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  Traveling Scholar Reports 2009 - 2010 (Part I)

The IGCS Traveling Scholars Program has supported a variety of international training opportunities for physicians and nurses outside of their usual environments. Activities from 2009 and 2010 are summarized below, based on reports from the award recipients. IGCS congratulates the recipients on their achievements, and extends gratitude to the host institutions and mentors who made these experiences possible..

This is Reports Part I          See Reports Part II

Dr Uma K Devi (India)
University Hospital Leuven, Gasthuisberg, EU

Indeed , I applied on the last day for this prestigious IGCS Travel grant & subsequently forgotten…. As the Bangkok IGCS meeting was approaching, with many things to work on, including Atlas on Gynaecological Cancer , India Bid for IGCS -2014, forthcoming IGCS presentations & more. Within a short span of time, when I was informed about the successful award, it was indeed a real surprise!! Thanks to my Dear IGCS council members, Past President Professor Ignace Vergote, Present President Jonathan Berek and Education Committee Chair Ted Trimble.

By the end of March, the Consulate provided a work permit, and when the visa arrived it was less than 24 hours to travel! I reached Brussels, via Paris, it appeared that the sun accompanied all the way from India and finally reached the destination of my guest country by late noon. It reminded me of my earlier visit, with the same Centrum Square full of people & warmth, I felt privileged for few more months, and being away from my parent country. Reached the wonderful home of Ms Nancy S.Hamles and family, can never forget them for their lovely hospitality. Felt at home throughout the stay & her five year-old daughter was my teacher for Flemish!

Immediately reported at the Division of Gynaecological Oncology, University Hospital Leuven, Gasthuisberg, and met Ms H Camps then went to level IV (favorite Centrum place) for the next-day OR list, and walked home, missing Professor Vergote, who was away for meetings.
Next day at 0730 logged into OR and watched Cone Biopsy, laparoscopic extraperitoneal PALND, and later assisted on a few cases. It was an enjoyable time to learn, well organized, starting at 0745 on OR days. Indeed, really missing Thursday evening Tumor Board. It was an enriched meeting including the presentation by assistants, Professors and Chair, as well as staff from Radiology, Pathology, Radiation , Breast & Gynaecologic Oncology. It was like a kingdom where the decision was made for the pre-op / post -op adjuvant therapies and all patients on relapse , including progressive complex cases. Monday and Wednesday mornings began with pre-op and post-op discussion on ward rounds, followed by outpatient chemotherapy. Friday early morning and Tuesday afternoon included interesting staff meetings.

It was beautiful to watch and assist Robotic radical surgery by Professor Vergote. It was always interesting to watch & assist whether cytoreductive surgery for ovarian cancer, exenteration for recurrent cervical cancer, or minimally invasive surgery for early vulvar cancer. Amazing to watch that even women aged 93 years with endometrial cancer tolerate the surgical procedure, and women after 8 procedures for ovarian cancer, sitting on the next post-op day smiling, thanks to the beautiful team co-ordination. Hope our Indian women cope with these extensive surgical procedures, or we may have to find alternatives.

August and September were occupied with laparoscopic training and conventional surgeries, research overviews, and completing the paper work! It was indeed excellent to learn basic to advanced laparoscopic techniques with Dr. A.L. at CST. Thanks to Professor Vergote and colleagues for assigned training at CST including participation at the ESHRE meeting, and a manuscript of GTT data. We look forward to have more joint ventures with IGCS through KMIO and AGOI. THANK YOU VERY MUCH again to Dear Erica Riley, for all her kind co-operations, and also to Professors Vergote, Berek, Trimble, and all IGCS Council Members for providing this worthwhile opportunity!

Dr. Maria Jimena Lange (Argentina)
MD Anderson Cancer Center, Houston, Texas, US

Thank you very much to the IGCS for so much help in organizing my rotation at the MD Anderson Cancer Center. I had a wonderful time in Houston. It was a great experience for me to visit such a big and important Medical Center. I learned a lot with Dr. Ramirez who was very kind and I really appreciated the whole gynecologic oncology staff. I had the opportunity to watch many robotic, laparoscopic and conventional surgeries and I worked with in- and outpatients on almost a daily basis. I also spent a lot of time with the fellows, and in discussion about the differences between our countries.

A very important point is that I have been working with Dr. Ramirez and other faculty of the gynecologic oncology staff on a project about dehiscence of vaginal cuff after robotic vs. laparoscopic hysterectomy. Fortunately, this abstract has been accepted by the SGO, and will be in a poster in San Francisco, March 2010.

Thank you very much for all.

Dr. Ganendra Raj Kader Ali Mohan (Malaysia)
Memorial Sloan-Kettering Cancer Center, New York

I would like to thank IGCS for granting me the travelling scholarship which enabled me to visit and do a period of observer ship in the Gynaecologic Oncology Department of Memorial Sloan-Kettering Cancer Center, New York, which is one of the premier cancer centres for gynaecologic oncology in the world.

It was indeed an invaluable experience to observe and learn how a well-established Gynaecologic Oncology unit in a developed country differs from those in developing countries. With the availability of the latest technology such as the Robotic surgical consoles in most major hospitals in the United States, the vast majority of surgeries done in Gynaecologic Oncology are done as minimally invasive procedures. I personally had a chance to observe and discuss these surgeries with Dr. Richard Barakat the Chief of Gynaecologic Oncology Services and Dr. Mario Leitao, another gynaecologic oncologist at MSKCC, while observing them perform some very complex surgical procedures using the robot. It was also very educational to see Dr. Dennis Chi perform various ovarian cancer debulking procedures especially when they had to strip the disease from the diaphragm to ensure that residual disease was no more than 1 cm.

The educational tumour conference meetings held on Thursday mornings were very high-powered and motivational. The MSKCC library, located in the Rockefeller research centre opposite the hospital, has an excellent collection of educational resources. During my visit I had the opportunity to meet other colleagues observing from different countries and managed to compare notes on Gynaecologic Oncology practises in our respective countries. New York is a very beautiful, busy and expensive city to visit. However in my spare time when I was not in surgery or the library I was out exploring this beautiful city. Finally I would like to say a special thanks to Ms. Erica Riley of the IGCS and Ms. Lori Justiniano of MSKCC for all their invaluable help.

Dr. Francois Nérette (Haiti)
Institut Claudius Regaud, Toulouse, France

From 05-JAN to 09-JUN 2009, I had the opportunity to act as a visiting doctor, observing oncologic surgical procedures at the Division of Gynecologic Oncology Surgery at Institute Claudius Regaud (ICR). My heartfelt gratitude to IGCS for granting me the opportunity to share this marvelous experience at ICR, thank to its valuable grant support. Special thanks to Erica Riley for all her assistance in communicating, planning and coordinating my trip to France, Toulouse.

I remain indebted to Prof. Querleu, Chief of the Division of Gynecologic Oncology Surgery for his acceptance and for hosting me at ICR. His relevant teachings on laparoscopic surgery were very instructive and fruitful. He deserves all my consideration and respect for all he has done to allow me a pleasant stay.

Surgical activities were particularly intense during this 6 m period with 181 operations including: laparotomy, laparoscopy, LEEP (3), Laser surgery (2), Hysteroscopy (1) and breast surgery including, lumpectomy, tumorectomy +/- needle localization, SLND, mastectomy with AxLND, breast reconstruction with or without implant, and Port-A Cath insertions.

After a warm welcome by Prof. Querleu, I was immediately introduced to the operating room to observe a laparoscopy staging procedure with pelvic and common iliac node dissection followed with bilateral ovarian transposition for a stage IIa cervical carcinoma. I was very impressed by this minimally invasive surgery in gynecologic oncology, as laparoscopy in oncology is unusual in my country. I owe my gratitude to Prof. Querleu for providing me his recent edited book, “Surgery of Gynecologic Cancers” to learn the techniques, and for reviewing my manuscripts on VIA and Cold Knife Conisation.

I was fortunate enough during this period to observe and provided with the opportunity of assisting in twelve operations, to witness Laparoscopy Radical hysterectomy (LAVH-RH), Laparoscopy Total Hysterectomy (LAV-TH), extra peritoneal staging laparoscopy with PALND up to the renal vessels for locally advanced cervical, endometrial cancer and ovarian cancer. Extensive debulking surgery mostly was carried out for ovarian carcinoma including, a peritonectomy according to Sugarbaker’s technique, a total omentectomy, and/or a colic resection with anastomosis, and/or an anterior pelvic exenteration with right hemi colectomy and ileo colic continent ureterostomy diversion (Miami pouch), and/or a caeliac dissection, a splenectomy and distal pancreastectomy, diaphragmatic stripping or a retroperitoneal para aortic lymph node dissection ( PALND).

The use and efficacy of high-technology instruments including Argon beam coagulator, gamma probe, Harmonic scalpel, Ligasure, and staplers and gamma probe, were precious tools in achieving hemostasis, good surgery, and detecting SLN. Attractive was and very amazing ICHP with the Coliseum technique using the Thompson’s retractor which provides a panoramic view of the entire abdominal cavity.

Wednesdays and Thursdays afternoons were opened for lecturing and multidisciplinary team (MDT) activities. I regularly attended these instructive activities which were informative channels. Opportunity regarding new readings in imaging studies MRI, CT, PET-CT during MDT meetings was rewarding.

My stay at ICR was particularly fruitful and helped me to enhance and broaden my knowledge on the field of gynecologic cancer. Since I dedicated all my time to observe surgery, there was no time left for visiting or diversion. With a thirst for knowledge, I steel myself for research and studying. Understanding “cancer as a matter business orchestra and not a soloist,” returning home changed my scope over the reality of gynecologic cancer in my country, with much more demanding effort, better collaboration with groups and organization fighting against cancer, and a new open mind for changing attitudes and behavior. Certainly, I shall not only overcome obstacles, disillusionment and frustration, resulting from failing structures and resources of my poor country, but also face new commitments and challenges. I’m still confident that IGCS will continue to help me achieving my goals and supporting me with a fellowship with better hands on training formation

Hats off to Drs. G. Ferron, P. Martel who took interest in teaching me relevant aspects of surgical techniques including extensive debulking surgery, sentinel node (SLND) and axillary lymph node dissection (ALND), and providing me in assisting surgery. My heartfelt thanks to Dr. P. Rouge and his staff, Michel, C. Giraud, and B. Chaminade’s family for making me feel at home.  Finally, congratulations to IGCS for promoting the fight against cancer through its excellent educational Traveling Scholarship Program.

Audrey Tieko Tsunoda (Brazil)
Mayo Clinic Arizona

I am a Brazilian surgical oncologist and attending surgeon from Gynecologic Oncology Division at Hospital de Câncer de Barretos (HCB), Brazil. HCB’s main effort has been improving the Brazilian public health system standard of care for cancer patients. It admits more than 900 new gynecological cancer cases each year. In order to improve quality of life and minimize hospital stay and surgical complications, we have been developing minimally invasive surgery since the 90’s, initially for colon and rectal cases, and progressively to urology, gynecology, upper digestive tract, head and neck and neurosurgery. We extended our laparoscopic indications for gynecologic cancer patients during the last two years and we intend to develop robotics for the next year, as the first public hospital in Brazil to offer robotic surgery in this setting.

This year, we were profoundly grateful to the IGCS for a unique opportunity. I was pleased to receive an IGCS Traveling Scholarship to visit the Gynecology department at Mayo Clinic Arizona, between October 10th and November 12th, 2009, under the guidance of Professor Javier F. Magrina.

Dr. Magrina is a long-time laparoscopist and during recent years he has been dedicated to complex pelvic reconstruction and cancer patients through robotic or laparoscopic surgery. His expertise includes robotic radical hysterectomies and lymphadenectomies, which seems uncomplicated procedures in his hands. He teaches a “3Es” technique, Efficiency, Elegance and Economy of movements. His procedures are standardized, clean, anatomy-based, and objective. He is open-minded to new technologies and he has designed some instruments, including a scalpel for vaginal morcelation and a vaginal probe. Dr. Magrina is highly skilled, and I could understand perfectly the successful results he has been publishing after observing his daily practice.

At the clinic, Dr. Magrina has an objective, though serene, way of attending his patients. Many come from other states or countries to receive his advice or second opinion. He understands the needs of his patients and his appointments sometimes are time-consuming, as he is concerned and fully dedicated to each single patient.

Dr. Magrina has some very skilled colleagues as well, including Dr. Rosanne M. C. Kho, Dr. Paul M. Magtibay, and Dr. Jeffrey L. Cornella, who kindly received me and explained many details of their routines. Besides observing their surgeries, I also attended some of their multidisciplinary conferences and seminars.

During this period, I was able to understand the evidence based applications and limitations of each approach (open, laparoscopy or robotics), as I observed the indications and the performance of a variety of procedures. I attended 34 laparoscopic and/or robotic procedures, 18 vaginal procedures, 3 open procedures, including a total pelvic exenteration, 2 vulvar procedures, and 2 other surgeries.

Between the surgical cases, I went to the Pathology Facility, where I had very interesting conversations and case discussions with Drs. Colby, Petris, Tolgay, McCullough, and their colleagues.

Many of the Gynecology regular patients are submitted to surgery as outpatients, with the support of an organized multidisciplinary team. I could balance the differences between our patients and theirs, and acquire some pre and postoperative care details that we can include in my hospital routine.

I also had the opportunity to meet Dr. Erik Castle, from the Urology Department. I observed this outstanding surgeon performing some complex laparoscopic and robotic cancer surgeries in a really impressive manner. Dr. Castle is concerned about training his residents, and also explained to me each step and its implications so I could follow his movements during the surgeries.

I was able to practice with DaVinci and DaVinci S using inanimate models for more than five hours, improving my surgical skills. After the surgical schedule of the day was complete, several days I went to the clinic and watched more than 16 surgical videos from their files at the fellows’ office. While I was reading their articles published on robotics, I was able to watch and review the details of many surgical steps in those videos. The pelvic reconstruction fellows, Dr. Jennifer Klauschie and Dr. Kristine Jacob, and the minimally invasive fellow, Dr. Vasilis Kapetanakis, were prompt in helping me with this and so many other activities.

At the end of the program, I attended a very useful course on Robotic Surgery in Gynecology. This interactive activity from Mayo School of Continuous Professional Development covered many details of their routine and indications, in a very didactic fashion.

The experience of visiting Mayo Clinic Arizona would have never been the same without the presence of Mrs. Marta Jaskulski, RN. As the team leader of the Gynecologic Surgery and Perioperative Services, she is responsible for maintaining the Mayo Clinic standards during the gynecological surgical procedures, for organizing and training the surgical team, and for managing all the equipment necessary for each procedure. Overall, she is a profound admirer of Dr. Magrina and his team. This lovable person guided me through the hospital and its policies, advised me about the city and sightseeing options, went dinner with me and other nurses, and even took me on a pleasant visit to Paradise Valley.

So many people were very important during my visit. I want to thank Mrs. Elaine Purchase; all the nurses, attending physicians, and other staff from the operating rooms and Specialty Building; and Mrs. Linda Benkowski from Mayo Clinic Arizona Continuing Medical Education. I had very important support from HCB administration, Dr. Armando Melani, Chief of the Pelvic Surgery Department, and Dr. Jose Humberto Fregnani, coordinator of the Gynecologic Oncology Division.

I want to express my gratitude and recognition to Mrs. Erica Riley, administrator director of IGCS, for her superb efficiency and kind attention. The ICGS support is a remarkable source of motivation in our specialty.

I realize I achieved my main objectives during this visit. There were many aspects I learned that I will be able to apply in HCB. I had the opportunity to observe the newest technologic resources adequately managed. I learned Mayo Clinic institutional policies and how the main surgical routines work. I could discuss and observe indications, surgical procedures, pathology review and perioperative care. I reviewed many articles and surgical steps. I acquired the operational routine with laparoscopy and robotics at the operating rooms. I met interesting and pleasant people, and I could create bonds between HCB and a renowned Institution. And so many other experiences that contributed to enrich this very unique month.

I highly recommend IGCS Traveling Scholarship for all colleagues looking forward to expanding their horizons, and those who pursue improvement of their practice and the way patients are managed.