At the Zentralklinik Bad Berka, under the direction of Professor Merten Hommann, patients can expect outstanding care in the fields of general surgery and visceral surgery. Prof. Dr Merten Hommann is particularly renowned for his pioneering work in the treatment of neuroendocrine tumors and pancreatic surgery. The clinic is distinguished not only by its medical expertise, but also by the warm and compassionate care extended to every patient.
The Zentralklinik Bad Berka offers a wide range of visceral surgical procedures of the highest standard. From the treatment of malignant tumors of the gastrointestinal tract to diseases of the pancreas and the endocrine system – here, patients receive comprehensive care from a multidisciplinary team of specialists. An outstanding example of this interdisciplinary collaboration is the “Center for Neuroendocrine Tumors”, which is certified as a Center of Excellence by the “European Neuroendocrine Tumor Society”.
Under the leadership of Prof. Dr Hommann, the surgical team has specialized in the individual care of patients with neuroendocrine tumors. Thanks to their dedicated commitment and many years of experience, they have built up expertise that benefits patients from all over the world. The clinic relies on innovative methods such as the high-energy gamma probe for the precise localization of tumors during surgery and the use of state-of-the-art technologies such as irreversible electroporation (IRE) in pancreatic surgery.
Prof. Dr Hommann and his team place great importance on treating each patient as an individual and offering a bespoke treatment plan. In doing so, they take into account not only the latest scientific findings and technologies, but also the personal needs and wishes of the patients. The commitment of Prof. Dr Hommann and his team to research and continuing professional development ensures that the clinic remains at the cutting edge of medicine.
The editorial team of the Leading Medicine Guide had the opportunity to learn more about visceral surgery relating to the pancreas and liver in a conversation with the expert Prof. Dr Hommann.
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Visceral surgery encompasses a wide range of surgical procedures in the abdominal cavity, dealing with the diagnosis and treatment of diseases of the internal organs. These include, among others, pancreatic surgery, as well as liver surgery, which deals with diseases and tumors of the liver. These areas of surgery require specialist expertise and innovative treatment methods to ensure optimal patient care.
Diseases of the pancreas and liver can cause serious health problems that require careful medical assessment and often surgical intervention.
“There is a wide range of conditions affecting the pancreas and the liver, but of course not all of them require surgical treatment, as there are both benign and malignant conditions. Conservative therapies are also an option. Even if a malignant condition has been diagnosed, the Tumor Board holds an interdisciplinary discussion to determine whether the patient can be spared surgery. After all, one must bear in mind that for patients there is no such thing as a ‘minor’ operation – every procedure is, in the truest sense of the word, an incision. And particularly when it comes to the liver and pancreas, these are usually complex operations, with the most common conditions treated being tumors, pre-cancerous lesions or metastases. Even in the case of benign conditions, surgery is sometimes unavoidable for the patient; for example, in cases of chronic pancreatitis, which can cause not only pain but also a blockage in the bile duct or make it difficult to eat. Surgery is also performed on the liver, for instance in the case of a large but benign liver adenoma, as this can become malignant or rupture. Liver cysts are usually removed using minimally invasive surgery, as they can cause pressure or displace other structures,” explains Prof. Dr Hommann at the start of our conversation, before listing examples where surgery is not necessary:
“However, if a patient has, for example, a benign serous cystic tumor in the pancreas that causes no symptoms, surgery would not be considered. The same applies in the case of benign liver lesions, known as focal nodular hyperplasia (FNH), lobed connective tissue with a scar in the center, or in the case of a haemangioma, a benign liver tumor consisting of a cluster of abnormal blood vessels. Usually, these conditions are simply monitored at regular intervals, which is done, for example, in the case of the pancreas using an internal ultrasound, or endosonography, and in the case of the liver using an MRI with a liver-specific contrast agent.
In a healthy adult, the liver weighs approximately 1.5 kilograms. If a cyst within it grows to the size of a grapefruit, the patient will feel it. This is because, in certain positions, the cyst then causes pressure symptoms. It can also compress blood vessels, disrupting blood flow and increasing the risk of thrombosis, or it can press on the biliary tract system. If this causes noticeable symptoms, surgery should be performed. However, many people live with small cysts of which they are completely unaware and grow old with them.
The pancreas, a gland in the upper abdomen, plays a crucial role in digestion and the regulation of blood sugar levels through the production of enzymes and hormones such as insulin. The liver, the body’s largest internal organ, has a wide range of functions, including the processing of nutrients, the detoxification of harmful substances and the production of bile for digestion. In pancreatic disorders, inflammations such as acute and chronic pancreatitis, as well as pancreatic pseudocysts, are common problems. These conditions can cause severe abdominal pain, indigestion and other symptoms. Furthermore, pancreatic cancer or pancreatic tumors are a serious condition that is sometimes diagnosed late and has a poor prognosis. Liver diseases may also require various surgical procedures. Liver resections, in which part of the liver is removed, are performed for malignant liver tumors such as hepatocellular carcinoma or metastases from other types of cancer. Liver transplantation is a life-saving option for patients with end-stage liver disease, such as cirrhosis or primary sclerosing cholangitis (PSC), where the organ is no longer functioning properly. Ablative procedures such as radiofrequency ablation (RFA) or microwave ablation (MWA) can be used for small liver tumors to destroy them without performing a resection. The decision to proceed with surgical intervention for pancreatic or liver diseases requires a comprehensive assessment by an interdisciplinary team of doctors, including surgeons, oncologists, radiologists and gastroenterologists. The choice of the appropriate procedure depends on the type of disease, the stage, the location of the tumor and the patient’s state of health.
“If surgical treatment is necessary, many procedures can be performed using minimally invasive techniques. Sometimes, however, open surgery is necessary, depending on the size and location of a cyst or tumor. The trend is definitely toward minimally invasive surgery, as this offers many advantages in terms of pain reduction, recovery and healing. The procedures are often carried out with robotic assistance. With the help of a robot, for example, minimally invasive suturing is much easier, and overall, the handling of the medical instruments is more intuitive and better. But not everything can be done minimally invasively, and this must also be discussed with the patient. There is certainly no mistake in opting for open surgery, as this is sometimes definitely the better option. For instance, with certain tumors such as neuroendocrine tumors, the surgeon needs to be able to palpate the organ, which is made more difficult in minimally invasive procedures and in operations using robotics. However, this will certainly continue to develop technically in the future, so that palpation will also be possible during robot-assisted operations. Of course, as an experienced surgeon, you have a feel for how something would feel to the touch, even if you aren’t actually doing it. “We must always keep the risk-benefit ratio in mind, and the cost factor, particularly with regard to robotics, certainly plays a role,” explains Prof. Dr Hommann, adding further information regarding the duration of the operation:
“If we take the removal of a tumor in the pancreas as an example, and the tumor is located in the tail of the pancreas in the left half of the abdominal cavity, then the operation takes less than 3 hours. However, if the tumor is located in the head of the pancreas in the right-hand half of the abdominal cavity, then one must expect the operation to take between 5 and 6 hours. The shorter duration of the operation on the tail is due to the fact that no reconstruction is required on the left side. Surgery on the head of the pancreas involves a significant reconstructive component, as the pancreas must be reattached to the intestine or the stomach and the bile duct reconnected to the small intestine, which naturally takes more time. The situation is similar in liver surgery. Here, it depends on the location and size of the tumor – does a segment, an outer segment of the liver need to be removed, or even half the liver? The latter takes around 3–4 hours, while removing a segment takes about 2 hours. Everything generally takes longer once structures need to be removed and subsequently replaced or reconstructed.”
Surgical procedures in the field of visceral surgery, particularly pancreatic and liver surgery, are complex procedures that can be associated with a range of risks and complications.
One of the most common complications is bleeding during or after the operation. As many of these procedures involve manipulation of blood vessels, there is always a risk of uncontrolled bleeding, which requires careful surgical technique to prevent or manage. “Another complication is fistula formation; that is, in the case of liver surgery, a bile duct is not initially sealed and drains into the free abdominal cavity. With the pancreas, the tricky part is the pancreatic fistula, a leak in the suture between the pancreas and the small intestine or stomach, which can lead to inflammation, sepsis and secondary bleeding. This is because the aggressive pancreatic juice can erode blood vessels. Furthermore, interventional radiologists can now occlude the vessels from the inside in the event of bleeding, a procedure that is called upon in such rare cases. In this respect, my guiding principle is: ‘A hospital should only perform this operation if it is also capable of effectively managing complications in this area,’ emphasises Prof. Dr Hommann.
“In liver surgery, liver failure is the worst complication. This can occur if the remaining portion of the liver is too small to function fully. However, this is very rare today, as the potential remaining liver volume and the associated liver function can be measured much more accurately prior to surgery. In addition, surgical techniques have improved today with the aid of imaging, and thanks to modern equipment, we are able to operate with less blood loss and greater anatomical precision. Added to this are the significant improvements in anesthesia and intensive care medicine,” explains Prof. Dr Hommann.
Pancreatic cancer, also known as pancreatic carcinoma, is one of the most dangerous forms of cancer due to its often late detection and aggressive nature.
The exact causes of pancreatic cancer are not fully understood, but certain risk factors such as smoking, a family history of pancreatic cancer, chronic pancreatitis, obesity and an unhealthy diet can increase the risk. “One of the challenges with pancreatic cancer is that it often causes no early symptoms, which means it is usually only diagnosed at an advanced stage. If the tumor is located near the bile duct and blocks it at an early stage, the patient will feel this and develop jaundice without pain, which is a warning sign, and there would be a good chance of diagnosing the pancreatic cancer. In diagnosis, the key piece of evidence is a positive tissue sample. The crux of the matter is that the tumor is sometimes not hit during the biopsy; in other words, a positive tissue sample is conclusive, whereas a negative one is not. Fortunately, patients nowadays go to the doctor more quickly if they notice anything, and on top of that, diagnostic imaging has improved, and we doctors also have a better understanding of the precancerous conditions from which such a tumor can develop. “We can guide patients toward appropriate follow-up examinations to prevent this tumor from developing in the first place,” explains Prof. Dr Hommann, highlighting the improved starting point compared to the past.
When symptoms do appear, they can be non-specific and include weight loss, abdominal pain, jaundice, indigestion, nausea and vomiting, sometimes back pain, the onset of diabetes or a venous thrombosis. The diagnosis of pancreatic cancer is often made through a combination of imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS), as well as laboratory tests and tissue biopsies. Some patients may also undergo diagnostic laparoscopy to obtain further information about the tumor and its spread.
“We are also in a better position today in terms of surgical techniques and have more options available. However, it must also be said that if pancreatic cancer is not treated surgically, the prognosis is poor. Pancreatic cancer is very aggressive. For patients, this means that even if the tumor (and any metastases) has been removed macroscopically and microscopically, very few patients survive for five years, unlike with tumors that are less aggressive. This is because there may be small cancerous deposits that are not located in the surgical area and cannot be reached. And for patients who cannot undergo primary surgery and who have no metastases, there is the option of local ablation using electrical treatment (irreversible electroporation) following prior systemic therapy, which then enables prolonged survival. Which treatment is suitable for which patient must be decided on a case-by-case basis. As a rule, we try to make surgery possible for the patient through prior therapy,” says Prof. Dr Hommann on the distinctive features of pancreatic cancer and the associated challenges.
Irreversible electroporation (IRE) is a minimally invasive method for treating pancreatic cancer that uses electric fields to destroy cancer cells while sparing healthy tissue. Special electrodes are inserted into the tumor, which emit short, high-voltage electrical pulses. These create pores in the cell membranes of the cancer cells, causing the cells to die. A major advantage of IRE is its precision, as it does not use heat and therefore does not damage sensitive structures such as blood vessels and nerves. The treatment is performed under imaging guidance, such as ultrasound or CT. The entire procedure can take several hours, but the actual application of the pulses lasts only a few minutes. After IRE, patients usually remain in hospital for a few days for monitoring. Possible side effects include pain, swelling or minor bleeding. IRE can be used on its own or in combination with other treatments such as surgery or chemotherapy, and offers a promising option for patients with locally advanced pancreatic cancer.
Post-operative care and rehabilitation following pancreatic or liver surgery play a crucial role in supporting recovery and preventing complications.
“In the case of a standard partial pancreatectomy, the patient has a recovery period of approximately 7–14 days, initially in the intensive care unit, then on the general ward, depending on the extent of the procedure. Afterward, the patient usually undergoes rehabilitation, which lasts approximately 3 weeks. Here, the areas of diet and exercise are discussed once again. If, for example, the entire pancreas is removed, it is 100% certain that the patient will subsequently become insulin-dependent. In addition, the patient may need to take medication following a pancreatic resection, for example digestive enzymes. A normal life is generally possible. Patients we have operated on here travel the world and play sport,” says Prof. Dr Hommann, who also has some words of advice on prevention:
“Unfortunately, in Germany, preventive medicine does not yet hold the same status as in other countries. We tend to be a nation of reparative medicine. Yet so much can be done preventively. For instance, one should eat sensibly and not commit suicide with a knife and fork. Personally, I’m a strong advocate of regular fasting. In my opinion, one should consume very little meat (organic, of course, and preferably no pork). You really need to think carefully about your diet and make sure you don’t develop any deficiencies, taking supplements if necessary. And you should eliminate things that make you ill and stress factors (perhaps through meditation) as much as possible and get more exercise.
In good hands at Bad Berka Clinic!
Bad Berka Clinic offers diagnostic and therapeutic options of the highest medical standard, placing great emphasis on person-centered care. It works closely with specialist colleagues from other clinics, GPs and partner hospitals to ensure comprehensive patient care.
“Here in Bad Berka, we place great importance on communicative medicine. Patients should always be offered an opinion, advice and empathy. The patient and the doctor must walk a shared path and also address any fears. Patients should feel confident asking questions. For the future, I hope to see greater openness toward all medical professions. And surgeons, in particular, should learn that the medical world consists of more than just scalpels and chemotherapy. We need to broaden our medical thinking. Because there are other clever things that therapists do – people who haven’t necessarily studied medicine – which can be put to good use for the patient’s benefit. “I hope for a synthesis of all the good things in the medical world and a shared vision for the benefit of the patient,” says Prof. Dr Hommann hopefully, and we conclude our conversation with these fine thoughts.
Thank you very much, Prof. Dr Hommann, for this extremely engaging and highly informative conversation!
