.

Sept. 13, 2007 Edinburgh

This morning Professor Garden picked me up at the apartment and we went to the Royal Infirmary. We went to the operating room (theatre) together where he had a patient on the schedule for the second stage of a two stage hepatectomy. She had bilobar metastatic colorectal cancer and she had undergone a previous left lateral segment resection and non anatomic resection of segment 6.

At this time she had residual disease in segment 7 and 8 in very close proximity to the right hepatic vein. Fortunately she had an accessory right hepatic vein. He was able to resect segment 8 with the tumor and the right hepatic vein and preserve the accessory right vein. He transected the parenchyma with CUSA with intermittent pringle control. The CVP was kept very low by the anesthetist. The transaction was nearly bloodless.

Following the operation I returned to the hotel where I took my children on an outing to the Discovery Earth museum.

Sept. 14, 2007 Edinburgh

This morning I joined Professor Garden, Mr. Rowan Parks and other members of the HPB staff on a ward round on the service. We saw approximately 20 patients with the full spectrum of HPB disease. This included several patients with pancreatitis. The Royal Infirmary group is increasingly managing pancreatitis with a multidisciplinary, minimally invasive approach. This involves image guidance for drain placement. The drain tracts are dilated and the drains are irrigated and upsized. Over time necrotic material works it way out through the drain sites. This avoids the major morbidity associated with the incision. There were also patients with liver tumors, metastatic disease, liver trauma, and pancreatic cancer. The rounds were run by a registrar with assistance from one of the foundation doctors. These are physicians generally heading towards a career in general practice who get hospital experience for a year.

After the ward round I attended a research presentation by Drs. Damian Mole and Mark Duxbury. Damian is studying the inflammatory mechanisms in acute pancreatitis. He has identified a class of mediators named kalyneurinins which appear to be a major stimulant of pancreatitis associated acute lung injury. This work was carried out in a rat model of pancreatitis. Damian has worked with Dr. Ed Deitch in New Jersey. Damian is also interested in using array technology to identify early markers for patients that will develop life threatening complications from pancreatitis. The goal is to develop an array profile that will allow a serum screen and identification of patients that will develop potentially lethal complications.

Mark Duxbury has worked with Stan Ashley at the Brigham in Boston. His work centers around cell surface markers in pancreatic cancer. While in Boston he identified a cell surface marker CEACAM 3 which is reliably expressed on PANIN 3 and invasive pancreatic cancer epithelium. This molecule also contributes to tumorigenicity and he has done a number of interesting experiments with RNA inhibitors of CEACAM 3 transcription which block tumorigenicity in SCID mouse models. This molecule may allow early identification of pancreatic cancer or PANIN and may offer a therapeutic target.

I learned that the pathway that the Univ. of Edinburgh uses for faculty development is to bring academic faculty in a the level of a lecturer. They have limited clinical responsibilities and they are expected to pursue their research close to full time. They are also expected to secure some outside funding. This period is variable in length depending on goals and funding but is often 3-4 years in duration.

I also heard presentation from two of the research trainees. These young surgeons generally have completed 2-3 years of basic surgical training. They then have to compete for research training slots. They then have the opportunity to do research full time for 2-3 years before returning for the remainder of their clinical training. The presentations involved work in the department on the biology of cancer cachexia and liver stem cell biology.

I then gave a talk to the department entitled Evolving multidisciplinary approaches to hepatic colorectal metastases. Following the talk, Professor Garden very kindly took me for a pint of ale in a classic Scottish pub. We were joined by Mr. John Forsythe of the transplant service.

Sept. 15, 2007 Edinburgh

The family and I spent a relaxed day touring Edinburgh and doing some shopping. The weather was a bit cool and rainy but still pleasant.

Sept. 16, 2007 Travel to Paris

September 17, 2007 Paris

This morning I arose and took the Paris Metro out to the suburb of Creteil where the Hopital Henri Mondor is located. This facility is a 1000 bed general hospital run by the French health service.

I met Dr. Daniel Cherqui who is chief of digestive and GI surgery. He is a noted hepatobiliary surgeon and he has done much to develop laparoscopic approaches to liver resection. He also does transplant surgery. He leads a 6-8 surgeon group that does a significant amount of HPB surgery, but also does general GI surgery including bariatrics. They also take general surgery call.

The morning routine at Henri Mondor consists of a team morning report followed by coffee in the lounge. We then went on a brief ward round. Prof. Cherqui explained that France has a significant nursing shortage and it is preventing them at times from completing a full surgical schedule.

We then went to the operating room where Prof. Cherqui had a patient with two CRC liver mets. One large lesion was deep in segment 5 near the gall bladder fossa. The other lesion was in the caudate. He had decided to perform a right hepatectomy with in continuity caudate resection. This was an open procedure. He explained that he selects patients for laparoscopic liver resection very carefully.

He did several things that were interesting. He isolated and divided the inflow to the caudate very early. He dissected these pedicles off the left portal pedicle. The caudate was then turned to the right and he was able to lift it off the cava, taking some small caudate IVC branches.

He then dissected the hilum, starting high and lateral to expose the right artery and the portal vein. Much of the dissection was done with a bipolar forceps — a device rarely used in the US. Once the inflow was controlled, the right liver was mobilized. He took time to show me the hanging liver maneuver. The key here is dividing the inflow, then lifting the liver up off the cava and dividing the inferior caval branches. A large gently curved right angle or a pean clamp are passed gently up the center of the cava. An umbilical tape is then passed from between the right and middle veins down to below the liver. He did go ahead and divide the right vein with the stapler.

The liver parenchyma was divided with intermittent pringle control. The clamping periods were as long as twenty minutes. He had also encircled the middle and left veins. This allowed control of backbleeding. He admitted that this maneuver is often not necessary if the CVP is low.

The liver transaction was done using irrigating bipolar forceps which provide nice hemostasis on smaller vessels. The remainder of the parenchymal division was done with CUSA. Cherquie admitted that he had used clamp fracture technique in the past but had recently switched back to CUSA because he felt it was more precise. The most difficult portion of this particular resection was getting around behind the portal vein to resect the caudate and the caudate process. During the final portion of the resection he clamped the middle hepatic vein to prevent venous backbleeding during the final phase of transaction. This allowed dissection right down along the middle vein without the vision being obscured by venous bleeding.

Following the transaction, the Europeans rarely use argon beam coagulation as we do. A sponge-like product named tacho sil is applied to the cut surface of the liver and this provides hemostasis and controls biliary leak. A single drain was left in this case.

Following the operation we went for lunch in the hospital cafeteria. This was a sit down affair with silverware and glassware. The food was remarkably good and charmingly served. We were joined by Dr. Claude Tayar. Dr. Tayar is a GI surgeon who does a lot of laparoscopic bariatric work.

Sept. 18, 2007 Paris

I took the day as a family travel day. After breakfasting, my wife and children and I took the train out to Versailles. We had a very nice time exploring the grounds which were beautiful and expansive. We also toured the royal apartments in the Versailles palace. Home to Louis XIV and Marie Antoinette, these rooms were beautifully preserved. They gave us a feel for the opulence of French royal living at the time.

On the trip home we had an early dinner in a brasserie and ascended the Eiffel tower for a spectacular view of the city. Although I had been to the tower before I am always awed by its graceful silohouette. The view from the top observation platform was breathtaking.

Sept. 19, 2007 Paris

I joined the team at the Hopital Henri Mondor this morning for morning report at 8:15. Per custom this was followed by coffee and discussion. I spent some time talking to the international fellows, Raphael Miller from Israel and Richard from Australia. These surgeons have come to spend variable amounts of time in France. They work only in the operating room assisting and learning. They have no real clinical responsibility for the care of the patients outside of the operating room.

We then went to the OR where Prof. Cherqui was performing a laparoscopic left lateral segment resection for HCC. The patient had early cirrhosis but no portal hypertension.

The patient was position in a split leg position on a Maquet table. Access to the abdomen was obtained by veress needle approx. 3 cm above the umbilicus. Two 10 mm working ports were placed above and lateral to the camera ports. Two additional 5 mm ports were placed in the right and left subcostal areas , laterally. The falciform ligament was transected flush with the abdominal wall.

I took detailed notes of the technical aspects of this procedure. In brief the round ligament is used for retraction. The entire left lateral segment is dissect to the left hepatic vein. The parehchymal division is done using harmonic down to the pedicles which are stapled. The vein is then stapled. The specimen is placed in a bag and brought out through a lower abdominal incision. There was virtually no blood loss.

September 20, 2007 Paris

This morning, I joined the other international fellows in the hospital caféˆ before heading to the operating rooms.

The French have a fellowship program that is quite different from the American model. The fellows assist in the operating room, but have essentially no clinical responsibility for preoperative or postoperative care and they do not take call for emergencies. The current group of fellows includes surgeons from Romania, Australia and Israel.

The cases today included an extended right hepatectomy for a very large HCC in a non cirrhotic liver and a biliary reconstruction in a patient with a bile duct stricture after choledochoduodenostomy. The two operating rooms were side by side.

One of the differences between the European system and the American model is that at least in France, a team approach is taken to the operative care of the patients and all major decisions go through the professor. Today, senior hospital surgeons on the Henri Mondor staff, started the operations in both rooms, but Professor Cherqui traveled between both rooms and operated himself during the most critical junctures of each case. This means less autonomy for the surgeons, yet I also think it creates a very collaborative team dynamic.

The patient with the large HCC was operated on using an extended J shaped incision that provided good exposure. An anterior approach was utilized. A hanging maneuver was performed. A standard hilar dissection was performed. A slight modification was made to the hanging maneuver. The space between the middle and the left hepatic veins was dissected and the retrohepatic tape was repositioned to this space. This allowed the line of transaction to come down directly on the left hepatic vein. This did narrow a left vein branch which did cause some congestion in the remnant.

After the cases there was a staff meeting in which all new patients were reviewed and plans for management were discussed. Following the case discussion. I gave my talk on chemotherapy for liver mets. I admitted my chagrin at presenting French data in France.

Sept. 24, 2007 Paris

Today I traveled to the Northern Paris suburb of Clichy, Where Professor Jacques Belghiti is the professor of digestive surgery and liver transplantation at Public Hospital Beaujon.

This is an enormous 16 floor general hospital. Professor Belghiti’­s unit is on the second floor and it is a self contained unit which performs only hepatic and pancreatic surgery and liver transplantation. There are two additional surgical professors, Olivier Farges and Alain Sauvenet.

The unit includes an ICU, a ward, a three room operating suite and offices and meeting space. I joined the later portion of the team meeting in which all patients are discussed.

Professor Belghiti then showed me around the unit and we discussed some clinical cases. He noted that he is increasingly seeing cases of HCC arising in patients with NASH (background of obesity and diabetes). Often the liver has normalized by the time the patient develops HCC and they can be safely resected. We then discussed a patient with a large left liver tumor. The patient is scheduled for surgery the following day. He is clearly resectable only with an extended left hepatectomy. I asked about the possibility of preoperative portal vein embolization. Professor Belghiti explained that he believes portal vein embo is risky on the left side. He also explained that if the posterior sector is left intact the patient will always have at least 30% functional residual volume. Moreover, he explained, the most critical element in the function of the remnant is the outflow. If the right hepatic vein is preserved ( as it should be in an extended left) the remnant will recover nicely.

I then spent the remaineder of the day observing two interesting cases. In one room Professor Sauvenet was performing a Whipple for IPMN in a patient that had suffered from a previous episode of acute pancreatitis. There were many inflammatory changes and adhesions and the dissection was difficult. As I am learning is common in France, he used the bipolar a great deal for dissection. Of note he did do a pancreaticogastrostomy which I had not seen before. He simple opened a small mucosal defect in the back wall of the stomach and sewed in multiple duct to mucosa sutures through the body of the gland. He explained that if the PD is particularly small he will perform the same technique and use a pancreatic stent.

In the second room the team was performing a liver transplant for alcoholic cirrhosis. The liver was incredibly scarred in and had to be excavated for the hepatectomy. They perform a temporary portal caval shunt while the patient is anhepatic and they leave the cava open as much as possible. The graft is piggy backed on to the left and middle hepatic veins.

Sept. 25, 2007 Paris

Today I joined Professor Belghiti in the operating room for the surgical management of the patient whose films I reviewed yesterday. This patient has a history of fatty liver disease and now has a very large HCC involving all of segement 4 with extension into the right anterior sector and segment 2.

This proved to be an extraordinarily challenging resection because of the size of the tumor and its proximity to the hilus. The general strategy was to control and divide the left portal pedicle and subsequently divide the right anterior sectoral pedicle. The tumor sat right over the hilus and made this difficult. It was eventually necessary to resect segment 1 to obtain a proximal division of the left portal vein. The right hepatic artery was extremely difficult to identify. Prof. Belghiti repeatedly used the Doppler to make sure that he had perfusion of the right liver particularly the posterior sector.

He did demonstrate a novel development of the hanging maneuver. The space between the right and middle hepatic veins was dissected using a long right angle vascular clamp. An NG tube was then passed from this space to below the liver in the precaval plane. The tube was then used extensively throughout the resection to guide the appropriate resection plane in front of the right hepatic vein.

Professor Belghiti then began the transaction with the plan to control the right ant. Sectoral pedicle within the parenchyma. The transaction was performed using intermittent inflow occlusion. The CUSA as well as bipolar were used for division. Eventually the pedicle was identified and divided near the end of the transaction. Following transaction the bile duct was thinned and damaged in several places. This was meticulously repaired with 5-0 Maxon. Dr. Belghiti did note that biliary complications were now the greatest challenge in the arena of resectional liver surgery.

Following this difficult operation, we chatted some more before I returned to the hotel to catch up on work. We spent some time talking about the various personalities in the field of hepatobiliary surgery.

September 26, 2007 Paris

I returned to Hopital Beaujon this morning. The general function of the unit centers around a morning meeting that generally runs from about 0830 to 0930. The resident staff reviews all service patients with the senior staff. This is also used as a teaching conference. The trainees are questioned about individual patients and clinical management as well as general questions about disease management. Following conference, the operating room begins. Most of the cases do not actually get going until about 10 am. It is typical to have all three rooms in the hepatobiliary suite running. Most transplants seem to occur during the day and there is some disruption of the elective operative schedule.

Following the morning meeting, I went to the operating room to observe a left pancreatectomy/splenectomy. This resection was performed for a large, mucinous tumor. The general operative approach was straightforward. A left subcostal incision was utilized. The gland was dissected over the mesenteric vessels. The splenic vein and splenic artery were dissected and ligated. The specimen was then dissected right to left. The pancreatic remnant was managed by direct oversew of the duct with 5-0 prolene and then oversewing with figure of 8 sutures again with 5-0 prolene.

I spent the afternoon catching up on email and work from home. At 5 pm I gave a talk entitled, “Controversies in the multidisciplinary treatment of pancreatic cancer.” The audience was the weekly medical/surgical GI conference. The talk was politely received and many thoughtful questions were answered. I am continually amazed at the Europeans ability to speak multiple laqnguages with ease. I am somewhat embarrassed on my inability to speak anything other than English.

This evening Professor Belghiti kindly offered to take me out to dinner. I took the Metro down the Montparnasse area. I was able to find his apartment without difficulty. I met his wife then we headed out for a restaurant in his neighborhood. We went to a small neighborhood run by this friend, George. We enjoyed a superb coq au vin. The food was hearty and delicious. We had a wonderful time talking about career challenges and the different personalities that that are involved in liver surgery around the world. The time with one of the foremost liver surgeons in the world was one of the greatest pleasures of the trip.

September 27, 2007 Paris

As per the routine, the day began with the usual review meeting at Hopital Beaujon. The patients were discussed and plans were made. Although I could not follow much of the discussion as it is in French, I take from the tone of the interchanges that Professor Belghiti continuously challenges his trainees with questions to think not only about the individual patients but clinical research questions that arise as they care for these complex patients with hepatobiliary disease.

I then went to the operating room. The patient was an Asian man with an extremely large HCC in the left liver and a satellite lesion in segment 8. He had normal liver without cirrhosis. The particularly challenge element of this case was the fact that there was thrombosis of the left portal vein and in fact, some extension of tumor thrombus in the right side.

The operation proceeded with mobilization of the gallbladder and cannulation of the cystic duct. The hilus was then dissected. The operation was started by Dr. Safi Domkak. Safi is a Lebanese born surgeon who works at Beaujon as a hospital practitioner surgeon. These hospital practitioners are a group of fully trained surgeons who work throughout France. They are not full academic staff. The position seems to be a bit of a hybrid between fellowship and what we would consider as junior faculty in the United States. They work independently, yet they ultimately serve the professor and do the cases that he or she assigns them.

The portal vein was dissected and controlled proximally. The right PV was also controlled. At this point, Professor Belghiti came into the case. He found and ligated the left hepatic artery. He often uses the Doppler to confirm portal and arterial flow. He did so at this junction. He then controlled the proximal and right portal vein. He then opened the vein and extracted the clot. He also divided the left portal vein. The portal vein was closed with a combination of interrupted and running suture. He encircled the suprahepatic cava and then temporarily occluded the cava to help back flush the portal vein by occlusion of the hepatic veins.

He then placed a hanging tape. This involved control of several small spigelian veins and dissection of the space between the right and middle hepatic veins. A right angle vascular clamp was used to dissect the space from above and the NG tube was passed.

The transaction was commenced. The left and middle veins were then encircled and the hanging tape was repositioned behind the veins and then around the arantius ligament. This guided the transaction down to the veins and facilitated transaction of the Arantius ligament which separated the left liver from the caudate. The transaction was done with the usual combination of CUSA and bipolar.

The day was completed with the weekly multidisciplinary staff meeting. This meeting is for case review and planning for the next weeks clinical activity. Professor Belghiti asked that the meeting be conducted in English primarily for my benefit. I also belief that he pushes his staff to develop their English presentation skills to facilitate presentations at international meetings. This was a superb multidisciplinary meeting. The cases were a complex and challenge set of hepatobiliary and pancreatic lesions, almost all tumors. The discussion was at an extremely high level. I was particularly impressed by the insights of Professor Valerie Vilgrain who is the director of the imaging services at Beaujon and an expert in pancreatic and hepatobiliary radiology. I was also impressed by the ease with which virtually all participants transitioned between French and English.

September 28 – 29, 2007 Paris

I spent Friday, the 28th doing some exploring of Paris on my own, as I my wife and children had returned to the United States the week before. I had a very nice visit to the Picasso museum which is in a lovely villa in the Marais, one of Paris’­ most charming districts. I also did some shopping and prepared for the trip home on Saturnday, September 29. It was a wonderful way to conclude my James IV travel experience.

Conclusions

There is no doubt that the opportunity to travel on the James IV fellowship has been one of the great highlights of my career. It has been an experience that has renewed my commitment to my career in academic surgery. The opportunity afforded to watch the technical approach of a number of master hepatobiliary surgeons has clearly strengthened my own ability to plan and perform these challenging operations.

The greatest lessons of the fellowship, however, go far beyond surgical technicalities. Travel of this nature reminds one that the world is indeed very small and we are all united by far more commonalities than differences that divide us.

During my travels, I gained broad exposure to a variety of systems of care and models of departmental organization. I anticipate that I will call on these experiences as I work to develop programs of multidisciplinary cancer care in my own institution.

Lastly, I observed an extraordinarily high level of surgical care delivered to patients in a variety of different health care systems. In all of the systems I visited, medical care was in essence guaranteed and accessible to all members of the populace. This is in stark contrast to our patchwork delivery system in the U.S. I found it difficult to explain our system to my hosts, and even more difficult to defend. This experience clearly sharpened my focus and commitment to help address the problem of health care access within the United States.