This month we have the pleasure of traveling to south China to interview an up-and-coming neurosurgeon in epilepsy surgery from Chengdu, China: Dr. Ke Mao from the West China Hospital of Sichuan University (WCH). Chengdu is known as the home of the panda and is hot most of the year. Dr. Mao specializes in temporal lobectomy, grid implantation and microvascular decompression. It is our pleasure to hear his perspectives on neurosurgery.
Jamie J. Van Gompel, MD (JV): Can you describe your practice for us?
Dr. Ke Mao (KM): I am working in the WCH. The precursors of the WCH, Cunren and Renji Hospitals, were set up in 1892 by joint efforts from Christian missions from the U.S., Great Britain and Canada. It has more than 13,000 medical staff working among 38 clinical departments and 16 non-clinical and laboratory departments. There are 54 neurosurgeons in my department who are in 11 subspecialty groups respectively, including cerebrovascular disease, anterior and middle skull base, posterior skull base, functional neurosurgery, endovascular/neuro-intervention, head and brain trauma, stereotactic radiosurgery/Gamma Knife, pediatric neurosurgery, spine disease, glioma and spontaneous intracranial hemorrhage. My department has 336 beds located in four independent wards and one Neurointensive Care Unit (NICU). We have acquired 103 national/provincial research projects in my department since 2006.
I have been working as a neurosurgeon for six years. I specialize in functional neurosurgery, and my practice focuses on epilepsy surgery, microvascular decompression (MVD) for trigeminal neuralgia and hemifacial spasm and deep brain stimulation (DBS). I enjoy epilepsy surgeries, especially anterior temporal lobectomies, subdural electrode implantations and stereoelectroencephalography (SEEG) and MVD procedures most of the time. In the functional subspecialty, there are seven neurosurgeons including myself. Three of us do epilepsy surgeries and MVDs most of the time, and the other four do Gamma Knife and DBS most of the time.
There were 6,134 neurosurgeries, 1,944 endovascular/neuro-interventional operations and 1,245 Gamma Knife cases done in my department in 2015.
JV: What attracted you to a neurosurgical practice?
KM: I chose neurosurgery as my career because I want to unravel the mysteries of the human brain, and I am very interested in neurosurgical anatomy.
My research right now focuses on the impact of DBS on human memory. Hippocampal degeneration contributes to the main symptoms of dementia. Our preliminary report found that we can enhance patients’ spatial memory by electrical stimulation on entorhinal cortex. The patients with temporal lobe epilepsy were implanted with depth electrodes to the epileptogenic focus, such as the hippocampus, parahippocamal gyrus, entorhinal cortex and orbitofrontal cortex, etc. They underwent a series of electrical stimulations with different frequency, voltage and pulse-width manipulation. Then, behavior tasks were performed with a synchronous local field potential recording. The recorded local field potential was processed with special software (Matlab) for time-frequency analysis. Next, we compared the result with baseline testing. Once the patients were ready for a temporal lobectomy, we collected samples of the hippocampus and dissected dentate gyrus after resective surgery. Then, the extracted cells from dentate gyrus were treated with a special surface marker. We put the samples under a microscope and performed quantitative analysis with flow cytometry. We tried to investigate how electrical brain stimulation impacted memory enhancement and biological change.
JV: Can you describe the typical practice of neurosurgeons in your country?
KM: In some big hospitals in China, the majority of neurosurgery departments have subspecialties. In my department, we have 11 subspecialty groups, including cerebrovascular disease, anterior and middle skull base, posterior skull base, functional neurosurgery, endovascular/neuro-intervention, head and brain trauma, stereotactic radiosurgery/Gamma Knife, pediatric neurosurgery, spine disease, glioma and spontaneous intracranial hemorrhage. Most of the spine neurosurgeries are done by us except a slipped disc procedure, which is done by orthopaedic surgeons.
JV: What is a typical day in practice for you?
KM: All days are operative days. Most of the time, as a functional neurosurgeon, I have one to two epilepsy cases and one to two MVDs in one operating day.
JV: Describe how you believe your practice differs from neurosurgery in the Americas?
KM: There are two main differences between China and the U.S. The first is the doctor training program. Take my hospital as an example, which will represent the most common doctor training program we have in the majority of big hospitals in China. We will spend 5, 8 and 10 years in medical school for a Bachelor’s degree, MD or PhD separately. Then, we will participate in the resident training program which always lasts an additional five years. After that, we need to take one year to be a chief resident. Then, we can become a qualified doctor. Another difference is that the majority of outpatients can see the appointed doctor in a few days. They do not need to wait too long to see a doctor most of the time.
JV: Describe the biggest issue you see challenging your practice?
KM: I think the biggest issue I see challenging my practice is that sometimes the outcome of a treatment is not as satisfactory as a patient expected.
Medical insurance in China does not cover many fees that patients will incur during hospitalization as in the U.S. So, most of the time, patients have a great financial burden whenever they go to see a doctor. In this circumstance, patients and their relatives have excessively high expectations of doctors, so if there are some complications after surgery, it is easier for them to complain about the outcomes even if those complications are normal according to medical textbooks throughout the world. I think that is the reason that patients are not satisfied sometimes.
JV: Describe the biggest issue you see challenging neurosurgery in your country?
KM: I think the biggest issue I see challenging neurosurgery in my country is that there are not enough neurosurgeons but there are always so many patients, including outpatients, inpatients and emergent patients, waiting for a neurosurgeon.
From my point of view, I think the way to solve this problem is to carry out a graded medical system which will facilitate the triage of patients. In the meantime, the government should increase their investment in health care in China.
JV: What is the biggest opportunity for neurosurgery in your country moving forward?
KM: I think the biggest opportunity for neurosurgery in my country is that nowadays, we are extremely open to the world, and we like communicating with neurosurgeons from the U.S. and other countries to share interesting cases and valuable experiences. There are many conferences held in China every week filled with neurosurgeons from all over the world. So with these collaborations, we can promote neurosurgery forward in a faster way.
JV: Please share with us a unique aspect of neurosurgery in your country that may not be practiced in the U.S. (no instrumented fusions, all aneurysms are clipped or coiled, a surgical procedure we do not commonly do, etc.)
KM: I believe it is hypertensive hemorrhage in the thalamus and brainstem. The spontaneous intracranial hemorrhage subspecialty group in my department will focus on surgical treatments for hypertensive intracranial hemorrhage (ICH)-randomized controlled trials (RCTs) in the future; therefore, most of these are still operatively managed, despite the results of the Surgical Trial in Intracerebral Hemorrhage (STICH).
JV: Do you do any procedures we do not offer in the U.S., and why?
KM: One procedure could be a minimally invasive hematoma removal from the thalamus or brainstem using a stereotactic technique with or without endoscope and thrombolytics.
I think the reason for this is that blood pressure in patients with hypertension in China is not controlled as well as in the U.S. causing far more hypertensive patients with spontaneous intracranial hemorrhage who need surgeries, including hematoma evacuation and decompressive craniectomy in China compared with the U.S. Since we have a larger population of hypertensive patients, treatment experience might be more valuable.
