Received date: April 22, 2017; Accepted date: June 06, 2017; Published date: June 08, 2017
Citation: Cordesmeyer A, Buhr J, Hoffmann MW, Allemeyer EH (2017) Structures for Surgical Proctology in German Hospitals. J Inflam Bowel Dis & Disord 2:120. doi:10.4172/2476-1958.1000120
Copyright: © 2017 Cordesmeyer A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Broad scientific evidence exists for positive effects of specialization in surgery while its ideal extent remains subject to controversy [1,2]. The level of specialization differs widely between European countries: whereas general surgery in Germany still encompasses upper and lower gastrointestinal tract in the wide majority of hospitals, surgeons in the US, UK or Ireland are usually specialized in either lower or upper GI. So far, there is no evidence for superiority of either of the two models. Within the field of lower GI, proctologic surgery underwent an extraordinarily dynamic development towards increasing specialization in Germany during the past decades. Landmarks for this evolvement were: a particular formal qualification in proctology with a demanding curriculum offered by the German Medical Association (Bundesärztekammer), scientific associations with high emphasis on proctology both in Europe (European Society of Coloproctology) and Germany itself (German Society of Coloproctology-Deutsche Gesellschaft für Koloproktologie, DGK), Surgical working group for coloproctology of the German Society for General and Visceral Surgery (DGAV) with growing activities both in education and scientific meetings of increasing numbers of attendents. Furthermore, the DGAV offers certification of specialized centres for coloproctology in three different degrees (“competence-, reference-, and excellence centre”, respectively). Apart from these efforts for quality in patient care, the professional association of German coloproctologists (BCD) is another expression of striving specialization in this field.
While these facts testify the current formal extent of specialization in surgical proctology, no data exist to date as to numerical structures for surgical proctology in German hospitals and discussion of the clinical importance of specialization in surgical proctology seems essential.
We therefore performed an analysis of the structures of surgical proctology in German hospitals and identified possible reasons for the different models as well as potential advantages and disadvantages [3,4].
For a nationwide inventory of surgical proctology in all German hospitals working in this field, we used demographic sources such as Bertelsmann Foundation Database, Federal Office for Statistics, Federal Medical Association as well as data from the DGAV, DGK and BDC. A review of medical and economic literature served to analyze reasons and possible effects of the different structures existing.
Among 1,013 hospitals providing surgical proctological service in Germany (12/30/2014), four different structures were identified: the vast majority of 941 hospitals (92.9%) provided proctologic surgery without specialization on this field (Departments of General Surgery, model I) followed by 56 attending surgeons (private practice, model II) and 10 highly specialized Departments of Coloproctology (0.99%, model III). 6 hospitals (0.59%) featured Departments of General Surgery including a specialized Proctology Unit (model IV).
To date, no formal or guideline recommendations exist in the literature on the structural prerequisites for managing surgical proctology. Analysis of the current literature on proctologic surgical procedures compared to evidence based data on effects of centralization, surgeon´s volume, hospital volume and learning curves clearly indicates that requirements for treating patients with proctologic disease can only be met by specialized teams. Departments exclusively working on coloproctology (model III) with a homogenous team of highly-trained surgeons ideally fulfill structural prerequisites for full modern proctologic treatment but are rare in numbers and yet in contrast to the majority of structures found in most German hospitals. Divisions of Proctologic Surgery (model IV) within large units of general surgery would fit into the structure of most German hospitals and combine all major advantages of personnel structures, specialized training and infrastructure for high quality treatment as well as specialized attending surgeons (model II). Calculation of personnel in relation to range and frequency of procedures indicates that the required degree of specialization is unlikely to be provided by non-specialized teams (model I). Certification of centres of surgical proctology aims to provide comparable quality and has been proceeding in recent years. Future strategies for referring proctologic patients will most likely take this into account.
In conclusion, despite clear evidence for positive effects of specialization and strong institutional representation of surgical proctology in Germany, the wide majority of hospitals in Germany does so far not provide a specialized infrastructure and personnel for patients in need for proctologic service. In our view, studies on quality of care for proctologic patients are needed to answer the question as to whether hospital structures in most German hospitals are sufficient for treating proctologic patients.