Table of Contents

HK J Paediatr (New Series)
Vol 8. No. 4, 2003

HK J Paediatr (New Series) 2003;8:269-271


From Mortality to Life Quality: Evolution of Surgical Care in Children in Hong Kong

CK Yeung

Many of us can probably recollect what used to be a heart-aching and not uncommon scene in a paediatric surgical ward until the late 80's or even the early 90's: an emaciated child suffering from end-stage liver failure with bleeding oesophageal varices dying in front of our eyes, without the hope for a liver transplantation; or a child with spina bifida and neuropathic bladder dysfunction resulting in progressive kidney damage and renal failure, passing away silently without making a fuss nor the knowledge that such course could all be preventable. Almost invariably there was no complaint from the family or pressure from the community, as these were the accepted norm here in those days. But as a medical professional dedicated to the care of children, one can still often recall the deep sense of helplessness, desperation, profound sadness and sometimes even shame very vividly even at this distance of time and place. Similar scenes did occur also in other surgical specialties in children. And understandably the focus, or priority, of surgical care in children then, was life-saving.

Much has however changed over the past decade. There have been remarkable developments in both medical knowledge and surgical techniques, coupled and perhaps also driven by astounding advances in technology, across all surgical specialties in children. For instance, the advent of laparoscopic or keyhole surgery technique has allowed surgeons to perform various operations with only tiny incisions and minimal invasiveness, with faster recovery and shortened hospital stay. The focus of surgical care in various disciplines like paediatric orthopaedics, paediatric neurosurgery, general paediatric surgery and paediatric urology, paediatric plastic surgery and burns care, and paediatric otorhinolaryngology, has shifted from previously mainly on patient survival, to ensuring a good or improved patient quality of life. Along with these encouraging developments, however, is that public and patient expectation has also greatly increased. The mass media has become utterly unforgiving for any "medical incidents". There is thus no room for one to move back or slack down. All these have amalgamated to provide enormous driving force and momentum for continual advances.

These exciting developments have been captured and epitomised by the various articles in this special issue of the Hong Kong Journal of Paediatrics on "Surgery in Children: An Update". After the first few successful living-related paediatric liver transplantation being performed in the Prince of Wales Hospital in 1993, liver transplant has now become an integral part in the management armament here in Hong Kong for children with biliary atresia as well as other hepatic pathologies associated with end-stage liver failure.1 Results from the paediatric liver transplant programmes from the two university hospitals in Hong Kong have been very satisfactory and in par with international standards. This has been translated to a dramatic improvement in the overall long-term survival for children suffering from biliary atresia from only around 30-40% in the pre-transplant era to approaching 90% currently with the availability of liver transplantation. These have been nicely summarised in the article by Wong et al on the management of biliary atresia in the era of liver transplantation. Similarly, the management of children with spina bifida has evolved and moved up to a much more sophisticated horizon over the last decade. It involves now the close collaboration of a highly integrated and multidisciplinary team comprising of paediatric orthopaedic surgeons, paediatric neurosurgeons, general paediatric surgeons and paediatric urologists, paediatric neurologists, physiotherapists, children incontinence care nurse specialists, occupational therapists and prosthetic-orthoticists, and social workers. The objectives are not only on patient survival, but ensuring a good quality of life that is fully ambulatory, clean and dry and nappy-free, and with normal activities. The article by Zhu et al on early untethering of tethered cord to prevent further neurological impairment highlights these principles and beliefs, and the importance of close surveillance and a proactive approach.

Remarkable advances have been made in minimally invasive surgery in infants and children over the past ten years. With the appropriate set-up and in experienced hands, the great majority of paediatric surgical operations that were done in the past using a conventional open method can now be very safely and effectively performed under the laparoscope. Lee et al have made a comprehensive review in their article on the latest advances in laparoscopic surgery in newborns and infants. Ng et al reviewed their impressive experience of limb lengthening for children with short stature over the last 10 years. Although the exact etiology of adolescent idiopathic scoliosis (AIS) still remains unclear, significant progresses and advances have been made in the understanding of the pathoanatomy, natural history, and clinical behaviour of the condition, and in surgical treatment as well as in prevention of complications. These recent advances on AIS have been summarised very comprehensively in the article by Tang et al.

Significant improvements have also been seen in paediatric burns care over the past decade. From an era with a high mortality rate from burns wound sepsis many years ago, burns care in children has now evolved to concentrate in highly sophisticated designated burns centres, and patient survival is no longer a big issue. The focus has shifted from mainly life-saving to prevention and quality of survival. Minimal scar wound treatment with the help of cutting-edge technology like tissue engineering, molecular manipulation, etc., and early rehabilitation to normal activities with satisfactory cosmetic results and a good life quality have now become the main objectives. These exciting developments have been captured in the article by Burd et al. The phenomenon of osseointegration, i.e. bonding between bone and certain metal, particularly titanium, has greatly facilitated the use of different types of prosthetic implants for various cosmetic reconstruction and rehabilitation surgery. The article by Soo et al explores the various extraoral applications of osseointegration for the anchorage of hearing aids and cosmetic prostheses in children. Abdullah et al made a nice review on the current indications, surgical techniques, and perhaps more importantly, subsequent care of tracheostomy in infants and children.

New insights into different gastrointestinal problems in children have been provided by the two articles by Tam et al. Helicobacter Pylori infection is now understood to be not only a main causative factor for peptic ulcer disease in children, but also a carcinogen for gastric cancer. Hence one can argue for the wisdom and need for early H. pylori eradication therapy. In addition, the study on inflammatory bowel disease, hitherto thought to be extremely rare if not non-existent among paediatric populations in Hong Kong, gives us important informations about these uncommon but potentially important entities. Finally, Professor Craft in his enlightening article on "Fetal programming or adult lifestyle lessons from the Newcastle 1000 families study" elaborated on the intricate relationships between fetal status and possible maladies in later adult life: a reminder that one should always start caring the fetus as a future potential patient.

The new millennium is full of challenges and opportunities: what could not be done in just a decade ago have now become standard therapeutic modalities. We should all be pleased to witness the paradigm shift in the focus of surgical care in children over the past decade. The emphasis is now not only on patient survival, but more on ensuring a good and active life style with quality, dignity and satisfactory productivity. As child care workers, paediatricians and surgeons alike, we need to embrace these fast changing scenes with all the rapidly advancing new technology and skills, for the ultimate benefits of our young patients.

CK Yeung
Guest Editor


1. Yeung CK, Ho JK, Lau WY, et al. Institution of a pediatric liver transplantation program with living-related orthotopic liver transplantation: initial experience in Hong Kong. Transplant Proc 1994;26:2215-7.


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