I was fortunate to be chosen as the American College of Surgeons (ACS) Traveling Fellow to Germany in 2016, and I thank both the ACS and the German Society of Surgery for this wonderful educational and cultural opportunity. I would especially like to thank Tobias Keck, MD, FACS, director and surgeon-in-chief, Universität zu Lübeck; Norbert Senninger, MD, FACS, director, clinical for general and visceral surgery, Universitätsklinikum Münster; Frau R. Nowoiski, MD; and Gabriele Schackert, MD, for their assistance in organizing and planning my two-week trip to Germany.
The primary goal of my fellowship was to learn about the German surgical training system and the approach used there to surgically treat hepatopancreatobiliary malignancies. I also wanted to attain a better understanding of a nation that is a leading economic power with a rich cultural history, and the seventh-most visited country in the world.*
I brought my wife, Jane, and my three daughters on this once-in-a-lifetime trip. I wanted my family to share in the experience and broaden their own view of the world through international travel.
My first stop was the 133rd Congress of the German Society of Surgery, April 26–29, 2016, in Berlin. On the first day of the meeting, I attended a joint session between the German and New Jersey Chapters of the ACS moderated by Drs. Senninger and Lewis Wetstein, MD, FACS, a thoracic and cardiovascular surgeon, Freehold, NJ. Dr. Keck started the session with a presentation on the benefits of ACS Fellowship for European surgeons and recounted his experiences as the German Traveling Fellow to the U.S. in 2008. He visited several medical centers that specialize in pancreatic surgery and became interested in learning how to perform a laparoscopic Whipple. Albert Tuchmann, MD, FACS, a vascular surgeon, Vienna, Austria, and Adam Dziki, MD, FACS(Hon), from Poland, also shared their experiences regarding involvement in ACS chapters. The session ended with members of the New Jersey Chapter of the ACS giving talks on adrenal incidentalomas and the changing paradigm of surgical management for perforated diverticulitis. It made for an interesting exchange of ideas and perspectives from European and U.S. surgeons about the challenges and rewards of international collaboration in surgery.
The next day I gave a presentation titled Bile Duct Surgery in the Treatment of Hepatobiliary and Gallbladder Malignancies: Effect of Hepatic and Vascular Resection on Outcomes. This was a outcomes-based analysis of the 2012 ACS National Surgical Quality Improvement Program Participant Use File showing increased morbidity and mortality when hepatic and vascular resection were performed for hilar cholangiocarcinoma and gallbladder cancer. Later that day my family and I ran in a 10 kilometer race sponsored by the German Surgical Society to promote organ donation.
On the third day of the Congress, I attended the Member Assembly meeting of the German Society of Surgery to receive a certificate of scholarship. I met with Gabriele Schackert, MD, President of the German Society of Surgery, and was truly honored to be recognized.
Afterward, I visited the Charité Campus Virchow-Klinikum, and met with Johann Pratschke, MD, FACS, chairman, department of general, visceral, and transplantation surgery. We discussed the economics of running a clinical department of surgery and the need to maintain a positive balance sheet. He introduced me to Moritz Schmelzle, MD, chief of hepatic surgery, who took me to the operating room (OR) to observe a donor organ harvest of pancreas and liver. Dr. Schmelzle then invited me to scrub with him on an extended left hepatectomy for a patient with a large symptomatic hemangioma. Dr. Schmelzle performed the operation expertly using the cavitron ultrasonic surgical aspirator device. When I asked him why he did not use any vascular staplers during the case, he said that for open hepatic resections their department does not use staplers in order to keep costs down, but they do use them for laparoscopic resections.
We discussed his research interests in the role of stem cells in liver regeneration, as well as his work in treating patients with advanced colorectal liver metastases with two-stage hepatectomy. At his institution, surgeons perform portal vein embolization between cycles of chemotherapy so that no time is lost waiting for liver hypertrophy. He also explained the German model of medical training, which includes medical school and residency training, and individual training that may vary in length and content depending on a surgeon’s interests and the availability of training opportunities.
On the last day of the Congress, I attended a video session on Oncologic Visceral Surgery. I heard Jurgen Weitz, MD, chair, department for visceral, thoracic, and vascular surgery, University Hospital in Dresden, speak on Stapler Hepatectomy: Tips and Tricks. He discussed the anatomic variations in portal vein, bile duct, and hepatic artery anatomy and the challenges these differences present for hepatic resection. Dr. Weitz then showed a video of a right hepatectomy using the stapler technique.
Dr. Pratschke presented a video on Laparoscopic Hemihepatectomy: Tips and Tricks, showing his method of extra-hepatic vascular control and then subsequent parenchymal transection using the stapler technique. Both videos were informative and well-produced.
During my time in Berlin, I was able to spend some time touring the city and found the architecture and cosmopolitan atmosphere impressive, especially in light of the fact that 75 percent of the city had been destroyed during World War II. The Holocaust Memorial was a powerful reminder of that dark chapter in German history, but the honesty and transparency of the exhibit were impressive. It is a fitting tribute to those who were killed during this period.
We visited the Berlin Wall and met a taxi driver who was 13 years old when the wall came down. His emotional retelling of the event was truly memorable.
Next, we traveled to Lübeck, a quaint city known for its coastal atmosphere and world-famous marzipan.
My wife and I had dinner with Dr. Keck and his wife, a gynecologist. Over dinner, we discussed Dr. Keck’s experience as an ACS Traveling Fellow to the U.S in 2008. He spoke about his experiences as a new chairman and how he expanded the pancreatic surgery program at his medical center from 17 pancreatic resections per year to more than 100. I also learned about his family and the challenges of maintaining work-life balance for someone in his position.
Dr. Keck took me to the surgical morning report at the medical center, during which the operations performed over the weekend were discussed. I then gave grand rounds on the Wake Forest experience with hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRS) for peritoneal disease from colorectal cancer in comparison with liver resection for colorectal hepatic metastases. Our data demonstrated similar outcomes for these two procedures, suggesting similar tumor biology for these patients. The talk was well received and I was asked numerous questions about the role of HIPEC and CRS for metastatic colorectal cancer and indications/contraindications for surgery.
Afterward, I spent some time with Dr. Keck discussing the biobanking system he has developed in his department and the integration of research data with the electronic health record. This approach allows patients to be identified through an automated screening process for potential clinical trials.
Jens Habermann, MD, head of the section on translational surgical oncology, gave me a tour of the proteomics lab, and in the afternoon I scrubbed in with Dr. Keck on a total gastrectomy with D2 lymph node dissection for gastric cancer.
The following day, I obtained firsthand experience with the medical center’s three state-of-the-art biospecimen storage and retrieval systems. The complexity and automation of these machines were impressive. I then went to the OR and scrubbed in on a distal pancreatectomy and splenectomy with chief consultant privatdozent (PD) Dirk Bausch, MD.
I visited the Heidelberg University Hospital, where I met Prof. Dr. med. Alexis Ulrich, MBA, vice-chairman, department of surgery. We discussed the German model of surgical training and the team approach that the surgical department uses. Essentially, the chair and vice-chair see patients and assign operative cases to the oberärzte (consultant surgeons with special expertise) in the department. The oberärzte operate five days a week. Though the consultant surgeons visit their patients on the wards a couple times a week, a separate team of residents that is supervised by another attending surgeon has primary responsibility for the day-to-day management and discharge of postoperative patients. Dr. Ulrich stressed that the team approach in German surgery departments makes for close working relationships among surgeons, improved efficiency, and better use of resources, time, and the workforce.
The weekly morbidity and mortality conference focused on adverse events from the previous week of operations. After the discussion, I visited the operating suites, where I met PD Dr. med. Oliver Strobel and scrubbed in on a Whipple resection for pancreatic cancer with intraductal papillary mucinous neoplasm, which turned into a total pancreatectomy due to a positive neck margin.
Professor and chairman Markus Büchler, MD, FACS, joined us for this case. Dr. Büchler told me about the University of Heidelberg department of surgery and the vast clinical and research enterprise he leads there. We briefly discussed the controversial role of radiation therapy for pancreatic cancer and the different approaches used in the U.S. and Europe. Dr. Büchler showed me around the operating suites and the multiple pancreatic and hepatobiliary operative cases going on at the same time, highlighting the high surgical volume of his department. I also observed a segment six partial hepatectomy for hydatid disease performed by PD Dr. med. Arianeb Mehrabi. Though rare in the U.S., echinococcal disease is endemic in parts of Germany.
Heidelberg is a beautiful city, and my family and I were able to visit the Castle (Schloss) Heidelberg, a famous landmark, and the University of Heidelberg Student Prison (Studentenkarzer), which housed academic miscreants in the 16th century.
An exceptional experience
After two wonderful weeks in Germany, I can say the ACS Traveling Fellowship exceeded my expectations on all accounts. All the surgeons I met openly welcomed me to their respective institutions, and I learned something from all of them. Hopefully, I returned the favor through my research presentation and grand rounds talk. Although I saw differences in technique and methods of training, I felt a common bond with my hosts as physicians committed to patient care through surgery and research.
I again want to thank the ACS and the German Society of Surgery for this opportunity and experience. It has affirmed my commitment to medicine and expanded my view of surgery on a global stage. I will always remember my time as a Traveling Fellow to Germany with honor and gratitude.
*World Atlas. 10 most visited countries in the world. Available at: www.worldatlas.com/articles/10-most-visited-countries-in-the-world.html. Accessed March 27, 2017.