train the trainers in highly specialized surgical field
TRANSCRIPT
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"Train the Trainers" in Highly Specialized Surgical Field - Reconstructive Microsurgery
Fu-Chan Wei M. D.
Distinguished Chair Professor
Department of Plastic Surgery
Chang Gung Memorial Hospital Chang Gung Medical College & University
Taipei, Taiwan
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Train the Trainers v. Train the Trainees
� Different goals
� “Training the Trainers” aims at cultivating
future leaders and educators
� Train higher order thinking
� Think at least 10 years ahead
� Ideally global strategy – geographic
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Reconstructive Microsurgery
� Operative Microscope (for magnification & illumination)
� Micro-instruments
� Micro-sutures
� Special skills
Clinical applications:
(vascular, neural, lymphatic, tubular)
� Replantation surgery� Free tissue
transplantation
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Replantation
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Trimmed Toe Transfer (T.T.T.) for
Thumb Reconstruction
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Microsurgical Lower Extremity Reconstruction
L R
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Tongue Reconstruction with a Thin Anterolateral Thigh Flap
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Immediate (Primary) Osteointegration Teeth in the Fibula Reconstructed Mandible
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Reconstructive Microsurgery Saves Lives, Reduces Amputation and Enhances Life Quality in Cancer and
Trauma Patients
� It increases reconstructibility of tissue defect� Enhances cancer resectability� Enhances limb salvagibility
� It provides one stage reconstruction� Better functional and esthetical result� Shorter rehabilitation� Less suffering for the patient
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Great Challenges Exist in Expanding Reconstructive Microsurgery Globally
� Labor, time and resource intensive
� Require highly specialized healthcare team and infrastructure� Multi-disciplinary – requires buy-in from others
� Lack of education within healthcare professionals
Patients and doctors don’t know what is possible!
� Perceived as economically unviable for most hospitalsHuge problems with coding & tariffs esp. when large proportion of reconstructive cases are not ‘routine’
� Lack of training place
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Chang Gung Memorial Hospital
Mr. YC Wang
Established in 1976
Keelung
Kaohsiung
Chiayi
Taipei & Linkou 4582 beds
851 beds889 beds
2482 beds
Total :7 hospitals, 1017 beds
• Chang Gung Medical College, 1987
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BU
RN
S
GE
NE
RA
L
PL
AS
TIC
S
CHANG GUNG MICROSURGICAL CENTER at Linkou
� Attending faculty 15� Head and neck surgery: 5
� Upper and lower extremity: 5
� Breast/lymphedema: 2
� Peripheral nerve, brachial plexus: 3
� PRS residents 21
� International Fellows 8-12
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� 24 Beds Microsurgical I. C. U.
2009 2011
2016
� Rehabilitation Center
15 Therapists
Established in 1988
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Jan 1985 - Dec 2015
Free Flaps: 22369 Hepatic Artery Anastomosis: 766
Replantations: 4711 Lymphaticovenous Anastomosis: 216
Brachial Plexus: 2627 Extracranial-Intracranial (EC-IC) bypass: 84
From Jan 1985 to Dec 2018Total : 30765
All Major Microsurgical Cases
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1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
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The Goals of Microsurgical Fellowship at Chang Gung (Train the Trainers)
� Clinical:
� Adequate knowledge� Sound judgement (critical thinking)� Competent and comfortable in all kinds of microsurgical
reconstruction
� Teaching mind and hand:
Willing and able to teach and to train future microsurgeons
� Academic capability:
Capable of carrying out clinical/basic research
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Rotations Schedule
� Compulsory rotations in all 4 major fields (each 2 months)
� Head and Neck � Upper and Lower Extremity � Breast / Lymphedema � Peripheral Nerve, Brachial Plexus
� 4 months elective courses for extra immersion in specific fields (to fit individual needs)
( One mentor-one fellow, No overlap)
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Rotation Schedule for International Microsurgical Fellows
2016-2017 2017-2018
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Fellowship Training Opportunities at Chang Gung
� Operation Room
� Outpatient Clinic
� Teaching / Research Activities:
� Morning meetings including journal club (3/week)
� M&M (2/month, 1 in the division, 1 in the department)
� Frequent international visiting professors
� Preoperative case-based discussions (2/week)
� Translational (2/month) & clinical research meetings (1/month)
� Wet lab opportunities
� External conferences
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Final Preoperative Planning
� PowerPoint presentation of patient’s profile book:
� Concise, up-to-date patient’s information� Precise description of surgical plan� Quick review of relevant literature
� Invitation for comments, questions and discussion
� Surgical plan confirmation
� Logistic considerations and tasks assignment
� Brain storming for possible research projects
- The best way to ensure quality and safety in surgical patients
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Category:
Microsurgical Head and Neck Reconstruction
Account:
Professor. Fu-Chan Wei
Additional Users of Different Levels:
Che-Hsiung Lee , Anton Fries, and Nidal F. AL Deek
Date: 2016-12-26
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Primary Microsurgical Reconstruction
10799226
39 year old female
IID: 40mm
Chief Complaint & History
� Chief Complaint: – Progressive enlarging lower gingival
mass noted for 2 years
� Present Illness:– Lower gum swelling mass, painless, no
open wound.
– Diagnosed at LMD revealed ameloblastoma at 2016/10/25
• No odynophagia, no dysphagia, no dyspnea, no hoarseness.
� Past Medical History: – Denied
� Past Surgical History: – Denied
� Allergies:– No known allergy.
� Social History:– Alcohol: Denied– Smoking: Denied
– Betel nut: Denied
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Panorex
2016/11/14
CT
Amelobalstoma over mandibular symphysis and left parasymphysis
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Additional Work-Up(s) & Diagnosis
� Exam:
� Left PTA & DPA: palpable and audible
� Pathology :
� 2016/10/25 at LMD
� Ameloblastoma
� Image Study:
� CXR:
� MRA for extremity was not done
� Diagnosis:
� Anterior lower gum ameloblastoma
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Ablation Team
Tracheostomy(-)
Bilateral neck dissection(-)
Tumor wide excision:
• Segmental mandibulectomy
Right to left body : 6-7 cm
• Mouth floor: limited
• Pre-bending plate based on 3D printing model
• Dental implantation (?)
Surgical PlanTwo-Team Approach, Combined Case with: Dr. YM Chang
3D Printing Model
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Surgical Plan - PRS
Double barrel to central mandible?
Nerve graft ?
Reconstruction of Compound Mandibulectomy, C Type
Flap:
� Flap A : Left fibula OSC flap with small skin paddle
� Flap B : Alternative bony tissue flap.
Recipient vessels:
� No restrictions
� Choice are:• Left-sided lingual artery or superior thyroid artery/v
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Discussion and Paper review
� Ameloblastoma is a rare benign tumourof the tooth enamel
� It commonly affects “high demand” patients
� “Immediate reconstruction” is a modern paradigm in breast and limb surgery
� Can we offer a “1-stop” service for these patients?
Introduction
Summary
Strengths
Weaknesses
Implications for our practice
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Discussion and Paper review
� Case series N=328F – ameloblastoma
34F – odontogenic myxoma20M – ameloblastoma
(21M AVM to maxilla)
� Follow-up = 22 months
� NYU
� CAD-CAMOsteotomy guides
Implant guidesDental prosthesis
� Complications – none reported
Introduction
Summary
Strengths
Weaknesses
Implications for our practice
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� Novel approach in line with current innovative thinking in plastic surgical practice
� Single stage surgery
� Multidisciplinary working
� Use of technology
� “Reverse planning”
Start with optimal occlusion
then work back to fibula design
Discussion and Paper reviewIntroduction
Summary
Strengths
Weaknesses
Implications for our practice
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� Short follow-up, small numbers
� “Suitable for highly motivated patients” Implies that this is currently still a very involved process
� Suitability for oncology patients, adjuvant therapy?
� What if there are complications?
Intra-op (CAD-CAM adjustment)
Early
Late (ameloblastoma recurrence in 15-25%)
Discussion and Paper reviewIntroduction
Summary
Strengths
Weaknesses
Implications for our practice
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� Depending on long term results this may be a potential treatment option for very select few patients
� Resource requirement would make it difficult to follow
� A modified (hybrid one) jaw-in-a day may be more feasible
Discussion and Paper ReviewIntroduction
Summary
Strengths
Weaknesses
Implications for our practice
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Final Plan
� Use left fibula osteoseptocutaneous flap with small skin flap to allow primary closure of the donor site
� One osteotomy, two struts
� Try to have double barrels in the center of the chin
� Nerve graft to bilateral inferior alveolar nerve
� Operator: Wei, Anton, Ike
� Video: Nidal
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Intra-operative Pictures
2016-12-26
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Intra-operative Pictures
2016-12-26
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Patient’s database
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Patients’ database
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Patients’ database
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Monthly Clinic Research Meeting
� Individual research proposal presentations
� Individual research progress reports
� Experts discussion and feedback
� Teaching videos
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Bio-Mechanic:Gait Analysis
Functional MRI :sensorimotor cortex after toe-to-hand transfer
Histological study: Meissner corpuscle for sensory recovery in transferred toe
Clinical Research Related to Toe-to-Hand Transfer
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VCA Meeting Twice a Month
� On going research projects
� Update on clinical VCAs done by our group
� Review & presentation of recent publications on
VCA from established groups
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Lab. Research in Vascular Composite Allotransplantation at CGMH/CGU (Since 2000)
VCA
Rejection
Rat Mice Swine
Survival (donor-specific tolerance)
• Animal model • Immunomodulation strategy with Cell
therapy (BMSC, ADSC, DC, Treg)• Vascularized bone marrow
• Functional recovery
• Cell tracking
• Molecular mechanism & cell/cytokine profile
• molecular mechanism
• cell/ cytokine profile
HY Cheng, PhD. 鄭惠云博士鄭惠云博士鄭惠云博士鄭惠云博士
YL Wang, PhD王燕玲博士王燕玲博士王燕玲博士王燕玲博士
CJ Wen, PhD.溫志仁博士溫志仁博士溫志仁博士溫志仁博士
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Lymph
node
spleen
In vivo Bioluminescence Imaging for
Cell-tracking of Treg (PID1 = POD11)
Experimental BN -> Lewis In vivo Bioluminescence Imaging
for Cell-tracking of Treg(PID1 = POD11)
Recipient
Allotransplant
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Five Hand Allotransplantations in Four Patients
2014-09-03 YR Kuo
Godina Lecture Award, ASRM
2007
2016-11-30
2017-03-06
� The Transplantation Society
Travel Award (IHCTAS
2011)
� Young Investigator Award
(ATC 2011)
� Young Innovator Award
(AST ASE 2011)
� Young Innovator Award
(AST CEOT 2014)
CH Lin
2018-03-14
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0
50
100
150
200
International Fellows and Visiting Scholars of Plastic Surgery, Chang Gung Memorial Hospital
31 Professors and 28 Chiefs / Program Directors (from survey of 90 previous fellows in 2014)
Updated to 2018
Total : 2228 Fellows and Visiting Scholars from 85 different countries
0
5
10
15
20
25
30
35
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A
UK
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Ca
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>1year fellows:
1984-2019, total 141 persons
(15 of total 36 countries)
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A Combined Program of Fellowship and Master Degree in Science in Reconstructive Microsurgery (since 2014)
� Strengthen and emphasize “train the trainer” philosophy
� Empower critical and scientific thinking to uplift them into an even better future trainers
� Pave the road for a future “surgeon-scientist” hybrid
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From year Sep. 2014 - Jun. 2019 :18 graduates / 38 students
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Face Allotransplantations
20172012 2015
Eduardo Rodriguez
2016
Samir Mardini
20172016
2018
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“Fu-Chan Wei Lectureship Award”. The aim is to select one who has great contribution to the reconstructive microsurgery specialty a s a role model for all reconstructive surgeons to follow.
World Society for Reconstructive Microsurgery (WSRM)
Fu-Chan Wei Club
20172019
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A Comprehensive Reconstructive Microsurgery Center at CGMH / CGU
� Service Center• Trauma• Cancer• Congenital, developemental• Difficult wounds
� Education, training Center
� Research Center
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Conclusions
� “Train the trainer” is the most cost-, time-, source-effective way of spreading knowledge and skill in highly specialized surgical fields
� Success of “train the trainer” depends on:
� Appropriate faculty with adequate support
� Setting appropriate goals of fellowship
� Selecting suitable fellow candidates
� Combined clinical fellowship and Master (PhD) degree of Science may help obtain even better result in the goals of “Train the Trainer”
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"Train the Trainers" in Highly Specialized Surgical Field - Reconstructive Microsurgery
Fu-Chan Wei M. D.
Distinguished Chair Professor
Department of Plastic Surgery
Chang Gung Memorial Hospital Chang Gung Medical College & University
Taipei, Taiwan