Multiple recurrence of spontaneous pneumothorax

Treatment of pneumothorax has not been standardised until 18- 19 years ago with the introduction of video assisted thoracoscopic surgery.
With simplicity of steps inovolved in bleb ligation and mechanical rub pleurodesis, the vision and access to majority of chest wall by videoscope allow easy performance of pleurodesis for patient.

Also the patient is usually is young and fit other than the pleural disease, the general anaesthesia procedure with double lumen endobronchial tube is well tolerated.

I remember the excitement when the laparoscopic instrument was put in the first few patient for VATS surgery back in 1992. We have looked at the bleb and feel extremely appealing and derive great satisfaction of putting the endo-loop on the apex. But not long after two or three such cases, dislodgement of the endo loop occur and we stick to using the endo stapler (the first generation of Autosuture endo GIA) for pneumothorax bleb resection.

For successful pleurodesis, certain amount of dense or extensive adhesion should be formed after the drain pulled and patient went home. Not infrequently, we do see patients with failed adhesion formation.

The means to prevent this include:

1. Keep the drain longer (but ususally drain has to pulled out after 6 or 7 days, usually the maximal duration that a young patient can tolerate without complaint.

2. Meticulous rubbing of pleural surface and chest wall is required.

3. Secure sealing of air leak point in lung

4. Modification of technique with addition of chemical sclerosant for every case.

There is discussion of the philosophy of first operation for VAT pleurodesis.
Some surgeon propose inclusion of small axillary or small maximally minithoracotomy in anteior port for better stapling of weak apex. The lung is mobilised down to the lung root near the SVC and hilar and lung apex delivered to outside through the throacotomy and single GIA application +/- oversewing is better than multiple fire.
Through the thoracotomy, the air leak can be tested and additional procedure of limited open pleurectomy can be added. Also the problem of intercostal neuralgia due to fulcrum pressure on the port site is avoided. The only small instrument port site will be the final drain site.

So there is revertion to minithoracotomy and Video assisted open thoracic surgery rather than keyhole VATS for pneumothorax.

The recurrence rate can be brought down from previously 10% to 4 or 5 %.

Recently I come across patients with immediate persistent air leak after first VAT surgery for pneumothorax and contralateral recurrence of pneumothorax.
I applied VAT endoscopic pleurectomy and ambulatory drainage method. The success is high and expected adhesion formation is secure.

I am practising specialist in pnemothorax and all kinds of thoracic surgery. I welcome question and queries for their problem with reasonable low consultation fee.
Clinic phone number: 3160 8865

Current trend of wound-less surgery in lung cancer: pushing to the limit of single 25mm wound

Single port surgery is the current trend in minimally invasive surgery. For lung cancer surgery, the adoption of extreme small wound is cautioned by the possibility of compromise of oncological clearance. However, as experience accumulate since the introduction of VATS surgery, the worry of delayed relapse or early recurrence is less of a concern. More and more surgeon believe in the reverse. With less immune suppressive effect of minimal access surgery, survival is prolonged for VAT operable lung cancer.
Recently I attend a workshop for the update of VATS in lung resection. Without expecting anything new to discover, the enthusiasm of speakers for VATS experience remains high despite coming along all those years of minimally invasive surgery. Yet they stress on the fact that only surgeon with a vision can push for limit of traditional belief and constraint.
So long as the surgeon believe in doing surgery with due care and good suprevision, pushing to the limit of two small wound then single uniport wound is best to achieve good recovery for same type of lung resection surgery. However, there is limit to everything. If it takes hours for the lung cancer to be removed when a slightly larger wound could allow swifter but not necessarily better clearance of tumour. One may not be too dogmatic to fight for shorter wound length.
Moreover, the reason of learning curve is not short for Uniport surgery.
From example of uniport laparoscopic cholesystectomy, the time will much vary with the inflammatory condition of the gallbladder. In occasional attempt, surgeon will take twice the usual time for difficult gallbladder.
I believe well trained surgeons do know the limit of his own and possiblitly of fatigue and psychological burden of prolonged surgery, they would convert at appropriate time. The imperative is patient's safety and the least of concern is surgeon's ego.

I applaud the skill and determination of surgeon pursing uniport VAT lobectomy. But  I personally would select less than 10% of all operable lung cancer for such attempt.

Value of Life or Health - Perspective from health care helper

As doctors, most of the medical ailments are commonly known to us. We understand that most of the complaint about pain and ache or discomfort did not signify important illness. This is to be said with a caution such as coughing out blood, severe weight loss, depression with suicidal thought or severe spontaneous syncope.
Conversely, some severe life threatening disease may not have symptoms.

I have talked about screening in previous blog and stress that the benefit of screening for example in lung cancer is not to be down played. However, there is a need for mentality and financial resource for proper screening. Acutally the drive is more important than money in such cases.

But when it come to important illness such as severe pneumonia, renal failure, severe trauma or stroke, medical personnels are the least to cope with this. Their knowledge would bring some advantage but add worry to the treatment course.

To me, the loss of life turn out to be some daily events. More eye cathing are victims in natural disaster, violence such as rape or terrorism or medical mishap or early cancer in young adults. Acutually, life is quite vulnerable. The possibility of serious blow to it is always there.

To treasure it is really necessary for us to rethink eveything. Our existence certaily would be transient in the history of time. If at one time and at one place, we can make our surrounding or family happy. Out existence will add meaning to us all.

For me, I would try my best to give the best possible treatment to them. I cannot change my patient's fate. At most, I hope to give them the best attiotude to face life and death. Treasure existing life but forget tommorrow trouble.

Dr Chung Shiu Shek tel of clinic: 31608865

Sino Japanese Relationship

As a medical professional, we like to talk about politics but seldom take it serious. With wide coverage and nearly daily report of riots in China, the tension between China (PRC) and Japan is on every news' front page.  We all know from the day of birth that Chinese and Japan are competing countries and seldom in good terms. But the value of peaceful coexistence is more than everything to avoid mutual terror at World War II.  As Chinese, the sense of being treated unfairly is especially sharp. From Japanese society, their education may be deviated towards self righeousness; but most japanese are well educated and also believe in peace rather than militarism.

Why do the approach of the subject create so many news and tension?  The answer should be timing. As Diaoyu island is an old problem, whehter you want or not, practically it is under the control of Japanese force.  As these problem has been years, and nearly no interest about it by Japanese governement. Why japanese want action or something to be done recently. Usually the target against another nation help stabilise force and create unity in home country in favour of the existing power. They are used by both government to consolidate  power. In China, the future of post HU Jianto governement has been clear but not fully established. To push aside discrepancy of opinion, the need of unity for different ages or different force within the central government is important. More than anything, the hate against japanese invasion can be used once again for Vice Premiere Xi to assume good central control of power.

To Japanese government, the power of democratic party has never been stable since take over of premiereship from opposing self democratic party. They are faced again by tragedy of nuclear incident. They need more fame and esteem to stay solid in control of Japan. To unify the parliament, the pride of owning Diaoyu island is brought in again. In fact Japan own this island for ages. is there any need for power or petroleum over there? I thnik no, the economic advantage is not great, The susceptibility of being invaded or destroyed by other force make investment risky. From recent report on Japaneses newsmedia, there is comment or criticism of current act of Japanese government. So not all japanese want War as depicted by chinese media.

Why the newspaper always focus on this? To sell more paper and be only source for news. In War times, newspaper sell. Remember 9/11, suddenly everyone want to grap newspaper as research by reporter attract more attention and bring satiety to news hunger in public.

So we would heard about riots , tension, demonstration against Japan in Chinese news. But not after the 18th NPC commitee. By then, every protest will be suppressed. Peaceful talk with Japan will begin. Concession for mutual benefit will be granted. Any civilian upset about government weakness will be gone. No news about Diayo island will be publicised. Like the control of internet, there would be information control as tight that even thought there is protest, it will not be reported or mentioned in any media.

As for the Japanese, the status of the island will remained the same. You can call it nationalisation. You can call is isolation. Thus, there is no real owners and no transaction of money ever to be made in the Bank for the ownership of the island. Japanese media has no interest and never want to be made use of by their polictian. The Diaoyu island cannot be anything of financially as one thousandth of Tokyo or even the nuclear accident town. They are just hyperbole of the news media.

Thank to the gift of life: on the recieving end

As medical professional, the preciousness of life make some of our patients extremely grateful to us. But is it our preference to have such feeling and reaction. Or is it the absence of such action make us uncomfortable or dissatisfied. From the patient point of view, will our action of grafeful feedback secure better follow up service?

I recently read about the ICU dying patient news about recieving a generous cavdever organ donation. The news state that as an emotional reaction, the heart surgeon shed his or her tears saying that the patient should treasure this timely gift of life.  I usually feel uneasy about that emotional side of providing medical treatment. But the meaning of doctors act should however touches heart of most patient and people.

For doctor either recieving pay from public money or from paying patient 's pocket, they are suitably remunmerated with proportionally correct sum. The doctor has the de facto responsibility to carry out a good and technically right work.  Compliment to doctor success is thus an extra.  Having said that, doctors usually appreciate very much the thankfullness of their patient. Sometime these are driving force for doctors altruism.

Once I have the experience of being touched by my patient's word. He is a gentlemen and always thanks me for whatever procedure or treatment I provide him.  Once I talked casually to him. Do not be too courteous , you know you have paid me for my professional service. I owe you the trust. He responded calmly. Dr Chung, I know I have paid all the professional fee related to my treatment and I knowed I am entitled to high standard care. But regarding your service and careful adminstration of care, I still owe you a words of thank because of trueworthiness of your work. Our care and attention if acted from our heart are much valued by our patient.

Occasionally as private specialist, the care of long term disease bring much concern to financial burden.  So some of my patients will not return for follow up. This is reasonable as chronic disease can bear the burden of waiting list and these conditions can best be dealt with in public sectors. Anyway, I would not anticipate that all patient will be my faithful followers for life.  Sometimes, I heard complimentary words about my service but later default in follow up. I find it perplexing to understand. But In the real world, this is not uncommon.

In essence, I do feel good on the recieving end of thank and gratefullness. But do not take it too serious as your driving force. Some patients and most indeed has the concern of financial constraint.  They are entitled to develop way to secure best mode of care to them. So they would swarm between private and public care depending what fit them most.  However, I do feel satisfied after tough surgery or long operation, the patient or patient's relative say from their heart: You have done a great job. You have done a favour to them.

Surgeon with a heart: I am Dr Chung Shiu Shek specialist in Cardiothoracic Surgery, Clinic phone no: 3160 8865

Cancer: cure or control

Lung cancer is common and a fatal disease if not treated early and appropriately.  Quite a number of patient with lung cancer has physically normal lifestyle until the time of detection. The psychological trauma is no doubt great. With the improvement of drug and radiation treatment, more option is available on top of curative surgery. Are over treatment always produce good result and ensure good long term outcome?
This question has occurred more than couples of time for real cases.
Usually they are relatively young patient and locally advanced disease.

I personally would stick to traditional guide line but allow oncologist to have tailored made decision with different patients. Most oncologist has keeness for chemotherapy and less favor towards post operative RT. (of course they are exception)

So the cancer boil down to control or cure debate? Must all treatment be comprehensive to be exhaustive that near absolute cure is the best?  In fact life is in a cycle. No living organism is blessed with everlasting existence. Most persons are destined to have limited lifespan about 70 or 90 years.  If the treatment can restore our body to near normal life expectency, then probably this is already the best.  Say if the cancer recur at age of 90 or even 87, we would rather not treat but palliate the cancer. Cancer drug itself may be carcinogenic in long run. Too much treatment , if not necessary, may even do harm then good.

For a different group of cancer patients, they are elderly with moderately advanced disease. So the primary aim is opting for cure within the tolerance ability of the patient. Secondly, control of symptom will be more important than too aggressive treatment.  Minimally invasive surgery are therefore of most benefit to this group of patient.  I have done a few such cases with small wound for old patient. They all come around the surgery satisfactorily. In such group of patient, too aggressive chemotherapy may be of considerable side effect.

For terminal cases where palliation of symptom is most important. Control with oral anticancer or target drug is the best. Luckily, these drug are well tolerated even in elderly. However, the cost may be substantial. Recently I heard about interesting presentation stating thalidomide, metformin and some other old style drugs has anti cancer effect that their use can bring palliative symptom relief at low cost.

I am Dr SS Chung specialist in Cardiothoracic Surgery and expert in lung cancer treatment. My clinic no is 3160 8865

Need for more doctors in public sector

As a private medcial specialist, the public service is not my major concern. In fact one may eye public sector as direct competitor for patients.
However, as part of the medical community, the state of running of public sector has a lot to be in consideration.

Over 60% doctors registered in Hong Kong are in private practice. Less than 40% work in the public sector.  Over 90% of patient are attending public hospital or clinic services.  The demand is already under control by crowding or long waiting list or concern for delay aspect.  Also the public sector has to shelter the purpose of training, internship supervision and front line reseach and other continued medical training problem. Last but not least, there is a lot of public services such as the arena of East Asian games, preparation of disaster, SARS drill training and mangerial work.

So we need more working hands in public sector, as versus we want more doctors in community. As in many large corporation, retention of human resources or experienced worker is key to success of an institution. So we should look into individual institution and develop ways to retain experienced person. Every year, there is new graduate who would largely join the public services. Out of all these trainess,only one third of them are fully trained and worked satisfactorily in their position. Although, for healthy institution, some movement of manpower is inevitable. However, for particular field such as medical field in Tuen Mun Hospital, A/E department in various hospitals or anaesthesia field. Shortage is constant.

So why did doctors move to private practice despite advantages of stable salary in public sector.
In fact, it is a competition to be retained inside the research based institution in oversea medical field.

Constraint of medical practice and overwork is keypoint for dissatisfaction.
Human resources control is another factor.

The burden of public doctors in senior role is always higher than their private counterpart.

Hierachy in pulbic service is also the reason for stress,

For example, every newly qualified specialist has to shoulder the clinical burden fo patient complaint or untoward event or even to unjustified complaint. However, the doctor has the right to choose his patient, call pattern or working subspecialty.

The clinical hierachy has been two tiered, resident and specialist.

However, the managerial hiearchy is long. HCE - COS - Team Head - Senor specialist - specialist - resident. So there is high likelihood that the senior guys choose the gem of the department and leave the tough and donkey work to the lower tier. Even worse, the reporting mechanism in HA is causing constraint of whistle blower, the poor performance of the senior is never reported and will be penalised. The senior control the promotion and yearly assessment of lower class workers.

Further more, the competence of junior doctors is largely reliance on altruistic sacrifice of the senior person. If the senior person would not teach his helpers for skill and training, the junior will foreever will be untrained unskilled doctor that see no satifaction of job. With such situation there is no way to ensure the senior doctor to do their job. They claim to provide consultant level to all patients by depriving the less experienced training opportunity.

For health care administrator, the over dominence of COS or department team head make job satisfaction ot lower class doctor impossible to be achieved.

Therefore the proposal of two tier system and the non-involved third party for specialist consultation or assessment must be implemented to eliminate such problem.
So as clinical duty is two tier, the managerial or reporting duty should also be two tier. An non involved committee is created to assess the capability and performance the two tiers. For junior specialist,they should care for less number of patient and be remnumerated less. As their performance justify more patient, more patient load is directed to him and more salary is given to the two tier team.

This is a preliminary thinking of how we should improve our public care system. Will discuss more in future.
Thank for reading. I am Dr SS Chung
Chung Shiu Shek Specialist in Cardiothroacic Surgery

Reward to doctor

I am discussing the satisfying experience as a specialist doctor. In fact, although there is everyday news of mis management and medico legal incidence. The number of successful medcial treatment far outweigh the complaint case.
Also for chronic disease, the compliance of the patient is partly the success of communication skill delivered by his care givers.

Peolple usually measure the amount of gratefulness by the amount of fee they are paying their doctors.  However, the art of charging medical treament professional fee is the skill of making compromise.  No same doctors charge same amount. No same cases are charged same amount. I think the customer would anticipate variation of service fee. Of course, in free market, there is no rule to set the price limit. The affordability is a guide. The supply and demand of the doctor's time is a factor. But as doctors are deriving their satifsfaction from successfully treating one disease, the amount they charge should be reasonable to induce patient to turn to private sector for more efficient and personalised care.

Recently I have performed two operations for two patients with severe retrosternal mass causing aerodigestive compression. The courses of the medical treatment is challenging and difficult. One patient required temporary tracheostomy for prevention of repeated aspiration because of temporary paralysis of the vocal cord. She made satisfactory but testing recovery from her operation. Although she has some loss of confidence in her own physical ability and treatment progress, she is overall compliant of necessary step for rehabilitation. Deep in her mind, she has felt relief of potential hazard of airway compromise and dysphagia she had for long years. I was impressed by her stamina and honest trust and doubt on the course of treatment. She paid for the medical cost out of her savings without complaint.

For the second patient, he has airway compromise and rapidly desaturation after induction of anaesthesia. Though previously without any symptom of breathing difficulty, the weight of the mass and relaxation of muslce tone cause compression of airway deep down on the bifurcation of windpipe. Forutnately the anaesthetist has placed the long enough breathing tube (an endobronchial ventilation plastic tube) to the right main bronchus, maintaining good oxygen supply to the body despite lack of air to the L side.  With time constraint and possible disastrous outcome of irreversible hypoxia, I  with two experieneced surgeons' help expeditiously removed the compressing mass with tedious but careful steps. Airway patency was achieved after the mass was delivered out of the wound. She made rapid and uneventful recovery. She was grateful to the surgeons and their team.  Even without being told exactly the challenging moment of the perioperative difficulty, she understood the complexity and the risk of the operation involved. She revealed her fear when other physicians describe how difficult and risky will be an attempt on the operation.

As an experienced specialist thoracic surgeon, I did not underestimate the risk of the operation. With good preoperative planning and prepartion (including to solicit good assitant surgeons help and anaesthesia and last but no least nursing team), the risk was minimised as much as possible. Preop counselling and education to prevent sputum retention, wound complication and post operative deep vein thrombosis were done. Post operative ICU care and prepartion to standby for any unexpected deleterious outcome was pre arranged.  With confidence and knowledgable communication, the patient was inspired to think positively and to overcome the fear.
Good cooperation helps the perfect outcome.

I did not ask for high financial reward for difficult operation. The trust and willingness to put their life to me is the highest honour the patient would give. Like the second case, I would anticipate the market price for such operation would be double the fee I collected. Given the dangerous and stressful situation, the operation is very demanding. A reward proportional to risk and preoperative planning skill is not unreasonable. But the happiness in seeing a fruiful outcome is immensely rewarding.

Lastly I mention two situations when I was in public hospital to make contrast with private health care.

First, for the very first heart transplant patient in Hong Kong dating back to 1992, I witnessed the harvesting surgery as I was assisting the harvest of the liver on the same donor in public hospital late in the night. After 21 year, the patient appears in the media for celebration of the Hong Kong University heart transplant team anniversary, most surgeon appears cheerful and delighted. I am also impressed the satisfaction derived from minor role I take part for this patient.

Shortly before I left my previous public surgical unit, I encountered two patients with late presentation of thymic tumour invading through pericardium into heart. In one patient I peformed debulking with thymectomy and pericardectomy and shaving of most tumour from R ventricular surface. Before operation I mentioned to the patient that the operation result was not guaranteed as remaining tumour would persist and rendered the operation unsuccessful. The patient told me that she put her life and hope on my hands without hesistation. Not suprisingly I found out that in more than two occasions, she was refused surgical treatment in private market. Eventually she was referred by private surgeon to oncology unit of public hospital that eventually channeled to surgical department once again for second opinion. I did not know the final outcome of this patient after she recovered and left hospital. But I achieved at least in prolonging her hope for life. I felt satisfied and rewarded.

The second patient with similar findings of extensive mediastinal tumour invading the root of left lung. Major surgery with resection and simultaneously L pneumonectomy through midline incision and exposure is needed.  As the patient is elderly (>70) female, and there is a chance of incomplete resection. No operation was proposed until I met her in out patient follow up for lung function studies as preparation for pneumonectomy. I proposed early surgery without delay as the chance of unresctability grew with time. I explained briefly the risk and possible operative death. The patient instead of the accompanying relatives strongly accepted the surgical plan. She had "blind trust" on me and had possibly encountered too much controversial or in-decisive doctors. Operation went well though difficult and I had only sacrifice the upper lobe vein with intrapericardial left upper lobectomy en bloc with the tumour. The patient recovered uneventfully and was sent for further radiotherapy despite clear resection margin. My satisfaction was more than anything financially or compliment from family.

Patient recovery is greatest reward to doctors.

To get the most from public hospital

In previous blog, I have mentioned difference in public versus private medical care. As consumer who pays for medical service either by direct charge or indirect charge through taxation but time consming waiting list, one would seek the best means to obtain good and personalised service in public system

1. Stress on making appointment to new case clinic

Usually the new case clinic is seen by senior doctors or specialist directly. This help to prevent missing important ill patient who may not have correct diagnosis on referral. This is much better than going back to the old clinic with regular FU and reporting a new symptom or new disease. Stree on getting referral addressed to the new case time slot of the specialist clinic.

2. Ask politely for being interviewed by senior team member of the in charge physicians team.

So always allow for being interview at day time. At rush hours or non office hour, usually the front line doctors or even the on call doctors are available. There is absolutely minimal effect in asking question or challange the care mode when you are interviewed by person without authority.

3  Make a gesture of asking for well documented information but do not make threat to complain

Human nature make public servants sensitive to clients requiring thorrough documentation of every details. But never pose a threat to complain, This iwill destroy the original relationship with caregiver.

4. Make careful research on mode of treatment of your own disease. Make suggestion or pose rational queries on the selected mode of treatment.

5. Before committing to have operation in this or that hospital. Do research on number of similar cases handled in those cedntres.also some hospital has shorter operatoperation waiting list than other. Borrow other address if necessary

6. Trust your care givers and maintain harmonious relatioship by mutual respect.

For private care, word of mouth and transparency of charge is important and reflect the professionalism of individual specialist.

If the specialist refues to discuss the cost or fees before committment of care or hospitalisation, beware of that. If the care of the specialist are to be split among other profession, the client retain the right to know how the fee is splitted or on which ground.

I am Dr Chung Shiu Shek specialised in cardiac and thoracic surgery. Feel free to discuss your own or your family medcial need with me. I strive to give my best possible advice to any questioners. Phone: 3160 8865  E mail: chungss@ymail.com

Thank you

Medical checkup : A devil or an angel

Recently I came across previously healthy persons having major pahtology after medcial examination for relatively non urgent symptoms.  It dose reveal how life is so fragile and the relative inaccuracy of sense of being good as indicator of own health.

One relatively young middle aged women complaint of feeling mass in the abdomen. Being regarded as inexperienced person, self reporting of a mass in the abdomen is usually wrong. The possiblity may be nothing, fecal loaded colon or ballotable kidney or transmitted abdominal aorta pulsation.

Further enquiry about the symptom is none. There is no change of bowel habit and appetite and body weight is normal.  She has early menopause and otherwise healthy. Routine USG examination review nodule and echogenic shadow in the liver. Subsequent high power imaging showed multiple enlarged cystic and cavernous haemangioma in liver. Haemangioma is one of the most commonest benign tumour in liver. It is even more benigh than polycystic disease.  The pathology of haemangioma is not certain but autopsies study did reveal lot of people dying with asymptomatic large cavernous haemangioma. She was told to lead normal life until condition change. Of course, rupture of haemangioma will be fatal and under reported because they seldom arrive alive at Emergency department.

Another patient has chronic appetite loss. X ray show upper mediastinal mass. CT showed huge mediastinal cyst displaying the esophagus and abutting trachea.
Early surgery is advised even if the chance of malignancy is low. Patient is feeling unexpected diagnosis being serious blow to life.

Following previous blogs on asymptomatic lung cancer, early lung cancer is usually not detected and can be found normally by low dose CT screening.

Whether we should screen ourselve for common disease or not?  Some may prefer not to know seious potential disease. However, cure of disease is usually only possible for early diagnosed cancer. So screening is useful for individual person althought nor always cost effective for whole society. (Because extra resource is needed to diagnose or rule out asymptomatic and normal but looking suspicious area.

If one afford to do screening with time and money, I think occasional CXR say every 3 - 4 years, stool x occult blood and exercise test (simlified with only resting or stress ECG and saturation monitor may be all required for middle aged person. For female cervical smear, breast examination is useful.
For elderly male, PSA for prostate and USG for hepatitis carrier will be necessary.

For whole society, immunisation of Hepatitis B vaccine, and health education and policy to eliminate promotion of smoking, alcohol and bad fast food is useful.
A postive attitude to life and treasure of life is always good.

So precious moment seems to be gone if one did not make preparation of possible bad things.

I have help cure some individual who only got news of advanced cancer in screening procedure. Hope they grow strong after difficult therapy pathway.

My name is Dr SS Chung, andrew, My clinic no is 3160 8865, I welcome question and query on helath issue and I practice general medicine, heart disease, chest disease and chest surgery and minimally invasive heart and lung and aortic surgery.

To be or not to be: ON call 36 小時

I have briefed the internet surfer that to be a doctor, one needs to sacrifice own lifestyle and time. Further doctors are not much respected nowadays as they need to dealt with personal conflict with patients at front line. Stress in life decrease quality of life of care taker. But is it worthwhile?
To many young people who graduate recently from secondary school. They may have to decide early in their life whether to take up the profession or not.

As one of the specialist in this field, I have every capacity that I need to make statement of this. It is worth while and still much challanging. To make sacrifice requires strength and determination. It is worth the effort to endure until you finish the training. Training takes 6 to 8 years on top of medical school teaching and life long commitment for further education is also required,
But it is worth while to devote oneself to meaningful life. Further, the recreational aspect for doctors education is fun.

So young people, do go for the touch job as medical student and future challange is worthwhile.

On call 36 hours 小時

Doctors need to be on call for whole day and night and finish work only after the usual 8 or 12 hour daily schedule before going to bed. But this happen to be only apllicable for trainee. For specialist doctor or chief of service in each major specilaty involving emergency care and surgical operation. They are on call for life or on call 24 hours a day and 7 days a week.

Who pay them for the on call? None but the devotion to work and satisfaction in treating patients. Hospital authority would not compensate for that. Neither would the chief of service ask for the compensation like the hours counted in recent doctor- HA settlement on contract hours court case in Hong Kong High court.

The court or judge does sympathise on call doctors but the judge cynically approve for minimal or bare inevitable counting of hourly paid for Sunday "voluntary" or traditionally implied obligatory duty in Sunday or rest day ward round and coverage.

So private specialists doctor are on call everyday for their patient. Neither would they charge a standby fee. But they can choose to accept patient or not. So their call is not compulsory.

To be a doctor , think twice about that. You may need to study 18 hours a day to get finished the medical school. Work with on call 36 hours or at least 32 hours once every three or five days during training. Then on call every day practically for life.

Is it worthwhile, in future blog, I would explain to you that it is worth.

My name is Dr Chung Shiu Shek, specialist in cardiac and thoracic surgery. My clinic number is 3160 8865

The most live-able city in the world HONG KONG 香港最能活的城市

Despite all the bad comment on the future of Hong Kong, the Economist Magazine/News corporation has rated Hong Kong the best city to live in the world in year 2011.
I would not doubt about it but the ranking surpasses previous years of being rated the fourth to tenth comes so abruptly amidst the political turmoil of this place.

Hong Kong is my home and my birhplace. I have no hesitation to admit my citizenship as Chinese or Mainland china civilian but the tie to region HKSAR is more close to my blood and knowledge than ever. Before the 1997 change over, I have much reservation but a real practical issue to wirte down my nationality as Overseas British National with my HK passport. I would rather wirte down Chinese bracket BON (British overseas National) in Hong Kong rather than identifying myself as second class UK countryman but without any right of citizenship or residency.

How come other people recognise the strong points of living in Hong Kong but other people including most Hong Kong people thought the glory of the Jewels of the East has faded out more or less entirely. We are only one but not the most recogisable independent cities in Mainland China. We cannot surpass but to be surpasssed by cities like Beijing, Shanghai, Tianjin and Chongqing. Even the size of economy will be taken over soon by Shenzhen and then Guangdong or even Xiamen.

The one and probably more significant factor is the medical facility and accessibility in Hong Kong. I am proud of myself being one the medical supplier (specialist doctor in cardiac and lung surgery) in Hong Kong. I would not agree this is perfect but would say it is keeping on improving. But most Hong Kong majority would criticise the apparent self sufficiency of the medical system available in Hong Kong.  In prinicple, all public health care is  free but rationed. All specialist care are availabe at nominal charge and the care provided is up to international standard. However, this is far from the truth to see primary care is failing badly in preventive medicine aspect. Lots of people complaint the general satisfaction lacking in Hospital authority hospital.Thousands of hospital authority staff be in professional or allied health voted by foot to leave the system.

Yet , vaccination is nearly universally compliant, control of disease like SARS or swine flu is superb, major surgery like liver and heart transplant, sex change or conjoint twins operation are successfully done from time to time. For the problem of private medical care. It is not regulated and a lot of over charging is suspected. However, the success can be illustrated by the fact that lot of wealthy mainland people come to HK for medical consultation or even treatment and lots of wealthy businessman enjoyed good care by lot of private specialists.  Care in Hong Kong is good provided that there is no counting of cost of time in public HA service or no restriction of charge or resources for private market.

In Hong Kong, the proportion of national expenditure is only around 9 to 12 percent of GDP.  But the standard of care is good and doctors and nurses enjoyed good living support. If hong kong is so good in providing first class medical service at such an efficent expenditure. Then other countries should model their health system to simulate Hong Kong.  Everyone knows there is no free lunch in the world. So the local or insider would recognise a lot of hidden problem of heath care in Hong Kong. Thanks to the marketing or image controller persons in Hospital Authority. The drawback of the system is not exposed or shown to journalist who are only expatriate or visitor in Hong Kong.

If you ask one of British overseas worker or Philipino maid in Hong Kong. Are they enjoying good medical care system in Hong Kong. They would certainly point out that medical care in Hong Kong tends to be fragmented and haphazard and accessibility is far from simple or intuitive.  The specialists is availabe at high price and competition among health provider is not transparent and open.  A few giant specialists clinics or doctor dominate the private market and the fees they charge are ususally not afforable from general public.

I remember not long ago (actually availabe in Wikepedia) that one overseas Malaysian British citizen died of treatable disease in one of the public hospital in Hong Kong. Her Causcacian husband spent more than eight years to secure out of court settlement for the lack of care or even discriminative care availabe in public hospital system.
Although this isolated event has lot of overtone of cultural or racial difference, this illustrate the medical care in Hong Kong is like a cat and mouse game. Those who is familiar with the system can play the game well. thouse who do not or just take it for granted would not recieving expert care.

As an insider, I would expose the skill and trick to recieve good medical care in public system and private care to all. Hope everybody get the best care in Hong Kong.
Three cheers to the journalist who choose Hong Kong to be the best place to live because of an "excellent" medical care system.

My name is Dr Chung Shiu Shek who provide 24 hours emergency medical care to all enquirers and  I am specialist in cardiac, lung, chest surgery.
My clinic no is  3160 8865

Hyperthermia and Over sweating 多汗症

In Hong Kong, summer temperature is very high and city pollution and over-crowding create an ever increasing stress for out door activites or transit.  Human bodies have adaptive ability to extreme ambient environment.  Working under hight temperature would cause dehydration, heat stroke and cardiac complications.
Over sweating is the consequence of compensation in heat dissipation method in body
Over sweating in the palm and axilla cause embarassment in social life. Usually this begin in young adolescent and has incapacitating effect on social interaction of the youngster.
Both male and female are affected. It appear that male are affected more or they are willing to seek help more. For female, the problem is related more to odor than wetness. Armpit odor is more a problem for them in summer when less covered clothing is trendy then.

Treatment of oversweating or primary hyperhidrosis has long been used in society.

They include

1) self help method
2) Local anti-perspirant
3) removal of sweat gland by local ablation, surgery or injection
4) Botox injection
5) hormonal therapy or drug treatment
6) electophoresis - iontophoresis
7) surgical treatment of sympathectomy

The last method is most effective and durable.

But the drawback must be stated before surgical treatment.

They are:

1) over sweating in body
2) reduce facial flushing or red or lively color of face
3) small chance of failure
4) definite though small risk of sympathetic damage causing dropped eyelids (Horner 's syndrome) and small pupil

For educated patients with well thought of problem, surgery is usually fruitful. Stay in hospital is short and stay for post operative one or two days are common.
wound pain and anaesthetic problem is minimal
Decrease in sweating is permenant.

Tuberculosis - Not a Dying Disease 肺結核從來沒有消失

Pulmonary tuberculosis is an infectious disease caused by slow growing bacterial species known as Mycobacteria. The name of this germ is borrowed from its characteristics of slow growing, indolent and can present as spore keeping bacteria alive in long term in adverse temperature and humidity condition similar to fungus. The air borne ability of the mycobacteria spore give it as much infectious concern as influenza. However, the man to man transmission ability is far lower than virus. Also the amount of infectious load is much higher than virus to cause clinical disease. For example, exposure to droplet transmitted virus like measle may cause successful disease transmission if only ten or a little more viral particle is inhaled by susceptible individual. In tuberculosis, intense exposure to hundreds of spores may not end up in clinical disease. However, as mycobacteria tuberculosis is ubiquitous in most human inhabitated area. Avoidance of it is much difficult.

Tuberculosis is still endemic disease in Hong Kong. Although treatment of such disease has made so much advancement that curing this disease is now mainly an out-patient managment problem.  A few decades ago, if young men or women has been infected with tuberculosis, the treatment of such is still old fashioned resting and sunlight and good nutrition. Housing in a sanatorium or convaslescent environment is only method to prevent spread of disease in densely potpulated cities. Paradoxically this air borne bacteria has much less infectivity potential if high ceilings, good ventilation and well space out beds in room with natural ventilation.  Few staff in such sanatorium will be infected due to working environment unless the nurse or doctor has overworked too much to have low immunity.

Are healthy individual always resistant to tuberculosis?  The answer may be yes and no. For malnourished and alcoholic, reactivation of tuberculosis and primary infection is likely. But for healthy individual, reaction to latent tuberculosis may be  exaggerated causing destruction of lung or granuloma formation.  Reactivation of tuberculosis or persistent of infection may also related to hormone, age and genetic make up.

Nowadays treatment of tuberculosis is effective and comprehensive. Different class of drugs has good effect on it. Investigation to underlying immune deficiency is necessary but rarely postive in endemic area like HK. But confusion with lung cancer shadow is much of a concern too. Therefore, if lung shadow has shown poor response to antituberculosis chemotherapy, excision biopsy is necessary in high risk individual like smokers of patients with strong family history of cancer.

Hong Kong has good system of treating pulmonary tuberculosis. Chest clinic offer walk in CXR and consultation if persistent cough for more than 2 weeks.
Supervision of tuberculosis treatment ensure good compliance. Expert of tuberculosis are easily found in governemnt services.

Sometime, thoracic surgeon may encounter cases mimmicking lung cancer. Final pathology turn out to be tuberculosis. The patient may be complaining about that. However, for lesion as big as a pseudo tumour, it is essential to remove it surgically even if good response to tuberculosis is found. Because if the lesion is left, confusion with later lung pathology or causing hemoptysis or bronchiectasis change may be as harmful as cancer itself.
For fit individual removal of granuloma of destryoed lobe by tuberculosis give better quality of life. Of course, to high risk indivdual lke patient with significant coroanary disease or renal failure, option for medical treatment alone is better suited then.

Tiny Sub centimetre Lung Nodules - Risk of early Adenocarcinoma of Lung

In Hong Kong, the incidence of lung cancer is growing gradually. There is some relation to wider detection and longer life expectency. Some other factors remain unknown.  Before the Second World War, lung cancer ;as I was told by my medical teacher: is a rare disease.  The rapid development of tobacco industry co-incide with the escalating cases of Lung cancer in the West.  Thoracic surgeons who used to treat different form of infectious disease, sequealae of pulmonary tuberculosis were burdened with different forms of malignant tumour of the chest.

So the cause of lung cancer growth is definitely related to increase in smoking population, air pollution, urban life style.  Since lung cancer is potentially more lethal than other solid tumousr. In male, lung cancer is second highest (next to colon and rectum) in incidence and highest in causes of death among malignant disease. In Female lung cancer is third highest in incidence ( second to breast, colon and rectum) and highest in cause of death.  In female and now in young male, adenocarcinoma is highest is frequency.

There has been several proposal of cause of high incidence of non smoking related lung cancer in South Chinese females esp Hong Kong women.  One of this is related to kerosene stove or cooking method with exposure to incomplete combustion product in stove.  Relation to hormone and Chinese herb or aflatoxin in fermented food or nuts has also been investigated. Genetic markers also has been looked into.  No scientific proof or conclusion can be drawn after decades of study.

So screening remains the only method to detect early lung cancer.
Are all minute nodules in CT scan (low dose CT scan for lung cancer detection) needed to be removed ?
This is a difficult question and each case has to be individually assessed and considered.

Surgical risk and ease of small wound resection of the mass needed to be assessed too.

For lung nodules about 6 mm in size.  Assume the tumour doubling time is 3 month. Six month later, the volume of the tumour will be quadruple and the diameter fo the nodule will be 1.6 time larger or about 9.6 mm. A normal 5 mm cut CT scan will easily detect the enlargement of the size. Although there is no guarantee of abse3nce of distal metastases, the chance of finding metastaes for primary lung cancer size less than 1 cm is low by restrospective study of clinical cases.
So it may be safe to observe 6 mm nodule with CT scan every 6 months for 2 to 3 years.

For lung nodules larger than 9 mm in size, the chance of being pathological lesion like tumour, benign adenoma, sclerosing hemangioma, hamartoma or secondary lung tumour, granuloma is high.  From VATS experience, for peripherally situated 9 mm nodule, more than 70% can be definitely located by digital palpation on lung surface. Excisional biopsy is recommended. For patient age less than 65 without major illness or cardiopulmonary compromise, the risk of VAT lung biospy with excisional wedge resection is minimal and usually required 2 - 3 days of hospitalisation.  So I recommend early surgery for that.  For deep seated 9 mm nodule, both excisional biopsy by VATS or fine needle aspiration biopsy cytology are difficult.  I would recommend observation with 3 monthly CT scan and opt for either Fine needle biopsy if size increases or open wedge resection if patient has high risk (smoker or family history of 2 family member having cancer) of malignancy,

For non well defined nodule or ground glass appearance, I would recommend PET CT scan instead of CT scan alone because measurement of size cause confusion in vague shadow.

For definite solid nodule without characteristics of cancer, PET CT is less helpful to define the nature except for measuring the size change.  For granuloma or post infectious change, the PET value or SUV value may be elevated. For broncho alveolar carcinoma, the PET SUV value will be normal.

For lesion less than 6 mm in size, I would recommend either repeating CXR or low dose CT scan in one year time. If the nodule is persistent, work up for lung cancer risk and repeat of CT scan in 6 month time for next 2 years are recommended.

For bilateral tiny nodules, screening for primary and PET CT would be useful. Consideration for millary TB may also be needed. Infiltrative lung disease and intersitial lung disease are also required. The final conclusion will depend on the VAT lung biopsy and resection the dominant nodule ( if present) for histology

The above recommendation is primarily subjective impression a, taking into consideration of guideline from European Society of Respirology 2010 guidelines and American College of Chest Physicians 2006 reommendation for solitary lung nodules. I am experienced cardithoracic surgery with more than 24 years of experience in public hospitals in Hong Kong and private hospital. I welcome any queries or question. Phone: 3160 8865 Dr Chung Shiu Shek

Non invasive Surgery - A myth or a new paradigm 非侵入性治療

There is a saying or "cliche" that Chinese medicine is good at chronic disease modulation and health maintainence and Western medicine is best suited for surgical condition like tumour  and/or obstruction, and traumatology.  Nowadays, surgical condition is more and more treated by catheter or percutaneous manipulation method.  Previous school of thinking on big incision and wide exposure has been out of favour and prevents patients' acceptance.  The one and may be the only one question that patient want to ask about is whether there is minimally invasive surgery option available.

It appears that all invasive procedure or wide wound exposure is wrong and not serving patients good.
I may be over exaggerating the vision and trend of going minimally invasive and conservative in treating most mechanical or surgical disease.

However, as surgeon witnessing the evolution of minimally invasive approach in various conditions. I believed that the patient may have an incorrect idea of how minimally invasive surgery develops and contributes to expansion the treatment armentarium. So , the new paradigm of going minimally invasive is not a new invention but a means to perfect the appraoach to meet the old well established target.  Should the operative target remain far from what minimally access approach can meet, old approach is as effective and the only soloution to be the best approach and fail safe approach.

Surgery includes ablation and reconstruction. In fact, the analogy of plumbers and surgeon is particularly intuitive as lot of lesions will be dealing of obstruction of tubular structure. Either replacing the entire passage with conduit or bypass or recannulating the stenotic part with stent or expansile scaffolding device will solve the condition.
So the use of stent and supporting stenting scaffold device will be universal in many disease system. For solid tumour in the body, so far ablation method using open appraoach stood the test of time. Complete removal leaving good margin of at least 5 mm or if not possible 3 mm clearance ensure minimal chance of local recurrence.  Any other compromise in margin or breach across the tumour capsule or surronding tissue will deprive patient only chance of survival.  Internal stenting may be used as temporarily a salvage option or pre operative optimisation. Radical removal usually still need bigger wound.  For complex reconstruction, open surgery still is the gold standard.

Secondly, the time  spent on the surgery and learning curve involved in mastering the necessary skill is the bar before contempating new approach. For example, in robotic surgery requiring wide movement of target operation site, e.g. removing a lung tumour. The time spent on setting up the robotic arms and concentrating on relevant structure tilt the balance favoring traditional Thoracosocpic resection rather than Robot assisted minimally invasive surgery.  Learning curve is indeed the major concern for both the surgeon and the patient.  For patient demanding the less practiced minimally invasive surgery, he or she must do good research to go to surgeon with good track record in other new surgical appraoach so that the relative time for learning cujrve is small.

Risk of bleeding in going minimal invasive.  The extent of surgery dose not become smaller even if minimally invasive surgery. However, paradoxically, minimally invasive surgery to some extent increase the safety margin because hemostasis is better and picture is clear on optically ideal magnified view. Good surgical tecnique can circumvent the absence of tactile sensation and degree of freedom of long through the hole instrument.  Yet, from time to time. Heavy bleeding as a result of small wound surgery approach is never short of examples.  Years and years and time after time. Patients' interest is at risk for unjustified minimally access for complex surgery or absence of good surpervision and help in steps moving away from conventional surgery. No compromise of safety should be allowed for surgeons choosing small wound or non invasive approach.

Pooling of cases may be difficult for less common patholgy. In another words, minimally invasive surgery may not be vivable if the encountered pathology is rare or the referral basis of that centre is small. Like so mnay audit report, in rare pathology, the surgical outcome is in direct proportion to the case volume.  But in ususal pathogy like gallstone or hernia., the difference between small centre and big referral centre is negligible.

In short, I really support the current trend of going minimally invasive in every possible operation. But still I believe it needs right time, right place and last but not least the right occasion (patient and skill mix). Otherwise, I believe in the old saying that it is safer to detour a usual path to guarantee arrival than to risk for new route. And, old dogs usually learn new tricks slow but can play it safe after skill acquirment.