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.