Results
In total, 48 lawsuit cases were found through a search of the written judgments. Twenty-six cases were excluded due to being non-colonoscopy cases (n=2), non-perforation cases (n=18), non-colon perforation (n=1) and cases with insufficient clinical information (n=5) (Figure 1). Finally, 22 cases were considered for the analysis. Demographics and clinical characteristics are presented in Table 1. The most common perforation location was the sigmoid colon (54.5%). Perforations occurred most frequently after polypectomy (68.2%). 40.9% of perforations were detected by a doctor during colonoscopy, and the rest (59.1%) were found after the patient complained of abdominal pain or hematochezia. Perforations were most often detected 24 hours after colonoscopy (40.9%). Thirteen patients (59.1%) were transferred to other institutions for optimal management after recognition of perforation. Seventeen (77.3%) of the total patients recovered after treatment, while five (22.7%) died. Twenty-one patients, except for one patient who died of cardiac arrest after perforation, underwent surgery for perforation treatment. The most common surgeries were simple closure and temporary colostomy with seven patients each. Table 2 presents the detailed nine cases in which perforation was detected 24 hours later after colonoscopy. All nine patients underwent polypectomy, and six of them had symptoms such as abdominal pain, hematochezia, or vomiting 21 to 57 hours after colonoscopy. Two out of nine revisited the hospital after 18 hours or more in spite of the symptom onset (Case 4, 20). For cases 11 and 20, the diagnosis of perforation was delayed because the patients visited the hospital after meals. Two patients had symptoms when they were in the hospital, but the diagnosis was delayed because no perforation was found even in additional colonoscopy or x-ray (Case 5, 15). Table 3 shows the judicial information for all 22 lawsuits. Most cases (95.5%) were concluded at first trial and 91.0% were ruled in favor of the plaintiff. The median compensation claimed by plaintiffs was 47,917.83 USD, but the median compensation awarded was 9,335.47 USD, which is a fifth of the median compensation claimed. All plaintiffs made more than one allegation against defendants which were categorized into three groups: performance error (n=22), improper monitoring after colonoscopy (n=7), and lack of informed consent (n=8). Of the eight cases claiming lack of informed consent, five were judged as negligence on the part of the doctor. Four doctors out of the five did not explain the possibility of perforation before colonoscopy, and one explained it to the caregiver, not to the patient. In the case of improper monitoring after colonoscopy, four cases (in which perforation diagnosis was delayed because the patients’ complaints of abdominal pain were ignored) and one case (in which no appropriate measures were taken although perforation was suspected during the colonoscopy) were judged as negligence on the part of the doctor. All plaintiffs claimed the perforation occurred due to the doctor’s performance error, but the courts did not judged it as the negligence of the doctor in four cases. In addition, for 13 cases, the courts declared doctor negligence but reduced the liability for damage. The most common reason of extenuating circumstances was the doctor’s quick and appropriate response to perforation (Figure 2). Table 4 shows data comparing the three groups based on Flint’s classification. Ten patients were classified as Grade 1. Grade 2 included seven patients, and Grade 3 included five. There was no statistically significant difference in the time elapsed from procedure to diagnosis of perforation between the three groups (p=0.102). Patients in Grade 2 experienced a longer time lapse from procedure to diagnosis of perforation than those in Grade 3 who had severe colon damage. The difference in the compensation between the groups was statistically significant (p=0.016) and, as a result of Bonferroni Correction, the groups with significant differences were Grade 1 and Grade 3. The median compensation for Grade 3 was 4.6 times higher than that of Grade 1. As a result of analyzing the loss of earning capacity affecting the indemnity for damages (Table 5), ’100% loss of the remaining lifespan’ was recognized in all cases where the patient died (n=5). On the other hand, when the patient recovered, there were various court’s decisions regardless of the type of surgery the patients received. Among them, ’ Not recognized of loss of labor ability’ was the highest with seven cases.