A quest to learn from the best
Gastroenterologist spends seven months in Japan to learn new technique
After practising Gastroenterology for 13 years, Ralph Lee, MD, MMed(Dist), FRCPC, wanted to learn something more, something career changing. That something more, the Ottawa physician decided, would be a new, challenging technique for removing difficult, often oversized, polyps.
Dr. Ralph Lee (Submitted photo)
As a gastroenterologist, Dr. Lee frequently removes polyps in the colon that can become cancerous. Most (90%) are less than a centimetre and are easily removed, but the five per cent that measure more than two centimetres “require a bit more advanced skill,” he explains. Some even measure greater than 12 centimetres, while others are significantly scarred, and with greater difficulty comes greater risk. A procedure pioneered in Japan and commonly used in Asia could be the best solution for some patients, but it is rarely used in the West. Dr. Lee wanted to learn how to do it and, eventually, perform the technique in Canada.
Comparing two procedures
The main procedure in Canada, Endoscopic Mucosal Resection (EMR), involves using an electrified snare to take a larger polyp off, piece by piece, resulting in multiple tissue fragments. The more invasive procedure Dr. Lee sought to learn, Endoscopic Submucosal Dissection (ESD), involves removing larger polyps in one complete piece. For the right patients, it’s been proven to reduce the incidence and mortality of colorectal cancer.
“There are certain polyps that, the bigger it grows, the more chance it can turn into a cancer,” says Dr. Lee. “When a polyp starts invading into the wall, past certain layers, it basically becomes a cancer. And at that point, if it invades too deep, we can’t remove it through endoscopy, and we have to send the patient to surgery.”
When the polyp is cut out in one piece, the pathologist can look under a microscope to see if the margins – the outside borders and the deep border – are clear of the lesion, which can usually save patients from having to undergo surgery, he explains.
“But if you take it off in several pieces, using the EMR method, the pathologist receives multiple fragments. It’s like a jigsaw puzzle; the pathologist can’t tell where the outside and deep borders are, so they can’t tell you whether the margins are clear of polyp or not.”
Eastern advantage
“In ESD, you’re actually navigating in the wall of the colon, which is really thin, but the Japanese have developed a technique where they can do it very quickly and very safely.”
To learn to do it right, Dr. Lee says he felt he had to spend some time in Japan.
“They’ve done ESD studies that compared Western-trained doctors versus Eastern-trained doctors, and they found that there’s definitely a difference between the two. The ones who were trained in the East and actually went to Japan to learn had lower complication rates and better success rates, because you’re actually learning from the true masters, the ones who developed the technique.”
Dr. Ralph Lee at Kanazawa Castle, Kanazawa, Ishikawa, Japan, during his sabbatical in November 2019. (Submitted photo)
Learning from the master
Dr. Lee decided he wanted to take a sabbatical to learn alongside a master of the technique, professor Hironori Yamamoto, at Jichi Medical University in Shimotsuke, Tochigi, Japan. “I’m not exaggerating, he is probably one of the best, if not the best, [at ESD], in the world,” he says.
The opportunity to ask came following a lecture at an ESD training course just outside of Chicago, Illinois.
“I said, ‘Can I do a sabbatical with you?’ The answer, in short was, ‘Yes, we can’t pay you, but absolutely you could come for that.’”
Dr. Lee made it clear he wanted to do more than just stand back and watch the procedure. He wanted hands-on experience. As such, he would have to come for at least six months.
After getting all of the paperwork done, securing a visa and making arrangements to cover his practice at The Ottawa Hospital, there was also the matter of seven months with no pay. “I had to essentially bite the bullet and just do it,” he says.
Starting at square one
Although Dr. Lee arrived with impressive credentials, including previous advanced EMR training in Sydney, Australia, he would need to start at the very beginning.
“The Japanese are very regimented in their approach. They firmly believe that you should start from the bottom and work your way upwards…I’ve done advanced training in Australia. I work on advanced cases. But, to be quite honest, it didn’t impress anybody. The bottom line is, I had to start at the beginning again with this process.”
That meant just observing for the first six weeks and preparing the room. Then, the student advanced, but only a little.
“They want you to become a true master of every aspect of the procedure so that you can troubleshoot it yourself if you run into problems.”
“For the next six weeks, I was the second assistant, which means I wasn’t scoping, but I would hand them the instruments and then take the instruments from them, basically refilling the solutions and things like that. And then after that, I went on to being first assistant, which meant I was still not actually the one doing the scoping, but I was the person right beside the person doing the scoping. I would basically feed the instruments down the centre of the scope for them.”
Once his teachers thought he was ready, Dr. Lee did the procedure himself for several weeks.
Understanding the Japanese approach
Dr. Ralph Lee (front row, second from left) during his sabbatical in Japan in 2019 with Professor Hironori Yamamoto (front row, centre) and the gastroenterologists of Jichi Medical University. (Submitted photo)
“It was initially frustrating, but I started to realize why they wanted me to do all of this. They want you to become a true master of every aspect of the procedure so that you can troubleshoot it yourself if you run into problems. And it’s true. After a while, I could figure out exactly what instruments to use, when to use them and how to prepare and use them. Which is what I’m grateful for now because I can take what they taught me and teach our nurses how to do this. I can implement their protocols because I actually did all of that stuff.
“I was arrogantly believing that if I went there for six months, I’d be amazing at this technique. Now, I believe I’m safe and competent at the technique, but it’s going to take several years before I become ‘good’ at the technique.
Complementary technique for Canada
ESD isn’t a replacement for current procedures here, he says. It’s a complementary technique for certain cases.
“For certain situations, it’s an amazing technique. But the biggest question that all the researchers are trying to figure out right now is how to determine which lesions are better removed by ESD and which ones are better removed using EMR.
Dr. Lee has started doing the procedure in Canada, but has chosen only simple cases.
“I’m starting with only simple cases so that I can make sure my nurses are trained properly, our equipment is good and everything is safe for the patients.”
Renewed love of medicine
Dr. Lee already sees the whole experience as a highlight of his life.
“At the end of the day, I wouldn’t trade that [experience] for anything because it’s refreshed my career – it’s refreshed my love of medicine.”
Dr. Lee is one of a handful of gastroenterologists who have traveled to Japan to learn ESD and the first internationally-trained endoscopist to have received hands-on ESD training under professor Yamamoto.
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