Jacob C. Langer, MD

It is an honour to submit this report to the Canadian James IV Association. The opportunity provided to me by the Association was unprecedented, and the six weeks I spent travelling will have a profound and long-lasting effect on me, my family, and my academic surgical career. I would like to begin my report by thanking the Association for permitting me to have this wonderful experience. During my trip I attempted to contact all of the James IV members in the places I was going. Unfortunately, there were no living James IV members in some of the countries I visited, and in many other cases they were unavailable. However, my contacts with them by mail, email or in person were universally helpful and productive, and I greatly appreciated their input.

My travelling took place over two three-week periods during 2007. The first was a trip to New Zealand and Australia in February, and the second was a trip to China and Southeast Asia in November. The goal of the Travelling Fellowship was “to teach and to learn”, and I did a lot of both during my six weeks. In this report I will try to outline the things I taught, and more importantly the things I learned and the insights I was able to bring back with me to my professional life in Canadian pediatric surgery. I had three broad areas that I particularly wanted to learn about during my travels: 1. How are surgeons dealing with the pediatric surgical diseases I’m most interested in (ie fetal anomalies, Hirschsprung disease, minimal access surgery)? 2. How are pediatric surgeons being trained? and 3. How is pediatric surgical care being delivered, particularly to children who live outside of major centres? Although my report is set up chronologically, I will try to illustrate the things I learned in each of these three areas throughout the narrative.

New Zealand

Saturday February 10

After a very long flight from Toronto, connecting through Los Angeles, my wife Ferne, my son Alexander (age 14), and I arrived in Auckland at 6AM, tired and jetlagged. We called Joel Fish, a friend of ours who is a plastic surgeon from Toronto, and who had just started an eight month sabbatical. We rented a car, drove to the Fish’s house, had breakfast and a nap, and then had a tour of the neighbourhood and a refreshing swim on the beach. During the afternoon conversations with Joel I got a Canadian-eye view and crash course on the New Zealand medical system, as well as some of the history of the country. After an early dinner we took our melatonin and dove into bed.

Sunday February 11 and Monday February 12

After a nice breakfast with the Fish’s, we drove to the Coromandel peninsula, a beautiful area several hours from Auckland. Driving on the left side of the road took a little getting used to, especially when the roads were increasingly hilly and winding. However, like riding a bike, it came back quickly. We settled into “The Shed” B&B in Hahei, and then spent the day hiking down to the beaches around Cathedral Cove.

The following day we got up early and drove to Hot Water Beach, which is situated over superficial geothermal streams just below the surface of the sand. We dug a hot tub in the sand and watched the tide come in. In the afternoon we slowly drove back to Auckland, and checked in to the Quest hotel.

That afternoon we were picked up by Phil Moreau, the chief of pediatric surgery at the Starship Children’s Hospital. We were taken to his house to meet his wife Mandy and their four sons. Alexander immediately disappeared with the boys and we didn’t see him again until dinner time. Phil is an extreme athlete, who at the time was training for the iron man competition (4 km swim, 180 km cycle, 38 km run). As we were to learn, many Kiwis (New Zealanders) are very focused on the outdoors and on healthy lifestyle and exercise, something we found very refreshing. We had a wonderful evening with the Moreau family, and got an excellent introduction to Auckland, New Zealand society, and of course New Zealand wine.

Tuesday February 13

Today was my visit to the Starship Children’s Hospital, the only free-standing children’s hospital in New Zealand. I gave neonatal grand rounds on the topic of congenital abdominal wall defects (gastroschisis and omphalocele), which generated a lot of discussion and questions, particularly with respect to the management and prevention of abdominal compartment syndrome during reduction of the viscera.

After tea, I gave several talks to the pediatric surgery department: the management of the failed fundoplication, and the use of population-based data to answer questions about the delivery of pediatric surgical care. There were also talks by some of the faculty and trainees from New Zealand, on the indications for contralateral groin exploration during hernia repair, and the incidence of gastroesophageal reflux in patients undergoing percutaneous endoscopic gastrostomy.

I then had the opportunity to meet with the trainees, who came originally from New Zealand, Australia, Scotland, and England. We talked about the system for pediatric surgical training in Australasia, which involves basic training in general surgery and then at least 4 years of pediatric surgery. This differs from our system in North American, where we do two years of pediatric surgery training after completing full general surgery training. The trainees told me that the plan is to move toward a basic two year training in general surgery followed by 4-5 years of pediatric surgery, and possibly eventually to enter pediatric surgery straight from medical school. We had a healthy debate about the wisdom of minimal general surgery training, and there were excellent arguments made on both sides. It was interesting to me because there have been recent discussions in both the United States and in Canada about shortening the basic general surgery training, and lengthening pediatric surgical training. The other issue that came up was the requirement for the trainees to work in several centers during their training. Although this does expand and broaden the experience for each trainee, and prevents inbreeding of ideas, it can have a deleterious effect on the trainee’s family life.

I then had lunch with the trainees and the staff, and there was a bet made on the quality of the coffee in New Zealand (I became convinced that it was far better than any coffee available at Starbuck’s). After a quick round of the inpatient unit, I was then delivered back to my hotel.

In the afternoon Ferne, Alexander and I went to the marine museum, which was excellent, and walked around Auckland. We then went out for dinner with Phil and his staff, along with their spouses. The conversation at dinner was very enlightening, and much of it focused on the training of pediatric surgeons in New Zealand. Phil is very involved with setting the Royal College exams for entry into the surgery program, and had introduced an OSCE component to these exams which evaluate clinical skills as well as manual dexterity. We also discussed a module during surgical training which will teach and evaluate “what a house officer needs to know” ie response to sick patient, what the staff wants to hear, etc. I also learned about the liver transplant program in New Zealand, which along with a number of other highly specialized pediatric surgical conditions is concentrated in a single centre. All of the transplants are done in Auckland. Phil participates with the adult transplant program and does about six per year. All of the biliary atresia surgery is also done in Auckland. Some other complex conditions such as cloacal anomalies and bladder exstrophy (Auckland) and esophageal replacement (Christchurch) are concentrated in one centre. This concept is something that the pediatric surgery community in Canada has struggled with, especially because of our relatively small size and the increasing evidence in the literature of a volume-outcome relationship for many complex medical problems.

Wednesday February 14

After a good night’s sleep, finally shaking our jetlag, Ferne, Alexander and I took a long walk to the harbour, did some shopping, and then took the ferry to Waiheke Island, a beautiful island off the coast of Auckland. We spent the afternoon walking there, then took the ferry and a taxi back to the hotel, picked up our bags, and headed to the airport for our flight to Wellington, which is on the southern tip of the North Island of New Zealand (Auckland is near the north end of the North Island). At the Wellington airport we were picked up by Kevin Pringle, a pediatric surgeon I’ve known for over 20 years through our mutual interest in fetal surgery. Kevin is a native Kiwi who was one of the first pediatric surgeons to work in the area of fetal surgery. I met him when I worked in Michael Harrison’s lab in San Francisco, and at that time Kevin was working as a pediatric surgeon in Iowa, but he subsequently moved home to New Zealand. Kevin took us on a brief tour of Wellington, which is the capital of New Zealand, and taught us about the history of the city, as well as giving us an introduction to the relationship between the indigenous Maori population and the largely European population. Unlike most countries that have been colonized by Europeans, the Maori are relatively populous, influential, and integrated into New Zealand society. This was a theme we came to understand even more through our weeks there.

We checked in to our apartment hotel, walked to a locally famous restaurant called the Green Parrott for dinner, and had a good sleep after a long day.

Thursday February 15

Kevin picked me up first thing in the morning for my visit to the Wellington Children’s Hospital. Although it is a children’s facility within an adult hospital, it was established in 1912 and has a long history of excellence in the community. We started the morning with me presenting a talk on necrotizing enterocolitis (NEC) at neonatology rounds. I particularly focused on several innovations from the Hospital for Sick Children, the use of ultrasound to help make decisions about who to operate on and when, and the use of peritoneal drainage as an alternative to laparotomy for very small babies with this condition. There was a lot of interest by their group about both topics and a lot of interesting discussion. They also felt that the incidence of NEC in their NICU is lower than they see in their referring hospitals, and they believe it is because of different feeding practices. This is something we have also observed, and I found this discussion very informative and thought-provoking.

After rounds I did a tour of the hospital, focusing on the NICU and the ward. I saw several complicated NICU babies including two with short bowel syndrome, and one with NEC (in whom they decided to try ultrasound to see if a laparotomy was necessary). We had an involved discussion about the ethics of palliative vs aggressive treatment of neonates with severe problems. They also showed me a child with complex hypospadius, which stimulated a conversation about the management of children with urological problems. Most pediatric surgeons are still doing urology in New Zealand, which is different than the North American model. However, in Auckland things are a little more subspecialized ie Phil is doing most of the liver surgery, and no urology.

The next activity was pediatrics rounds, at which I presented a talk on minimal access surgery (MAS) in children. The faculty in Wellington are mixed in their level of enthusiasm; Brendan Bowkett is doing a lot of it and on the other end of the spectrum, Kevin is resistant. There was a lot of discussion about the use of MAS for common pediatric surgical problems such as appendectomy and pyloromyotomy, in which the evidence for better outcomes to the patient is not overwhelming, but in which there may be significant benefits for training. The group were worried about using MAS for neonatal surgery because of their relatively low volumes, and I encouraged them to develop their skills by doing pyloromyotomies and fundoplications, since the skills are probably transferable to neonatal conditions such as esophageal atresia and choledochal cysts. There was also a lively discussion about the management of post-pneumonic empyema, which is very much more common in New Zealand than in Canada. I benefited from this discussion, particularly around the issues of thoracoscopic debridement vs chest tube and tPA.

After lunch I was dropped back at my hotel, and spent the afternoon with Ferne and Alexander at the Te Papa museum. This is the national museum of New Zealand, and was extremely educational. We saw exhibits on Maori culture and history, the introduction of mammals to New Zealand (the biggest mammal in New Zealand prior to the arrival of the Europeans was a bat), and saw a Maori musical presentation.

Dinner this evening was with Kevin and his faculty at the Tugboat restaurant, which is located on a boat in the Wellington harbour. A beautiful meal in a beautiful location.

Friday February 16 to Monday February 19

We got up early, checked out of the hotel, and walked to the harbour, where in the pouring rain boarded a ferry to Picton, just on the other side of the straight that separates the North Island from the South Island of New Zealand. In Picton we rented a car and drove to Nelson. This drive took us through the Marlborough region, one of the most productive wine regions in New Zealand. It is also the home of Cloudy Bay, producer of my favourite sauvignon blanc. I was in heaven. We also stopped at several other wineries with which I was not yet familiar, including Herzog and Allen Scott, both of which were wonderful. I learned a lot about the New Zealand wine industry, which although not directly related to pediatric surgery, was of great interest to me! We arrived in Nelson in the evening, checked into our apartment hotel, took a long walk on the beach and went to bed.

The following day we drove to Abel Tasman Park, a huge conservation area on the north shore of the North Island. We spent the day sea kayaking with a small group led by our guide, Kyle, a part-Maori storyteller who kept us energized and entertained. We saw seals, stingrays, and many kinds of birds. It was a magical day.

The next day we drove back to Nelson and did some shopping for gifts and for Lord of the Rings paraphernalia. We then got back in the car for the long drive down the coast to Kaikoura. We stopped for lunch in Havelock, the green-lipped mussel capital of the world, and also the home of two Nobel laureates in physics, Ernest Rutherford and William Pickering. North of Kaikoura we saw a large colony of seals at the side of the road, and stopped to photograph and walk among them.

Kaikoura is the site of the best whale-watching tours in the country. The tours are run by the Maori and there is a money-back guarantee that you will see whales. We were not disappointed, and saw three sperm whales during the following day’s tour. At a medical level, I learned the value of ginger in preventing motion sickness. For the first time in her life, Ferne spent three hours on a small boat among rolling waves and didn’t get even a little bit sick. (Alexander, on the other hand, who didn’t take the ginger, didn’t feel so good at the end of the tour).

After whale watching, we got back in the car and completed the gorgeous drive down the coast to Christchurch. On the way we stopped at the Pegasus Bay winery, which is owned by a surgeon in Christchurch. We learned that an increasing number of sheep farms are being converted to grapes in the South Island, and that many of them are owned by members of our profession! In the early evening we arrived at the home of Spencer Beasley, the chief of pediatric surgery at the Children’s Hospital in Christchurch. I first met Spencer when I was still a fellow at SickKids, and he was a young attending surgeon at the Royal Children’s Hospital in Melbourne who was visiting us. Spencer has had a prestigious career, has edited a number of textbooks, has done basic science research, and is a well-recognized expert in the management of esophageal atresia and many other congenital anomalies. He moved back to his home in New Zealand about 10 years ago. Spencer wasn’t home yet (he was operating late on a child from Italy), but his wife Christy and their two small children made us feel at home. When Spencer did arrive home we had a lovely dinner then went off to bed.

Tuesday February 20

Spencer and I got up very early for our day at the Christchurch Hospital. I started by giving a presentation to the faculty of the pediatric surgery division (Spencer, Kiki Maoate, and Russell Blakelock) as well as a large number of clinical and research trainees. The topic of this talk was my work on outcomes for “routine” pediatric surgical operations (such as appendectomy, pyloromyotomy and inguinal hernia repair) when done by general surgeons vs subspecialty-trained pediatric surgeons. This is very topical in the South Island of New Zealand, because of the relatively small population which is scattered through a large and mountainous geographical area (like much of Canada). There was a lot of discussion about the appropriate system for taking care of these kind of “bread and butter” cases. Until the time that Spencer arrived, there were no pediatric surgeons in the South Island, and all of these cases were done by general surgeons. Now they are finding that the general surgeons are not willing to take care of children. Because they are the only pediatric surgeons on the South Island, Spencer’s group now does outreach to six locations around the Island, five of which they need to fly to. The solution that I’ve proposed for Ontario is to create an intermediate level of pediatric surgeon that just does bread and butter cases. Although we agreed on this solution, the process by which these surgeons should be trained was the subject of ongoing debate. Next we heard several basic science presentations from Spencer’s lab, on the topic of sonic hedgehog signalling and the developmental biology of tracheo- esophageal anomalies. This was particularly interesting for me, as one of the members of my division, Peter Kim, is involved in similar work in his laboratory. Finally, I showed a video of my technique for doing a transanal pullthrough procedure for Hirschsprung disease, with generated a lot of interesting discussion. This was followed by lunch with the group, after which Spencer had to leave for Melbourne, where he was to attend a meeting of the Australasian College of Surgeons committee on training.

In the afternoon I went to the operating room, where I watched Kiki and Amaria, his registrar, perform a laparoscopic nephrectomy using an extraperitoneal approach. I was impressed by his technical skill and the efficiency of the operating room staff. I was also impressed that no one wears a surgical mask in the operating room, without any documented increase in infection risk! After the operating room, we re-joined Ferne and Alexander, and Kiki took us on a tour of the mountain that surrounds Christchurch. It was beautiful, and full of cyclists and joggers of all ages.

That evening we had dinner with Russell, Kiki and Kiki’s wife, Allie, as well as the trainees, research fellows and office staff. There was a lot of interesting discussion about resident work hours, the undergraduate medical school curriculum (ie basic approach vs system and problem-based approach), and the role of harassment and intimidation. These are all themes that are commonly discussed at our residency program committee meetings in Toronto, and I was pleased to hear that things are no different on the other side of the world. Alexander and I also learned a lot about the sports world in New Zealand. Not to our surprise, we discovered that the most popular sports are rugby, cricket, and soccer, with soccer being more popular among younger children who then move toward rugby. We also learned that the word “hockey” means field hockey, even though they do have ice hockey in Christchurch.

Wednesday February 21 to Sunday February 25

We were up early and Kiki drove us to the airport for our flight to Queenstown, which is a striking town in the south of the South Island that has become the centre of the “extreme sport” culture. After settling into our apartment hotel, we rented bicycles and cycled around the lake. We had lunch on the waterfront and did some shopping and walking. In the late afternoon we went up the gondola to a restaurant on the top of the mountain, and saw a live show about Maori culture. This was extremely entertaining, and also very educational.

The following two days we explored the area around Queenstown. This included a Lord of the Rings tour, tasting the wonderful Pinot Noirs from Central Otaga, riding the famous Shotover Jet, and a wonderful afternoon rafting down the Shotover River. We even watched the movie Whale Rider with Alexander, which explores the clashes between European and Maori culture through the eyes of a young Maori girl. We contemplated, but did not indulge in, a number of extreme activities such as bungie jumping, sky diving, and jumping off cliffs with a kite. On Saturday Alexander and Ferne headed back to Toronto, and I went fly fishing for the day with Nick Clark, a local guide. I hooked six trout and landed three, so all in all it was a great day with fantastic weather amidst beautiful scenery. I also learned from Nick about the New Zealand Accident Compensation Commission (ACC), which provides free timely care for any injury, and is paid for by employers and employees. I was fascinated by the fact that there is such a difference in access to care for trauma, compared to any other disease or health condition.

The next day I spent the morning catching up on email at the internet café, which doubled as a Laundromat. I then caught a taxi to the airport for my flight to Brisbane via Christchurch. The flights were uneventful, and after landing in Brisbane I checked into my hotel and did some more computer work before shutting out the light in anticipation of the next leg of my trip in Australia.

Australia

Monday February 26

I woke up early and went for a run along the Brisbane River. There was a beautiful mangrove boardwalk along the river, and I was energized by the smell of the flowers and the rapidly increasing heat of the morning (something I had forgotten about in cold snowy Toronto!). After a shower and some breakfast I was picked up by Kelvin Choo, one of the pediatric surgeons at the Royal Children’s Hospital. My first stop at the hospital was pediatric surgery rounds, at which I gave two talks: one on NEC and one on the surgical management of the child with inflammatory bowel disease. There was a good discussion after both talks, but particularly after the talk on NEC. I was beginning to discover that the role of peritoneal drainage is not as widely accepted as I had thought.

After rounds we drove to Mater Children’s Hospital, which is the other free- standing children’s hospital in Brisbane. On the drive to Mater I learned about a plan to build a new children’s hospital on the site of Mater, which would represent a merger of the two existing hospitals. Having experienced a number of successful and unsuccessful mergers during my career in several different cities, I was very interested in the political issues that would be faced. Although there was anticipation of problems merging many of the subspecialty groups, Kelvin did not think it would be as much of an issue with the pediatric surgeons, since most of them already cover both hospitals, representing a population of about 4 million in Queensland province. Cardiac surgery is currently done at yet another hospital, but the plan is to move pediatric cardiac surgery to Mater in the near future. At Mater I attended Tumour Board, at which cases of Ewings sarcoma with lung metastases, an endodermal sinus tumour of the uterus, and an undifferentiated sarcoma of the buttock were presented. It was a good example of excellent multi-disciplinary patient care.

After lunch we went back to Royal Children’s Hospital where I went to the operating room with Peter Borzi, who is the chief of the division and a well-known pioneer in the field of pediatric MAS in Australia. He and his senior registrar did laparoscopy for a case of malrotation in a cardiac patient with pulmonary agenesis, and push endoscopy in a child with chronic GI bleeding, in which no source was found. Before and between cases I had an opportunity to talk to Peter and some of the trainees about the effect of work hour restrictions on their ability to adequately cover the patients. We also discussed the new training requirements, which I had heard about several times in New Zealand, and detected some uncertainty among both faculty and trainees about how it’s going to work out. They have several people close to retirement age in Brisbane, and they will have to recruit in the near future. The new training scheme may make it more difficult to find appropriate people for those jobs.

Back at the hotel I worked for a couple of hours, and then went for dinner at the hotel restaurant with all of the Division members. Also present at dinner was Russell Stitz, current president of the Australasian College of Surgeons and a member of the James IV Association. Neville Davis, another James IV member was supposed to come but couldn’t make it. Russell was an excellent host, and we had an extensive discussion about health care delivery, particularly in academic centres. He told me that they have a problem supporting teaching and research in surgery because there is no mechanism for universities to compensate surgeons for these activities. Because private practice is more lucrative than academic pursuits, most young surgeons choose not to engage in research and teaching. This was a theme that I was to hear several times again during my stay in Australia. At dinner we also discussed sub-specialization in pediatric surgery within the region and within Australia.

Tuesday February 27

Peter picked me up early and drove me to the airport for my flight to Melbourne. I checked into my hotel, across the street from the Royal Children’s Hospital of Melbourne, which is the largest and probably the most prestigious children’s hospital in Australia, and among the most well-known in the world. I arranged to meet my host, John Hutson. John is the chief of the pediatric surgery department, and is a well-known academic pediatric surgeon who has done most of the seminal work in our understanding of testicular descent. I’ve known John for many years through our interactions at international meetings, and also because of his interest in intestinal motility. John took me for a tour of the hospital. One of the most impressive parts of the tour was a plaque featuring all of the pediatric surgeons who have worked there. This is a who’s who of pediatric surgery, and includes people like Douglas Stephens, who worked out the embryology of the hindgut (and who at the age of 94 still comes in to work on a regular basis). I was impressed with the fact that there is carpeting on the floor in the wards, which keeps it quiet and calm. I was also surprised to hear that trauma is primarily managed by the emergency department, with the surgeons available as consultants. This of course is very different from the North American model.

During the tour, and at lunch afterwards, John explained the system to me. The pediatric surgical service has 12 surgeons, and is divided into general/urology, and general/thoracic. Recently they separated a Division of Urology away from General Surgery, so that urological procedures were being done by both Divisions. Within general surgery one surgeon is on first call every day, and another one is on second call for the opposite specialty. All but two of the surgeons are “visiting surgeons”, meaning that they spend about half their time at the Royal Children’s Hospital and the other half in private practice. John said that he does one half-day per week of private practice, which pays more than the other 4 ½ days combined. This was an echo of the conversation I’d had the previous evening with Russell Stitz in Brisbane, and it was clear to me how difficult it is to entice surgeons to be full time academic surgeons, or even to do academic pursuits at all. John is clearly frustrated by this, but he has little control over it because of the system.

After lunch we attended the weekly meeting of John’s laboratory. He has a total of 14 people working in the lab, including collaborators, post-doctoral students, PhD students, surgical trainees, medical students, and technicians, one of whom has been there over 20 years. His two main areas of interest are colonic motility, and testicular descent. I heard brief presentations from each of the people, including the following projects: 1. Neural crest cell migration in the etiology of Hirschsprung disease, looking particularly at GDNF and endothelin interactions; 2. Staining for substance P, nitric oxide synthase, VIP, and muscarinic receptors in slow transit constipation (STC) ; 3. Randomized crossover double blind trial of inferential electrical therapy for STC. A pilot study of 8 children showed excellent results with clinical improvement, normalized scans and manometry. This was a very interesting finding for me, since this is a common problem and the electrical therapy approach is completely novel; 4. Quality of life in STC; 5. A study of the incidence of hypermobile joints in children with STC. We also had an extended discussion about motility in children with anorectal malformations and gastroschisis, as well as about genetic issues with both Hirschsprung disease and STC. I also heard about a number of projects on testicular descent, mainly having to do with the role of the gubernaculum. John has a number of projects looking at the role of CGRP from the genitofemoral nerve, apoptosis and mitosis, as well as studies examining similarities of the gubernaculums to limb buds in morphology and gene expression, and has started to do some grafting experiments that are very interesting.

After the lab meeting John took me to his home, where we had wine and cheese with his wife and son, and then a lovely dinner at a small Italian restaurant near his house. John’s wife was a prominent psychiatrist, who worked primarily with victims of terrorism and genocide (many of whom immigrated to Australia because it’s as far as they could get from their home country). Unfortunately she has had to retire from practice because of Parkinson’s disease. It was a pleasure and an honour to finally meet her and be exposed to such a wonderful woman.

Wednesday February 28

I was picked up by Russell Taylor the chief of the general/thoracic division. Our first stop was the Royal Women’s Hospital where we attended neonatology rounds. The setup for neonatal care in Melbourne is similar to what we have in Toronto, with a 50-bed NICU at the children’s hospital, about half of which is surgical, and two other large NICU’s in the vicinity with no surgeons on site. One of the neonatologists presented a difficult case of NEC, after which I gave a talk on NEC, highlighting again the issues of ultrasound and peritoneal drainage. There was a very spicy discussion, particularly focusing on whether they should do either of the techniques there. It became clear during the discussion that they struggle with how to cover their surgical patients, and that the lack of surgical coverage may influence how the patients are managed.

After rounds we went back to the Royal Children’s Hospital, and I did rounds with the trainees, who showed me some complicated patients in the NICU. After that I gave a talk on Hirschsprung disease, and then had lunch with Michael O’Brien and several of the other surgeons and trainees. There was a lot of conversation about the new training scheme, and its effect on the supply of pediatric surgeons in Australia and New Zealand. The Royal Children’s Hospital has five pediatric surgery trainees, one of whom is foreign (they used to have four, three of whom were foreign). There is apparently pressure from the government to train more pediatric surgeons, but there was concern that there will not be enough jobs for them all. The other side of that coin is that they will all find jobs, but that will dilute the experience of tertiary cases, which may influence the quality of care for those patients. This was a similar discussion to the ones I had in Christchurch, and gave me food for thought about how we should be managing the training and delivery of pediatric surgical care in Canada.

After lunch, Craig drove me to airport, where I caught my flight to Adelaide. My host in Adelaide, Hock Tan, is also widely respected for his work in advancing the field of pediatric MAS. Hock picked me up at the airport, and took me to a Chinese restaurant for dinner with his wife and a number of other guests from the hospital administration. The highlight of the evening was a dancing dragon, who entertained us in honour of the Chinese New Year.

Thursday March 1

In Adelaide, Hock had organized a pediatric surgical symposium around my visit. We started the morning at the hospital by meeting with Andrew Sutherland, a pediatric orthopaedic surgeon who did his training in Toronto, and who is the incoming president of the Australasian College of Surgeons. I then spent the morning giving talks on pediatric MAS, and the management of the failed fundoplication. There were also talks by other members of Hock’s division and by other invited guests on the new training scheme, a new database for parents, and the use of the integrated operating room environment for MAS.

In the afternoon, we went to the operating room, where Hock did a laparoscopic choledochal cyst excision. I learned a number of new ideas from watching him do this very complicated MAS procedure, including the use of a new laparoscopic bipolar cautery instrument that he developed, the use of ambient green light to improve visualization of the monitor, the use of a loop suture for the first knot, and the use of a choledochoduodenostomy for reconstruction instead of a Roux- en-Y.

For dinner we went to an Italian restaurant. I had a long conversation with Tony Sparnon, one of Hock’s partners who is also the head of the Royal College pediatric surgery training program. In addition to the issue of the new training scheme, we touched on two other topics. The first is the fact that all of the surgical training programs in Australia and New Zealand are managed by the Royal College rather than by hospitals or universities. This provides consistency and a common curriculum, but there is also a conflict of interest because the Royal College also evaluates and ultimately credentials the candidates. The other topic that Tony was very interested in was how to increase the amount of research training done by trainees during clinical training. I explained to him about the University of Toronto surgeon scientist program, which has been very successful. However, he wasn’t sure how such a program would be funded in the Australian system.

Friday March 2

This morning Hock picked me up and we went back to the hospital for the second day of the symposium. Many of the participants were invited by Hock from developing countries in southeast Asia, such as Malaysia, Indonesia, Thailand, Vietnam, and the Philippines. There were a series of talks by representatives of these countries, particularly focusing on the delivery of pediatric surgical care. All of these countries have huge populations, with few pediatric surgeons. There is a clear need to set up training programs for general surgeons who can operate on emergencies and routine pediatric problems, in addition to increasing the number of pediatric surgeons who can take care of more complex problems. All of the participants from these countries, both during and after the symposium, expressed a desire to train some of their people in Canada. It struck me as a long-term problem that we in the developed world should be spending more time thinking about. I also gave another four talks, on abdominal wall defects, Hirschsprung disease, inflammatory bowel disease, and NEC.

After lunch I changed into shorts, went with Chris Kirby, one of Hock’s junior partners to rent a tuxedo for the evening, and then with Hock and several of the other participants in the symposium to the Bourassa Valley, where we tasted wine at Jacob’s Creek and Grant Burge vineyards. In the evening Hock and his wife Evelyn took me with them to a very fancy gala evening hosted by the Premier of the province of South Australia, which featured excellent food, wine tasting, entertainment, and interesting members of the Adelaide business community. It was an impressive ending to a very busy visit to Adelaide.

Saturday March 3

Up early for the marathon 30 hour trip home. Adelaide to Melbourne to Auckland to Los Angeles to Toronto. Arrived home exhausted but exhiliarated.

Hong Kong and China

Friday November 16

I was lucky to get a direct flight from Toronto, and arrived in Hong Kong at 2: 30PM. I was picked up by Ken Wong, one of the junior pediatric surgeons at the University of Hong Kong, who would be with me for the next ten days as my host. Ken took me to my hotel for a shower, shave and change of clothes. We then went to the university, where I met with John Wong, Chair of the Department of Surgery, and a member of the James IV Association. We had a long discussion about Hong Kong medical politics, and he particularly focused on the difficulty he has keeping faculty in university, with the financial rewards being so much more generous in private practice. This was very reminiscent of the conversations I had in Australia, which is not surprising since the health care systems are similar.

We then went on a tour of the pediatric surgery lab, led by Vincent Lui, one of the PhD scientists working in the department of surgery. The lab is focused on a number of topics, including the molecular biology of Hirschsprung disease, genetics and developmental biology of anorectal and tracheo-esophageal malformations, and the role of stem cells in neuroblastoma. Although I was very tired, I was fascinated by the incredible work being done by this group.

For dinner we went to the restaurant in my hotel with Ken, Paul Tam, and a number of the faculty and trainees. I got a very good sense of the training system for pediatric surgeons, which is very similar to the UK system and to the system that is being developed in Australasia. They do basic surgery training for two years, followed by 4-5 years of pediatric surgery. Many of them go abroad for several years, often to the UK. John Wong’s impression about the difficulty of recruiting and retaining academic surgeons was reinforced for me by the trainees, and there was also a sense of frustration with the limited number of positions in private practice.

Saturday November 17

After a good night’s sleep (thanks to my trusty melatonin), I was picked up early by Paul and his wife, Amy, for our flight to China. Paul is an old friend of mine, who was born and raised in Hong Kong and then worked for about 10 years at Oxford University, where he developed an international reputation as a surgeon- scientist, with a particular interest and expertise in molecular biology and genetics. His longstanding interest in Hirschsprung disease has brought us together many times, and his move back to Hong Kong occurred at the same time as my move back to Canada from the United States, stimulating many conversations between us at that time about the process of moving “home”.

Over the past 10 years he has risen to the role of Vice-Chancellor of Hong Kong University responsible for research. One of Paul’s initiatives has been the creation of a program called “Teach the Teachers”, which involves identification of young surgeons from China who spend a year training in Hong Kong, and also organization of visiting professorships where a Western academic surgeon spends a week or two visiting several Chinese centres. My trip to China was part of this program, and both Paul and Ken were to be my hosts throughout my visit. After sitting on the runway for an hour, we took a 2.5 hour flight to Xi’an, which is the ancient capital of China located in the central part of the country. We were picked up at airport by Harry Qin, a general surgery resident who had previously spent 2 years in Los Angeles with Eric Fonkalsrud. In the car we got a good idea about the training of a pediatric surgeon in Xi’an, where they do full training in general surgery first, and then three additional years of pediatric surgery. I also learned that the training of pediatric surgeons is not standardized throughout the country.

We checked into our hotel, and had lunch with Harry and Ya Gao, our host in Xi’ an and the local expert in the management of Hirschsprung disease. We then spent the rest of the afternoon at the Xi’an museum, which gave me an excellent introduction to the history of China. Dinner followed with the core pediatric surgery group, led by Quan Xu, the chief of pediatric surgery, their head nurse, and three other surgeons. I was introduced to Chinese rice wine (mao tai) and ritual of toasting each other all evening. It’s a good thing my body mass is a lot higher than most of my hosts, or I would have been under the table! As with most of my meals in China, dinner was a banquet with many courses. In this case every course consisted of dumplings, a specialty of the region. I also had the opportunity to share with my hosts the Hebrew “l’chaim” toast (meaning “to life”), which led to a fascinating discussion of the similarities between the Jews and the Chinese. Both cultures have 4,000 years of history, a focus on family, and suffered considerably during World War II. After dinner we went to the main square, and then walked down the street in the Muslim quarter. I was surprised that there was a Muslim quarter, but learned that Muslims have been in Xi’an since around 1,000 CE, having come there on the Silk Road, which ends in Xi’ an. Xu wanted to go beer-drinking, but I was too jetlagged and full of mao tai, and needed to sleep.

Sunday November 18, 2007

I went to the gym in the morning, and then we spent the day touring. The most famous attraction in Xi’an is the tomb of the first emperor of China, who had himself buried with a full army made of clay, known as the terracotta soldiers. This was incredible. We then had lunch at a traditional Chinese restaurant, then spent the afternoon at the Princess baths. There was a famous old Chinese poem that took place here, and was illustrated in several rooms. Paul and Amy were touched by this as they had grown up with this poem.

On the way back we stopped at a Women’s and Children’s Hospital on the outskirts of Xi’an. This hospital was built as a cooperative venture with the government of Canada. We met with the chief of surgery and had a tour of the hospital. They only do community level pediatric surgical cases there. Before dinner, we stopped at the Big Goose pagoda, which according to tradition is where the “Monkey King” stored all the books he brought back from India. Dinner was at a Muslim-style restaurant, with more mao tai and toasts.

Monday November 19, 2007

Once again went to the gym in the morning, trying to work off the plentiful food and rice wine. We started the day with a tour of the Jiaotong University research laboratories, and met Yong Liu, dean of the medical school, and a group of basic scientists who presented their work for us. These scientists are doing some interesting work with the human genome project, ischemia-reperfusion injury of the brain, and other areas related to neurophysiology. We had an interesting discussion about the role of translational research, and how this is an excellent role for surgeons to adopt.

The next stop was the Second Affiliated Hospital of Xi’an, which is the main centre for tertiary and quaternary pediatric surgery in this part of the country. We had an outdoor tour of the hospital, including their new building, the residence, and the medical school classrooms. I gave talks on Hirschsprung disease and pediatric MAS, and Paul gave a talk on laparoscopic repair of anorectal malformations. My talks were translated slide by slide by Gao, which required a change of pace from what I’m used to. Gao gave a talk on his experience with Hirschsprung disease (328 cases over 6 years, with 286 transanal pullthroughs). This was my first exposure to the massive volumes of cases being done by the Asian pediatric surgeons. At the Hospital for Sick Children in Toronto we consider ourselves a very high-volume centre (which we are, by North American standards). We do about 20 pullthroughs per year, and Gao was doing about 50! I realized that he could teach me a thing or two about surgery for Hirschsprung disease. We also heard talks by our hosts about an animal model of hemangioma in nude mice, a new technique for the repair of hypospadius, and an overview of the surgical service, particularly focused on the management of lymphatic and vascular malformations, for which they are a national referral centre (116,000 cases over 12 years seen by Quan Xu).

Despite the huge volumes, I was struck by the incomplete follow-up and the lack of reporting of complications. I believe that this is due to the time constraints of these busy surgeons, difficulty with patient transportation, and a cultural inhibition toward critical evaluation of results. This was a theme that repeated itself throughout my time in China.

After lunch (from Kentucky Fried Chicken!) we had a brief tour of the hospital, including the new building and the outpatient department. I noticed that there were no hand-washing facilities. We saw a number of very interesting patients, including a girl and a boy with large hemangiomas treated with topical methotrexate (a technique I had not seen before), a baby one month post- pullthrough with persistent obstruction and dehydration, who likely still has an aganglionic segment (although it was difficult to get them to admit to this possibility). We also discussed the use of CT scans to delineate the anatomy in infants with anorectal malformations and esophageal atresia, a technique we haven’t used but which is being used frequently in China and routinely in Hong Kong.

For dinner we went to a fancy restaurant, hosted by Jianqun Yan, vice-president of Jiaotong University and president of the Health Sciences Centre. We had a fascinating discussion about the funding of the health care system in China. According to Paul, there is no public funding for health care, although Gao said that everyone gets treated regardless of ability to pay. Yan told me that hospitals get funding for capital projects like building a new wing, but the hospital must fund operational expenses through charging patients. Doctors get paid nothing from the government, and rely completely on billing of patients. I went back to my hotel somewhat confused, as I was sure that most regular Chinese people would not be able to afford to pay for expensive surgical treatment, especially if they lived a long way away from the pediatric surgical centre.

Tuesday November 20, 2007

Once again I went to the gym in the morning, and then we spent the day at Mount Hua, one of the four famous mountains in China. We took a gondola to the top, and then I hiked with Paul, Amy, Ken, and Harry along the paths. We went up past the “gate of heaven”. I was impressed by the fresh air on the mountain and the smog visible in the valley, even though we were 90 minutes outside the city. We came back to Xi-an in the late afternoon and had dinner with the group plus Gao and Prof Liu (Dean of the medical school). There was more toasting with mao tai, but less this time (thank goodness). After dinner Prof Liu wanted us to have foot massages next door to the restaurant, but I came back to the hotel and had a Jacuzzi instead.

Wednesday November 21, 2007

We got up early for our flight to Shanghai. We checked into our hotel, and spent the afternoon catching up on email (we didn’t have any high-speed internet access in Xi’an) and working. Dinner was hosted by Yeming Wu, vice-president at the Shanghai Children’s Hospital. Also at dinner were five of the young pediatric surgeons at the hospital, most of whom had spent a year with Paul Tam as part of the “train the trainers” program. We talked about the program, and I developed a better understanding of how it is funded through charitable organizations. Paul emphasized the need to identify young surgeons who have the potential to become leaders in the Chinese system, so they will pass the new attitudes on. He also emphasized the fact that things in China must evolve slowly, and that it will take a generation for the new leadership to make significant change.

We also talked about the differences between Xi’an, Shanghai and Beijing in terms of their roles in the country. Xi’an is the historical cultural centre, having been the ancient capital for a thousand or so years. Beijing then became the political centre of the country, and remains very strongly the political centre both in national politics and, more interestingly to me, in surgical politics. For example, all of the presidents of the national surgical societies are from Beijing. In addition, Beijing is usually the first to get new institutions and equipment. For example, a new pediatric hematology-oncology centre was built first in Beijing, and now one is being built in Shanghai. Despite this, Shanghai has become the financial centre of the country, and the amount of new building all around me was evidence of this. I was told a story about Beijing taxi drivers getting emotional when they pass by the picture of Mao across from the Forbidden City, while Shanghai taxi drivers get emotional when they see the picture of Mao on the paper money. This story capsulized for me the differences between the two cities.

I learned about the history of the health care system in China, and clarified some of the confusion from my previous conversations on this topic in Xi’an. During the communist era everyone worked for a unit (ie government, a company, etc), who paid for their health care. In modern times, after “capitalization” of the system, people still work for a unit but health care is no longer paid for. Because of its booming economy, residents of Shanghai only pay $50 per day for medical care (of which doctors get nothing), but people outside Shanghai, which represents 80% of the patients cared for in the Children’s Hospital have to pay, which provides the doctors’ income. Some patients have insurance, but no one was sure what percentage that represents. The amount of payment is determined by which kind of room they stay in.

After dinner we drove to the Bund, the historic riverfront area of Shanghai which used to be the centre of European and then Japanese colonization, and walked along the river. We looked at all the lights and the tall buildings, particularly the Pearl of Shanghai and another one being built to be the tallest in the world. After our walk I shared a bottle of fine Cotes de Rhone at the hotel with Paul and Ken, and then went to bed.

Thursday November 22, 2007

I missed my alarm this morning, so had to forego the gym. We went off to Shanghai Children’s Medical Centre, where we had a tour of the hospital with Qimin Chen, director of pediatric surgery, as well as Jie Ma, a pediatric neurosurgeon. The hospital was established with funding from Project HOPE, and was opened by Hilary Clinton 10 years ago. We saw the heart centre which does >2,000 cases per year. I gave several talks on Hirschsprung disease and on pediatric MAS, with translation by one of the young staff. We also heard talks about their Hirschsprung disease experience and some basic science talks on Hirschsprung associated enterocolitis and on cultured neurospheres.

In the afternoon we moved to Xin Hua Hospital, a very large general hospital that also does pediatric surgery, and had a tour with Jun Wang, one of the pediatric general surgeons. We saw several interesting patients in the NICU, including five children with Hirschsprung disease, and a baby with pure esophageal atresia which had been treated by primary gastric pullup. This is a very unconventional approach in North America, but Jun told me that he uses it because parents don’ t tolerate a long hospitalization, and they’re also unwilling to take care of stomas. This led to a discussion about primary pullthroughs for anorectal malformations to avoid stomas, an approach which has not caught on in very many centres in North America, but which would have significant relevance in cultures that are aversive to stomas. We also had a conversation about separating conjoined twins, most of which in China are referred to Shanghai. After the tour I chatted with a group of trainees while waiting for the super-chief to come (he didn’t make it – was called for a last-minute meeting at the Ministry of Health, which apparently is a common event). The training in Shanghai consists of 3 years basic surgery then 3 years of pediatric surgery. Many trainees do some additional fellowship years. Because of the large volumes of cases, pediatric surgeons tend to specialize in pediatric general/thoracic surgery, neonatal surgery, urology, or cardiac. The trainees are on call about 1 in 5, but the staff also stay in-house. Eventually we were joined by Cai Wei, director of both units (both under the auspices of Shanghai Jiao Tong University), who is also Deputy Director General of the Shanghai Municipal Health Bureau. We spent some time talking about their intestinal rehabilitation program, which is of great interest to me as we have recently established such a program in our Division under the leadership of Paul Wales. They haven’t done any STEP or Bianchi operations for intestinal lengthening, and almost never do intestinal transplantation. They tend to use nutritional support with lower calories (80 kcal/kg.day) to avoid liver injury. They were a little vague about their outcomes using this approach.

We had dinner at fancy restaurant, and waited for an hour for the others to get there (they were stuck in traffic, which is also apparently a very common problem in Shanghai). We spent the time drinking gensing tea. Cai Wei had another meeting in the same restaurant, and spent the evening going back and forth between the two. I learned to eat hairy crab, which is a characteristic Shanghai dish that was in the middle of high season.

Friday November 23, 2007

Back to the gym in the morning, then out for a day touring Shanghai with Ken and Clarissa, one of the nurses from SCMC who had spent time in North America and spoke English very well. The highlight of this day was a visit to the Jewish Museum and the old Jewish neighbourhood. I learned that the people of Shanghai welcomed Sephardic Jews in the 19th century, who became very successful (ie the Sassoon family) and contributed significantly to the economy of the city. During World War II Shanghai also welcomed many refugees from Nazi-occupied Europe, many of whom stayed until the communist takeover in 1948. Much of the old synagogue has been restored, largely due to donations from the Toronto Jewish community. We also went to the observation deck of the Pearl of Asia, and had lunch in the revolving restaurant, followed by a tour of the Shanghai history museum.

We went back to the hotel for quick rest, and then out for dinner with Prof Wu (Qimin Chen couldn’t come because he was doing a liver transplant). We had traditional dumplings filled with soup. During dinner we discussed the training of nurses in China, which is similar to nursing training in Canada in that there are two streams: diploma and degree. We also had an interesting discussion of traditional Chinese medicine vs western medicine. They each are well- established in China, with different hospitals and different training. Some attempts are being made to combine the two. I asked whether there had been any attempts to scientifically prove the value and efficacy of traditional medicine, but I was told that this was not considered relevant to most people because traditional medicine is based on philosophy rather than science. To me this was a fascinating concept, and one which I had trouble getting my Western head around. There have been a few investigators who have entered this arena, including one of the people working in Paul Tam’s laboratory in Hong Kong, who is looking at one of the traditional Chinese medicines being used to treat liver cancer.

Saturday November 24, 2007 and Sunday November 25, 2007

We were up early for our flight to Beijing. Paul and Amy headed back to Hong Kong, and Ken continued with me. We were picked up by Cao Jun, one of the surgical residents. After lunch at the hotel, Ken and I took a taxi to Tianemen Square and the Forbidden City. We spent the afternoon touring both places, and at sundown watched the flag-lowering ceremony in Tianemen Square. We then took the subway (an experience in itself!) back to hotel and ate Szechwan food at a local place across the street.

On Sunday we went to the Great Wall of China, hosted by Tian Jun, a pediatric urologist who does 500 hypospadius cases per year. This was a wonderful experience, and we worked up quite a sweat. We then had lunch and toured the Ming tombs. Dinner was at a “hot pot” restaurant, which is a Muslim style meal with many different cuts of lamb and countless types of vegetables, which each diner cooks individually in a pot with boiling water in the centre of the table, leaving a delicious soup at the end of the meal. We once again took the subway but got off at wrong stop and walked a long way through Beijing, which was fascinating.

Monday November 26, 2007

We spent the day at Beijing Children’s Hospital and the private international hospital beside it. We started with a tour by Weihong Guo, a female pediatric surgeon who had spent two years in Los Angeles with Eric Fonkalsrud 15 years ago. The surgery department consists of 10 divisions, including neonatal, general pediatric surgery, thoracic, urology, plastics, orthopedics, neurosurgery, cardiac, etc. There are four neonatal surgeons, including Guo. The hospital has 7,000 outpatient visits per day, which is a mind-numbing number. I saw the outpatient department and was amazed by the swarms of people. The cost for care at the Beijing Children’s Hospital is 20RMB per day, and the cost of care at the private hospital is about 100RMB per day. I saw many families sitting on the floor in the waiting rooms, and many family members sleeping in stairwells, since most of them come from a long way away and can’t afford to stay in hotels. I was also told that there are very few private pediatricians or family doctors in the community, and people therefore use the hospital for primary care. This also results in very little preventive care such as nutritional education, vaccination, or injury prevention. Another phenomenon that I found interesting is that there is no incentive for early discharge of patients, and the hospital stay is often very long as families don’t want to leave and then come back again. This is one of the reasons that follow-up is so poor. It’s also the reason that one stage surgery for conditions like anorectal malformations, Hirschsprung disease and esophageal atresia has become so popular, as I had previously learned in Shanghai. We spent a lot of time discussing the other options for esophageal atresia, particularly the Foker procedure, with which they have had significant experience.

I had questions about the effect of the Chinese “one family one child” policy, and the effect it may have had on the management of neonates with congenital anomalies. I had heard previously that many infants were not treated. My hosts admitted that this was still very prevalent, particularly in the rural areas, although they believed that it was changing in the cities, where people are more willing and able to care for disabled or potentially disabled children. The truth of this, and the changes occurring, is reflected in the volume of certain cases seen at Beijing Children’s Hospital. They see a steady volume of approximately 80-100 cases of Hirschsprung disease per year. Three years ago they had 10-15 cases of esophageal atresia, last year they had 40, and this year they had over 50 already. However, they have had a steady volume of only 5 cases of gastroschisis per year, although the population incidence of all three of these conditions is similar. Clearly many patients are still being allowed to die and not referred, either due to issues with transportation, or due to the one child policy. I also learned that there are some exceptions to the rule: minority races of Chinese (other than Han), minority religious groups (ie Muslim), or families in which the first child is a girl, are exempt in some jurisdictions. Also, there is no way to track or enforce the rule in the countryside, so no one knows what is really happening in rural China.

I spent some time in the operating room watching some cases. I saw a complex cloaca repair, and was impressed by the level of expertise and experience, but surprised that they were not using loupes or any other type of magnification. I saw a thoracoscopic empyema debridement, and learned that they are doing a lot of MAS, particularly in the chest.

I also spent some time with Cao Jun, the resident who had picked us up at the airport. As I had heard before, he told me that each province in China has a different curriculum and training scheme, which is not standardized. He’s doing four years of pediatric surgery after medical school, with no basic program in surgery. This reinforced the need for a “train the trainers” program, and for some kind of standardization in the Chinese system.

Throughout my visit to China, I had been impressed at how young all the chiefs were. At lunch I got some insight into why this is, as I had the honour of sitting beside Prof. Zhang, the previous chief of surgery at Beijing Children’s Hospital and widely considered to be the grandfather of pediatric surgery in China. Prof. Zhang is now 87 years old and still doing a clinic several times per week. He started his career in the early 1950’s, developed the field and trained many young pediatric surgeons. He then talked about the Cultural Revolution, during which time most of the leaders in all aspects of life, including medicine and the universities, were stripped of their jobs and sent to work in the rice fields. Because of this there was an entire generation of leaders missing, which explains why the chiefs are all my age or younger. Interestingly, Prof. Zhang didn’ t want to talk about what he did during that tumultuous time, or how he survived with his position intact. What he did tell me is that the mandatory retirement age for men in China is 60 and for a woman is 55 (so they can stay home with the grandchild). He is exempt from this.

In the afternoon I gave talks on Hirschsprung disease and pediatric MAS. Unlike in Xi’an and Shanghai, there was no translation, but most of the participants understood English well enough.

For dinner Ken and I were on our own. We went to a restaurant which is famous for Peking duck, and had special candy apples that are characteristic of Beijing on our way home again.

Tuesday November 27, 2007

Today we were up early for our flight back to Hong Kong. I had a few hours in the afternoon at the hotel in Hong Kong, where I went to the gym and had a shower. We then went to Queen Mary Hospital, did rounds with Lawrence Lan, one of the junior staff surgeons I had met the first night in Hong Kong. We saw several children with short bowel syndrome, two with biliary atresia, one with chronic enterocolitis after a Martin procedure for total colonic Hirschsprung disease, and one with a high anorectal malformation who was suffering from incontinence. I then gave a lecture on Hirschsprung disease to the general surgeons, trainees, and nurses from Hong Kong University, as well as a large group of surgeons from Shenzhen Children’s Hospital on the Chinese mainland, led by Prof Liu Lei. Shenzhen is a city of 12 million, originally created out of nothing by the Chinese government in order to compete with Hong Kong. The hospital is 10 years old and still developing its expertise. Following the lecture we all went for dinner at Jumbo Floating restaurant, where we picked our own fish straight from the ocean and had a beautiful view of the Hong Kong harbour. After dinner I presented Paul and Ken each with a bottle of Ontario icewine, as a small token of thanks for the tremendous effort each of them had put into making my experience in China so incredible.

Southeast Asia

Wednesday November 28, 2007

I got up early for my flight to Kuala Lumpur, Malaysia, where I was picked up by Dayang Aziz, a pediatric surgeon I had previously met in Adelaide at the pediatric surgery symposium, and Mahmud Mohamed Noor, a senior pediatric surgeon working in Kuala Lumpur. They took me to my hotel, where I met once again with Hock Tan, who two months earlier had moved from Adelaide to Kuala Lumpur (where he was born, and had left at age 13). He had once again arranged a two-day symposium on pediatric surgery, and was ready to put me to work. He had also invited two other guest speakers: Sebastian van As, a trauma surgeon from Capetown, South Africa, and Tony Sparnon from Adelaide, who I had previously met on the first leg of my James IV traveling. Hock had developed Bell’s palsy shortly after arriving, but was already busy planning to build an MAS skills centre and was hoping to make Kuala Lumpur an accredited one year rotation for UK and Australasian trainees. We had lunch at the Kuala Lumpur Civic Centre, known locally as the “twin towers”, which had previously been the tallest building in the world. At lunch I learned about Malaysia. The population is approximately 25 million, and the population of the greater Kuala Lumpur area is 7 million. 60% are Muslim, 25% Chinese, and 10% Indian. They have a publicly funded health care system, but also have a parallel private system, in which doctors get paid 4-5 more than in the public system. This was a theme that had repeated itself throughout my travels, and once again made me glad to be working in Canada. Training for pediatric surgery involves 4-5 years of general surgery, then 3 years pediatric surgery (one of which has to be overseas). Currently there are three places in Kuala Lumpur doing pediatric surgery: Institute of Pediatrics and another hospital, both managed by the Ministry of Health, and the university hospital which is managed by the Ministry of Education. I learned that all university hospitals are run by the Ministry of Education, which includes covering all patient care costs, a concept that I had not yet run across. The biggest volume by far is at the Institute of Pediatrics. Dayang had just left there to move to the university, where there had been only one pediatric surgeon when Hock arrived. Mahmud used to be at the university, and is now at the Institute of Pediatrics. Since the relationships among the hospitals are sometimes tenuous and competitive, I felt that Hock had his work cut out for him. However, there are only 7 pediatric surgeons in Kuala Lumpur, most in private practice, and only 20 in the country, so there should be enough business for all, and in fact it looked to me as if they are very much under- serviced. This was consistent with the impression I had when I was in Adelaide. In the late afternoon I went back to the hotel, where I did some work and plowed through some email. In the evening I had drinks with Tony and Sebastian, then the three of us had dinner at a Chinese restaurant in the hotel with Hock, Dayang, Mahmud, and Mahmud’s wife, Professor Dato Sharifah Shahabusin Hapsah, who is the Vice Chancellor of the National University of Malaysia.

Thursday November 29, 2007

This was the first day of the conference, and was attended by a large number of pediatric surgeons from Malaysia, Thailand, and other neighboring countries. The topic was pediatric minimal access surgery, and I gave three talks: pediatric laparoscopic surgery, pediatric thoracoscopic surgery, and the future of pediatric minimal access surgery. There were also talks on minimal access pediatric urology, history of minimal access surgery, and the local experience by the other guest speakers and by a few of the local pediatric surgeons. After a brief lunch, I and the other guest speakers met with the Deputy Minister of Health, who officially opened the proceedings, followed immediately by a press conference in which we all were interviewed. In the afternoon I did a transanal pullthrough on a child with Hirschsprung disease, with Dayang assisting. The case was broadcast by closed circuit television to the conference attendees, and there were many questions and comments during the operation. The case was unusual in that the transition zone was higher than expected, requiring multiple biopsies, and there was a long wait for each of the frozen sections, so that we didn’t finish the case until 7PM.

After completing the case and changing, we drove to Malaka, the ancient capital of Malaysia, with Hock and Michael Ee, who I had previously met in Melbourne. We stopped on the way for satay at a little roadside place called Samuri’s Restaurant in the town of Kajang, which is famous for its satay. It was in fact the best satay and the best peanut sauce I have ever had. We arrived late at the hotel, and went straight to bed.

Friday November 30, 2007

The second day of the conference was a combined day with the National Malaysian Trauma Association, and was attended not only by the pediatric surgeons from the day before, but by a large number of emergency medicine specialists and adult general surgeons. The reason Hock organized this day is because of the large number of pediatric deaths due to trauma and burns in Malaysia. I gave two talks. One was on the topic of trauma prevention, using as examples the helmet legislation initiative that David Wesson developed at the Hospital for Sick Children, and the “See Me Walk” program developed in Uganda by Alexandra Mihailovic, one of the general surgery residents in our training program. This talk was very well received, since trauma prevention is the key to decreasing trauma deaths, and the examples I used were applicable to both developed and developing countries. My other talk was on the non-operative management of spleen and liver injuries, an innovation that was first developed at the Hospital for Sick Children. There was a lot of interest in both of these topics. Other topics dealt with by the other guest speakers and by some of the Malaysian speakers included burn prevention and management, the optimal imaging for abdominal and chest trauma, and the development of a national trauma system in Malaysia.

After lunch we walked around Malaka, saw a couple of museums on the history of Malaka, and had delicious Malaysian snacks at several small places along the street of the old city. We then drove back to Kuala Lumpur, stopping again for dinner at the same satay restaurant. When we got back to the hotel, Tony and Sebastian and I went for a beer and had a very interesting conversation about the politics of academic surgery in developing countries. Although many of the issues are the same as those we deal with in North America, there are differences that are due to funding mechanisms, education, resources for research, and cultural paradigms that take generations to change. Hock’s experiences in Australia and now in Malaysia are a good illustration of these differences.

Saturday December 1, 2007

Hock took me to the airport in the morning. On the ride there we talked about his plans to build an academic group and be the premier laparoscopic training centre in southeast Asia. He is recruiting new faculty, but because of the limited number of pediatric surgeons in the country, and the income differential between private practice and academic practice, he will have a difficult time with recruitment. I suggested that Dayang spend some time training in clinical epidemiology research, perhaps in Toronto. One of the keys to improving the quality of academic surgery in countries like Malaysia will be stronger ties with more developed countries. Hock has already created such ties with Australia, but we in North America need to be more proactive in this regard.

My flight to Siem Reap, Cambodia was uneventful. I was picked up by Paullin (which had been arranged by Dayang) and driven to my hotel. In the afternoon I rented a bicycle and did a large loop around Angkor, a distance of approximately 25 km. I had brought my own cycling helmet. When I got back I had dinner at my hotel, then straight to bed.

Sunday December 2, 2007 and Monday December 3, 2007

Paullin picked me up at 5AM, and we went to Angkor Wat to watch the sunrise. This was one of the most beautiful sights I’ve ever seen. Angkor was a huge city of a lost civilization in the 8th century CE. The architecture has largely been preserved, and is both massive and ornate in its detail. I spent the day doing a tour of the many temples in the Angkor area. I also stopped at the Landmine museum, which was largely funded by Canadians and which I found very informative and also very scary. I had lunch near Angkor Wat – a delicious fish, curry and coconut milk dish served in a coconut. I got back to the hotel in the early evening, had a swim in the pool, dinner in my room, then bed. The following day, I was up at 7:30 and had breakfast in my hotel. My goal for the day was to explore how sick children were cared for in Cambodia. On my bicycle ride, and again during my tour of Angkor, I had passed what appeared to be a Children’s Hospital. The hospital was apparently started by a Swiss pediatrician who runs this hospital as well as two in others in Phnom Penh. I asked my hotel to see if I could visit, but after calling the hospital they said that I was unable to go in. They did, however, suggest that I visit the other children’s hospital in Siem Reap, which was a big surprise since Siem Reap is a very small place. The other hospital was only a few blocks from the hotel, so I walked over to it, knocked on the door, and after a few minutes was on a tour of the hospital. This hospital is run by an American organization called “Friends Without a Border”, and provides free health care to all children in the north of Cambodia. I met David, the administrator, and Bob, who is a pediatrician from Vermont who volunteers here for several months per year with his wife Nancy. Bob introduced me to the surgeon and the ophthalmologist. I saw a child with a facial deformity due to untreated mastoiditis which had resulted in significant proptosis. I also saw a 16 month old with Down syndrome and an undiagnosed heart problem who had developed cor pulmonale. Another surgeon had done a splenectomy today for a massive spleen. The hospital uses mainly Cambodian doctors, most of who trained in Vietnam, Thailand, or other countries. They have a lot of visiting residents, students, nurses and pediatricians/surgeons, who provide on the job training for the local team. There is only one operating room, which shuts down for elective local surgery for the week while the visiting surgeons are here. Wait lists for hernias and cleft lips and palates extend into 2009. Families cook their own meals in an outdoor kitchen area with fire pits. Many families come on foot from a long way away, and if the child needs a long course of treatment, the rest of the family sleeps on the street.

The Angkor Children’s Hospital competes with the other children’s hospital, which has more money, a CT scanner, and better equipment, but there is little cooperation or communication between the two hospitals. I was told that the other hospital doesn’t deal with chronic problems and gives short courses (3-4 days) of tuberculosis therapy, which tend to breed resistance. It was amazing to me that wherever you go in the world, you’ll find two children’s hospitals in the same city, that don’t talk to each other. Some things seem to be universal! Throughout my time in Siem Reap, I saw many “crippled” children, ie unrepaired cleft lip, bilateral hip dislocation, amputations. Rabies is also a big problem. Bob told me a story about a child who was bitten by a stray dog. When they went into the child’s village to trace the dog they were told that it had already been eaten! Other common problems seen there are Dengue fever, tuberculosis, osteomyelitis and other infections with abscesses. There is not much neonatal surgery, although the other hospital does obstetrics so may see more newborns. They do some colostomies for anorectal malformations or Hirschsprung disease, but the level of care for neonates is extremely basic.

I learned that there is one government-funded medical school in Cambodia, and several private ones now opening. There are no accredited surgical training programs, and there are no fully trained pediatric surgeons in the country. When I asked why the health care system is so undeveloped, I was told that the entire country was reduced to chaos during the Khmer Rouge regime, and after that the Vietnamese took control. However, the Vietnamese did not rebuild the country, and when they left there was even more chaos (for example, I was told that access to the Ankgor complex is controlled by a Vietnamese company, and most of the proceeds go back to Vietnam rather than to the local administration). As with the results of the Cultural Revolution that I witnessed in China, it will take at least a generation for Cambodia’s health care system, and indeed its society, to recover.

At the end of the afternoon I checked out of my hotel, and Paullin drove me to airport for my flight to Hanoi. On arrival in Hanoi I took a taxi to the hotel and went straight to bed.

Tuesday December 4, 2007

I was picked up early by one of the young pediatric surgeons, and taken to the National Hospital of Pediatrics. Although I had seen fast and reckless driving in many places during my travels, the drivers in Hanoi were worse than anywhere yet. There were literally thousands of motorbikes, cars, and bicycles sharing the road with no apparent organization or rulebook. Seatbelts were nowhere to be found in any of the vehicles I rode in. I was told that a new bike and motorcycle helmet law was to be in force on Dec 15, but it was hard for me to believe that it would actually be enforced. I learned that trauma is a major cause of death and morbidity in Vietnam, which was easy to believe.

When we got to the hospital, I met with Liem Nguyen, who is the chief of surgery and a well-recognized innovator in pediatric MAS. We went to the morning conference, at which last night’s new admissions and consults were presented. I was amazed by the sheer volume of cases: two new megacolon cases, one new total colon Hirschsprung disease, one newborn with both esophageal atresia and an anorectal malformation, one possible malrotation, and one large omphalocele. There was also one child with appendicitis and two intussusceptions. The radiologist presented last night’s activity: 23 ultrasounds done, four positive (including 1 tumour and 1 pericardial/pleural effusion post nephrectomy for trauma at another hospital). After this I gave a talk on Hirschsprung disease, which was followed by a lot of excellent questions from a very large audience.

Following the conference, I did a transanal pullthrough for Hirschsprung disease, assisted by Bui Duc Hau, the designated pediatric colorectal surgeon who does 2-3 Hirschsprung cases per week and is in the process of doing a PhD on the transanal pullthrough. I felt somewhat awed by this wonderful surgeon who has so much more experience than I do. The patient’s mother was very appreciative and gave me flowers after the case. I found it very interesting that they keep the children in hospital for 6 days after a pullthrough (as opposed to 1 or 2 days in my practice), because they’re worried about them getting an infection at home. When I finished the pullthrough, I watched Liem do a very difficult laparoscopic choledochal cyst excision, and then a neonatal thoracoscopic diaphragmatic hernia repair. I then left for a tour of Hanoi, and Liem went ahead and did another laparoscopic choledochal cyst excision. For the next day he had scheduled a third laparoscopic choledochal cyst excision, another thoracoscopic diaphragmatic hernia repair, and a gastric pullup for pure esophageal atresia. Liem is an incredibly busy and technically superb surgeon, and I learned a lot of technical tips from watching him for just one day. We then went to the Van Mieu-Quoc Tu Giam, a historical site that’s been there for 1,000 years. It was the site of the first National University in Vietnam (constructed in 1076). It has also been a Confucian sanctuary at various points during its history. We then did a brief tour around old Hanoi, and then went back to the hotel. I went to the gym, and then worked on my computer until it was time for dinner with Liem, his family, and Dr. Hau. Liem’s wife is an obstetrician, his son is in university and and his daughter is 12 years old. We had a wonderful Vietnamese meal at a very fancy restaurant. We talked about pediatric surgery in Vietnam. With a population of 100 million, there are only 100 pediatric surgeons and only 3 children’s hospitals, one in Hanoi and two in Ho Chi Minh City. Hanoi has about 5 million people, but the National Hospital of Pediatrics has a referral base for tertiary care of 30 million, which explains the very high volumes I had seen. Most Vietnamese surgeons have done some training in the UK, Australia, or the United States. Surgeons from Laos, Cambodia and other countries in Southeast Asia come to Vietnam for their training. I talked to Liem’s wife about obstetrics and prenatal diagnosis. She said that ultrasound use is increasing. Although previously most babies were born at home (as almost all are in Cambodia), now 90% are born in hospital by a midwife or doctor. Prenatal diagnosis of congenital anomalies, and the potential to improve perinatal management of these pregnancies, is rapidly improving, especially in the major urban areas.

Wednesday December 5, 2007

I got up early, exercised, ate breakfast, packed, took a taxi to the airport with one of junior surgeons, and boarded my flight to Hong Kong, and subsequently to Toronto. I had a lot to think about on the trip, and again I arrived home exhausted but exhilarated.

Final Thoughts

In my two trips to the other side of the world, I had many opportunities to teach and to learn in countries ranging from the most highly developed to among the most underdeveloped in the world. I was able to share my expertise in a variety of settings, including lecture theatres, the operating room, the wards, and the research laboratory. I felt that I was given the opportunity to reach a large number of people at all levels of training and experience, and that my contributions were greatly appreciated everywhere I went.

More importantly, I had an opportunity to learn a great deal from my colleagues in each of the places I visited. I was exposed to new techniques and tricks, new approaches to treating pediatric surgical conditions, and new ideas for ongoing research. I developed an understanding of how pediatric surgeons can be trained in many different ways, and I saw new perspectives on how surgical care can be organized to optimize outcomes for all children. Many of these lessons will be helpful to me as I continue to struggle with the challenges I face as a pediatric surgeon, researcher, and leader.

Finally, I have been enriched by the relationships I developed and friends I made during these six weeks of travel. I have already had the opportunity to invite several of them to Toronto as visiting professors, have interacted with a number of others at the pediatric surgery meetings, and have communicated with most of them by email. I am hopeful that we can build stronger bridges, particularly with the less developed countries I visited, and participate in training a strong, well-trained pediatric surgical community for each of their populations. I would once again like to thank the James IV Association for giving me this incredible opportunity.