Appraisal of the current guidelines for the management of diverticular disease using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument

Introduction Diverticular disease is one of the most frequent reasons for attending emergency departments and surgical causes of hospital admission. In the past decade, many surgical and gastroenterological societies have published guidelines for the management of diverticular disease. The aim of the present study was to appraise the methodological quality of these guidelines using the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool. Methods PubMed, Embase, Cochrane Library and Google Scholar databases were searched systematically. The methodological quality of the guidelines was appraised independently by five appraisers using the AGREE II instrument. Findings A systematic search of the literature identified 12 guidelines. The median overall score of all guidelines was 68%. Across all guidelines, the highest score of 85% was demonstrated in the domain ‘Scope and purpose’. The domains ‘Clarity and presentation’ and ‘Editorial independence’ both scored a median of 72%. The lowest scores were demonstrated in the domains ‘Stakeholder involvement’ and ‘Applicability’ at 46% and 40%, respectively. Overall, the National Institute for Health and Care Excellence (NICE) guidelines performed consistently well, scoring 100% in five of six domains; NICE was one of the few guidelines that specifically reported stakeholder involvement, scoring 97%. Generally, the domain of ‘Stakeholder involvement’ ranked poorly with seven of twelve guidelines scoring below 50%, with the worst score in this domain demonstrated by Danish guidelines at 25%. Conclusion Six of twelve guidelines (NICE, American Society of Colon & Rectal Surgeons (ASCRS), European Society of Coloproctology (ESCP), American Gastroenterological Association, German Society of Gastroenterology/German Society for General and Visceral Surgery (German), Netherlands Society of Surgery) scored above 70%. Only three, NICE, ASCRS and ESCP, scored above 75% and were voted unanimously by the appraisers for use as they are. Therefore, use of AGREE II may help improve the methodological quality of guidelines and their future updates.

STAY IN THE ULM UNIVERSITY CLINIC (GERMANY)

In March 2020 I was in the Ulm University Clinic for 2 weeks. My internship course took place on the basis of the department of general and visceral surgery. The work in the clinic is structured in such a way that not only surgeons but also doctors of the adjoining specialties, trainees and students participate in the discussion of patients’ treatment. And at the morning conferences, a resuscitator, a radiologist and an endoscopist must always be present. The operating unit has all necessary equipment in sufficient quantity. Preoperative preparation is carried out by the anesthetic team in the preoperative room. A special role is given to the patient’s thermal isolation using special blankets, protection of the patient’s eyes with a patch, and perioperative antibiotic prophylaxis. In addition to the operating surgeon and two main assistants, the operating team obligatorily includes a student. Continuous training by senior surgeons of junior ones is practiced. Basic surgical instruments are represented with everything you need. In the postoperative period all drugs are charged into infusion machines at a daily dosage, which simplifies the work of paramedical personnel and also reduces the risk of catheter infection. When entering a medical university the competition is initially very high (more than 20 people per place). All doctors work in a unified team, there is no strict division into university chairs and clinic departments. Two weeks spent in the Ulm University Clinic have shaped my understanding of medical care and medical education in Germany, acquainted me with the specificity of the surgical service and the technical features of performing surgical interventions.

Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery

Background Increasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation. Methods We performed a monocentric retrospective two-arm matched cohort study. Patients that received perioperative bridging anticoagulation were compared to a matched control group with identical surgical procedure, age, and sex. Emergency and vascular operations were excluded. The primary endpoint was the incidence of major postoperative bleeding. Secondary endpoints were minor postoperative bleeding, thromboembolic events, length of stay, and in-hospital mortality. Multivariate analysis explored risk factors of major postoperative bleeding. Results A total of 263 patients in each study arm were analyzed. The patient cohort included the entire field of general and visceral surgery including a large proportion of major oncological resections. Bridging anticoagulation increased the postoperative incidence of major bleeding events (8% vs. 1%; p < 0.001) as well as minor bleeding events (14% vs. 5%; p < 0.001). Thromboembolic events were equally rare in both groups (1% vs. 2%; p = 0.45). No effect on mortality was observed (1.5% vs. 1.9%). Independent risk factors of major postoperative bleeding were full-therapeutic dose of LMWH, renal insufficiency, and the procedure-specific bleeding risk. Conclusion Perioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging.

LI-RADS in the year 2020 – Are you already using it or still considering?

Purpose The working group for gastrointestinal and abdominal imaging within the German Radiological Society performed a nationwide online survey in order to assess the current status regarding the awareness and application of LI-RADS, a classification for evaluation of liver lesions in patients at risk. Materials and Methods Using the website www.deutsches-krankenhausverzeichnis.de a list of hospitals was generated meeting the criteria internal medicine, gastroenterology, general and visceral surgery and radiology (n = 391). Randomly, 102 department directors were contacted, and asked to name one consultant and one resident from their department in order to participate in the survey. 177 potential participants were invited to fill out an approximately 10-minute online survey in the form of 17 questions regarding the awareness and application of LI-RADS. The results of the survey were analyzed by means of descriptive statistics. Results 77 participants were registered, which corresponds to a response rate of 43.5 %. 47 % of all participants were radiologists, 30 % surgeons and 23 % internal doctors/gastroenterologists, respectively, many with more than 13 years of professional experience (37.2 %). The majority of participants worked in a hospital with a focus (37.2 %) or a university hospital (29.1 %). Even though the majority of participants knows about or has heard of LI-RADS (73.2 %), only a minority uses the classification themselves (26 %) or within the context of tumor boards (19.2 %). Conclusion The results of our survey demonstrate that LI-RADS is relatively known in Germany, the application however quite sparse. This is in contrast to the general desire and endeavor for more standardized reporting in radiology. Key points Citation Format

Non-Surgical and Non-Radioiodine Techniques for Ablation of Benign Thyroid Nodules: Consensus Statement and Recommendation

Thyroid nodules and cysts are frequently diagnosed in Germany with a prevalence of about 20% in young adults reaching up to 70% in older adults. Surgery is the standard treatment of symptomatic nodules, nodules with suspicion of malignancy and thyroid cancer. Radioiodine treatment is applied for autonomously functioning nodules. During the last years new non-surgical and non-radioiodine techniques have been introduced to treat thyroid nodules. These techniques include ethanol/polidocanol treatment, radiofrequency, microwave, and laser ablation, and high frequency ultrasound ablation. A significant reduction in nodule size could be documented for these techniques in several studies, but long-term outcome data are missing. Until now, there is no general consensus regarding the appropriate indications for these methods. For this reason, the Thyroid Section (German Society for Endocrinology), the Thyroid Working Committee (German Society for Nuclear Medicine), and the German Association of Endocrine Surgeons (CAEK) for the German Society of General and Visceral Surgery (DGAV) reviewed the respective literature, discussed the pro and cons and developed a consensus statement and recommendation to help physicians and patients in their decision making.

What can we learn from other countries—lessons from the CAJC Happiness Report

Most countries have their own programs and requirements for surgical residency. To investigate the differences as well as the advantages and disadvantages of the programs and to explore the happiness of the residents in the different countries, the Surgical Working Group of “Young Surgeons” of the German Society for General and Visceral Surgery has designed a questionnaire. It focuses on three parts: structural and legal requirements, operating room (OR)- and non-OR-related content of the program, and contentment of the residents. In this opinion paper, first the results are shared by the description of the programs in nine different countries. It is shown that the requirements to become a surgeon differ highly between the different countries. Nonetheless, a structured curriculum, the possibility of feedback or a surgical mentoring program, and transparency regarding the OR schedule seem to be important to all residents to reach job satisfaction.

Pancreatic diseases register of the German society for general and visceral surgery

Modern standards of registering the medical information involve a creation of registers of patients with various nosologicalentities, which allows to standardize the services provided by the health care system, as well as to increase the efficiency and safety of treatment in actual clinical practice. The Pancreatic Disease Register of the German Society of General and Visceral Surgery, which is a database of patients with pancreatic diseases and their surgeries, has become very popular in the medical field. The register is a multidisciplinary database with its own infrastructure, coordination center and it contains information on surgical diseases and surgical interventions performed on the pancreas. The register is used to collect and analyze information online and integrates clinics of German-speaking countries (Germany, Switzerland, Austria), as well as doctors from other countries after receiving the relevant permission. The review analyzes the features of information collection and the creation of own register infrastructure, aspects of the implementation of methodological and organizational support, as well as the nuances of its logistics. The ways of statistical processing and validation of the collected information are listed, the possibility of autonomous functioning of the system and the presence of strict measures to protect the confidentiality of data are emphasized. The register is an optimal set of possibilities for correct, full-fledged introduction and analysis of extensive medical data, which is a prerequisite for conducting the prospective randomized studies in the field of pancreatic surgery.