Report of the AUGIS Travelling Fellowship 2013 Visit to the National Cancer Centre Hospital and the Cancer Institute, Tokyo, Japan. Miss Jolene Witherspoon, University Hospital of Wales In 2013, I was awarded the AUGIS travelling fellowship visiting two world-leading hospitals for oesophagogastric cancer surgery in Tokyo; the National Cancer Centre Hospital (NCCH) for three weeks and the Cancer Institute for one week. National Cancer Centre, Tokyo In Japan, gastric cancer carries the second highest mortality rate after lung cancer for males and records the third highest for females after colorectal and lung cancer. The proportion of gastric cancers has decreased since the 1960s with the national screening rate increasing but remaining low at 36.6% for males and 28.3% for females in 2010. The NCCH, in Tsukiji, accommodates approximately 1,000 new and follow-up outpatients daily, and has 600 inpatient beds. The Gastric Division, led by Dr Hitoshi Katai, comprises 4 staff surgeons (Dr Fukagawa, Dr Morita, Dr Fujiwara), 2 chief residents and 3-4 rotating residents. Approximately 400 gastrectomies are performed annually and I witnessed several pyloruspreserving gastrectomies, which are only performed for early gastric cancers (EGC). These can be resected with an acceptable margin, leaving a minimum of 4cm of antrum. The lesions are clipped endoscopically prior to surgery to allow intra-operative identification. The 5-year survival rates for stage IA, IB, II, IIIA, IIIB and IV disease in NCCH are 94, 91, 79, 60, 45 and 15% respectively. The Gastric Division actively recruit patients for a number of clinical trials; the current JCOG 1001 trial is evaluating the significance of bursectomy for patients with gastric cancer and patients are randomized to bursectomy or omentectomy alone and I witnessed both meticulous techniques. Each day began at 7.45am with a consultant-led ward round although the residents started work at 7am. On the ward round, residents performed dressing changes and sterile aspiration of pancreatic fistulas/abscesses through open drains. Due to the extensive lymphadenectomies performed routinely for patients with gastric cancer, approximately 16% will develop these complications. Surgery commenced at 9.30am and gastrectomies for EGC were performed by residents (3-4 years post-graduation), whereas the chief resident was the primary surgeon for more advanced cases. The lead consultant scrubbed and would discuss the finer parts of the procedure, demonstrating techniques to the scrubbed staff and an audience of myself and other residents who perched above the operating table on stools. The dedicated unscrubbed residents would practice knot-tying on their scrubs throughout the procedure. The Oesophageal Division, led by Dr Tachimori, consists of 3 staff surgeons who perform approximately 120 oesophagectomies per year and they train a chief resident and 2-3 rotating residents. The 5-year survival rates for stage IA, IIA, IIB, III, IVA and IVB disease in NCCH are 80, 71, 73, 37, 21 and 28% respectively. My time with the Oesophageal Division coincided with a conference, which limited elective surgery. During this period, I visited the endoscopy unit, headed by Dr Saito, and observed Endoscopic Submucosal Dissections (ESD) of the oesophagus and stomach and an Endoscopic Mucosal Resection (EMR) of the duodenum. The Endoscopy unit is vast; annually they perform approximately 360 gastric ESDs including treatment for 330 EGCs. ESDs are performed under propofol infusions administered by the gastroenterologists and patients remain in-patients for 5 days. There were travelling fellows from all over the world visiting this unit to learn advanced endoscopic techniques. I was impressed by the diagnostic ability of the endoscopists for early lesions using chromoendoscopy. For the final week of my fellowship I visited the Cancer Institute Hospital of The Japanese Foundation for Cancer Research (JFCR) in Ariake under the supervision of Dr Takeshi Sano who is the Department Director of Gastroenterological Surgery. This hospital is a short train ride from Tuskiji, sits on the waterfront and has approximately 700 beds. Dr Sano is world famous for developing and publicising the techniques for D2 lymphadenectomy and has travelled extensively in order to educate others on surgical techniques. His team comprises 3 other consultant surgeons: Dr Yamaguci, Dr Hiki and Dr Ohashi, and 8 residents. They perform approximately 550 gastrectomies annually, approximately half of these are performed laparoscopically. Dr Sano and his Unit have demonstrated the importance of team working, technical expertise and high volume. At both hospitals, I attended MDTs which are led by the surgical team and attended by gastroenterologists. In turn, the surgical residents were encouraged to present patients in English, including their endoscopic findings, radiology, surgery and histopathology. I was informed that this was in preparation for presenting their research to International meetings and also for my benefit, which was greatly appreciated! Outside of my scheduled time in the hospitals, I spent my weekends discovering Japan; travelling within Tokyo, to Yokohama and further afield on the high-speed train (Skinkansen) to Kyoto in West Japan. My visit coincided with the rainy season (tsuyu) but thankfully the rainfall was light, although it was hot and humid. I was overwhelmed by the beauty and serenity of the temples and parks. I watched a Geisha performance, a traditional puppet show, bathed in an Onsen (hot natural mountain spring) and fell in love with Japanese food. I thank AUGIS for awarding this fellowship and also Dr Sano, Dr Katai and their colleagues for warmly welcoming me to their centres of excellence.