- Email: [email protected]
Great Hospitals of Asia: Neurosurgery at Prince of Wales Hospital
Forum
Wai S. Poon, M.D. Chair, Professor & Chief in Neurosurgery, Division of Neurosurgery, Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong
Great Hospitals of Asia: Neurosurgery at Prince of Wales Hospital Wai S. Poon
Prince of Wales Hospital, a 1400-bed regional referral center, was established in 1984 as the primary teaching hospital of the second medical school in Hong Kong at the Chinese University of Hong Kong. The Academic Division of Neurosurgery was given an autonomous status, the support of 40 acute beds, and a well-equipped and well-staffed intensive care unit (ICU), in developing neurosurgery as a distinct surgical specialty. Over this short 26-year history, we have gone through the difficult time of one-man-band neurosurgery, excelled in emergency neurosurgery, and evolved to an era of organized neurosurgical practice, where clinical services, teaching of undergraduate and postgraduate students, and clinical and translational research have been brought up to international standards.
INTRODUCTION
F
ull-time neurosurgery in Hong Kong was started in the 1950s as a one-man-band service (7, 23, 31). This developing region practice was maintained until the formation of the Hospital Authority in the early 1990s, when seven structured neurosurgical services were formed to take care of the population of 7 million of Hong Kong. Between 1950 and mid-1970s, the population of Hong Kong increased dramatically, that is, by about nine-fold, from 0.6 to 5 million (12). The annual intake of 150 medical students to the only medical school had become inadequate to staff the medical services of the Colony. A new medical school at the Chinese University of Hong Kong was therefore conceived in the mid-1970s and established in 1981. Its primary teaching hospital, the Prince of Wales Hospital, was constructed in the early 1980s.
Key words 䡲 Clinical research 䡲 Clinical service 䡲 Neurosurgery 䡲 Translational research From the Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
WORLD NEUROSURGERY 75 [3/4]: 383-386, MARCH/APRIL 2011
THE ESTABLISHMENT OF A NEW TEACHING HOSPITAL The Prince of Wales Hospital started its service in 1984 (Figure 1) for the 1.3 million population of the New Territories. At the time it was the best equipped acute hospital with 1400 beds, a publicly funded primary teaching hospital to function as a tertiary referral center, to serve the population. A feature of this new teaching hospital was that it was nontraditional. There is a combined medical and surgical endoscopy unit where surgeons, physicians, pediatricians, and pediatric surgeons work together, which has ensured a very efficient service and provided excellent opportunity to do good randomized controlled trials. There is also a neuro-endovascular service, where radiologists, neurosurgeons, and neurologists work together, to deliver the best service for the patients (41-43). Neurosurgical activities function as an autonomous academic division within the Department of Surgery. The first Chief of the Division was Roger South, who had trained under Sir Wylie McKissock of Atkinson Morley Hospital in London. I joined the unit in 1986 as a clinical lecturer, having completed my neurosurgical training at the Institute of Neurological Sciences in Glasgow with Bryant Jennett, and took over from Roger in 1988 a well-equipped unit and a team of forwardlooking medical and nursing staff. Emergency neurosurgery accounted for more than 60% of the clinical service in this early stage of the unit’s development. Hospital Management has always been preoccupied with the acute management of head injury. The prospective clinical data we have show that closely observing all head injuries, mild cases included, in a neurosurgical unit carries a close-to-zero mortality for surgical extradural hematomas, whereas if they were secondarily transferred, the mortality was 24% (24). Close observation in these cases may not be adequate: we have shown that mortality and disability can be avoided by selecting high-risk patients for interval computed tomographic scanning and intracranial pressure monitoring (16, 24, 29). Based
To whom correspondence should be addressed: Wai S. Poon, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2011) 75, 3/4:383-386. DOI: 10.1016/j.wneu.2011.02.027 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
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Figure 1. Prince of Wales Hospital 1984.
on these audit results, all head injuries in Hong Kong are justified to be managed in the seven neurosurgical units of the Territory. In the event when a neurosurgical emergency occurs in a district general hospital without on-site neurosurgery, teleradiology has been made available for its proven value in the early transfer of these patients to their prescribed neurosurgical unit (8, 9, 39). In the event that the patient had become “unfit for transfer,” a protocol-driven “mobile neurosurgeon” can be offered, where favorable results can be achieved (30). Early development and adoption of new technology has been the hallmark of this maturing young unit. The adoption of computed tomographic angiography as the investigation of choice for intracranial aneurysms and intracerebral hematoma (13, 44, 38), endovascular coiling of intracranial aneurysm at the time of the International Study on Aneurysmal Subarachnoid Hemorrhage Trial recruitment of patients in 1995–1997 (41), vagus nerve stimulation for intractable epilepsy in the mid-1990s (15), deep brain stimulation of the subthalamic nuclei in 1997, brainstem auditory implant for patients with bilateral acoustic neurinoma, and deaf children without tumor since 2002. This has led to the past decade’s effort in subspecialization. Vascular neurosurgery (1, 2) is the first to mature, with neurosurgeons, radiologists, and neurologists working together for early diagnosis and timely treatment of aneurysms, arteriovenous malformations, ischemic brain that requires low- and high-flow bypasses, carotid endarterectomy, and stenting, both extracranial and intracranial. This is followed by functional neurosurgery for movement disorders and intractable epilepsy, matured because of the keen collaboration between neurosurgeons, movement disorder neurologists, and epileptologists. Skull base, endoscopy (endonasal and
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ventricular), and spine surgeons (11) have formed their own teams for development of the clinical service and research. ESTABLISHMENT OF THE NEUROSURGICAL TRAINING PROGRAM The Specialist Registry of the Hong Kong Medical Council requires of specialist neurosurgeons to have gone through a structured training program of a minimum of 7 years, supervised by the Specialty Board in Neurosurgery of the College of Surgeons (20) and the Academy of Medicine of Hong Kong. The completion of training of a specialist neurosurgeon is governed by two formal examinations: the entrance examination after the completion of 2-year training of surgery in general and the exit examination at the completion of 5 years of career neurosurgical training. The first exit examination for qualifying specialist neurosurgeons was held in 1997. This is now jointly organized by the Hong Kong College and the Royal College of Surgeons of Edinburgh from October 2004. More recently, we have relied on a central selection mechanism in selecting the best candidate in basic surgical training to enter formal neurosurgical training at 6-month intervals. The objective selection mechanism, the structured training program, and the stringent conjoint examination have guaranteed a constant supply of high-quality competent young neurosurgeons to staff our service and academic units. MINIMALLY INVASIVE SURGICAL TRAINING Cadaver surgical anatomy teaching and live surgical demonstration of complex neurosurgery had been a popular mode of training over
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.02.027
FORUM WAI S. POON
NEUROSURGERY AT PRINCE OF WALES HOSPITAL
the 1990s. This type of training was hugely facilitated by the purposely built and well equipped Minimally Invasive Surgical Skill Training Center, established in 2004. The best international neurosurgical teachers who have taught us in these facilities include Professors Yasargil, the late Axel Pernekzki, Madji Samii, Alan Crockard, and Taira and Mitch Berger, to name just a few.
RESEARCH Clinical research (3, 4, 10, 19, 22, 25, 26, 28, 32, 45) that changes the practice of medicine has been our target. Although the majority of the multicenter clinical trials on vasospasm such as the traumatic subarachnoid hemorrhage, magnesium (34, 36), and the endothelin-antagonists on aneurysmal subarachnoid hemorrhage, our studies on the prevention of cerebrospinal fluid infection using antibiotics (27), frequent change of catheter (37), and antibiotic-impregnated catheter (35) do allow us to modify clinical practice. The past decade also takes us from doing small laboratory studies (14, 17, 18), relying on technicians and postgraduate students, to employing full-time faculty staff to do the translational research (5, 6, 21, 33, 40), to the establishment of the Chinese University of Hong Kong Brain Tumor Center in 2008 (www.surgery.cukhk.edu.hk/btc).
FUTURE In 2010, the opening of the New Extension Block (Figure 2) with the best-equipped emergency and trauma center in the Region, patient-
REFERENCES 1. Boet R, Poon WS, Lam JM, Yu SC: The surgical treatment of intracranial aneurysms based on computer tomographic angiography alone—streamlining the acute management of symptomatic aneurysms. Acta Neurochir (Wien) 145:101-105, 2003. 2. Boet R, Poon WS, Yu SC, Chan MS: Endovascular GDC-mediated flow-reversal for complex posterior circulation saccular aneurysms. A report of two cases and critical appraisal. Minim Invasive Neurosurg 46:220-227, 2003. 3. Chan MT, Boet R, Ng SC, Poon WS, Gin T: Effect of ischemic preconditioning on brain tissue gases and pH during temporary cerebral artery occlusion. Acta Neurochir Suppl 95:93-96, 2005. 4. Chan MT, Boet R, Ng SC, Poon WS, Gin T: Magnesium sulfate for brain protection during temporary cerebral artery occlusion. Acta Neurochir Suppl 95: 107-111, 2005. 5. Chen GG, Sin FL, Leung BC, Ng HK, Poon WS: Differential role of hydrogen peroxide and staurosporine in induction of cell death in glioblastoma cells lacking DNA-dependent protein kinase. Apoptosis 10:185-192, 2005. 6. Chen GG, Sin FL, Leung BC, Ng HK, Poon WS: Glioblastoma cells deficient in DNA-dependent pro-
Figure 2. The new extension block of the Prince of Wales Hospital 2010.
friendly clinical areas, and large operating theaters will facilitate this young team of neurosurgeons to continue to excel in clinical service, training, and research. The government-initiated project of the Center of Excellence in Neuroscience will be the next opportunity for neurosurgery at the Prince of Wales Hospital to contribute to the field internationally.
tein kinase are resistant to cell death. J Cell Physiol 203:127-132, 2005. 7. Fong DTS: History of neurosurgery in Hong Kong. In: Fong DTS, Poon WS, eds. Hong Kong Neurosurgery, Four Decades and Beyond. Hong Kong: Lippincott Williams & Wilkins Asia; 1999:1-4. 8. Goh KY, Poon WS: Recombinant tissue plasminogen activator for the treatment of spontaneous adult intraventricular hemorrhage. Surg Neurol 50:526531, 1998. 9. Goh KY, Tsang KY, Poon WS: Does teleradiology improve inter-hospital management of head injuries? Can J Neurol Sci 24:235-239, 1997. 10. Goh KY, Tsoi WC, Feng CS, Wickham B, Poon WS: Haemostatic changes during surgery for primary brain tumours. J Neurol Neurosurg Psychiatry 63: 334-338, 1997. 11. Hodgson AR, Stock FE, Fang HS, Ong GB: Anterior Spinal Fusion. The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg 48:172-178, 1960. 12. Hong Kong Annual Report: Hong Kong Information Services Department, 1973:5. 13. Hsiang JN, Liang EY, Lam JM, Zhu XL, Poon WS: The role of computed tomographic angiography in the diagnosis of intracranial aneurysms and emergent aneurysm clipping. Neurosurgery 38:481-487, 1996.
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14. Hsiang JN, Wang JY, Ip SM, Ng HK, Stadlin A, Yu AL, Poon WS: The time course and regional variations of lipid peroxidation after diffuse brain injury in rats. Acta Neurochir (Wien) 139:464-468, 1997. 15. Hsiang JN, Wong LK, Kay R, Poon WS: Vagus nerve stimulation for seizure control: the local experience. J Clin Neurosci 5:294-297, 1998. 16. Hsiang JN, Yeung T, Yu AL, Poon WS: High-risk head injury. J Neurosurg 87:234-238, 1997. 17. Ke C, Poon WS, Ng HK, Lai M, Tang JL, Pang JC: Impact of experimental acute hyponatremia on severe traumatic brain injury in rats: influences on injuries, permeability of blood-brain barrier, ultrastructural features, and aquaporin-4 expression. Exp Neurol 178:194-206, 2002. 18. Ke C, Poon WS, Ng HK, Pang J, Chan Y: Heterogeneous responses of aquaporin-4 in oedema formation in a replicated severe traumatic brain injury model in rats. Neurosci Lett 301:21-24, 2001. 19. Lam JM, Hsiang JN, Poon WS: Monitoring of autoregulation using laser Doppler flowmetry in patients with head injury. J Neurosurg 86:438-445, 1997. 20. Li AKC: The College of Surgeons of Hong Kong. In: Leong CH, Shiu MH, Ching F, eds. Healing with the Scalpel, from the First Colonial Surgeon to the College of Surgeons of Hong Kong. Hong Kong: Hong Kong Academy of Medicine Press, 2010:106-129.
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21. Liu AM, Lu G, Tsang KS, Li G, Wu Y, Huang ZS, Ng HK, Kung HF, Poon WS: Umbilical cord-derived mesenchymal stem cells with forced expression of hepatocyte growth factor enhance remyelination and functional recovery in a rat intracerebral hemorrhage model. Neurosurgery 67:357-365, 2010. 22. Ng SC, Poon WS, Chan MT, Lam JM, Lam WW: Is transcranial Doppler ultrasonography (TCD) good enough in determining CO2 reactivity and pressure autoregulation in head-injured patients? Acta Neurochir Suppl 81:125-127, 2002. 23. Poon WS, Fong TS: Neurosurgery. In: Leong CH, Shiu MH, Ching F, eds. Healing with the Scalpel, from the First Colonial Surgeon to the College of Surgeons of Hong Kong. Hong Kong: Hong Kong Academy of Medicine Press, 2010:153-158. 24. Poon WS, Li AK: Comparison of management outcome of primary and secondary referred patients with traumatic extradural haematoma in a neurosurgical unit. Injury 22:323-325, 1991. 25. Poon WS, Lolin YL, Yeung TF, Yip CP, Goh KY, Lam MK, Cockram C: Water and sodium disorders following surgical excision of pituitary region tumours. Acta Neurochir (Wien) 138:921-927, 1996. 26. Poon WS, Mendelow AD, Davies DL, Watxon W, Easton J, Morton J: Secretion of antidiuretic hormone in neurosurgical patients: appropriate or inappropriate? Aust N Z J Surg 59:173-180, 1989. 27. Poon WS, Ng S, Wai S: CSF antibiotic prophylaxis for neurosurgical patients with ventriculostomy: a randomised study. Acta Neurochir Suppl 71:146148, 1998. 28. Poon WS, Ng SC, Chan MT, Lam JM, Lam WW: Cerebral blood flow (CBF)-directed management of ventilated head-injured patients. Acta Neurochir Suppl 95:9-11, 2005. 29. Poon WS, Rehman SU, Poon CYF, Li AKC: Traumatic extradural haematoma of delayed onset is not a rarity. Neurosurgery 30:681-686, 1992. 30. Sun DT, Poon WS, Lam JM, Leung CH, Kwok SP: Spontaneous intracerebral hematoma with rapidly deteriorating level of consciousness: treatment by a
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mobile neurosurgeon. J Telemed Telecare 5:257259, 1999. 31. Tan TC: Father of neurosurgery in Hong Kong. Neurosurgery 54:984-991, 2004. 32. Teasdale GM, Murray G, Anderson E, Mendelow AD, MacMillan R, Jennett B, Brookes M: Risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries. Br Med J 300:363-367, 1990. 33. Wang YX, Zhu XL, Deng M, Siu DY, Leung JC, Chan Q, Chan DT, Mak CH, Poon WS: The use of diffusion tensor tractography to measure the distance between the anterior tip of the MEYER loop and the temporal pole in a cohort from Southern China. J Neurosurg 113:1144-1151, 2010. 34. Wong GK, Chan MT, Boet R, Poon WS, Gin T: Intravenous magnesium sulfate after aneurysmal subarachnoid hemorrhage: a prospective randomized pilot study. J Neurosurg Anesthesiol 18:142-148, 2006. 35. Wong GK, Ip M, Poon WS, Mak CW, Ng RY: Antibiotics-impregnated ventricular catheter versus systemic antibiotics for prevention of nosocomial CSF and non-CSF infections: a prospective randomized clinical trial. J Neurol Neurosurg Psychiatry 81: 1064-1067, 2010. 36. Wong GK, Poon WS, Chan MT, Boet R, Gin T, Ng SC, Zee BC; IMASH Investigators: Intravenous magnesium sulphate for aneurysmal hemorrhage (IMASH): a randomized double-blinded, placebo controlled, multicenter phase III trial. Stroke 41: 921-926, 2010. 37. Wong GK, Poon WS, Wai S, Yu LM, Lyon D, Lam JM: Failure of regular external ventricular drain exchange to reduce cerebrospinal fluid infection: result of a randomised controlled trial. J Neurol Neurosurg Psychiatry 73:759-761, 2002. 38. Wong GK, Siu DY, Abrigo JM, Poon WS, Tsang FC, Zhu XL, Yu SC, Ahuja AT: CT angiography and venography for young or non-hypertensive patients with acute spontaneous ICH. Stroke 42:211-213, 2011.
39. Wong HT, Poon WS, Jacobs P, Goh KY: The comparative impact of video consultation on emergency neurosurgical referrals. Neurosurgery 59:607-613, 2006. 40. Xia H, Cheung WK, Sze J, Lu G, Jiang S, Yao H, Bian XW, Poon WS, Kung HF, Lin MC: miR-200a regulates epithelia mesenchymal to stem-like transition via ZEB2 via beta-catenin signaling. J Biol Chem 285:36995-37004, 2011. 41. Yu SC, Chan MS, Boet B, Wong JK, Lam JM, Poon WS: Intracranial aneurysms treated with Guglielmi detachable coils: midterm clinical and radiological outcome in 97 consecutive Chinese patients in Hong Kong. AJNR Am J Neuroradiol 25:307-313, 2004. 42. Yu SC, Chan MS, Lam JM, Tam PH, Poon WS: Complete obliteration of intracranial arteriovenous malformation with endovascular cyanoacrylate embolization: initial success and rate of permanent cure. AJNR Am J Neuroradiol 25:1139-1143, 2004. 43. Yu SC, Leung TW, Lam JS, Lam WW, Wong LK: Symptomatic ostial vertebral artery stenosis: treatment with drug-eluting stents— clinical and angiographic results at one year. Radiology 251:224-232, 2009. 44. Zhu XL, Chan MS, Poon WS: Spontaneous intracranial hemorrhage: which patients need diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature. Stroke 28:14061409, 1997. 45. Zhu XL, Poon WS, Chan CCH, Chan SH: Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial. Brain Inj 21:681-690, 2007.
Citation: World Neurosurg. (2011) 75, 3/4:383-386. DOI: 10.1016/j.wneu.2011.02.027 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.02.027
Wai S. Poon, M.D. Chair, Professor & Chief in Neurosurgery, Division of Neurosurgery, Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong
Great Hospitals of Asia: Neurosurgery at Prince of Wales Hospital Wai S. Poon
Prince of Wales Hospital, a 1400-bed regional referral center, was established in 1984 as the primary teaching hospital of the second medical school in Hong Kong at the Chinese University of Hong Kong. The Academic Division of Neurosurgery was given an autonomous status, the support of 40 acute beds, and a well-equipped and well-staffed intensive care unit (ICU), in developing neurosurgery as a distinct surgical specialty. Over this short 26-year history, we have gone through the difficult time of one-man-band neurosurgery, excelled in emergency neurosurgery, and evolved to an era of organized neurosurgical practice, where clinical services, teaching of undergraduate and postgraduate students, and clinical and translational research have been brought up to international standards.
INTRODUCTION
F
ull-time neurosurgery in Hong Kong was started in the 1950s as a one-man-band service (7, 23, 31). This developing region practice was maintained until the formation of the Hospital Authority in the early 1990s, when seven structured neurosurgical services were formed to take care of the population of 7 million of Hong Kong. Between 1950 and mid-1970s, the population of Hong Kong increased dramatically, that is, by about nine-fold, from 0.6 to 5 million (12). The annual intake of 150 medical students to the only medical school had become inadequate to staff the medical services of the Colony. A new medical school at the Chinese University of Hong Kong was therefore conceived in the mid-1970s and established in 1981. Its primary teaching hospital, the Prince of Wales Hospital, was constructed in the early 1980s.
Key words 䡲 Clinical research 䡲 Clinical service 䡲 Neurosurgery 䡲 Translational research From the Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
WORLD NEUROSURGERY 75 [3/4]: 383-386, MARCH/APRIL 2011
THE ESTABLISHMENT OF A NEW TEACHING HOSPITAL The Prince of Wales Hospital started its service in 1984 (Figure 1) for the 1.3 million population of the New Territories. At the time it was the best equipped acute hospital with 1400 beds, a publicly funded primary teaching hospital to function as a tertiary referral center, to serve the population. A feature of this new teaching hospital was that it was nontraditional. There is a combined medical and surgical endoscopy unit where surgeons, physicians, pediatricians, and pediatric surgeons work together, which has ensured a very efficient service and provided excellent opportunity to do good randomized controlled trials. There is also a neuro-endovascular service, where radiologists, neurosurgeons, and neurologists work together, to deliver the best service for the patients (41-43). Neurosurgical activities function as an autonomous academic division within the Department of Surgery. The first Chief of the Division was Roger South, who had trained under Sir Wylie McKissock of Atkinson Morley Hospital in London. I joined the unit in 1986 as a clinical lecturer, having completed my neurosurgical training at the Institute of Neurological Sciences in Glasgow with Bryant Jennett, and took over from Roger in 1988 a well-equipped unit and a team of forwardlooking medical and nursing staff. Emergency neurosurgery accounted for more than 60% of the clinical service in this early stage of the unit’s development. Hospital Management has always been preoccupied with the acute management of head injury. The prospective clinical data we have show that closely observing all head injuries, mild cases included, in a neurosurgical unit carries a close-to-zero mortality for surgical extradural hematomas, whereas if they were secondarily transferred, the mortality was 24% (24). Close observation in these cases may not be adequate: we have shown that mortality and disability can be avoided by selecting high-risk patients for interval computed tomographic scanning and intracranial pressure monitoring (16, 24, 29). Based
To whom correspondence should be addressed: Wai S. Poon, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2011) 75, 3/4:383-386. DOI: 10.1016/j.wneu.2011.02.027 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
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Figure 1. Prince of Wales Hospital 1984.
on these audit results, all head injuries in Hong Kong are justified to be managed in the seven neurosurgical units of the Territory. In the event when a neurosurgical emergency occurs in a district general hospital without on-site neurosurgery, teleradiology has been made available for its proven value in the early transfer of these patients to their prescribed neurosurgical unit (8, 9, 39). In the event that the patient had become “unfit for transfer,” a protocol-driven “mobile neurosurgeon” can be offered, where favorable results can be achieved (30). Early development and adoption of new technology has been the hallmark of this maturing young unit. The adoption of computed tomographic angiography as the investigation of choice for intracranial aneurysms and intracerebral hematoma (13, 44, 38), endovascular coiling of intracranial aneurysm at the time of the International Study on Aneurysmal Subarachnoid Hemorrhage Trial recruitment of patients in 1995–1997 (41), vagus nerve stimulation for intractable epilepsy in the mid-1990s (15), deep brain stimulation of the subthalamic nuclei in 1997, brainstem auditory implant for patients with bilateral acoustic neurinoma, and deaf children without tumor since 2002. This has led to the past decade’s effort in subspecialization. Vascular neurosurgery (1, 2) is the first to mature, with neurosurgeons, radiologists, and neurologists working together for early diagnosis and timely treatment of aneurysms, arteriovenous malformations, ischemic brain that requires low- and high-flow bypasses, carotid endarterectomy, and stenting, both extracranial and intracranial. This is followed by functional neurosurgery for movement disorders and intractable epilepsy, matured because of the keen collaboration between neurosurgeons, movement disorder neurologists, and epileptologists. Skull base, endoscopy (endonasal and
384
www.SCIENCEDIRECT.com
ventricular), and spine surgeons (11) have formed their own teams for development of the clinical service and research. ESTABLISHMENT OF THE NEUROSURGICAL TRAINING PROGRAM The Specialist Registry of the Hong Kong Medical Council requires of specialist neurosurgeons to have gone through a structured training program of a minimum of 7 years, supervised by the Specialty Board in Neurosurgery of the College of Surgeons (20) and the Academy of Medicine of Hong Kong. The completion of training of a specialist neurosurgeon is governed by two formal examinations: the entrance examination after the completion of 2-year training of surgery in general and the exit examination at the completion of 5 years of career neurosurgical training. The first exit examination for qualifying specialist neurosurgeons was held in 1997. This is now jointly organized by the Hong Kong College and the Royal College of Surgeons of Edinburgh from October 2004. More recently, we have relied on a central selection mechanism in selecting the best candidate in basic surgical training to enter formal neurosurgical training at 6-month intervals. The objective selection mechanism, the structured training program, and the stringent conjoint examination have guaranteed a constant supply of high-quality competent young neurosurgeons to staff our service and academic units. MINIMALLY INVASIVE SURGICAL TRAINING Cadaver surgical anatomy teaching and live surgical demonstration of complex neurosurgery had been a popular mode of training over
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.02.027
FORUM WAI S. POON
NEUROSURGERY AT PRINCE OF WALES HOSPITAL
the 1990s. This type of training was hugely facilitated by the purposely built and well equipped Minimally Invasive Surgical Skill Training Center, established in 2004. The best international neurosurgical teachers who have taught us in these facilities include Professors Yasargil, the late Axel Pernekzki, Madji Samii, Alan Crockard, and Taira and Mitch Berger, to name just a few.
RESEARCH Clinical research (3, 4, 10, 19, 22, 25, 26, 28, 32, 45) that changes the practice of medicine has been our target. Although the majority of the multicenter clinical trials on vasospasm such as the traumatic subarachnoid hemorrhage, magnesium (34, 36), and the endothelin-antagonists on aneurysmal subarachnoid hemorrhage, our studies on the prevention of cerebrospinal fluid infection using antibiotics (27), frequent change of catheter (37), and antibiotic-impregnated catheter (35) do allow us to modify clinical practice. The past decade also takes us from doing small laboratory studies (14, 17, 18), relying on technicians and postgraduate students, to employing full-time faculty staff to do the translational research (5, 6, 21, 33, 40), to the establishment of the Chinese University of Hong Kong Brain Tumor Center in 2008 (www.surgery.cukhk.edu.hk/btc).
FUTURE In 2010, the opening of the New Extension Block (Figure 2) with the best-equipped emergency and trauma center in the Region, patient-
REFERENCES 1. Boet R, Poon WS, Lam JM, Yu SC: The surgical treatment of intracranial aneurysms based on computer tomographic angiography alone—streamlining the acute management of symptomatic aneurysms. Acta Neurochir (Wien) 145:101-105, 2003. 2. Boet R, Poon WS, Yu SC, Chan MS: Endovascular GDC-mediated flow-reversal for complex posterior circulation saccular aneurysms. A report of two cases and critical appraisal. Minim Invasive Neurosurg 46:220-227, 2003. 3. Chan MT, Boet R, Ng SC, Poon WS, Gin T: Effect of ischemic preconditioning on brain tissue gases and pH during temporary cerebral artery occlusion. Acta Neurochir Suppl 95:93-96, 2005. 4. Chan MT, Boet R, Ng SC, Poon WS, Gin T: Magnesium sulfate for brain protection during temporary cerebral artery occlusion. Acta Neurochir Suppl 95: 107-111, 2005. 5. Chen GG, Sin FL, Leung BC, Ng HK, Poon WS: Differential role of hydrogen peroxide and staurosporine in induction of cell death in glioblastoma cells lacking DNA-dependent protein kinase. Apoptosis 10:185-192, 2005. 6. Chen GG, Sin FL, Leung BC, Ng HK, Poon WS: Glioblastoma cells deficient in DNA-dependent pro-
Figure 2. The new extension block of the Prince of Wales Hospital 2010.
friendly clinical areas, and large operating theaters will facilitate this young team of neurosurgeons to continue to excel in clinical service, training, and research. The government-initiated project of the Center of Excellence in Neuroscience will be the next opportunity for neurosurgery at the Prince of Wales Hospital to contribute to the field internationally.
tein kinase are resistant to cell death. J Cell Physiol 203:127-132, 2005. 7. Fong DTS: History of neurosurgery in Hong Kong. In: Fong DTS, Poon WS, eds. Hong Kong Neurosurgery, Four Decades and Beyond. Hong Kong: Lippincott Williams & Wilkins Asia; 1999:1-4. 8. Goh KY, Poon WS: Recombinant tissue plasminogen activator for the treatment of spontaneous adult intraventricular hemorrhage. Surg Neurol 50:526531, 1998. 9. Goh KY, Tsang KY, Poon WS: Does teleradiology improve inter-hospital management of head injuries? Can J Neurol Sci 24:235-239, 1997. 10. Goh KY, Tsoi WC, Feng CS, Wickham B, Poon WS: Haemostatic changes during surgery for primary brain tumours. J Neurol Neurosurg Psychiatry 63: 334-338, 1997. 11. Hodgson AR, Stock FE, Fang HS, Ong GB: Anterior Spinal Fusion. The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg 48:172-178, 1960. 12. Hong Kong Annual Report: Hong Kong Information Services Department, 1973:5. 13. Hsiang JN, Liang EY, Lam JM, Zhu XL, Poon WS: The role of computed tomographic angiography in the diagnosis of intracranial aneurysms and emergent aneurysm clipping. Neurosurgery 38:481-487, 1996.
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14. Hsiang JN, Wang JY, Ip SM, Ng HK, Stadlin A, Yu AL, Poon WS: The time course and regional variations of lipid peroxidation after diffuse brain injury in rats. Acta Neurochir (Wien) 139:464-468, 1997. 15. Hsiang JN, Wong LK, Kay R, Poon WS: Vagus nerve stimulation for seizure control: the local experience. J Clin Neurosci 5:294-297, 1998. 16. Hsiang JN, Yeung T, Yu AL, Poon WS: High-risk head injury. J Neurosurg 87:234-238, 1997. 17. Ke C, Poon WS, Ng HK, Lai M, Tang JL, Pang JC: Impact of experimental acute hyponatremia on severe traumatic brain injury in rats: influences on injuries, permeability of blood-brain barrier, ultrastructural features, and aquaporin-4 expression. Exp Neurol 178:194-206, 2002. 18. Ke C, Poon WS, Ng HK, Pang J, Chan Y: Heterogeneous responses of aquaporin-4 in oedema formation in a replicated severe traumatic brain injury model in rats. Neurosci Lett 301:21-24, 2001. 19. Lam JM, Hsiang JN, Poon WS: Monitoring of autoregulation using laser Doppler flowmetry in patients with head injury. J Neurosurg 86:438-445, 1997. 20. Li AKC: The College of Surgeons of Hong Kong. In: Leong CH, Shiu MH, Ching F, eds. Healing with the Scalpel, from the First Colonial Surgeon to the College of Surgeons of Hong Kong. Hong Kong: Hong Kong Academy of Medicine Press, 2010:106-129.
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21. Liu AM, Lu G, Tsang KS, Li G, Wu Y, Huang ZS, Ng HK, Kung HF, Poon WS: Umbilical cord-derived mesenchymal stem cells with forced expression of hepatocyte growth factor enhance remyelination and functional recovery in a rat intracerebral hemorrhage model. Neurosurgery 67:357-365, 2010. 22. Ng SC, Poon WS, Chan MT, Lam JM, Lam WW: Is transcranial Doppler ultrasonography (TCD) good enough in determining CO2 reactivity and pressure autoregulation in head-injured patients? Acta Neurochir Suppl 81:125-127, 2002. 23. Poon WS, Fong TS: Neurosurgery. In: Leong CH, Shiu MH, Ching F, eds. Healing with the Scalpel, from the First Colonial Surgeon to the College of Surgeons of Hong Kong. Hong Kong: Hong Kong Academy of Medicine Press, 2010:153-158. 24. Poon WS, Li AK: Comparison of management outcome of primary and secondary referred patients with traumatic extradural haematoma in a neurosurgical unit. Injury 22:323-325, 1991. 25. Poon WS, Lolin YL, Yeung TF, Yip CP, Goh KY, Lam MK, Cockram C: Water and sodium disorders following surgical excision of pituitary region tumours. Acta Neurochir (Wien) 138:921-927, 1996. 26. Poon WS, Mendelow AD, Davies DL, Watxon W, Easton J, Morton J: Secretion of antidiuretic hormone in neurosurgical patients: appropriate or inappropriate? Aust N Z J Surg 59:173-180, 1989. 27. Poon WS, Ng S, Wai S: CSF antibiotic prophylaxis for neurosurgical patients with ventriculostomy: a randomised study. Acta Neurochir Suppl 71:146148, 1998. 28. Poon WS, Ng SC, Chan MT, Lam JM, Lam WW: Cerebral blood flow (CBF)-directed management of ventilated head-injured patients. Acta Neurochir Suppl 95:9-11, 2005. 29. Poon WS, Rehman SU, Poon CYF, Li AKC: Traumatic extradural haematoma of delayed onset is not a rarity. Neurosurgery 30:681-686, 1992. 30. Sun DT, Poon WS, Lam JM, Leung CH, Kwok SP: Spontaneous intracerebral hematoma with rapidly deteriorating level of consciousness: treatment by a
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39. Wong HT, Poon WS, Jacobs P, Goh KY: The comparative impact of video consultation on emergency neurosurgical referrals. Neurosurgery 59:607-613, 2006. 40. Xia H, Cheung WK, Sze J, Lu G, Jiang S, Yao H, Bian XW, Poon WS, Kung HF, Lin MC: miR-200a regulates epithelia mesenchymal to stem-like transition via ZEB2 via beta-catenin signaling. J Biol Chem 285:36995-37004, 2011. 41. Yu SC, Chan MS, Boet B, Wong JK, Lam JM, Poon WS: Intracranial aneurysms treated with Guglielmi detachable coils: midterm clinical and radiological outcome in 97 consecutive Chinese patients in Hong Kong. AJNR Am J Neuroradiol 25:307-313, 2004. 42. Yu SC, Chan MS, Lam JM, Tam PH, Poon WS: Complete obliteration of intracranial arteriovenous malformation with endovascular cyanoacrylate embolization: initial success and rate of permanent cure. AJNR Am J Neuroradiol 25:1139-1143, 2004. 43. Yu SC, Leung TW, Lam JS, Lam WW, Wong LK: Symptomatic ostial vertebral artery stenosis: treatment with drug-eluting stents— clinical and angiographic results at one year. Radiology 251:224-232, 2009. 44. Zhu XL, Chan MS, Poon WS: Spontaneous intracranial hemorrhage: which patients need diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature. Stroke 28:14061409, 1997. 45. Zhu XL, Poon WS, Chan CCH, Chan SH: Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial. Brain Inj 21:681-690, 2007.
Citation: World Neurosurg. (2011) 75, 3/4:383-386. DOI: 10.1016/j.wneu.2011.02.027 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.02.027