Chinese Surgeons Research Articles

Breast reconstruction after mastectomy in breast cancer patients: specialization and standardization

In recent years, with the improvement of screening and early diagnosis, the overall prognosis of breast cancer patients has been greatly improved in China. Breast reconstruction is an option to improve cosmetic outcomes and quality of life for the patients received mastectomy, this procedure has attracted a lot of attention. The breast reconstruction surgery is recommended by the 2018 NCCN Clinical Practice Guidelines in Oncology for Breast Cancer in patients with appropriate indications. Despite the high proportion of breast reconstruction after mastectomy in western countries, Chinese breast surgeon should objectively understand the differences in breast structure and cultural backgrounds between Chinese and foreign women, and conduct rigorous clinical practice on the basis of calm thinking. In particular, it should be clearly recognized that we have more local advanced and high-risk cases in newly diagnosed breast cancer patients. Making efforts to improve the overall survival for patients with breast cancer must be the top priority for our surgeon. Breast reconstruction for all patients without identifying the distinction of personal characters and indications should be avoided, and the pursuing of high proportion of clinical data with no consideration of the realities of clinical practice in China should also be avoided. The indication of breast reconstruction for breast cancer patients received mastectomy must be strictly determined by the surgeon.

Application of Enhanced Recovery after Surgery in Gastrointestinal Surgery based on Multidisciplinary Team

Chinese gastrointestinal surgeons are building up our own high level evidence in evidence-based medicine, With tremendous clinical trials carrying out in gastrointestinal cancers. Besides, Standardized procedure of diagnosis and treatment should be promoted. More personalized schemes are needed. The model of multidisciplinary team can be more widely and deeply applied. In order to further optimize the surgical pathways and promote the clinical application of ERAS in surgery, it is important to raise awareness of the ERAS concept, advocate multi-disciplinary cooperation model, including surgery, anesthesiology, nursing, clinical nutrition, etc. to improve the application of ERAS in gastrointestinal surgery, promote medical and health management performance. And the concept of enhanced recovery after surgery should be more operable. To keep pace with the times, the gastrointestinal surgeons have to seek for innovative technology and new ideas.

Cross-sectional survey on Chinese surgeons’ practice patterns and views on video-assisted thoracoscopic surgery

Background: Surgeons’ opinions on video-assisted thoracoscopic surgery (VATS) may influence VATS adoption. This study aims to understand Chinese surgeons’ view on VATS. Methods: A questionnaire was developed to collect surgeons’ opinions on the benefits of VATS over open procedures, potential obstacles to adopt VATS, and possible indications and contraindications of VATS to treat lung cancer. Results: Ninety-six surgeons from ≥75 hospitals in ≥23 provinces completed the questionnaire. Of them, 95.8% were thoracic surgeons; 38.5%, 30.2%, and 28.1% were chief, associate chief, and attending surgeons, respectively. The chief and associate chief surgeons had significantly more years of experiences in VATS and higher monthly VATS volume than the attending surgeons (All P 75% in their practice. The top three mostly agreed (96.9–92.7%) benefits of VATS were shortening hospital stay, reducing postoperative pain, and decreasing the incidence of postoperative complications. In addition, 81% of the 96 surgeons agreed that VATS could reduce drug fee. The mostly agreed (70.8%) potential obstacle for VATS adoption was insufficient training for surgeons. The opinions on the benefit of VATS and hurdles to adopt VATS were consistent across the three professional titles. The mostly agreed indication (91.7%) and contraindication (80.2%) were stage I and II non-small cell lung cancer and inability to tolerate single lung ventilation, respectively. Conclusions: Chinese thoracic surgeons consistently agreed on clinical benefits and indications of VATS and believed insufficient training as a key obstacle to adopt VATS.

Review of sixty years of burn discipline in Shanghai Ruijin Hospital

Department of Burns and Plastic Surgery of Ruijin Hospital Affiliated to the Medical School of Shanghai Jiao Tong University is derived from the group of severe burn treatment in Surgical Department of Kuang-Ci Hospital in Shanghai in 1958. In three score years, they created and developed distinctive technologies in treatment of massive deep burns, including early eschar excision on deep burn wound by stages and batches, taking the scalp as a donor site, wound covering with the large sheet of allo- or xeno-skin graft with small holes covered by small pieces of autoskin, the Ruijin formula for fluid resuscitation in early stage post burn and the " hibernation remedy" , which achieved actual effects in clinic, and they summed up academically the experiences of their clinical practice and researches. These technologies with other creations by Chinese burn surgeons have been named as " Chinese method" of burn treatment.

Perioperative fasting management by traumatic surgeons in China

Objective To investigate the current perioperative fasting management by Chinese traumatic surgeons for elective patients and the related awareness in Chinese traumatic surgeons. Methods Traumatic surgeons were interviewed through questionnaires which addressed the current pre-and post-operative fasting time for liquid and solid food in their hospitals, the postoperative practice to keep the patients in recumbent position without pillow, their reasons to choose perioperative fasting management and their knowledge of the current related guidelines. The associations between surgeons’ information and their reasons to choose fasting management and their knowledge of the related guidelines were analyzed. Results A total of 187 valid questionnaires were collected. The percentages of the surgeons who indicated perioperative fasting time for liquid for at least 2 hours and for solid food for at least 6 hours were only 3.74% and 27.27%, respectively. Nil by mouth from midnight for liquid or for solid food was actually indicated by 29.95% and 31.55% of the surgeons, respectively. 64.71% of the surgeons still required their patients to fast for liquid for at least 6 hours postoperatively, even longer for solid food. Only 1.6% of the surgeons did not ask their patients to keep in recumbent position without pillow postoperatively whatever the anesthesia types were. Only 6.95% of the surgeons chose a perioperative fasting protocol based on the related guidelines. Only 9.09% of the surgeons knew the related guidelines very well. The reasons of the surgeons to choose a perioperative fasting protocol and the knowledge of the surgeons about the related guidelines were not associated with the professional ranks of the surgeons, hospital ranking or hospital location (P>0.05). Conclusions The current management of perioperative fasting is backward in the Chinese communities of traumatic orthopedics, and the related guidelines are not well implemented due to the poor awareness of them. Key words: Questionnaires; Wounds and injuries; Water deprivation; Fasting

Future trends and prospect of surgery of gastrointestinal cancer in China

With the development of medical concepts and technology, the surgical treatment of gastrointestinal cancer is gradually moving towards a new era. Chinese gastrointestinal surgeons are building up our own high-level evidence in evidence-based medicine, with tremendous clinical trials carrying out in gastrointestinal cancers. Besides, standardized procedure of diagnosis and treatment should be promoted. More personalized schemes are needed. The model of multidisciplinary team can be more widely and deeply applied. And the concept of enhanced recovery after surgery should be more operable. To keep pace with the times, the gastrointestinal surgeons have to seek for innovative technology and new ideas.

Performing laparoscopic surgery - Perspectives of young Chinese hepatobiliary surgeons.

Laparoscopic liver resection (LLR) has garnered attention as a new form of liver surgery. In China, many hepatobiliary surgeons are now encouraging the examination and assessment of LLC in order to improve its outcomes, and several young hepatobiliary surgeons recently shared their clinical experiences and the results of their research in presentations at the Akamon Forum as part of the 118th Annual Congress of the Japan Surgical Society, which was held April 5-7, 2018 in Tokyo, Japan. In China, LLR has gradually improved over the past 20 years, including both expanded indications and improved surgical approaches. However, China is a vast country, and the level of medical care varies nationwide. Medical facilities that can perform advanced laparoscopic techniques are currently limited to those in large cities. Moreover, additional clinical studies of the long-term oncological outcomes of LLR need to be performed in the future.

Brief discussion on the development and cultivation of the vocational ability of young orthopedic surgeon

Orthopedic, as an important subject of medical system, is complementary and common progress with young orthopedic surgeon. So, strengthening the standardized training of clinical and scientific research ability for young orthopedic is the primary task in department of orthopedics in our country. Unfor-tunately, the development of the professional career of Chinese young orthopedic surgeon is presently entrapped in a dilemma due to the diverse contents of the orthopedic subject and the abstract structure of the bone science, and the short time for college education and practice training. In practice, we focus on the ability cultivation based on problem oriented clinical practice, and integrate reasonable and standardized assessment mechanism referring to the international excellent physician training mode. We also integrate the comprehensive development of medicine, teaching and research to promote the improvement of the professional ability of the young doctors in the department of orthopedics. Key words: Young doctor; Orthopedics; Training

Palatal Fistula Risk after Primary Palatoplasty

Humanitarian surgical organizations provide palatoplasties for patients without access to surgical care. Few organizations have evaluated the outcomes of these trips. This study evaluates the palatal fistula rate in patients from two cohorts in rural China and one in the United States. This study compared the odds of fistula formation among three cohorts whose palates were repaired between 2005 and 2009. One cohort included 97 Chinese patients operated on by teams from the United States and Canada under the auspices of Resurge International. They were compared to cohorts at Huaxi Stomatology Hospital and the University of California San Francisco (UCSF). Age, fistula presence, and Veau class were compared among cohorts using Chi-square tests. Logistic regression was used to analyze predictors of fistula formation. The fistula risk was 35.4% in patients treated by humanitarian teams, 12.8% at Huaxi University Hospital and 2.5% at UCSF ( P < 0.001). Age and Veau class were associated with fistula formation (Age P = 0.0015; Veau P < 0.001). ReSurge and Huaxi patients had 20.2 and 5.6 times the odds of developing a fistula, respectively, compared to UCSF patients ( P < 0.01, both). A multivariable model controlling for surgical group, age, and gender showed an association between Veau class and the odds of fistula formation. Chinese children undergoing palatoplasty by international teams had higher odds of palatal fistula than children treated by Chinese surgeons in established institutions and children treated in the United States. More research is required to identify factors affecting complication rates in low-resource environments.

History of orthopaedics in China: a brief review

Chinese orthopaedic surgeons have made asubstantial contribution to the development of orthopaedics worldwide, and traditional Chinese medicine (TCM) in orthopaedics has a very long history in China. We make a brief review of the development of orthopaedics in China, intending to pave the way for further understanding of Chinese orthopaedics for scholars all over the world. The description of fractures firstly appeared in 3600years ago in China, and the theories, experience, and treatment strategies of TCM still play important roles in clinical diagnosis and treatment of orthopaedic disorders in our country. Western orthopaedics was first introduced into China in the early twentieth century. After decades of development, Chinese scholars have made some gratifying achievements in orthopaedics. Orthopaedics is constantly evolving, and we need to strengthen the ability of independent innovation to achieve orthopaedic surgeons' Chinese dream, and better serve our patients.

Evidence-based guideline for the management of acute subaxial cervical spine injury

In order to provide the clinical guidelines of acute subaxial cervical spine injury for the Chinese orthopedic surgeons, the Spine Trauma Group of Chinese Association of Orthopedic Surgeons compiled this guidelines.The guidelines apply to adult patients with acute (less than 3 weeks) subaxial cervical spine and/(or) spinal cord or nerve root injuries. The Study Group wrote the guidelines by setting up questions, determining search words, screening literatures according to inclusion and exclusion criteria, analyzing the included literatures, confirming evidence levels and then providing recommendations. The guidelines include 141 literatures, 27 Chinese articles and 114 English articles. The guidelines set up 18 questions divided into 4 sections: pre-hospital care, diagnosis and evaluation, treatment and prevention of complications, which include 39 recommendations.

Burnout Among Chinese Adult Reconstructive Surgeons: Incidence, Risk Factors, and Relationship With Intraoperative Irritability

BackgroundBurnout is a major concern in human service occupations, mainly characterizing in emotional exhaustion and depersonalization. There is very limited research dealing with burnout in orthopedic surgeons. Exploring burnout prevalence, risk factors, and intraoperative irritability-related incidences is necessary to improve the quality of life for surgeons. MethodsThe study population consisted of 202 registered adult reconstructive doctors in China. Burnout was measured using a normalized translated version of the Maslach Burnout Inventory-Human Service Survey. Demographics, professional characteristics, and intraoperative irritability-related questions were also collected by electronic questionnaires. Statistical analysis was performed using SPSS 22.0. ResultsThe overall rate of burnout was 85.1%. Variables significantly associated with high emotional exhaustion scores included poor sleeping time per day (P = .008), more nights on call per week (P = .048), and absence of research (P = .014). For depersonalization, absence of marriage (P < .001) and more nights on call per week (P < .001) were selected as risk factors. The incidence of losing temper in operation is 58.9%, significantly higher in senior surgeons (P = .001). Three major reasons for irritation during operations included delays by companies providing operative devices, poor coordination of assistants, and slow movements of instrument nurses. Intraoperative irritability was found to be significantly correlated with burnout, especially in emotional exhaustion. Residents were the population having the least opportunities to lose temper in operation. ConclusionBurnout is highly prevalent in Chinese adult reconstructive surgeons, and it had some correlations with irritability. Further research is needed to determine more risk factors and reduce intraoperative irritability-related incidences.

Nine issues about clinical application of thoracolumbar injury classification and severity score

Spinal fractures are a big challenge to orthopedists. Thoracolumbar Injury Classification and Severity Score (TLICS), a newly developed evaluation system for thoracolumbar fractures, has proved to be valid and reliable in the last decade. However, there have still been many problems in the clinical application of TLICS in China. We discussed nine issues about the clinical application of TLICS in this article, hoping to promote better understanding and application of TLICS in Chinese spinal surgeons in their daily practice. Key words: Thoracic verterae; Lumber verterae; Fractures,bone; Posterior ligament complex; Load-sharing classification score

Definition of colorectal anastomotic leakage: A consensus survey among Dutch and Chinese colorectal surgeons.

AIMTo determine the level of consensus on the definition of colorectal anastomotic leakage (CAL) among Dutch and Chinese colorectal surgeons.METHODSDutch and Chinese colorectal surgeons were asked to partake in an online questionnaire. Consensus in the online questionnaire was defined as > 80% agreement between respondents on various statements regarding a general definition of CAL, and regarding clinical and radiological diagnosis of the complication.RESULTSFifty-nine Dutch and 202 Chinese dedicated colorectal surgeons participated in the online survey. Consensus was found on only one of the proposed elements of a general definition of CAL in both countries: ‘extravasation of contrast medium after rectal enema on a CT scan’. Another two were found relevant according to Dutch surgeons: ‘necrosis of the anastomosis found during reoperation’, and ‘a radiological collection treated with percutaneous drainage’. No consensus was found for all other proposed elements that may be included in a general definition.CONCLUSIONThere is no universally accepted definition of CAL in the Netherlands and China. Diagnosis of CAL based on clinical manifestations remains a point of discussion in both countries. Dutch surgeons are more likely to report ‘subclinical’ leaks as CAL, which partly explains the higher reported Dutch CAL rates.

Survey of current status of prevention of venous thromboembolism after thoracic surgery in China

Objective: To investigate the current status of prevention and treatment of venous thromboembolism (VTE) after thoracic surgery in China. Method: Chinese thoracic surgeons were investigated by the online questionnaire which was based on the Chinese version of International VTE questionnaire added with 6 extra questions with Chinese characteristics. Results: A total of 1 150 valid questionnaires were retrieved, accounting for about 20% of all the Chinese thoracic surgeons. The surgeons participating in this survey came from all over the country, most of whom were experienced professionals with high academic titles.For lung cancer patients, 66.96% (770/1 150) of the surgeons suggested that VTE prophylaxis should start 1 day after lung cancer resection, and 64.61% (743/1 150) of the surgeons suggested extending after discharge. For esophagestomy patients, and 48.35% (514/1 063) of the surgeons suggested that there was no need for patients to extend VTE prophylaxis after discharge. More than half of the surgeons participating in this survey made decision of the method and duration of VTE prophylaxis after lung cancer resection (53.91% (620/1 150)) or esophagectomy (52.49% (558/1 063)) depending on the clinical experience.Low molecular weight heparin was the common choice of most surgeons in VTE prophylaxis. More than half of the surgeons thought that previous history of VTE, advanced age, complicated with thrombophilia, obesity (body mass index>30 kg/m2), duration of surgery longer than 6 hours and family history of VTE were key risk factors of the occurrence of postoperative VTE. Conclusions: The results of this survey are highly credible and are a good reflection of the current status of VTE prevention and treatment after thoracic surgery in China. This survey will play an important role in promoting VTE prevention and treatment in Chinese thoracic surgery department, it will also provide data support for government setting new policies, hospital construction of VTE prevention and control as well as raising physicians' awareness.

Recognition of postoperative complication after surgery for gastric cancer

Complications significantly postpone postoperative recovery and increase mortality after gastric cancer surgery. However, varied complication rates have been reported in the literature as well as in our annual report of China Gastrointestinal Oncological Surgery League. It appears that there have been some misunderstandings regarding the diagnosis and interventions as well as the etiology of major complications. We should be aware of the fact that reaching worldwide consensus for the diagnostic criteria is a difficult task in most complications, which disabled the possibility of data comparison among different studies in most cases. Disagreements among the Chinese and western surgeons in the complication diagnosis should also be acknowledged when interpreting data from both ends. The western colleagues appreciate more latent manifestations of the complications, which eventually lead to earlier and more aggressive examinations and interventions. We, together with all Chinese centers, need to acknowledge the differences, ensure the integrity of our reported data while proposing respective countermeasures. Although the complication registration may continue to differ among centers, we can register complications with the intervention details so that the reported complications can be classified with the same standard (i.e. Clavien-Dindo scoring system). We should also encourage multi-center collaborations and trials, which facilitate the standardization of complication diagnosis and registration. Recognizing the difficulty and long-course nature of reaching national or even international consensus, we continue aiming at the ultimate goal with our best effort.

Survey on laparoscopic total gastrectomy at the 11th China-Korea-Japan Laparoscopic Gastrectomy Joint Seminar.

Laparoscopic total gastrectomy (LTG) has been widely performed for gastric cancer in China, Korea, and Japan. The current status of this surgical approach needs to be investigated. During the 11th China-Korea-Japan Laparoscopic Gastrectomy Joint Seminar in Shanghai, China, on 5 March 2016, a questionnaire was completed by 65 experts in LTG. The survey included questions on surgical indication, operation team, laparoscopic instruments, and operative procedures. Of the 65 respondents, 35 (53.8%) were from China, 18 (27.7%) were from Korea, and 12 (18.5%) were from Japan. Surgeons have various indications for LTG. Among respondents, stage II gastric cancer (42.9%) was the most acceptable indication, but Japanese surgeons were more cautious on this issue (P=0.005). Using a flexible scope was more popular with Japanese surgeons than with others (P=0.003). A goose-neck curved grasper was used more often in China and Korea than in Japan (P=0.006). Chinese surgeons preferred vertical subxiphoid mini-laparotomy rather than vertical transumbilical laparotomy. Intracorporeal reconstruction (73.0%) was most frequently adopted for LTG. Linear staplers (53.8%) and circular staplers (42.1%) were both popular for esophagojejunostomy. However, jejunojejunostomy was more often conducted extracorporeally (67.7%), in which case a linear stapler (86.4%) was usually selected. Significant differences were observed between the three countries with regard to reinforcement of the duodenal stump (P=0.018) and closure of Peterson's space (P<0.001). This survey on LTG involving surgeons from China, Korea, and Japan clearly informed the current practice of this surgical approach and will likely aid future research studies as well as clinical treatment for gastric cancer.

Development of Percutaneous Endoscopic Lumbar Discectomy (PELD)Technology in China

Introduction: The history and development of endoscopic spine surgery (PELD) in China is reviewed. Its significance and effect is predicted to have great implications for advancing spine care in China’s working and aging population. Percutaneous spine technology was introduced simultaneously from Japan and the United states by Hijikata and Kambin in the early 1980s. It was called Arthroscopic Microdiscectomy (AMD). The access portal was called “Kambin’s Triangle, with the discectomy technique through a “safe” puncture portal through an anatomical triangular zone in the foramen bordered by the facet and foraminal ligament dorsally, the exiting nerve ventrally, and the endplate of the caudal margin of the triangle. Method: An expanded indication for the transforaminal Kambin technique was introduced to China by Anthony Yeung in 1998, and its evolution and contribution to modern minimally invasive spine care, called the Yeung Endoscopic Spine System (YESSTM) technique, is reviewed. The percutaneous technique has been adopted by surgeons as well as non-surgeons who also undergo surgical training in their rehabilitation programs who integrate the technique through their various affiliations in China for painful degenerative conditions of the spine. Results: The efficacy of the endoscopic technique has evolved significantly since Kambin, with additional contributions by Chinese surgeons and key opinion leaders of surgical and non-surgical Chinese associations that have co-existed, but are focused on providing treatment options for the Chinese population for centuries. Western Medicine has provided great influence on Chinese medicine, but a significant percentage of the Chinese population still cling to traditional treatment, embracing both Old and New methods. With respect to modern surgical techniques, surgeons and no surgeons are cooperative, and focus on results while working together. They recognize that with endoscopic spine surgery, it is important to maintain a success rate comparable to traditional western open surgery with less surgical morbidity utilizing the endoscope. Peer reviewed papers are emerging from China, using the EBM guidelines of Western Journals. Conclusion: A rapidly increasing number of surgeries along with improving results will continue to drive this minimally invasive surgical method to China that bridges the gap between non-surgical pain management, physical medicine, and surgical intervention that focuses on the patho-anatomy and patho-physiology of spinal conditions of pain. This will be known as “surgical pain management, a term coined by Dr Anthony Yeung. Future developments will continue to drive the adoption of endoscopic surgery as a significant advancement for Chinese medicine and surgery.

Reliability and reproducibility analysis of the AOSpine thoracolumbar spine injury classification system by Chinese spinal surgeons.

The objective of this study was to analyze the interobserver reliability and intraobserver reproducibility of the new AOSpine thoracolumbar spine injury classification system in young Chinese orthopedic surgeons with different levels of experience in spinal trauma. Previous reports suggest that the new AOSpine thoracolumbar spine injury classification system demonstrates acceptable interobserver reliability and intraobserver reproducibility. However, there are few studies in Asia, especially in China. The AOSpine thoracolumbar spine injury classification system was applied to 109 patients with acute, traumatic thoracolumbar spinal injuries by two groups of spinal surgeons with different levels of clinical experience. The Kappa coefficient was used to determine interobserver reliability and intraobserver reproducibility. The overall Kappa coefficient for all cases was 0.362, which represents fair reliability. The Kappa statistic was 0.385 for A-type injuries and 0.292 for B-type injuries, which represents fair reliability, and 0.552 for C-type injuries, which represents moderate reliability. The Kappa coefficient for intraobserver reproducibility was 0.442 for A-type injuries, 0.485 for B-type injuries, and 0.412 for C-type injuries. These values represent moderate reproducibility for all injury types. The raters in Group A provided significantly better interobserver reliability than Group B (P<0.05). There were no between-group differences in intraobserver reproducibility. This study suggests that the new AO spine injury classification system may be applied in day-to-day clinical practice in China following extensive training of healthcare providers. Further prospective studies in different healthcare providers and clinical settings are essential for validation of this classification system and to assess its utility.

Xiao-Ping Chen-A leading figure among Chinese surgeons.

Xiao-Ping Chen-A leading figure among Chinese surgeons.