[Bowel preparation for elective colorectal surgery in Germany 2017 : Results of a survey among members of the German Society of General and Visceral Surgery]. / Darmvorbereitung bei elektiven kolorektalen Resektionen in Deutschland 2017 : Ergebnisse einer Umfrage unter den Mitgliedern der DGAV.

BACKGROUND: The morbidity after colorectal resection is still high. Perioperative i.v. antibiotic administration has become established as the standard to decrease the wound infection rate. An ongoing discussion is the status of preoperative mechanical bowel preparation. There seems to be evidence that mechanical bowel preparation in combination with administration of oral non-resorbable antibiotics significantly decreases the rate of anastomotic leakage and postoperative wound infections. OBJECTIVE: In order to obtain an overview on the state of preoperative preparation before elective colorectal surgery in Germany, a survey was initiated among the members of the German Society of General and Visceral Surgery. MATERIAL AND METHODS: In March 2017 the 5200 members of the German Society of General and Visceral Surgery (DGAV) received via email a link to an online survey on bowel preparation before elective colorectal surgery. RESULTS: A total of 557 colleagues answered the questionnaire online. Mechanical bowel preparation with orthograde lavage was the predominant method for bowel preparation prior to colon resection in over 50%. In rectal surgery with primary anastomosis and planned protective stoma, mechanical bowel preparation with orthograde lavage dominated with 76.5%. An oral antibiotic administration alone and in combination with mechanical bowel preparation for colon resection was used by less than 10% and 2%, respectively and ca. 11 % for rectal surgery both with and without mechanical bowel preparation. CONCLUSION: In contrast to the evidence in the current literature to carry out preoperative mechanical preparation of the bowel in combination with an oral antibiotic administration prior to colorectal resection, in practice these recommendations have not become established among the participants of this survey.

[Psychological stressors, resources and well-being of surgeons in Germany : A cross-sectional study]. / Psychische Belastungen, Ressourcen und Wohlbefinden von Chirurgen in Deutschland : Eine Querschnittsstudie.

BACKGROUND: Psychological stress at work is associated with detrimental and health-impairing consequences for employees. OBJECTIVE: In this study major stress factors and the resource job control at the workplace of surgeons and facets of mental health were examined and compared to benchmark results of a large reference sample. METHOD: Data were collected by a representative online survey among surgeons throughout Germany who were contacted via the Professional Association of German Surgeons. In total 643 surgeons from different organizations and different disciplines completed the questionnaire that was developed using well-validated instruments. RESULTS: Time pressure was the most meaningful stress factor for surgeons. Moreover, the results for medical assistants showed adverse stress combinations of high goal uncertainty and low job control as well as high emotional exhaustion and low job satisfaction. In addition, the results indicated that surgeons in single and group practices as well as in outpatient healthcare centers have less stressors and more job resources. CONCLUSION: The survey results suggest high levels of burnout risk for German surgeons, especially among medical assistants and medical specialists from large hospitals. In order to maintain a high quality in the surgical disciplines, a concerted effort by all players in the healthcare system is necessary.

Power of Judgment: The Significance of Kant's Philosophy for the Medical System Today.

The ways of thinking in the manufacturing sciences are increasingly determining the rationality within medicine as a practical or action-based science. This "technological paradigm" infiltrates the field of medicine with the promise of increasing efficiency while simultaneously improving quality at various points in the system. Simple linear causal relationships generally need to be taken into account when manufacturing products. Even complex manufacturing processes can be broken down into the smallest units and, therefore, also be automated. The situation in complex systems such as the human body, however, is completely different. In order for doctors to be able to carry out their actions within this complex system, medicine as a science provides the physician with rules on the means that should be used to decide which remedy should be used, when and how. This judgment of which remedy should be used, when and how, what is known as the indication, is a central medical moment. This requires a power of judgment sharpened by experience. The indication, in turn, essentially determines the course of a disease and thus the quality of the treatment or the quality of result so often referred to these days.

[Trust and reliability in surgery]. / Vertrauen und Verlässlichkeit in der Chirurgie.

Social interactions are hardly possible without trust. Medical and in particular surgical actions can change the lives of people directly and indirectly existentially. Thus, the relationship between doctor and patient is a special form of social interaction, and will be hard to find anywhere else. The nature of the doctor-patient relationship also determines the success of a treatment. The core and the importance of trust, as a central part of this relationship, will be reconstructed in the present paper. The increasing possibilities of information acquisition in modern societies, and the ever-present need for transparency, impact more and more on the doctor-patient relationship. At first glance, concepts of trust seem to be of secondary importance. The current developments regarding the remuneration of services in the medical system likewise bear the risk to increasingly determine the importance of trust in the doctor-patient relationship. However, it is necessary to delineate reliability from trust. Due to the conditions which are constitutive for the operational disciplines, a climate of trust, even in a modern information society, is more necessary than ever.

3D vs. 2D imaging in laparoscopic surgery-an advantage? Results of standardised black box training in laparoscopic surgery.

PURPOSE: 3D imaging is an upcoming technology in laparoscopic surgery, and recent studies have shown that the modern 3D technique is superior in an experimental setting. METHODS: All 14 members of the Asklepios Klinik Langen Department of Visceral and Thoracic Surgery, as well as two gynaecologists, were asked to undertake 2D vs. 3D laparoscopic black box skill training. The black box training was adapted to the "fundamentals of laparoscopic surgery" programme provided by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). First, the participants categorised themselves as beginner, advanced or expert in laparoscopic surgery. Then, they were randomised in terms of whether the black box training commenced with 2D or 3D vision. The exercises included peg transfer with the dominant hand and the non-dominant hand (with and without transfer between the graspers), needle capping and cutting a sutured knot. The time taken to complete these exercises was measured. After the training, each participant was asked to describe his/her personal impression of the imaging systems employed. RESULTS: Overall, for the participants in all groups, the time required for all exercises showed a significant advantage for 3D imaging (3D vs. 2D; Wilcoxon matched pair test; mean 68.0 ± 94.9 s (3D) vs. 90.1 ± 69.4 s (2D); p = 0.002). Regarding the subgroups, the experts significantly improved their time in completing the exercises in 3D vs. 2D by a margin of 25.8 % (mean 30.8 ± 20.1 s (3D) vs. 41.5 ± 25.0 s (2D); p = 0.010). In the group of advanced surgeons, the results were similar, showing an improvement of 23.6 % for 3D, but without significance (mean 61.5 ± 41.1 s (3D) vs. 80.4 ± 72.8 s (2D); p = 0.123). The results for the beginner group also showed an improvement in the 3D exercises of 24.8 %; here, the result also showed a trend towards 3D but did not reach significance (mean 93.9 ± 90.7 s (3D) vs. 124.8 ± 118.72 (2D); p = 0.062). CONCLUSION: In our opinion, 3D imaging could be an advantage in laparoscopic surgery, especially in the surgical education of upcoming surgical generations. To determine whether these ex vivo results can be transferred to the clinical situation, our group has initiated a randomised controlled study.

[The validity of routine data on quality assurance: A qualitative systematic review]. / Die Validität von Routinedaten zur Qualitätssicherung : Eine qualitative systematische Übersichtsarbeit.

BACKGROUND: The assessment of the quality of medical practice is a legitimate requirement by society. Reliable methods for measurement of the quality of performance are sought worldwide. Quality is often quantified by using administrative data and in Germany this method has been implemented by the health insurance company AOK. OBJECTIVES: (1) How is the AOK quality system rated by senior consultant surgeons? (2) How valid are quality statements derived from administrative data? METHODS: This article was compiled following the PRISMA (i.e. preferred reporting items for systematic reviews and meta-analyses) statement for qualitative systematic reviews. In order to answer the first question the Professional Association of German Surgeons (Berufsverband der Deutschen Chirurgen) initiated two surveys and to answer the second question a structured literature search following the PICO (i.e. patient problem or population, intervention, comparison control or comparator and outcomes) format was initiated. In addition numerous websites were contacted. RESULTS: Of the responding senior consultant surgeons 95% considered that the AOK method of quality measurement by administrative data is not objective. One third was definitely wrongly classified. The literature search revealed that no validation data exist for the AOK indicators, including the Elixhauser comorbidity risk score. Altogether, the sensitivity of indicators is poor when good sensitivity is defined by the Institute for Applied Quality Improvement and Research in Health Care (AQUA Institute) as ≥ 80 < 90%. CONCLUSIONS: Quality statements resulting from administrative data alone are unreliable.

Clinical characteristics of pain in patients with pituitary adenomas.

OBJECTIVE: Clinical presentation of pituitary adenomas frequently involves pain, particularly headache, due to structural and functional properties of the tumour. Our aim was to investigate the clinical characteristics of pain in a large cohort of patients with pituitary disease. DESIGN: In a cross-sectional study, we assessed 278 patients with pituitary disease (n=81 acromegaly; n=45 Cushing's disease; n=92 prolactinoma; n=60 non-functioning pituitary adenoma). METHODS: Pain was studied using validated questionnaires to screen for nociceptive vs neuropathic pain components (painDETECT), determine pain severity, quality, duration and location (German pain questionnaire) and to assess the impact of pain on disability (migraine disability assessment, MIDAS) and quality of life (QoL). RESULTS: We recorded a high prevalence of bodily pain (n=180, 65%) and headache (n=178, 64%); adrenocorticotropic adenomas were most frequently associated with pain (n=34, 76%). Headache was equally frequent in patients with macro- and microadenomas (68 vs 60%; P=0.266). According to painDETECT, the majority of the patients had a nociceptive pain component (n=193, 80%). Despite high prevalence of headache, 72% reported little or no headache-related disability (MIDAS). Modifiable factors including tumour size, genetic predisposition, previous surgery, irradiation or medical therapy did not have significant impact neither on neuropathic pain components (painDETECT) nor on headache-related disability (MIDAS). Neuropathic pain and pain-related disability correlated significantly with depression and impaired QoL. CONCLUSIONS: Pain appears to be a frequent problem in pituitary disease. The data suggest that pain should be integrated in the diagnostic and therapeutic work-up of patients with pituitary disease in order to treat them appropriately and improve their QoL.

First experiences with laparoscopic adjustable gastric banding (LAGB) in the treatment of patients with childhood craniopharyngioma and morbid obesity.

Craniopharyngiomas are embryogenic malformations which lead to eating disorders and morbid obesity due to hypothalamic involvement in about 50% of all patients with pediatric craniopharyngioma. The experience with laparoscopic adjustable gastric banding (LAGB) in obese craniopharyngioma patients is limited. We are reporting on four patients with childhood craniopharyngioma diagnosed at age 2, 11, 12, and 21 years. BMI-SDS at diagnosis was +0.9, +4.5, +4.7 and -0.1 SD. During follow-up, all patients developed morbid obesity (BMI-SDS: +13.9, +10.3, +11.4, +7.3) so that 11, 6, 9 and 3 years after diagnosis LAGB were performed. After a follow-up of 4.5, 1.5, 3.0 and 2.5 years BMI decreased or stabilized continuously in all patients (BMI-SDS at latest visit: +9.9, +9.7, +9.5, +5.9 SD). The eating behavior changed in all patients profoundly. The addiction to food and especially sweets significantly improved based on self-assessment. In two patients a dislocation of the LAGB occurred and resulted in weight gain. We conclude that LAGB could be effective in weight reduction of obese craniopharyngioma patients with hypothalamic syndrome. Close follow-up is necessary in order to analyze long-term effects and complications of LAGB in patients with childhood craniopharyngioma and morbid obesity.

Comparative evaluation of a new bedside faecal occult blood test in a prospective multicentre study.

BACKGROUND: Faecal occult blood testing is an established method of colorectal neoplasia screening. Guaiac-based tests are limited by poor patient compliance, low sensitivity, specificity and positive predictive value. Newer immunochemical-based tests, accurate but tedious, require a well-established laboratory set up. There is need for simpler immunochemical tests that can be performed at the out-patient clinic. AIM: To compare the performance characteristics of a new bedside immunological test strip device with a sensitive Guaiac-based and established immunochemical test for detection of faecal occult blood in patients undergoing colonoscopy. METHODS: A total of 389 consecutive patients from four centres who were referred for colonoscopy also provided the stool samples for detection of occult blood without dietary restrictions. Stool tests performed were (i) Guaiac-based, (ii) immunochemical enzyme-linked immunosorbent assay and (iii) bedside immunochemical strip test. RESULTS: At the optimal threshold level, the sensitivity and specificity of the beside immunochemical strip test for detection of significant colorectal neoplasia (adenomas >1.0 cm and carcinomas) were 60% and 95%, respectively. CONCLUSIONS: This bedside immunochemical strip test proved to be a simple, convenient, non-cumbersome and accurate tool with similar performance characteristics for detection of any bleeding lesion including colorectal neoplasia when compared with an established immunochemical faecal occult blood test.