Mark Bloomston, M.D.
Assistant Professor of Surgery
Division of Surgical Oncology
The Ohio State University
2009 James IV Traveling Fellow Summary
I had the fortune of being selected as a James IV Traveling Fellow for 2009. While I was tremendously honored to even be nominated, being selected was truly humbling. I immediately sought advice from previous travelers (Tim Yeatman, John Sweeney, and Richard Shulick) as well as other James IV members and respected members of the surgical community (Murray Brennan, Yuman Fong, Jean-Nicolas Vauthey, and James Garden). With their invaluable assistance, particularly Dr. Brennan, I planned a two-part trip to Europe then Hong Kong and Australia to visit some of the world leaders in liver and pancreas surgery.
Reading the reports from previous travelers and discussions with people directly and indirectly familiar with the experience still did not prepare me for the magnitude of the experience. As someone early in his career that has not done much traveling abroad, to describe this experience as life-changing would be a gross understatement. I gained an entirely new perspective in the management of HPB malignancies, learned new techniques of surgery, formed research collaborations, and forged new friendships; all clearly embodying the spirit of the award. I was immediately amazed by how quickly and enthusiastically my travels were embraced by each prospective host. Given the complexity of coordinating multiple visits in succession to foreign countries, the assistance offered by each host and his team was invaluable and made for a smooth trip.
Trip 1: Europe, June 2009 (4 weeks)
The first trip was planned for four weeks to tour major centers of excellence in HPB surgery throughout Europe. This included visits to see James Garden in Edinburgh, Pierre Clavien in Zurich, Claudio Bassi in Verona, Markus Buechler in Heidelberg, and Jacques Belghiti in Paris. Through the generosity of my division chief, Dr. Bill Farrar, I was fortunate to be able to bring my wife and three daughters (we left the 2 year old with the grandparents) with me for the entire month. Not only was the trip professionally fulfilling, the impact it has had on my family is immeasurable. Not a day goes by where we don’t reminisce about our experience.
My journey began in Edinburgh, Scotland where I was hosted by Professor James Garden at the University of Edinburgh. The hospitality from him and his team was outstanding. I was warmly greeted by Professor Garden at the New Royal Infirmary of Edinburgh where we had some time to discuss some of the history of the department and the hospital.
We met Rowan Parks and Stephen Wigmore (both previous James IV travelers) and the rest of the HPB team for morning rounds. The service consisted of the full gamut of HPB patients with benign and malignant diseases, along with various complex General Surgery patients from emergency in-take. Rounds were truly multidisciplinary and the highlight of the visit.
Basic and translational research is clearly a central component of the Department of Surgery. A tour of the newly opened Biomedical Research Facility demonstrated state-of-the-art labs with fully functional core facilities. The majority of the principal investigators had R01-level funding with Surgery residents playing an active role in many of the labs. Mr. Wigmore arranged a nice afternoon of scientific presentations which highlighted their high-quality research.
Dinner was with Rowan Parks, James Garden, and Neil Mortensen (colorectal surgeon from Oxford and James IV member). We had dinner at the New Club of Edinburgh which was very exclusive and offered a beautiful view of the castle. We discussed many issues, including the future of medical journals.
We had rented an apartment on the Royal Mile, which captured the essence of Edinburgh. The days ended early enough to spend great quality time with the family visiting the castles and walking the city.
In Zurich, I was mostly hosted by Stefan Brightenstein. We met at morning report then straight to ICU rounds with the consultants and fellows. These were all HPB patients ranging from liver transplants to acute pancreatitis. The strong research atmosphere that Professor Clavien has created was immediately palpable. Ward rounds were also completed as a group, including residents, students, and fellows.
Everyone was naturally inquisitive and continually discussed ongoing projects and new ideas in the context of patient care, continuing into the multidisciplinary clinic. The operating theatre was certainly in line with the academic theme. During the course of two hepatectomies (one for colon metastases and one for gallbladder cancer), studies were undertaken on ischemia-reperfusion and tissue collected on protocol.
We then toured the research facilities, which were quite extensive. The lab was quite active and state-of-the-art including capabilities for small and large animal surgery and imaging.
Zurich was beautiful and quite easy to manage on foot and by tram. While I had limited time to visit the city, my girls still refer to it as one of their favorite stops.
Professor Claudio Bassi was a most gracious host and embodied the Italian spirit. I was greeted with a hug at morning report and immediately treated like one of the team. Case discussions were open and honest with the expected underpinning of evidence-based medicine. As one of the busiest pancreas units in Italy and all of Europe, the University of Verona has been instrumental in shaping modern pancreas surgery.
In the operating theatre, there was never a rush but the cases always moved along. I was fascinated to watch a radiofrequency ablation for a locally advanced pancreatic cancer, marking their 92nd patient undergoing such treatment.
I had an opportunity to visit the new research facilities housed in the Department of Pathology run by Aldo Scarpa. Although Professor Scarpa was away, his team graciously gave me a tour and we had opportunity to discuss ongoing research between our two institutions.
Professor Bassi had arranged adjoining rooms at the nearby Hotel Siros which comfortably accommodated my family. The hospitality was outstanding and Verona did not disappoint as an enchanting city.
In Heidelberg, we found a place we would happily call home. We rented an apartment within walking distance of the University of Heidelberg, the Neckar River, and the Heidelberg Castle. There were sites and playgrounds around every corner for the kids and the Germans were incredibly welcoming.
The magic, of course, was visiting Professor Buechler and what is arguably the heart of pancreas surgery. The Department is incredibly busy, full of HPB surgeons who find time to maintain great academic productivity. Each faculty member manages a database and is given resources to manage a research team.
They clearly demand high level productivity from themselves. The highlight of the trip, though, was the two to three hours spent with Professor Buechler in his office drinking coffee, discussing clinical trials in Germany, his thoughts on building and maintaining a productive department, and his views on modern academic surgery.
I was impressed by the devotion to data management, clinical protocol, and tissue collection in spite of the tremendous volume of surgery.
I met Professor Jacques Belghiti at morning conference on Friday at 9:30AM. He welcomed me and immediately invited me in and introduced me to the faculty and residents. Professor Belghiti has developed a truly modern Department of Surgery, surrounding himself with many young, energetic surgeons, nearly half of which are women. The discussion was lively and the Professor clearly respected everyone’s opinion. Friday conference was to discuss cases for the following week. Every case was discussed openly and at length. They referenced literature and described their own experience as well. The day ended early and I was encouraged to enjoy Paris with my family, which I did.
Monday’s cases were the expected bevy of complicated liver cases. Professor Belghiti did not disappoint as he demonstrated the hanging maneuver to better access a posterior lesion along the IVC in what he termed “segment IX.” The common theme each day was collegiality, multidisciplinary discussion, and evidence-based medicine.
On the last night we had a nice dinner at Chez Fernand with Dr. and Mrs. Belghiti. The conversation was light and friendly. We discussed US economics, politics, and geography.
Trip 2: Asia/Australia (2 weeks)
For the second leg of the trip, we left the kids behind with their grandparents for the long journey to Hong Kong. We were met by Professor John Wong on Sunday morning in a traditional Chinese teahouse where we ate dim sum. Most of the conversation revolved around life in Hong Kong, family, plans during our visit, etc. He did speak about his training in Australia and his views on the evolution of the Department of Surgery at Hong Kong University. He was amazingly kind and made my wife and I feel quite welcomed.
The remainder of my visit to Hong Kong was largely orchestrated by Professor Poon. There was no detail left unattended. Cars promptly met us everywhere and a gift basket from Professor Fan welcomed us to our hotel room. I was met on Monday by Dr. Poon, and ushered directly to the operating theatre for a live donor right hepatectomy. As expected, the dissection was meticulous. There was a crowd of visiting surgeons but, as the James IV traveler, Professors Poon and Lo made sure I was always part of the case. Following surgery (and a traditional Chinese lunch), I was granted a tour of the research facilities. Members of Professor Poon’s lab presented their work where we had a lively discussion. The lab residents were familiar with my interests and tailored their presentations accordingly.
The Hong Kong Jockey Club was the setting for a Chinese dinner hosted by Ronnie Poon and his wife. They were most gracious hosts and amazed us with their devotion to academia and their account of life in Hong Kong with a large family and busy careers. They were glad to finish their day “early” with us around 10:30PM.
The next two days were filled with operative cases, multidisciplinary cases conferences, and resident presentations of clinical research. Dinners ranged from a Western motif in the “Central” with visiting surgeons from India, Saudi Arabia, and Great Britain to a traditional Chinese theme with house staff and junior faculty on our third night. Common were great hospitality and lively diverse conversation. Thursday and Friday we were left to our own devices. We went to Macao to do a little gambling and walked up and down the streets of Hong Kong shopping. Of course, we took the opportunity to watch the nightly skyline light show along the river.
For our last stop, we arrived in Adelaide on a Saturday afternoon. We were able to unwind and walk the beach. Sunday we went to Barossa Valley for sightseeing and wine tasting. That night, Dr. Rob Padbury picked us up at the hotel to take us back to his house for dinner. Being a wine expert, he and his wife treated us to great wine and food. I was the 3rd James IV traveler to visit their home in the last 12 months.
The next two days gave me the opportunity to visit both Flinders Hospital and the Royal Adelaide. Discussions of complex HPB cases focused on multidisciplinary approaches and protocol-driven therapies. These conferences were lively and honest and reflected their state-of-the-art management. Evident throughout all patient care was Dr. Padbury’s commitment to quality control and minimization of errors.
In summary, to describe this experience as an opportunity of a lifetime just doesn’t give it justice. Professionally, I learned both technical and philosophical approaches to diseases that I have been able to immediately incorporate into my practice. I formed collaborations which have already proven fruitful and developed friendships that will hopefully last a lifetime. Personally, it gave me an opportunity to spend time with my wife and children in a way that few get to experience. Not a day passes where we don’t reminisce about our whirlwind tour through Europe.
I thank the members of the James IV Association of Surgeons for their generosity. I would also be remiss if I did not thank my Chairman, my Division Chief, and my partners for graciously supporting me and my practice through this process.
Mark Bloomston, MD
Assistant Professor of Surgery
Division of Surgical Oncology
The Ohio State University