Cardiothoracic Surgery

STAFF

Dr. Wing-kuk AU Division Chief and Consultant

• Dr. Timmy Wing-Kuk AU
  Division Chief and Consultant
  MBBS (NSW), FRCS (Edin), FCSHK, FHKAM (Surgery)

• Dr. Lik-Cheung CHENG
  Division Chief and Consultant (Part Time)
  MBBS (HK), FRCS (Edin), FCSHK, FHKAM (Surgery)

• Dr. Alan Wai-Sing SUEN
  Senior Medical Officer
  MBBS (HK), FRCS (Edin), FCSHK, FHKAM (Surgery)

• Dr. Alan SIHOE
  Associate Consultant
  MA (Cantab), MBBChir, FRCS (Edin), FCSHK, FHKAM (Surgery)

• Dr. Xin LI
  Assistant Professor
  MD(Fudan), PhD(Fudan)

• Dr. Flora Hau-Fung TSANG
  Associate Consultant
  MBBS (HK), FRCS (CTh), FCSHK, FHKAM (Surgery)

• Dr. Cally Ka-Lai HO
  Associate Consultant
  MBBS (HK), FRCS (Edin)(CTh), FCSHK, FHKAM (Surgery)

• Dr. Daniel Tai-Leung CHAN
  Associate Consultant
  MBBS (HK), FRCS (Edin), FCSHK, FHKAM (Surgery)

• Dr. Barnabe Antonio ROCHA
  Resident Specialist
  MBBS (HK), FRCS (Edin), FCSHK, FHKAM (Surgery)

• Dr. Ko-Yung SIT
  Resident Specialist
  MBBS (HK), FRCS (Edin), FCSHK, FHKAM (Surgery)

INTRODUCTION

On 19^th June 2008, the Hong Kong media disclosed to the public that the Cardiothoracic Surgical Unit [Division of Cardiothoracic Surgery (DCTS), Department of Surgery, Queen Mary Hospital (QMH)] and Paediatric Cardiac Unit at Grantham Hospital (GH) will be relocated to QMH in July this year. To the DCTS, the year 2008 is like the year 1997 to Hong Kong. It is opportune to document the early development of cardiothoracic surgery in Hong Kong and GH, to pay tributes to the founding members and unveil the rationale of relocating DCTS to QMH.

In the mid-1940s and 1950s, with the understanding of the clinical application of hypothermia and development of the heart-lung machine, cardiac surgery became an everyday reality in large hospital surgical services in United States of America (USA). On the other hand, in Hong Kong, in the 1950s and up to early 1960s, thoracic surgery was mostly confined to thoracoplasty for extensive pulmonary tuberculosis with residual cavities and lung resections for the more localized disease not amenable to medical treatment alone. Esophageal surgery was introduced to Hong Kong by then Dr. GB Ong, Consultant Surgeon of the Medical and Health Department at Kowloon Hospital and Honorary Consultant Surgeon at Kwong Wah Hospital (Personal communication). At that time, cardiac surgery was confined to few closed heart procedure, viz. closed mitral valvotomy (CMV), closure of PDA and occasional Blalock-Taussig shunts. To my knowledge, only four surgeons had been involved including three government consultant surgeons (Drs. GB Ong, Morgan Lu and John Chen) and one Senior Lecturer in Surgery, The University of Hong Kong – Dr. Kenneth Hui. When Dr. GB Ong was appointed to the Chair of Surgery at the University of Hong Kong in 1964, there was a demand from the public that open-heart surgery be available in Hong Kong. In response to the quest of the public, the Departments of Medicine and Surgery at the University of Hong Kong together with the M&HD and Hong Kong Anti-Tuberculosis Association initiated a joint venture to introduce open-heart surgery to Hong Kong. The following incidents were testimonies of their endeavours.

• In 1964, the Department of Surgery took over one of the two Thoracic Surgical Units at GH and then both units in 1966.
• The first open-heart operation was performed by Professor Ong at QMH on 11^th December, 1964 on a female patient with patent ductus arteriosis (PDA), pulmonary valve stenosis and atrial septal defect (ASD). He divided the PDA, performed the pulmonary valvotomy and closed the ASD under hypothermic circulatory arrest, (QMH OT Registry) and on 2^nd February, 1966, he closed another ASD on another female patient also at QMH with the atrial-well technique, an ingenious method devised by Dr. Robert Gross in 1953.
• The then HKATA responded to "a world trend of similar associations and organizations to expand their activities to the diagnosis and treatment of diseases of the chest and heart" and revised the Ordinance under which the Association was incorporated. The revised Ordinance was enacted on 1^st February, 1967 (Annual Report of the Board of Directors for the year ended 31^st March, 1967). The Association also changed its name to Hong Kong Tuberculosis Chest and Heart Diseases Association
• In his presidential address on 25^th October, 1967, Dr. the Hon. PH Teng (DMHS) stated "Some time ago there was much ill-informed of "open heart surgery", I use the words "ill-informed" deliberately as the critics were unable or unwilling to accept any detailed explanation of the long and careful programme of planning, and training of special personnel before the introduction of this specialised form of surgery…"
• "the long and careful programme of planning, and training of special personnel" included
  1. Up-grading the diagnostic equipments of the Lewis Laboratory at QMH with a donation of HK$160,000 from Miss Aw Sian;
  2. Training of special personnel:
         Ms M. Abbott, nursing officer-in-charge of OT at GH underwent 4 weeks study leave to study open-heart surgery at Westminster and other hospitals in England in 1965
         Drs. KH Kwong and John Leung underwent open-heart surgery study overseas - Dr. Kwong to the University of Colorado USA, under Professor Bruce Paton, in 1966-67, and Dr. Leung to the Green Lane Hospital, New Zealand, under Sir Brian Barratt-Boyes in 1968-69.
         The designated open-heart team members started to practice the technique of cardiopulmonary bypass on dogs at GH in 1967/68.
     

Towards the end of 1967 when Dr. KH Kwong (then Senior Lecturer) returned from USA, he started closed heart surgery at GH. On 30^th July, 1968, at GH, Dr. Kwong assisted Dr. Lester Bryant, an American cardiac surgeon from Lexington, Kentucky, sponsored by the American Heart Association successfully closed an ASD in a 17-year-old girl with the aid of the heart-lung machine. Dr. Gibbon’s success in 1953 in USA was repeated in Hong Kong, a lapse of 15 years. Other members of the team were Dr. Nancy Butt, consultant anaesthetist, Drs. Chow Tak Yam and Tsang Lik Hang (1967 HKU graduates), surgical MOs, Mr. Anthony Hung, a male nurse seconded from QMH as the perfusionist and Mr. Yeung Wai Ho, a medical technologist seconded from Government. When Dr. Kwong resigned from the University In February 1969, Dr. John Leung became the Chief-of-Service (1969-1977). Dr. Kwong remained as an honorary surgeon at GH and performed on an average of one open-heart operation/week until September 1978.

The administrators who were instrumental in the setting up of the open-heart unit at GH included Miss Sheila Iu, the first matron of the GH; and the late Mrs. Susan Yuen, Chairperson of the GH House Committee in the 1960s/70s.

In the formative years at GH, a single independent cardiologist Dr. Titus Cheung, was appointed in March 1968 by Dr. Gerald Choa, then DM&HS. Dr. Cheung’s duty was to assist the setting up of the cardiac surgical service; he remained in that position until August 1971 when he immigrated to Melbourne, Australia. The cardiologist post remained vacant until 1974 when Dr. Cheung King Loong was posted to GH, initially as part-time and later full-time staff. With her support, not only the number of operations performed increased, the results also improved. Her totally commitment and dedication to the cardiac surgical patients became an invaluable asset of the DCTS. It was regrettable that the DCTS had to release her to form the Adult Cardiac Medical Unit, a Division of Cardiology of the Department of Medicine at QMH, in 1980. Dr. KL Cheung was the Consultant Cardiologist-in-charge.

Paediatric cardiac surgery was developed at a slightly later stage. At the time, in Hong Kong, there was only one formally trained paediatric cardiologist - Dr. Gregory KH Wai. Although Dr. Wai was a part-time staff at GH, his enthusiasm and motivation help to incorporate paediatric cardiac surgery into the open-heart programme. Results of initial attempts at repair of congenital cardiac defects in neonates/infants were discouraging; probably related to difficulty in diagnosis and delayed in transfer. The first neonatal survivor was a 2-month-old girl who underwent VSD & ASD closure on 16^th September, 1975. In 1978/79 Dr. Lau Kai Chiu finished his paediatric cardiology training at the Bromptom Hospital and joined the GH as a full-time staff. At the same time, a cardiac catherization laboratory was established at GH, on-site investigation and expertise became available. Results of paediatric cardiac surgery improved. By 1980 the DCTS led by Professor Mok was able to report to the literature 30 consecutive children less than 2 years age underwent VSD repair with a hospital mortality of 6.7%. (Aust N Z J Surg. 1980; 50:378-81) In retrospect, it had taken over 10 years for Professor Mok and the efforts of a team of enthusiastic individuals with a common goal to establish a comprehensive cardiac surgery tertiary referral centre.

The Hospital Authority (HA) completely took over the GH in 1990 and in the latter part of the 1990s, a GH redevelopment plan was drawn up, supported by HA and submitted to government for approval and funding. With the economic downturn in 1997, the redevelopment plan was shelved. In the ensuing 10 years, Professor John Wong, as Head of Department of Surgery and Member of the Hospital Governing Committee (HGC), felt duty-bound to informed the HGC and HA explicitly and repeatedly that without the implementation of the long overdue redevelopment, it was extremely unfair to the cardiac surgical patients if the DCTS was to remain in GH status quo. Because, with time, patients’ profiles and expectations, complexity of their clinical problems have changed significantly, many of them, premature neonates and octogenarians, require multi medical/paediatric and surgical sub-specialties’ supports which are only available in an appropriately equipped and staffed hospital. Short of a brand new specialty hospital, relocation and integration of the DCTS to a general hospital like QMH would be the simplest solution. Despite Professor Wong’s repeated, explicit explanations and urge to HA, the GH Governing Committee (HGC), Board of Directors of HKTCHDA (Minutes of Board of Directors’ meeting on 28^th June, 2002, HKTCHDA); it had taken over 10 years for the stakeholders to come to agreement on this "simple solution". The protracted course was probably a testimony of the Chinese saying that the prerequisites of success are 天時, 地利, 人和 (right climate, amiable terrain and humane harmony). It is hoped that the integration would be less problematic.

The relocation was conducted in two phases. In July, the DCTS was relocated to the 5^th floor of QMH – three OT suites at E5; 16 cardiothoracic ICU beds at E5 and 30 step-down beds at C5 respectively. The Specialty OPD is in S3. By June 2009, D5 was renovated as a female cardiothoracic general ward.

Dr Lawrence Lai, former CCE, HKW, announced recently that the Government has in principle approved a proposed new clinical block for Accident & Emergency, Trauma and Heart Centre in QMH. The project is anticipated to be completed by late 2015. By then the block will have 3 Cardiothoarcic Operating Theatres, 3 cardiac catheterization laboratories, two Cardiothoracic wards with a total 60-80 beds and other facilities. The next generation of cardiac and thoracic surgeons will have more opportunities of development both in clinical and academic aspects and will continue to play a significant role.

ACTIVITES AND SERVICES

The Division of Cardiothoracic Surgery is the largest tertiary referral centre for patients with heart and lung diseases in Hong Kong. The service was originally established in Grantham Hospital and was relocated back to QMH on 25 July, 2008. The Division provides adult cardiac surgery, paediatric cardiac surgery, intrathoracic organ transplantation and thoracic surgery. Each year, the Division performs 650 open heart operations, 150 closed heart operations and 400 thoracic procedures. Congenital heart surgery accounts for about 40% of all the cardiac operations.

The Division receives referrals of both elective and emergency cases from all public and private hospitals in Hong Kong as well as from Macau and nearby regions. Regular conferences on cardiac and thoracic surgery, interhospital CME meeting, fellowships etc provide a platform for exchange of valuable ideas, knowledge and experience not only for local doctors but also for doctors from abroad. Cross-disciplinary support is also provided for other clinical units in Queen Mary Hospital.

As an integral Division of the Department of Surgery of the University of Hong Kong, the Division maintains a strong commitment to training the next generation of surgeons in the territory. The Division provides regular lectures for medical students, clinical and tutorial attachment at Queen Mary Hospital.

STRENGTHS AND DEVELOPMENTS

The Division is the only designated paediatric cardiac surgical centre in Hong Kong. The Division involved in over 95% of all paediatric cardiac operations that are performed in Hong Kong. Complex congenital heart procedures such as arterial switch operation, Ross procedure, Rastelli procedure and Fontan operation are routinely performed. We have achieved an overall less than 3% mortality rate in paediatric open heart surgery in the recent several years.

The first heart transplantation in Hong Kong was performed at Grantham Hospital in 1992. The first heart-lung transplantation and double-lung transplantation were successfully performed in 1995 and 1997 respectively. Currently, the Division is the sole provider of intra-thoracic organ transplantation in Hong Kong. Up to June 2009, 97 heart transplantations have been performed. The 10-year survival rate for heart transplantation now exceeds 80%, with all patients achieving a New York Heart Association Class I to II functional status postoperatively. In 2004, we performed the first successful implantation of the Left Ventricular Assist Device (LVAD) using the Berlin Heart Device in a 7-year-old boy with acute fulminant myocarditis.

Ten years ago, the Division was the pioneer in introducing minimally invasive direct coronary artery bypass (MIDCAB) into Hong Kong. Shortly afterwards, we introduced multiple vessel off-pump coronary artery bypass grafting (OPCABG) and over 250 patients have benefited from this technique. Recent introduction of the endoscopic vein harvesting (EVH) technique has further decreased morbidity in our CABG patients. With the advent of new instrumentation, the Division is heading towards less invasive cardiac surgery e.g. closure of atrial septal defect and mitral valve repair have already been successfully performed by the Division. A newly structured programme of surgical radiofrequency ablation of atrial fibrillation has been developed.

Thoracic Surgical services have continued to be improved and expanded through the incorporation of key innovations and advances since 2006. These include:

• Establishing the use of minimally invasive surgery as the routine approach for complex thoracic operations, including major lung cancer resection, thymectomy for myasthenia gravis, and decortication for advanced pleural empyema.
• Adopting a new nursing care program designed specifically to complement the superior recovery of patients following modern minimally invasive thoracic procedures.
• Development of ‘next generation’ minimally invasive thoracic surgical techniques, such as needlescopic surgery for pneumothorax and palmar hyperhidrosis.
• Introduction of advanced technological advances in the operating theatre, including high-definition video systems, endobronchial bronchoscopy, and ultrasonic surgical systems.
• Pioneering the use of digital air flow monitoring technology to improve chest drain management following thoracic surgery.
• Reduction of pain and morbidity following thoracic operations through application of the latest pre-emptive and loco-regional analgesic strategies during surgery.

RESEARCH

The Division of Cardiothoracic Surgery has a number of clinical research areas.  Current research interest include:

• Minimally invasive cardiac surgery
  • Endoscopic long saphenous vein and radial artery harvesting
  • Valvular heart surgery
• Surgical radiofrequency ablation of atrial fibrillation
• Mitral valve repair programme
• Aortic dissection
  • Short-term and long-term surgical outcome
• Heart and lung transplantation
• Risk stratification for adult cardiac patients leading to the establishment of local risk scoring system
• In Thoracic Surgery, a large number of clinical and basic research projects have been initiated with other departments (Department of Pathology and Department of Medicine etc) since 2006, including:
  • Molecular genetic, proteonomic and stem cell research in Lung Cancer amongst Hong Kong patients.
  • Investigation of novel techniques to treat air leakage in lung resection surgery, including the use of endoscopic application of aerosolized fibrin.
  • Identification of different components of post-operative pain following thoracic surgery, and development of novel strategies targeting individual components such as neuropathy.
  • Prospective surveys into the quality of life following thoracic surgery, with specific analysis of influences from elements of peri-operative care, socio-economic factors, and pain.
  • Continuing evaluation of operative efficacy, enhancement of post-operative recovery, and long-term outcomes following minimally invasive thoracic surgery.
• Current Prospective Research Projects in Thoracic Surgery
  • Prospective clinical database on all patients receiving surgery for Pneumothorax
  • Prospective clinical database on all patients receiving surgery for Lung Cancer
  • Prospective Quality of Life survey on all patients receiving surgery for Palmar Hyperhidrosis
  • Lung Cancer Molecular Genetics and Clinico-pathological Correlations study (in partnership with The University of Hong Kong Department of Pathology)
  • Lung Cancer Tissue Banking for Proteonomics research (in partnership with The University of Hong Kong Department of Surgery)
  • Lymph Node Sampling in Lung Cancer: comparison of VATS and open Thoracotomy techniques and correlation with clinical outcomes
  • Viral and Microbial Markers in Lung Tissue in Hong Kong (in partnership with The University of Hong Kong Department of Microbiology)
  • Lung Cancer Stem Cell research (in partnership with The University of Hong Kong Department of Medicine)
  • Aquaporin-4 Expression in Thymic tissue in patients with Thymoma and/or Myasthenia Gravis (in partnership with The University of Hong Kong Department of Medicine)
  • Randomized Controlled Trial of Endoscopic Application of Aerosolized Fibrin in the treatment of Air Leakage following VATS lung surgery
  • Routine Endobronchial Ultrasosnography for intra-operative Lung Cancer Staging
  • Tumor Markers for Lung Cancer in Sputum (in partnership with The University of Hong Kong Department of Medicine)
  • Lung Cancer Systemic and Airway Cytokines (in partnership with The University of Hong Kong Department of Medicine)
  • Pharmaco-physiological Characteristics of Pulmonary Vasculature in Lung Malignancies (in partnership with The University of Hong Kong Department of Pharmacology)
  • Prospective survey on Patient Attitudes and Socio-Economic Influences on Discharge Home following Thoracic Surgery
  • Randomized Placebo-Controlled Trial on use of Gabapentin for the management of Post-Thoracotomy Pain Syndrome
  • Prospective survey on Patient Morbidity from Chest Drain use following Thoracic Surgery
  • Use of novel Portable Chest Drain System with Digital Air Flow and Pleural Pressure Monitoring in Thoracic Surgery
  • Use of novel Needlescopic VATS Pleurodesis technique for Primary Spontaneous Pneumothorax
  • Prospective clinical database on patients receiving complete VATS Thymectomy for Myasthenia Gravis
  • Endoscopic Screening for Esophageal Malignancy in patients with previous Squamous Cell Lung Cancer (in partnership with Oesophageal team)

COLLABORATIONS

The Division jointly with the Anaesthetic Department ( before we were relocated in July 2008 ) introduced 3 scoring systems namely Euroscore, Parsonnet and Malaysian, to risk stratify our patients. After collecting data of nearly 3000 patients, we have found that the Euroscore system is more suitable for our local patients. We have through our current database developed a local risk-stratification scoring system. We anticipate that with further data collection and analysis, our own scoring system can be refined.

In Thoracic Surgery, there has been a very rapid expansion in both the scope and range of surgical research by the Division since 2006. This strong growth in academic activity was complemented by the constructive development of many collaborative research efforts with other departments of the University of Hong Kong. These include studies in Thoracic Surgery in partnership with the Departments of Surgery (tissue banking, proteonomic research), Pathology (molecular genetics), Medicine (stem cell research, inflammatory markers), Pharmacology (pulmonary vascular physiology), and Pharmacy (neuropathic pain).

GALLERY

Fig. 1 - LVAD

Fig. 2 - Palmar hyderhidrosis (sweaty hands) can now be treated using needlescopic sympathectomy with barely noticeable wounds.

Fig. 3 - Department Photo

Fig. 4 - Lung cancer surgery is now routinely performed using Video-Assisted Thoracic Surgery (left) which offers potentially less morbidity and better recovery than traditional open thoracotomy (right).