2014 Traveling Fellow to Germany reports on experiences

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Dr. Farma (left) with Dr. Schwenk in Hamburg.

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Drs. Keck and Farma at Klinik für Chirurgie Universitatsklinikum Schleswig-Holstein.

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Dr. Farma and GSS president Prof. Joachim Jahne (second from right) at the GSS president’s dinner, with Professor Jahne’s wife (second from left) and Dr. Farma’s wife, Daria (far right).

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Heidelberg: Kliniken und Institute des Universitätsklinikums, with Dr. Büchler.

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Berlin: Charité Campus Benjamin Franklin. From left: Drs. Müller, Farma, and Kreis.

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Münster: Universitätsklinikum Münster. From left: Drs. Senninger, Farma, and Rijcken.

This report documents my experience as the 2014 American College of Surgeons (ACS) Traveling Fellow to Germany. First, I offer my utmost appreciation to the ACS, the German Surgical Society (GSS), and to Pon Satitpunwaycha, MD, FACS, who assisted in funding the fellowship. I attended the 131st Congress of the GSS in Berlin and six medical centers throughout Germany. I extend my sincere gratitude to my hosts Profs. Norbert Senninger, MD, PhD, FACS, and Tobias Keck, MD, FACS, who were instrumental in planning my trip.

The primary focus of my fellowship was to gain a broader understanding of surgical training and education in Germany, a deeper knowledge of its national health care system, and to observe multidisciplinary cancer care and clinical trial infrastructure.

My journey started at the 2013 Clinical Congress in Washington, DC. I met Professor Senninger, ACS Governor for Germany, at the International Reception and met members of the GSS at the annual dinner of the German-American reunion. After this dinner, I knew that my fellowship, which I was able to experience with my wife, Daria, would be a life-changing experience, as everyone I met was extremely kind and willing to assist me in any way possible.

Hamburg: Asklepios Klinik Altona

We flew into Frankfurt and took another flight to Hamburg, which is a beautiful mix of old and new and is the second-largest city in Germany. Prior to my arrival, I had been in contact with Prof. Wolfgang Schwenk, MD, FACS, at the Asklepios Klinik Altona, which is an 800-bed tertiary hospital that is nationally certified to treat pancreatic and colon cancer. Professor Schwenk provided me with his perspective on the German national health care system. As the department chief, he is required to operate on all privately insured patients, a small subset of the general population. We also discussed medical education and surgical training in Germany, particularly the differences in training residents and junior attendings.

I was then taken on intensive care unit (ICU) rounds, during which I met Professor Schwenk’s four senior attendings, all of whom are general visceral surgeons. Interestingly, trauma is a separate training path in Germany, although general surgeons are called upon if an operation is warranted.

I also found it interesting that dermatologists provide most care to melanoma patients and perform sentinel node biopsies. Meanwhile, sarcomas are generally referred to tertiary specialty centers.

At every hospital I visited, the day starts at 6:45 am with team ICU rounds, followed by a meeting to review overnight cases and consults. Each afternoon includes radiology rounds and each evening includes ICU rounds; the tumor board convenes multiple times a week.

I toured Klinik Altona with Dr. med. Curosh Taylessani. Although it is one of the largest emergency departments (EDs) in Hamburg, it was very quiet and not as busy as the EDs in the U.S. Despite fast-track protocols, it was interesting to see that patients generally remain in the hospital longer than patients in the U.S. Traditionally, German patients expect to stay in the hospital until they feel better, and, as a result, the number of rehabilitation centers is limited.

At that point, I met again with Professor Schwenk in the operating room (OR). The 12 ORs had sliding air-locking doors with anterooms. This hospital also had a new hybrid vascular and an integrated laparoscopic OR in Klinik Altona, making it one of the most modern ORs I have seen. I scrubbed for his first case—a female with sigmoid colon cancer invading the ureter. Most of the procedure was performed laparoscopically. It is interesting to note that a few German medical centers have a robotic system; however, because of their cost, surgical robots are used infrequently.

That evening, Professor Schwenk took Daria and me out for an enjoyable dinner on the harbor near the Fischmarket. Professor Schwenk was sincere and welcoming to us, and we will continue to keep in contact with him.

Lübeck: Klinik für Chirurgie Universitatsklinikum Schleswig-Holstein

We left Hamburg and took the train to Lübeck, where we met Professor Keck of the Klinik Fur Chirurgie. Professor Keck, who was the 2008 ACS Germany Traveling Fellow, had spent two years in Boston, MA, performing research. We met Professor Keck and Nicholas Zyromski, MD, FACS, from Indiana, for a tour of the old city.

After our tour, we had dinner and met privatdozent (PD) Dr. Dirk Bausch and Dr. med Ulrich Wellner. We had an interesting discussion about professional advancement in the German medical system.

Dr. Keck performs transplants, esophagectomies, and a large volume of hepato-pancreato-biliary surgeries (HPB). He is very interested in laparoscopic surgery and is one of the few surgeons who perform laparoscopic pancreaticoduodenectomies in Germany. Professor Keck also is building a remarkable academic department of surgery with a strong emphasis on translational research focused on pancreatic surgery. We spoke about the barriers to performing clinical trials in Germany, although Professor Keck is the principal investigator on multiple national pancreas clinical trials.

The next morning I arrived at Klinik Fur Chirurgie, a 1,000-bed hospital. I was taken on ICU rounds and then to their morning report. In the OR, I observed a laparoscopic sigmoid colectomy with Dr. med Claudia Benecke, who has extensive experience with transanal minimally invasive surgery for early rectal cancers. We discussed the treatment of rectal cancer in Germany, which is very similar to our approach in the U.S., for the most part, although for many upper rectal cancers, German physicians forgo radiation, and a fair number of patients do not receive adjuvant chemotherapy after rectal cancer operations. Next, I observed a pancreaticoduodenectomy with Dr. Bausch.

Later that day, I again met with Professor Keck, who gave me a tour of the private ward. On the tour, I learned that hospital leaders are planning to build a new three-dimensional-integrated OR. We then met with Prof. Dr. med Jens Habermann and Dr. med and PD Dr. Tilman Laubert in their translational research lab, which is situated opposite the clinic space to foster true bench-to-bedside research and collaboration. Professors Habermann and Laubert are very interested in cancer epigenetics and proteomics and are working on a computer chip for early detection of colon cancer. They also have established a system of tissue banking for their biosample repository. Next, we saw one of their patients in the endoscopy suite with Prof. Dr. Martin Kraus, a surgeon gastroenterologist. They treated an esophageal “anastomotic insufficiency” with a vacuum-assisted endosponge—a novel approach to this situation.

Berlin: GSS meeting

We left Lübeck and took the train to Berlin for the GSS national meeting. I attended an interesting session at the 131st Congress of the GSS, which was titled GSS and ACS: A Living Relation for the Future? At another session, I gave a presentation titled The Bilateral Scholarship Programs: Experience of an ACS Scholar, which was followed by a roundtable discussion including Professors Heuer, Keck, Senninger, and Zyromski; Ernst Klar, MD, FACS; Prof. med and GSS president Joachim Jahne, MBA; and myself about future prospects for building relationships between our two organizations and the benefits of formalized exchange programs. I also gave a lecture during the Essentials of Surgery session titled Changing the Treatment Paradigm for Locally Advanced Rectal Cancer.

A session addressing problems with health care in Germany and other European countries included a lecture on surgical training in Europe. The discussion centered on resident duty hours and training; their maximum hours are 48 hours per week, in contrast to our 80 hours.

As part of the congress, the GSS offered a guided tour of the Wannsee Conference memorial exhibit. This experience was both emotional and educational, centering on the historic meeting of senior members of Nazi Germany, which was held to discuss the implementation of the Final Solution. I also attended a working session on international cooperation of the GSS with other surgical societies and met visiting professors from Austria, England, Israel, Poland, and Japan. President Jahne and secretary general Hans-Joachim Meyer, MD, FACS, moderated the discussion.

Berlin: Charité Campus Benjamin Franklin

The next day, I took the subway to the Benjamin Franklin campus of Charité hospital—a certified center for colorectal cancer with approximately 1,500 beds. Dr. med Mario Müller, who trained in Toronto, ON, in a surgical oncology fellowship, greeted me. I was then introduced to Prof. Dr. med Martin Kreis, director of surgery. We attended rounds, and I toured the facilities before visiting the OR. Professor Kreis had a young male patient with recurrent rectal cancer, which turned out to be a very interesting and difficult case requiring anterior dissection and a partial sacrectomy.

I had a lengthy conversation with the surgeons concerning resident duty hours, quality of residents in smaller hospitals, reimbursements, and nurse-to-patient ratios. Both Dr. Müller and I trained in a surgical oncology fellowship. Moreover, he provided me with unique insights into the similarities and difference between the American and German training model.

Heidelberg: Kliniken und Institute des Universitätsklinikums

After sightseeing in Munich, we arrived in Heidelberg in the afternoon, and then I was off to visit the Kliniken und Institute des Universitätsklinikums. Heidelberg is one of the largest tertiary referral centers for HPB surgery in Germany. Surgeons there perform approximately 700 pancreas resections, 100 liver transplants, and 300 liver resections a year. This institution is also the site of the GSS Research Group—a centralized department managing national surgical and clinical trials.

Prof. Dr. med. Dr. H.C. Markus W. Büchler’s department includes transplantation. On my first day there, I went to the OR and met Professor Büchler, who was performing a liver resection for metastatic pancreatic cancer. After the procedure, Professor Büchler and I sat for some time discussing his experience with clinical trials in Germany and his perspective on the limitations on performing surgical trials in the U.S.

After leaving the OR, I met one of the fourth-year residents, who accompanied me on a tour of the NCT Heidelberg (Nationales Centrum für Tumorerkrankungen), which is a new multidisciplinary cancer facility. This facility housed translational labs, as well as medical and radiation oncology clinics and an infusion center. I toured the facility’s cell culture, flow cytometry, and genomics labs.

We then moved on to the Heidelberg Ion-Beam Therapy (HIT) Center, which opened in 2010. The unique HIT is one of the world’s first medical centers to use ion therapy with a 360-degree rotating gantry system and has the ability to combine protons and heavy ions. Currently, physicians at this facility are mostly treating brain and skull base tumors; however, they run the machine for research purposes 24 hours a day and are also investigating prostate and pancreatic cancers.

We then met Prof. Dr. Alexis Ulrich and two residents for dinner in downtown Heidelberg. Professor Ulrich spoke of his experience performing research in the U.S. and the differences between our countries, particularly the large volume of cases they perform and his lifestyle as a surgeon in Germany. We discussed education of the residents, mentoring, examinations, and length of training. The following morning I observed a laparoscopic distal pancreatectomy and then scrubbed in to observe a total pancreatectomy.

Mannheim: Universitätsmedizin

I took the train and a taxi from Heidelberg to Mannheim, where I was greeted by PD Dr. med. Karoline Horisberger. We met Prof. Dr. med Stefan Post and proceeded to ICU rounds, which were impressive and regimented. We then went to the morning report and a tour of clinical wards. I saw the surgeon-supervised endoscopy suite. We discussed the successful use of the endovac for rectal anastomotic leaks, following the German guidelines for rectal cancer and neoadjuvant therapy. The surgeons rarely use short-course radiation therapy for rectal cancer and always give adjuvant chemotherapy. Until more data are available, they do not propose watchful waiting for patients with a complete pathologic response.

I was introduced to one of their radiologists, who was using a Seimens 4D-computed tomography (CT) scan in both pancreas and rectal cancer, looking at CT perfusion characteristics of the tumor and lymph nodes.

I observed a laparoscopic rectopexy with Professor Post, who has an interest in colorectal surgery, and during the procedure we discussed management of rectal cancer. He asked me about health care in the U.S. and had numerous questions about the Affordable Care Act. We discussed medical costs, and he noted that his department prides itself on the cost-effectiveness of their ORs.

I then scrubbed in with their sarcoma surgeon, Prof. Dr. med Peter Hohenberger during a resection of a retroperitoneal mass. We discussed his involvement with the European Organisation for Research and Treatment of Cancer sarcoma trials operations. It was a rewarding day, during which I saw two interesting operations and a well-run division of surgery.

Münster: Universitätsklinikum Münster

We took a train ride along the Rhine river to Münster, a beautiful town with a church on every corner and bikes everywhere.

I met Prof. Dr. med Emile Rijcken, and we toured the facility, followed by morning rounds. The first case I saw was a laparoscopic rectopexy, and the second case was total proctocolectomy. That evening, we met Dr. Rijcken and Dr. med. Thorsten Vowinkel for dinner. We discussed training, clinical practices, and areas of research.

The next morning, I met with Professors Senninger and Rijcken, and I presented my research projects to the faculty and trainees during morning rounds. I scrubbed in for a pancreaticoduodenectomy with Dr. med. Heiner Wolters. After the case, I toured the clinic, which has basic science lab space where residents have dedicated time for research. The clinic has its own endoscopy suite, and most of the surgeons perform upper and lower endoscopies. They are developing a virtual laparoscopic trainer for the residents and plan on performing analytic research studies with this tool.

Across the street from the clinic is a new skills lab for medical students and trainees. The main central clinic is composed of two 10-story circular towers, housing approximately 1,450 beds. The clinic includes the Comprehensive Cancer Center, with multidisciplinary tumor boards and an extensive radiation oncology department. We ventured to the top floor of one of the towers, which houses the ICU, to view the beautiful skyline of Münster.

On the final evening of our trip, we had a lovely dinner with Professor Senninger and his wife Christina. We spoke about his research years in Houston, TX, our families, and his involvement with international surgery over the years. Professor Senninger is a true gentleman and has built a world-class department of surgery. I know this experience will lead to continued collaboration and exchange.

I extend my thanks to the ACS and its International Relations Committee for this once-in-a-lifetime experience. I am extremely grateful to Professors Senninger and Keck, the GSS, and my hosts in Hamburg, Lübeck, Berlin, Heidelberg, Mannheim, and Münster. My thanks as well to my chairman at Fox Chase Cancer Center, Robert Uzzo, MD, FACS; my division chief, Elin Sigurdson, MD, PhD, FACS; and one of my mentors, John M. Daly, MD, FACS, for supporting my pursuit of this traveling fellowship.

This was a tremendous experience that I will cherish for my entire career. Building international relationships is paramount for advancing surgery. I learned that surgeons all speak the same language, despite subtle differences in techniques and culture. I wholeheartedly encourage my colleagues to participate in international fellowships, and I look forward to hosting and building international relationships and collaborations in the future.

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