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Zusammenfassung  Die vorliegenden Untersuchungen aus verschiedenen Weiterbildungssystemen zeigen, dass die chirurgische Weiterbildung ein relevanter Kostenfaktor für den Krankenhausträger ist. Kosten entstehen insbesondere durch verlängerte Operationszeiten mit Bindung des im OP beschäftigten Personals, aber auch eine im Vergleich zum Facharzt geringere Effizienz des Berufsanfängers auf Station. Demgegenüber stehen Einsparungen des Krankenhausträgers durch die tariflich festgelegte geringere Vergütung des chirurgischen Assistenten während seiner Weiterbildungszeit. Der Umfang einer möglichen Finanzierung ist schwer zu ermitteln, da Weiterbildung als „training on the job“ stattfindet und deshalb aus betriebswirtschaftlicher Sicht die Produkte Patientenversorgung und Weiterbildung (sog. Kuppelproduktion) nur bedingt voneinander zu trennen sind. Für das deutsche Weiterbildungssystem gibt es keine validen Analysen zu den tatsächlichen Kosten. Gegenwärtig wird die Weiterbildung indirekt durch die Krankenkassen über das DRG-System finanziert. Mögliche Modelle einer Finanzierung sind die Bereitstellung von zusätzlichen Mitteln aus dem Gesundheitsfond oder eine Umverteilung durch Zu- oder Abschläge der DRG-Pauschalen entsprechend dem prozentualen Anteil an Weiterbildungsassistenten. Stellungnahmen der beteiligten Spitzenverbände zur Problematik der Finanzierung zeigen, wie schwierig eine Kompromisslösung zum gegenwärtigen Zeitpunkt zu erzielen ist. Bei dieser kontroversen Debatte sollte aber berücksichtigt werden, dass eine hochwertige Weiterbildung junger Kollegen die entscheidende Grundlage für ein effizientes Gesundheitssystem und daher eine entsprechende Finanzierung unumgänglich ist. [ABSTRACT FROM AUTHOR]

Introduction: An important goal in every lung resection is airtight closure of the resected lung surface. This can be achieved with several techniques, including clamp resection, stapler, laser, and various high-frequency methods. By quantitatively measuring the air fistula across the resection surface of porcine lungs, two resection techniques were compared in our study: BipoJet dissecting scissors (Aesculap, Inc., Tuttlingen, Germany) and laser (Ceralas HPD®, Biolitec Inc., Jena, Germany)., Methods: Following a stencil, wedge resections were performed in porcine lungs using water-irrigated bipolar scissors and laser (1350 nm, 40 watts, non-contact mode). The volume of the air fistula was then measured. The irrigation technique involved the attachment of an irrigation channel to a pair of standard surgical scissors. A sodium chloride (NaCl) solution was fed at a defined flow rate, along the blades of the scissors onto the parenchyma. This technique was used on a total of 10 specimens each., Results: Somewhat better pneumostasis was achieved with laser resection, though the difference was small and not statistically significant. The flow rate was 124 mL/min/cm² after laser resection and 145 mL/min/cm² after using the BipoJet scissors. The difference was not statistically significant. Water irrigation during resection with the BipoJet scissors prevents the temperature in the tissue from exceeding 100°C thus avoiding tissue carbonization. These scissors offer the following advantages: ease of use, no need to change instruments, no need for staff training, no protective measures, all-in-one incision/coagulation/dissection, low cost, and a clear surgical field due to the irrigation effect., Conclusions: Resection of lung parenchyma, e.g., during resection of metastases, is easier with BipoJet scissors and comparable to laser resection. This was established both experimentally and by resecting lung metastases., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Prisadov et al.)

Background: The tumor involvement of lymph nodes (LN) in N2 station is a very important factor for the further therapy decision and the prognosis of lung cancer patients. Today, integrated positron emission tomography-computed tomography (PET-CT) is considered to be the new standard in the staging of bronchial carcinoma. The aim of this study is to investigate the correctness of the clinical staging of the mediastinal LNs in operated patients and to investigate the sensitivity and specificity of the PET-CT examination for mediastinal LNs., Subjects and Methods: In the years 2010-2014, 359 patients underwent surgery for bronchial carcinoma. The histological examination of all mediastinal and hilar LNs was used as a reference to the data from the PET-CT examinations. The correctness of the PET staging, overestimation, and underestimation for the N stage was analyzed. In addition, the "sensitivity," "specificity," and "overall accuracy" of the PET-CT examination with regard to the N2 LNs were calculated., Results: It was found that in 8.9% the staging of the mediastinal N2/N3 LN stations was rated too high by the PET and in 11.2% too low. The study showed a sensitivity of 47.37%, a specificity of 90.07%, and an accuracy of 81.01% for the mediastinal LNs., Conclusion: Our study confirms the limited ability of integrated PET-CT in staging the mediastinal LNs. We, therefore, recommend a histological examination of the LNs in patients with PET-positive N2 LNs to avoid false-positive results and to initiate correct therapy., Competing Interests: None

Background/objective: Inefficient nursing care of chest drains may associated with unacceptable and sometimes life-threatening complications. This report aims to ascertain the level of knowledge of care of chest drains among nurses working in wards in a teaching hospital in Nigeria., Methods: A cross-sectional study among nurses at teaching hospital using pretested self-administered questionnaires., Results: The majority were respondents aged between 31 and 40 years (45.4%) and those who have nursing experience between 6 and 10 years. Only 37 respondents (26.2%) had a good knowledge of nursing care of chest drains. Knowledge was relatively higher among nurses who cared for chest drains daily, nurses who have a work experience of <10 years, low-rank nurses and those working in the female medical ward; however, the relationship were not statistically significant (P > 0.05). Performance was poor on the questions on position of drainage system were not statistically significant with relationship to waist level while mobilizing the patient, application of suction to chest drains, daily changing of dressing over chest drain insertion site, milking of tubes and drainage system with dependent loop., Conclusion: The knowledge of care of chest drains among nurses is poor, especially in the key post procedural care. There is an urgent need to train them so as to improve the nursing care of patients managed with chest drains.

Systemic air embolism is known to rarely complicate blunt chest trauma. However, cerebral infarction caused by air emboli possibly originating from a traumatic pneumatocele has not been previously reported. We report a case of a 46-year-old woman who sustained blunt chest trauma with multiple rib and clavicular fractures, hemothorax and a huge, tense traumatic pneumatocele. She subsequently developed clinical and radiologic features of cerebral infarction. The cerebral infarct is likely to be secondary to cerebral air embolism originating from a traumatic pneumatocele., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: The frequent and prolonged use of thoracoscopic equipment raises ergonomic risks which may cause physical distress. We aimed to determine the relationship between ergonomic problems encountered in thoracoscopic surgery and physical distress among thoracic surgeons., Methods: An online questionnaire which investigated personal factors, product factors, interaction factors and physical discomfort was sent to all members of the European Society of Thoracic Surgeons (ESTS)., Results: Of the respondents, 2.4% indicated that a one arm's length should be the optimal distance between the surgeon and the monitor. Only 2.4% indicated that the monitor should be positioned below the eye level of the surgeon. Most of the respondents agreed, partially to fully, that they experienced neck discomfort because of inappropriate monitor height, bad monitor position and bad table height. Most respondents experienced numb fingers and shoulder discomfort due to instrument manipulation. Most of the respondents (77.1%) experienced muscle fatigue to some extent due to a static posture during thoracoscopic surgery. The majority of respondents (81.9, 76.3 and 83.2% respectively) indicated that they had varying degrees of discomfort mainly in the neck, shoulder and back. Some 94.4% of respondents were unaware of any guidelines concerning table height, monitor and instrument placement for endoscopic surgery., Conclusions: Most thoracic surgeons in Europe are unaware of ergonomic guidelines and do not practise them, hence they suffer varying degrees of physical discomfort arising from ergonomic issues.

Unlabelled: Patients presenting with a solitary pulmonary nodule are often a serious diagnostic-therapeutic problem. The AIM of the present report is to share our experience with VATS in the diagnostics and therapy of patients with solitary pulmonary nodules., Patients and Methods: Between 2005 and 2009 we performed primary videothoracoscopic tumor resection in 125 patients with peripheral lung tumours., Results: In 93 (74.4%) of the cases complete successful thoracoscopic resection of the tumor and subsequent intraoperative frozen section histology was accomplished. In the remaining 32 cases (25.6%) various reasons demanded conversion to thoracotomie with wedge resection of the nodule. 54.2% of the removed tumours were malignant and 45.8% - benign. In 18 of the patients the intraoperative frozen section histology diagnosis was primary bronchial carcinoma which required to do oncologic resection of the tumor. In 10 patients the intraoperative frozen section histology was unable to differentiate between pulmonary metastasis and primary bronchial carcinoma, and the oncologic resection was performed in another surgical session after the definitive pathomorphologic diagnosis had been available. In 28 of the cases pulmonary metastases of a primary extrapulmonary tumor were removed., Conclusions: Despite improvement in the diagnostic techniques, only the video-thoracoscopic removal of the lung nodule and its subsequent histological examination enables the definitive diagnosis, solving definitively the problem with benign lesions and indicating appropriate treatment of the malignant pulmonary lesions.

Intestinal permeability can be measured by the sugar absorption test. This test is based on determining the ratio of the urinary excretion of a large and a small carbohydrate after oral administration. The aim of this study was to determine which combination of carbohydrates used in the test gives the highest correlation with disease activity in inflammatory bowel disease. 26 patients with Crohn's disease, 21 patients with ulcerative colitis and 27 healthy control subjects were included in the study. The patients with inflammatory bowel disease had either minimal or highly active disease or were in remission. Two disaccharides (lactulose: L, and cellobiose: C) and two smaller carbohydrates (rhamnose:R, and mannitol:M) were given orally and the urinary excretion was measured by high pressure liquid chromatography followed by pulsed amperometric electrochemical detection on a gold electrode. The ratios C/R, L/R, C/M and L/M were used as indicators for intestinal permeability. - There were no side effects of oral sugar administration. All patients tolerated the test well. Lactulose, rhamnose and cellobiose concentrations are easily be measured in the urine whereas mannitol measurement requires the use of an anion exchanger. This produced inconsistent results. Patients with Crohn's disease or with ulcerative colitis had increased permeability indices in comparison to healthy controls, even in remission. The L/R ratio gave a better differentiation between the healthy controls and patients with active disease than the other agents. Changes in disease activity are best reflected by use of cellobiose/rhamnose excretion quotient.

Background: A critical look at the effectiveness of medical procedures and therapies is important with the increasing limitations on resources in health care., Method: The costs for treatment and the quality of life according to the SF-36 were analyzed in a retrospective health economic study on 65 patients who had undergone surgery for primary non-small-cell lung cancer., Results: The mean cost for all patients was 7,169 euro per patient. 38.8 % resulted from surgery, 31.6 % were attached to the preoperative phase on the general ward, 11 % postoperatively to the general ward. Intensive care costs accounted for 18.7 %. The cost of each surgical procedure ranged from 4,634 euro for a pneumonectomy to 8,366 euro for a lobectomy with sleeve resection of the bronchus. The most expensive factors were staff, disposable materials, pathological investigations, and radiology services. There was no difference in these proportions with stage of tumor or the surgical procedures undertaken. Quality of life as assessed by the SF-36 questionnaire ranged from 31.82 (physical functioning) to 75.0 (social functioning) one year after the operation. These scores were lower than for those with other chronic diseases. On average, 4.62 quality-adjusted life years were achieved. The cost per QALY was 1,970 euro. The extent of resection and the tumor staging correlates significantly with the mean cost per QALY., Conclusion: Thoracic surgery is cost intensive. With increasing staging of the tumor, the cost for treatment increased as with increased operation complexity.

In a prospective, randomized, controlled trial the effect of high dose intravenous antithrombin III and intraabdominal donor serum was analyzed in 36 patients with diffuse secondary peritonitis. The direct cost for treatment was 25,370 euros per patient, and the post acute hospital care costs and societal costs were 6273 euros. The cost for intensive care of these patients accounted for approximately 83% of the direct costs, while the expenditures for operating theater and general wards accounted for 9% each. The most expensive factors were staff, medication, and blood products. The hospital incurred a deficit of 3696 euros for each patient after reimbursement from public health insurance companies. Quality of life as assessed by the gastrointestinal quality of life index (GIQI) showed a good outcome. On average 11 quality adjusted life years (QALY) were achieved. The cost per QALY was 2631 euros. Use of adjuvant therapy was associated with a reduced duration of intensive care unit (ICU) treatment, times on mechanical respiration, and hemofiltration; the cost of treatment was reduced by 6614 euros per patient. The additional cost of antithrombin III (5155 euros) was more than offset by the savings made when adjuvant therapy was used.

Background: Patients with diffuse peritonitis show an overall mortality of about 20%, probably caused by the breakdown of local defence mechanisms combined with a systemic outspread of bacteria and toxins, which often results in sepsis syndrome., Design: In a prospective, randomized, controlled study 50 patients with diffuse secondary peritonitis were included. Patients in the therapy group were treated with an adjuvant medication consisting of a continuous intravenous infusion of antithrombin III and two intraperitoneal instillations of fresh frozen human donor serum. The aim of the study was the reduction of mortality and incidence of multiple organ failure., Results: Mean antithrombin III plasma levels in the therapy group were raised above 140% for 4 days and were significantly higher than in the control group. With the intraperitoneal application of fresh frozen serum and antithrombin III opsonic capacity as well as thrombin, inhibitory activity in the exudate could be significantly elevated over 2 days. The 90-day-mortality rate was 6/26 (23%) in the control group and 6/24 (25%) in the therapy group. Although no improvement of mortality was achieved, a slight but not significant reduction of the severity of the multiple organ failure was seen., Conclusions: The chosen therapeutic approach was feasible and showed no side-effects. Yet, neither mortality nor multiple organ failure were significantly improved by the applied short-term adjuvant therapy. Thus, for future trials in severely-ill patients a longer treatment period and/or combinations of antithrombin III with other anti-inflammatory agents should be considered.