Chirurgie (Heidelberg, Germany)最新文献

Outpatient visceral surgery is still in its infancy in Germany. While hernia repair that can be performed on an outpatient basis is still being discussed in this country, larger visceral surgery procedures such as thyroidectomy, fundoplication, bariatric procedures and colorectal resection are increasingly being performed abroad on an outpatient basis or in a short inpatient setting (< 24 h). The USA is the pioneer of outpatient care. Due to the private sector character of the American health insurance system, structures were created that ensure seamless care for patients. Overall, a look abroad shows that outpatient surgical procedures are a promising development that can also be further promoted in Germany through appropriate measures and strategies.

The introduction of hybrid diagnosis-related groups (DRG) presents new challenges for healthcare providers and health insurances. The same applied in 2023 to the institute designated by the Federal Ministry of Health (BMG) to extract medical procedures and calculate remuneration levels for the first hybrid DRGs. A responsible calculation methodology and a realistic data basis are required as the result of the calculation can lead to controversy, even to a splitting among specialist groups and constructs. There is also the threat of mismanagement with subsequent supply problems. In this context, a loss of quality can occur due to the use of simple surgical procedures that are less complex and not expensive with respect to material costs and are economical but not state of the art and thus directly worsen the medical care of patients in the statutory health insurance (GKV). Furthermore, it is already becoming apparent that procedures that are uneconomical due to the miscalculation are partially no longer being comprehensively rendered by healthcare providers due to adjustment of the service portfolio. An appropriate compensation of procedures is only possible based on a remuneration that adequately covers the costs. In this respect, this article is not intended to be understood as a "solution to the problem of the internal distribution of the remuneration in hybrid DRGs" but more to offer suggestions for solutions for the required further development of the hybrid DRG compensation level calculation to prevent a threat to the treatment of GKV patients due to mismanagement. As required in § 115f of the Sozialgesetzbuch V (SGB V), the recalculation of an economic remuneration must be carried out urgently and promptly using an empirical calculation basis and methodology and this must be regularly adapted.

Background: Despite the introduction of the diagnosis-related groups (DRG) system, costs in the German healthcare system have risen continuously for years. In order to reduce costs the federal government is aiming to shift inpatient services to the outpatient sector. Outpatient services affect many areas of medicine, including proctological operations as these are common and can often be carried out on an outpatient basis.

Objective: The aim of the present work is to discuss which areas of proctology are suitable for outpatient treatment and which structural requirements are necessary.

Material and methods: The present article is intended to provide a narrative overview with reference to the literature on the topic of outpatient care in proctology. A literature search was carried out using the following keywords: outpatient care, selective sector-level remuneration, day care, proctological operations, AOP catalog and hybrid DRG.

Results: In proctology, outpatient surgical care is implementable in many cases; however, not every patient is suitable for this. In addition to previous illnesses, patient compliance and the possibility of postoperative care from relatives must also be taken into account. In addition, emergency treatment must be guaranteed. Contraindications include severe heart and circulatory diseases as well as severe coagulation or organ dysfunction. Extensive abscesses, complex fistulas or sphincter reconstructions should be surgically treated in an inpatient setting. The prerequisite for successful outpatient care is to make the sector boundaries between outpatient and inpatient patient care more permeable and to adequately remunerate the interventions.

Conclusion: In addition to the surgical indications, the prerequisites for successful proctological operations are the correct assessment of the operational capability and compliance. From an organizational and economic perspective, better networking between outpatient and inpatient treatment and equal remuneration across the sector boundaries are crucial.

Outpatient surgery in the treatment of hernia is currently a major challenge for patients and treating physicians in Germany due to the new legal regulations (key term hybrid diagnosis-related groups, DRG). Despite large economic challenges and empty funds, the principle of medical treatment is still the patient-oriented scientifically founded medicine. Although outpatient treatment would be very desirable, clear medical knowledge should the basis for the justification of surgical strategies: outpatient short hospitalization (24h) or fully inpatient hospitalization (>24h). A completely outpatient treatment of hernias is not meaningful and the demarcation of outpatient, short inpatient and inpatient treatment should be demonstrated in a risk-adjusted manner. A classification is essential, particularly against the background of an intersectoral hybrid DRG.

Background: While laparoscopic cholecystectomy has largely been performed in an outpatient setting in some countries for years, in Germany it is still generally performed on an inpatient basis; however, with the progressive ambitions for more outpatient treatment within the German healthcare system, laparoscopic cholecystectomy will (have to) increasingly be performed on an outpatient basis in the upcoming years.

Aim of the work: Presentation of the current framework conditions and the potential for outpatient performance of laparoscopic cholecystectomy in Germany. Presentation and discussion on the current state of knowledge regarding patient selection, treatment pathways and safety of outpatient laparoscopic cholecystectomy.

Results: The potential for outpatient management of laparoscopic cholecystectomy in Germany is high. Based on the current literature, there are no safety concerns regarding outpatient performance of laparoscopic cholecystectomy in selected patients.

Conclusion: Outpatient management of laparoscopic cholecystectomy is inevitably heading our way in the next years. The key to successful change will be comprehensive patient information, patient selection and structured outpatient treatment pathways.

Aim: The aim of this work is to illustrate the diversity of vascular injuries in terms of vascular segments or body regions, accident mechanisms and specific patient constellations.

Method: A representative case collection was compiled based on current and relevant scientific references in PubMed, own clinical experiences, vascular surgical and novel image-guided interventional options.

Results: The diagnostics of vascular injuries in the context of trauma and fractures are based on a thorough physical examination. In addition, the hard and soft signs preferred by the Western Trauma Association should be included in the decision. Doppler ultrasonography examination is the safest and gentlest noninvasive examination procedure for a suspected vascular injury due to repeatable and comparative measurements. The stabilization of a fracture, ideally using an external fixator, should be performed before vascular reconstruction whenever possible, unless massive bleeding, hypovolemic shock or a rapidly spreading hematoma represent an immediate indication for surgery. In pediatric supracondylar fractures, avascular injury without relevant ischemia has frequently been described (pink pulseless hand). In this case, the fracture should first be reduced as the pulse often recovers. Due to the increasing availability, good technical handling and high technical success rate as well as the relatively limited interventional trauma, endovascular treatment of traumatic vascular injuries has become widely accepted. Traumatic aortic ruptures are associated with a high mortality even at the accident site. Rapid endovascular treatment using a stent prosthesis significantly increases the injured person's chances of survival.

Conclusion: Vascular injuries in connection with fractures or multiple injuries require interdisciplinary cooperation between the specialties involved.

At the latest since the Medical Services Healthcare Insurance Reform Act (MDK), the declared will of the legislation is the conversion of operations previously carried out in an inpatient setting to an outpatient setting. In trauma surgery and orthopedics numerous operations are carried out that could principally also be performed in an outpatient setting; however, a prerequisite is a medical assessment of the suitability of patients as well as an economic and normative framework that makes outpatient surgery attractive. Both the Outpatient Surgery in Hospitals Catalogue (AOP-Katalog) and the first edition of the Hybrid Diagnosis-related Groups (DRG) define interventions in trauma surgery that could be carried out in an outpatient setting. Hospitals are therefore required to find solutions for these interventions under processual and economic provisos. These range from omission of outpatient operations to the expansion as a separate financial department in the hospital. With the introduction of the hybrid DRG, the legislation enables equal remuneration for outpatient versus short-term inpatient treatment and leaves the case management up to the hospital; however, the performance of the AOP in the setting of a hospital and also hybrid case flat rates are as a rule not economically viable and bear the risk of the failure of all efforts at conversion to outpatient settings. It is necessary to carry out a fundamental revision of the remuneration and framework conditions for outpatient operations in trauma surgery and orthopedics in hospitals, involving practitioners. This is the only way that the conversion to outpatient treatment can succeed.