耳鼻喉科扁桃体手术和其他标准程序的不当行为索赔和意外结果。

Jochen P Windfuhr
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引用次数: 0

摘要

背景:在德国,鼻中隔成形术、扁桃体切除术(有腺样体切除术和无腺样体摘除术)和颈部淋巴结切除术是最常见的50种住院手术。扁桃体囊内切除术(即扁桃体切除术)越来越多。本研究的目的是评估与扁桃体切除术(TE)、腺样体切除术(AE)、扁桃体切开术(TT)、纵隔成形术(SP)和颈淋巴结切除术(LN)相关的技术陷阱和陷阱以及所谓的医疗事故,健康保险公司(MDK)和德国地区法医研究院的医疗服务部门收集TE、TT、AE、LN和SP后的匿名并发症病例。结果:我们的调查回复率为55.9%。法医研究院提供了9个案例,49个案例由地区调解委员会提交,MDK没有提交。所有法医案例均与扁桃体切除术后的放血有关,包括两名儿童(5岁和8岁)和七名成年人(20至69岁)。扁桃体切除术后出血(PTH)平均发生8.7天;4名患者在家中出现出血(分别为第5天、第8天、第9天和第17天)。6名患者出现了需要手术干预的反复出血。三个调解委员会提交了与TT(1)、AE(4)、LN(3)、SP(16)和TE(25)有关的裁决。死亡病例未登记。49例病例中只有3例(6.1%)被评估为手术不当,包括脊髓副神经损伤、TE的错误指征和插入口塞后的牙齿损伤。在AE和TE(29)、LN(28)和SP(14)之后,对医疗法律文献的审查产生了71项已发表的判决,其中37项在LN(16;57%)、TE(10;37%)、SP(8;57%)和AE(2;100%)之后导致渎职赔偿。在TE后的27项试验中,有16例PTH导致死亡(5)或Apellic综合征(5)。只有2例患者在手术当天出现出血并发症。16项试验基于SP后的渎职索赔,包括缺乏知情同意(6)、嗅觉缺失(4)、间隔穿孔(2)、额叶损伤(2)和鼻子干燥(2)。LN手术后的试验仅与脊髓副神经损伤有关(28),包括19例患者缺乏知情同意。在29起AE/TE审判中的7起、28起LN审判中的9起和14起SP审判中的6起中,49起案件(69%)由被告决定,22起案件(31%)由原告决定并给予金钱赔偿。AE/TE、LN(11)和SP(2)未登记知情同意。结论:德国未系统收集TE、TT、ATE、SP和LN后的复杂病例。可以假设,并非所有复杂的病例都发表在医学文献或法律期刊上,因此无法用于科学研究。在审判阶段之前,被指控的医疗不当行为被证明不到6%。大约一半的案件在法庭上得到原告的裁决或和解。适当的心理咨询、检查、适应症、知情同意书和随访文件有助于外科医生进行诉讼。PTH的充分并发症管理至关重要,包括对患者/父母的指导、对医务人员的指导和现成的手术器械。危及生命的PTH的成功结果广泛基于跨学科方法中的正确气道管理。电手术扁桃体切除术技术被反复标记为TE后出血并发症的危险因素。各机构应每年对个人PTH比率进行分析。关于LN后脊髓附件神经损伤的专家意见和法院判决相互矛盾是由于缺乏手术标准。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology.

Background: Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

Methods: A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

Results: The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

Conclusion: Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

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