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Wai S. Poon, M.D.
Chair, Professor & Chief in Neurosurgery, Division of Neurosurgery, Department of SurgeryPrince of Wales Hospital
The Chinese University of Hong Kong
Great Hospitals of Asia: Neurosurgery at Prince of Wales Hospital
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Prince of Wales Hospital, a 1400-bed regional referralcenter, was established in 1984 as the primary teachinghospital of the second medical school in Hong Kong at theChinese University of Hong Kong. The Academic Division ofNeurosurgery was given an autonomous status, the supportof 40 acute beds, and a well-equipped and well-staffedintensive care unit (ICU), in developing neurosurgery as adistinct surgical specialty. Over this short 26-year history,we have gone through the difficult time of one-man-bandneurosurgery, excelled in emergency neurosurgery, andevolved to an era of organized neurosurgical practice,where clinical services, teaching of undergraduate andpostgraduate students, and clinical and translational re-search have been brought up to international standards.
INTRODUCTION
Full-time neurosurgery in Hong Kong was started in the 1950sas a one-man-band service (7, 23, 31). This developing regionpractice was maintained until the formation of the Hospital
uthority in the early 1990s, when seven structured neurosurgicalervices were formed to take care of the population of 7 million ofong Kong. Between 1950 and mid-1970s, the population of Hongong increased dramatically, that is, by about nine-fold, from 0.6 tomillion (12). The annual intake of 150 medical students to the onlyedical school had become inadequate to staff the medical services
f the Colony. A new medical school at the Chinese University ofong Kong was therefore conceived in the mid-1970s and estab-
ished in 1981. Its primary teaching hospital, the Prince of Walesospital, was constructed in the early 1980s.
Key words� Clinical research� Clinical service� Neurosurgery� Translational research
From the Division of Neurosurgery, Department of Surgery, Prince of Wales
Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong 1WORLD NEUROSURGERY 75 [3/4]: 383-386, MARCH/APRIL 2011
HE ESTABLISHMENT OF A NEW TEACHING HOSPITAL
he Prince of Wales Hospital started its service in 1984 (Figure 1) forhe 1.3 million population of the New Territories. At the time it washe best equipped acute hospital with 1400 beds, a publicly fundedrimary teaching hospital to function as a tertiary referral center, toerve the population. A feature of this new teaching hospital was thatt was nontraditional. There is a combined medical and surgicalndoscopy unit where surgeons, physicians, pediatricians, and pe-iatric surgeons work together, which has ensured a very efficientervice and provided excellent opportunity to do good randomizedontrolled trials. There is also a neuro-endovascular service, whereadiologists, neurosurgeons, and neurologists work together, toeliver the best service for the patients (41-43). Neurosurgical activ-
ties function as an autonomous academic division within the De-artment of Surgery. The first Chief of the Division was Roger South,ho had trained under Sir Wylie McKissock of Atkinson Morleyospital in London. I joined the unit in 1986 as a clinical lecturer,aving completed my neurosurgical training at the Institute of Neu-ological Sciences in Glasgow with Bryant Jennett, and took overrom Roger in 1988 a well-equipped unit and a team of forward-ooking medical and nursing staff.
Emergency neurosurgery accounted for more than 60% of thelinical service in this early stage of the unit’s development. Hospitalanagement has always been preoccupied with the acute manage-ent of head injury. The prospective clinical data we have show that
losely observing all head injuries, mild cases included, in a neuro-urgical unit carries a close-to-zero mortality for surgical extraduralematomas, whereas if they were secondarily transferred, the mor-
ality was 24% (24). Close observation in these cases may not bedequate: we have shown that mortality and disability can be avoidedy selecting high-risk patients for interval computed tomographiccanning and intracranial pressure monitoring (16, 24, 29). Based
o whom correspondence should be addressed: Wai S. Poon, M.D.E-mail: [email protected]]
itation: World Neurosurg. (2011) 75, 3/4:383-386.OI: 10.1016/j.wneu.2011.02.027
ournal homepage: www.WORLDNEUROSURGERY.org
vailable online: www.sciencedirect.com
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www.WORLDNEUROSURGERY.org 383
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on these audit results, all head injuries in Hong Kong are justified tobe managed in the seven neurosurgical units of the Territory. In theevent when a neurosurgical emergency occurs in a district generalhospital without on-site neurosurgery, teleradiology has been madeavailable for its proven value in the early transfer of these patients totheir prescribed neurosurgical unit (8, 9, 39). In the event that thepatient had become “unfit for transfer,” a protocol-driven “mobileneurosurgeon” can be offered, where favorable results can beachieved (30).
Early development and adoption of new technology has been thehallmark of this maturing young unit. The adoption of computedtomographic angiography as the investigation of choice for intracra-nial aneurysms and intracerebral hematoma (13, 44, 38), endovas-cular coiling of intracranial aneurysm at the time of the InternationalStudy on Aneurysmal Subarachnoid Hemorrhage Trial recruitmentof patients in 1995–1997 (41), vagus nerve stimulation for intractableepilepsy in the mid-1990s (15), deep brain stimulation of the subtha-amic nuclei in 1997, brainstem auditory implant for patients withilateral acoustic neurinoma, and deaf children without tumor since002. This has led to the past decade’s effort in subspecialization.ascular neurosurgery (1, 2) is the first to mature, with neurosur-eons, radiologists, and neurologists working together for earlyiagnosis and timely treatment of aneurysms, arteriovenous malfor-ations, ischemic brain that requires low- and high-flow bypasses,
arotid endarterectomy, and stenting, both extracranial and intra-ranial. This is followed by functional neurosurgery for movementisorders and intractable epilepsy, matured because of the keenollaboration between neurosurgeons, movement disorder neurol-
Figure 1. Prince of
gists, and epileptologists. Skull base, endoscopy (endonasal and
384 www.SCIENCEDIRECT.com WO
ventricular), and spine surgeons (11) have formed their own teamsfor development of the clinical service and research.
ESTABLISHMENT OF THE NEUROSURGICAL TRAININGPROGRAM
The Specialist Registry of the Hong Kong Medical Council requiresof specialist neurosurgeons to have gone through a structured train-ing program of a minimum of 7 years, supervised by the SpecialtyBoard in Neurosurgery of the College of Surgeons (20) and theAcademy of Medicine of Hong Kong. The completion of training ofa specialist neurosurgeon is governed by two formal examinations:the entrance examination after the completion of 2-year training ofsurgery in general and the exit examination at the completion of 5years of career neurosurgical training. The first exit examination forqualifying specialist neurosurgeons was held in 1997. This is nowjointly organized by the Hong Kong College and the Royal College ofSurgeons of Edinburgh from October 2004. More recently, we haverelied on a central selection mechanism in selecting the best candi-date in basic surgical training to enter formal neurosurgical trainingat 6-month intervals. The objective selection mechanism, the struc-tured training program, and the stringent conjoint examinationhave guaranteed a constant supply of high-quality competent youngneurosurgeons to staff our service and academic units.
MINIMALLY INVASIVE SURGICAL TRAINING
Cadaver surgical anatomy teaching and live surgical demonstration
s Hospital 1984.
of complex neurosurgery had been a popular mode of training over
RLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.02.027
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WAI S. POON NEUROSURGERY AT PRINCE OF WALES HOSPITAL
the 1990s. This type of training was hugely facilitated by the pur-posely built and well equipped Minimally Invasive Surgical SkillTraining Center, established in 2004. The best international neuro-surgical teachers who have taught us in these facilities include Pro-fessors Yasargil, the late Axel Pernekzki, Madji Samii, Alan Crock-ard, 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 thepractice of medicine has been our target. Although the majority ofthe multicenter clinical trials on vasospasm such as the traumaticsubarachnoid hemorrhage, magnesium (34, 36), and the endo-thelin-antagonists on aneurysmal subarachnoid hemorrhage, ourstudies on the prevention of cerebrospinal fluid infection using an-tibiotics (27), frequent change of catheter (37), and antibiotic-im-pregnated catheter (35) do allow us to modify clinical practice. Thepast decade also takes us from doing small laboratory studies (14, 17,18), relying on technicians and postgraduate students, to employingfull-time faculty staff to do the translational research (5, 6, 21, 33,40), to the establishment of the Chinese University of Hong KongBrain 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-6. Chen GG, Sin FL, Leung BC, Ng HK, Poon WS:Glioblastoma cells deficient in DNA-dependent pro-
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diagnosis of intracranial ananeurysm clipping. Neuros
WORLD NEUROSURGERY 75 [3/4]: 383-386, MARCH/APRIL 2011
friendly clinical areas, and large operating theaters will facilitate thisyoung team of neurosurgeons to continue to excel in clinical service,training, and research. The government-initiated project of the Cen-ter of Excellence in Neuroscience will be the next opportunity forneurosurgery at the Prince of Wales Hospital to contribute to the
Figure 2. The new extension block of the Prince of Wales Hospital 2010.
field internationally.
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REFERENCES
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2. Boet R, Poon WS, Yu SC, Chan MS: EndovascularGDC-mediated flow-reversal for complex posteriorcirculation saccular aneurysms. A report of twocases and critical appraisal. Minim Invasive Neuro-surg 46:220-227, 2003.
3. Chan MT, Boet R, Ng SC, Poon WS, Gin T: Effect ofischemic preconditioning on brain tissue gases andpH during temporary cerebral artery occlusion. ActaNeurochir Suppl 95:93-96, 2005.
4. Chan MT, Boet R, Ng SC, Poon WS, Gin T: Magne-sium sulfate for brain protection during temporarycerebral 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 stauro-sporine in induction of cell death in glioblastomacells lacking DNA-dependent protein kinase. Apop-tosis 10:185-192, 2005.
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21. Liu AM, Lu G, Tsang KS, Li G, Wu Y, Huang ZS, NgHK, Kung HF, Poon WS: Umbilical cord-derivedmesenchymal stem cells with forced expression ofhepatocyte growth factor enhance remyelinationand functional recovery in a rat intracerebral hem-orrhage model. Neurosurgery 67:357-365, 2010.
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27. Poon WS, Ng S, Wai S: CSF antibiotic prophylaxisfor neurosurgical patients with ventriculostomy: arandomised study. Acta Neurochir Suppl 71:146-148, 1998.
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33. Wang YX, Zhu XL, Deng M, Siu DY, Leung JC, ChanQ, Chan DT, Mak CH, Poon WS: The use of diffu-sion tensor tractography to measure the distancebetween the anterior tip of the MEYER loop and thetemporal pole in a cohort from Southern China. JNeurosurg 113:1144-1151, 2010.
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35. Wong GK, Ip M, Poon WS, Mak CW, Ng RY: Antibi-otics-impregnated ventricular catheter versus sys-temic antibiotics for prevention of nosocomial CSFand non-CSF infections: a prospective randomizedclinical trial. J Neurol Neurosurg Psychiatry 81:1064-1067, 2010.
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1. Yu SC, Chan MS, Boet B, Wong JK, Lam JM, PoonWS: Intracranial aneurysms treated with Guglielmidetachable coils: midterm clinical and radiologicaloutcome in 97 consecutive Chinese patients in HongKong. AJNR Am J Neuroradiol 25:307-313, 2004.
2. Yu SC, Chan MS, Lam JM, Tam PH, Poon WS: Com-plete obliteration of intracranial arteriovenous mal-formation with endovascular cyanoacrylate emboli-zation: initial success and rate of permanent cure.AJNR Am J Neuroradiol 25:1139-1143, 2004.
3. Yu SC, Leung TW, Lam JS, Lam WW, Wong LK:Symptomatic ostial vertebral artery stenosis: treat-ment with drug-eluting stents— clinical and angio-graphic results at one year. Radiology 251:224-232,2009.
4. Zhu XL, Chan MS, Poon WS: Spontaneous intracra-nial hemorrhage: which patients need diagnosticcerebral angiography? A prospective study of 206cases and review of the literature. Stroke 28:1406-1409, 1997.
5. Zhu XL, Poon WS, Chan CCH, Chan SH: Does inten-sive rehabilitation improve the functional outcomeof patients with traumatic brain injury (TBI)? A ran-domized controlled trial. Brain Inj 21:681-690,2007.
itation: World Neurosurg. (2011) 75, 3/4:383-386.OI: 10.1016/j.wneu.2011.02.027
ournal homepage: www.WORLDNEUROSURGERY.org
vailable online: www.sciencedirect.com
878-8750/$ - see front matter © 2011 Elsevier Inc.ll rights reserved.
RY, DOI:10.1016/j.wneu.2011.02.027
