Professional Liability in Orthopaedics and Traumatology in Italy

Background

Interest in medical errors has increased during the last few years owing to the number of medical malpractice claims. Reasons for the increasing number of claims may be related to patients’ higher expectations, iatrogenic injury, and the growth of the legal services industry. Claims analysis provides helpful information in specialties in which a higher number of errors occur, highlighting areas where orthopaedic care might be improved.

Questions/purposes

We determined: (1) the number of claims involving orthopaedics and traumatology in Rome; (2) the risk of litigation in elective and trauma surgery; (3) the most common surgical procedures involved in claims and indemnity payments; (4) the time between the adverse medical event and the judgment date; and (5) issues related to informed consent.

Methods

We analyzed 1925 malpractice judgments decided in the Civil Court of Rome between 2004 and 2010.

Results

In total, 243 orthopaedics claims were filed, and in 75% of these cases surgeons were found liable; 149 (61%) of these resulted from elective surgery. Surgical teams were sued in 30 claims and found liable in 22. The total indemnity payment ordered was more than €12,350,000 (USD 16,190,000). THA and spinal surgery were the most common surgical procedures involved. Inadequate informed consent was reported in 5.3% of cases.

Conclusions

Our study shows that careful medical examination, accurate documentation in medical records, and adequate informed consent might reduce the number of claims. We suggest monitoring of court judgments would be useful to develop prevention strategies to reduce claims.     

Ergonomics in Laparoendoscopic Single-Site Surgery: Survey Results

Background

Ergonomic issues are frequently reported by surgeons performing laparoendoscopic single-site (LESS) surgery. However, few studies have analysed this issue.

Methods

We used a web format survey to evaluate the opinion of surgeons with experience in this laparoscopic technique. This survey collected demographic information, surgical experience, physical and psychological symptoms, and technical problems related to this type of surgery.

Results

Some 78 surgeons filled out the questionnaire. All participants had clinical experience in this type of laparoscopic approach, and 68?% had performed more than 30 procedures. Two or more musculoskeletal symptoms were reported during or after performing LESS surgery by 81?% of all surgeons. Surgeons with more experience in this approach reported fewer symptoms and technical difficulties.

Conclusions

LESS surgery is accompanied by musculoskeletal problems and technical difficulties for surgeons. Technological advancements and greater surgical experience in the technique will alleviate these issues. More in-depth ergonomic studies are needed.     

Karriere im Gegenwind

Aim

The aim of our national survey was to determine personal, working, and career conditions of women in academic surgery in Germany.

Methods

A questionnaire with 47 items was sent to 261 female surgeons working in 36 departments of general, abdominal, trauma, and vascular surgery. A total of 134 (51.3%) from all 36 surgical departments responded with completed surveys.

Results

The mean age of the women was 35.1 years (range 27 to 54). Seventy-eight percent of the surgeons worked in departments for general or abdominal surgery, 17% in trauma, and 5% in vascular surgery. 45% of the women had finished residency and 19% were in faculty positions. Eighty percent of those asked were mostly or always content with their working conditions. However, 79% perceived career obstacles in academic surgery. The most frequently addressed obstructions were: predominant male structures (80%), the absence of mentoring programs (70%), too few operative cases per month (67%), and no equality of career opportunities compared to male surgeons (60%).

Conclusions

To reduce career obstructions, which were reported by 79% of the female surgeons, and to encourage those 33% who wanted to leave academic surgery, it seems necessary to improve cooperation between female surgeons, department chairs, and governmental institutions.     

Einfluss der Erfahrung des Operateurs in der Hüftendoprothetik

Background

As a consequence of limited personnel and financial resources, the increase in total hip arthroplasties places higher demands on orthopedic surgeons.

Objectives

In order to maintain high quality treatment, the correlation between surgical experience, duration of surgery and risk of complications was examined.

Material and methods

The surgery time and, if applicable, complications (until discharge from hospital) of 1129 total hip arthroplasties over a period of 4 years were evaluated retrospectively.

Results

The group of most experienced surgeons needed an average time of 53.2?±?17.6 min for each implantation, followed by moderately experienced surgeons (74.5?±?25.5 min) and less experienced surgeons (80.8?±?21.9 min). Of all included cases, a total of 41 complications until discharge from hospital occurred. The number of complications increased with duration of surgery, whereby the risk of complications was significantly lower for shorter surgery times conducted by the most experienced surgeons as well as moderately experienced surgeons. The complication risk of less experienced surgeons remained constant independent of surgery duration.

Conclusion

These results underline the recommendations of the German Endocert system, which determine a minimum number of total joint arthroplasties as a quality indicator not only for hospitals but also for individual surgeons.     

Esophageal Perforation and Rupture: a Comprehensive Medicolegal Examination of 59 Jury Verdicts and Settlements

Background

Consequences accompanying esophageal perforation make this complication a prime litigation target. We characterize factors in jury verdicts and settlements regarding esophageal perforation, including operative procedure, patient demographics, alleged cause(s) of malpractice, outcome, and other factors.

Methods

Pertinent court records were examined for the aforementioned factors.

Results

Gastroenterologists, general surgeons, and anesthesiologists were the most commonly named defendants. Two thirds of outcomes were for the defendant, and 11.9 % were settled (median—$650,000); 20.3 % resulted in awarded damages (median—$1.2 M). Esophagogastroduodenoscopy was the most commonly litigated procedure, followed by intubation and Nissen fundoplication. Necessity of repair, delayed diagnosis, death, and inadequate consent were the most frequently cited factors in litigation.

Conclusions

An understanding of the factors important in determining legal responsibility is of great interest for practitioners in multiple specialties. The requirement of surgical repair and a delay in diagnosis are two of the most common factors present in litigated cases resulting in a payment. The importance of explicitly listing esophageal perforation in the informed consent for esophagogastroduodenoscopy, abdominal surgery, and any patients at risk of intubation injury needs to be emphasized.     

Energy consumption during simulated minimal access surgery with and without using an armrest

Background

Minimal access surgery (MAS) can be a lengthy procedure when compared to open surgery and therefore surgeon fatigue becomes an important issue and surgeons may expose themselves to chronic injuries and making errors. There have been few studies on this topic and they have used only questionnaires and electromyography rather than direct measurement of energy expenditure (EE). The aim of this study was to investigate whether the use of an armrest could reduce the EE of surgeons during MAS.

Method

Sixteen surgeons performed simulated MAS with and without using an armrest. They were required to perform the time-consuming task of using scissors to cut a rubber glove through its top layer in a triangular fashion with the help of a laparoscopic camera. Energy consumptions were measured using the Oxycon^® Mobile system during all the procedures. Error rate and duration time for simulated surgery were recorded. After performing the simulated surgery, subjects scored how comfortable they felt using the armrest.

Results

It was found that O₂ uptake (VO₂) was 5 % less when surgeons used the armrest. The error rate when performing the procedure with the armrest was 35 % compared with 42.29 % without the armrest. Additionally, comfort levels with the armrest were higher than without the armrest. 75 % of surgeons indicated a preference for using the armrest during the simulated surgery.

Conclusion

The armrest provides support for surgeons and cuts energy consumption during simulated MAS.     

Uncovering Malpractice in Appendectomies: a Review of 234 Cases

Background

General surgery is a “high-risk specialty” with respect to medical malpractice rates, and appendicitis is one of the most common diagnoses encountered by practitioners. Our objectives were to detail issues affecting malpractice litigation regarding appendicitis and appendectomies, including outcomes, awards, alleged causes of malpractice, and other factors instrumental in determining legal responsibility and increasing patient safety.

Study Design

Publically available federal and state court records were examined for pertinent jury verdict and settlement reports. Information from 234 pertinent cases was collected, including alleged causes of malpractice and outcomes.

Results

Of the 234 cases included in this study, the most common factor noted was an alleged delay in diagnosis (67.1 %), followed by intraoperative negligence (16.2 %). Alleged deficits in informed consent, although only specifically cited as a cause of malpractice in 1.3 % of cases, were found to be an important aspect of many cases. In total, 59.8 % of cases were ruled in favor of the physician, 23.7 % in favor of the plaintiff, and 5.5 % reached a settlement. The average plaintiff award was US$794,152, and the average settlement award was US$1,434,286.

Conclusion

An important strategy to decrease liability in a physician's practice is prompt evaluation of an appendicitis patient. An integral part of this is efficient communication between physicians practicing a wide variety of specialties, especially including practitioners in emergency medicine and general surgery. Additionally, completing a thorough informed consent explaining all aspects of the procedure including the factors we outline will not only increase patient awareness of potential risks but also protect the physician in the face of litigation.     

Gutachterliche Behandlungsfehlervorwürfe bei der Behandlung von Karotisstenosen

Introduction

Surgery and interventions on the internal carotid artery are very common and the outcome is well defined by multiple trials. How often can malpractice be observed?

Method

Alleged malpractice in carotid endarterectomies and stenting was investigated in a nationwide study based on documents from 2006?C2010. Documents relating to out-of-court procedures by the expert committees and arbitration boards were provided by all German Medical Chambers (in the case of the North Rhine Medical Chamber the authors had access to the files in their entirety). In addition, court cases were also included in which the authors had acted as court experts.

Results

The overall number of complications which led to allegations of malpractice is remarkably low in proportion to the high number of vascular surgery and other procedures performed in the 5-year period studied, assuming a rate of complications of 3% and a total number of vascular surgery and other procedures amounting to 100,000 or 25,000 per year.

Conclusions

The low number of confirmed vs. alleged malpractice (1 in 10) is, on the one hand, considered evidence for good medical service being provided in the treatment of carotid stenoses in Germany. Also, patient information is provided very carefully and responsibly before interventions relating to the carotid artery are performed. In view of the many documents on record, on the other hand, it may be questioned whether a need for an intervention is not seen more often than would be suggested by the studies on which the criteria of the applicable quality standard are based. In other words, could it be that decisions for surgery or other interventional treatments are being made rather generously not mentioning sufficiently the possibilities of the natural history of this disease?     

Lawsuits After Primary and Revision Total Hip Arthroplasties: A Malpractice Claims Analysis

Background

As the prevalence of total hip arthroplasty (THA) expands, so too will complications and patient dissatisfaction. The goal of this study was to identify the common etiologies of malpractice suits and costs of claims after primary and revision THAs.

Maintaining a Surgery Service for Local Hospitals Under the Situation of a Decreasing Number of Surgeons in a Region of Japan

Background

The number of surgeons is decreasing in Japan, leading to the problem of how to maintain a surgery service in local hospitals. We introduce our strategy for supporting ongoing surgical services in regional hospitals by dispatching surgeons temporarily to assist in operations.

Methods

We conducted a questionnaire-based survey at three local hospitals in Tottori and a neighboring prefecture to which surgeons from our department were temporarily dispatched over 5 years from January 2008 to March 2013.

Results

We supported 686 operations at three hospitals over 5 years. The average age of the patients was 72.4 years. Of the diseases treated, 45.1 % were malignant, and 54.9 % were benign. The emergency operation rate was 17.3 %.

Conclusions

Our strategy has produced a continuous surgical service at local hospitals in the face of diminishing numbers of surgeons. We recommend that such a strategy be adopted in other regions in which there are a decreasing number of surgeons and where it is not easy to move patients elsewhere for care.     

Use of mesh for hiatal hernia repair: a survey of SAGES members

Background

Mesh use during hiatal hernia repair (HHR) has been suggested to be safe and effective. Concern has been raised about the risk of mesh-related complications, and the higher risk of complications if revisional hiatal surgery is undertaken after mesh has been used. Available data have not established a clear role for mesh in HHR. To assess surgeons’ adoption of the use of mesh for HHR, SAGES members were surveyed regarding their practice related to mesh use for HHR.

Methods

Between April and September 2010, an internet-based survey tool was used to survey SAGES members. Potential participants were contacted via e-mail and invited to complete the survey. Of the 5,323 attempted contacts, 5,024 reached active e-mail accounts. From these, 2,518 members responded (50% response rate).

Results

The majority of respondents currently perform HHR (69%), but only 18% perform more than 20 per year. Of those who perform HHR, 94% use a laparoscopic approach for the majority of repairs. Whereas 25% of surgeons use mesh for the majority of repairs, 23% of surgeons never use mesh. When mesh is used, an absorbable mesh is most commonly used (67%). An onlay technique is used by 93% of respondents. Only 7% of surgeons who have been in practice more than 20?years use mesh compared with 59% of surgeons in practice less than 10?years. Fifty-seven percent of surgeons have never performed revisional foregut surgery on a patient with prior mesh.

Conclusions

Although the majority of surgeons have used mesh for HHR, it is the minority who use it routinely, with younger surgeons more likely to use mesh than older surgeons. Absorbable mesh is most commonly used. When mesh is used, an onlay technique is most commonly used. There is no clear accepted use of mesh in hiatal hernia repair.     

Evaluation of 2,590 urological laparoscopic surgeries undertaken by urological surgeons accredited by an endoscopic surgical skill qualification system in urological laparoscopy in Japan

Background

In 2003, the Japanese Urological Association (JUA) and Japanese Society of Endourology (JSE) established a urological laparoscopic skill qualification system, called the Endoscopic Surgical Skill Qualification System in Urological Laparoscopy of JUA and JSE (ESSQSJJ). The main goal of the system is to decrease the prevalence of complications associated with laparoscopic surgery. To validate the qualification system, perioperative outcome and the prevalence of complications in different types of urological laparoscopic surgery performed by accredited surgeons were evaluated.

Methods

One hundred thirty-six surgeons who obtained the qualification in 2004 were prospectively asked to submit intraoperative and postoperative data of their latest 20 cases at the end of 2009, along with the number of laparoscopic urological surgeries performed in each year for a 5-year period (2004–2009). Intraoperative and postoperative complications were graded according to the Satava classification and modified Clavien classification, respectively.

Results

Data of 2,590 urological laparoscopic surgeries of 130 surgeons, including 904 laparoscopic radical nephrectomies, 430 laparoscopic nephroureterectomies, 390 laparoscopic adrenalectomies, 320 laparoscopic radical prostatectomies, and 170 laparoscopic partial nephrectomies, were analyzed. Complications were noted in 97 (3.7%) patients. Major intraoperative complications (grade II or III) occurred in 32 (1.2%) patients, and major postoperative complications (grade III or higher) occurred in 24 (0.9%) patients. The prevalence of conversion to open surgery, allogeneic transfusion, and perioperative mortality was 2.5%, 1.6%, and 0%, respectively. The number of surgeries performed by each qualified surgeon or the role of the surgeon (main operator vs. mentor/instructor) in the surgery did not affect the prevalence of intraoperative complications or postoperative complications. The open conversion rate was significantly higher in surgeons with a low surgical volume.

Conclusions

ESSQSJJ can ensure urological laparoscopic surgeons who can perform various types of urological laparoscopic surgeries with a low prevalence of perioperative complications and reasonable outcomes.     

Workforce Shortage for General Surgeons: Results from the Society for Surgery of the Alimentary Track (SSAT) Surgeon Shortage Survey

Background

Population shifts among surgeons and the general populous will contribute to a predicted general surgeon shortage by 2020. The Public Policy and Advocacy Committee of the Society for Surgery of the Alimentary Tract designed and conducted a survey to assess perceptions and possible solutions from important stakeholders: practicing surgeons of the society, general surgery residents, and medical students.

Results

Responses from 1,208 participants: 658 practicing surgeons, 183 general surgery residents, and 367 medical students, were analyzed. There was a strong perception of a current and future surgeon shortage. The majority of surgeons (59.3 %) and residents (64.5 %) perceived a current general surgeon shortage, while 28.6 % of medical students responded the same. When asked of a perceived general surgery shortage in 20 years, 82.4, 81.4, and 51 % said “yes”, respectively. There were generational differences in responses to contributors and solutions for the impending shortage. Surgeons placed a high value on improving reimbursement, tort reform, and surgeon burnout, while residents held a strong interest in a national loan forgiveness program and improving lifestyle barriers.

Conclusion

Our survey offers insight into possible solutions to ward off a surgeon shortage that should be addressed with programmatic changes in residency training and by reform of the national health care system.     

A Qualitative Assessment of a Provincial Quality Improvement Strategy for Pancreatic Cancer Surgery

Purpose

A study released in Ontario, Canada (1999) found a positive relationship between surgical volume and patient outcomes after pancreatic resection for cancer. In response, a province-level quality improvement (QI) strategy was initiated, which included the development and dissemination of a standards document and an audit and feedback exercise with surgeons. We assessed perceptions and actions of Ontario surgeons to this QI strategy.

Methods

We conducted semistructured interviews with surgeons and chiefs of surgery at three types of hospitals providing pancreatic cancer surgery, including hospitals that provided high volumes of surgery after 2001, hospitals that provided low volumes of surgery after 2001, and hospitals that provided low volumes of surgery before 2001 and stopped after year 2001. High-volume hospitals performed ten or more surgeries annually. The interview guide was based on Pathman’s model of physician practice change (i.e., awareness, agreement, adoption, and adherence). Grounded theory guided data collection and analysis.

Results

Twenty-four interviews were completed. All groups were aware of the 1999 province-level QI strategy and agreed in principle with the standards document recommendations. Many surgeons had concerns regarding the number of cases necessary to be considered high-volume. Decisions to cease pancreas cancer surgery were occurring before 1999 and made at the surgeon level, often with input from the chief of surgery, but rarely with input from hospital administration.

Conclusions

Surgeons were aware of and agreed in principle with the province-level QI strategy for pancreas cancer surgery. Decisions to continue or cease performing surgery were made by individual surgeons.     

Quality Improvement in Colorectal Cancer in Local Health Integration Network 4 (LHIN 4) Project (QICC-L4): Integrated Knowledge Translation in a Large Geographic Region

Background

Stakeholders suggest that integrating end users into the planning and execution of quality improvement interventions may more effectively close quality gaps. We tested if such an approach could improve the quality of colorectal cancer surgery in a large geographic region (i.e., LHIN4) in Ontario, Canada.

Methods

All LHIN4 surgeons who provide colorectal cancer surgery were invited to an October 2006 inaugural QICC-L4 workshop and subsequent workshops in 2008, 2010, and 2012. At workshops, surgeons selected clinically relevant quality markers for targeted improvement and interventions to achieve improvements. Selected markers included rates of colon and rectal radiology imaging, rate of pathology reporting of rectal radial margin distance, and rate of positive rectal radial margins. To date, implemented interventions have included audit and feedback, tailoring interviews to identify barriers and facilitators to optimal quality, and preoperative internet-based patient reviews. Hospital and regional cancer centre charts provide audit data for annual feedback reports to surgeons.

Results

Participating surgeons at workshops and surgeon participants in preoperative reviews treated approximately 70 % of all LHIN4 patients undergoing colorectal surgery. For years 2006–2012, the rate of radiology imaging for colon and rectal cases increased from 70 to 91 % and from 71 to 91 %, respectively. For rectal cases, the rate of reporting radial margins increased (55–93 %), and the rate of positive radial margins decreased (14–6 %).

Conclusions

Initiation of the integrated knowledge translation QICC-L4 project in a large geographic region was associated with marked improvements in relevant colorectal cancer surgery quality markers.     

Medically refractory gastroesophageal reflux disease in the obese: what is the best surgical approach?

Background

Obesity is a recognized risk factor for gastroesophageal reflux disease (GERD). Traditional antireflux surgery (fundoplication) may not be appropriate in the morbidly obese, especially when other effective alternatives exist (bariatric surgery).

Methods

A 13-item survey was designed to elicit professional opinions regarding the treatment of medically refractory GERD in obese patients. Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) were randomly selected and emailed a link to an online survey.

Results

A total of 550 surgeons were contacted via email, and 92 (17 %) completed the survey. Of the respondents, 88 % perform laparoscopic antireflux surgery, 63 % perform bariatric surgery, and 59 % perform both. Overall, 77 % completed a minimally invasive surgery fellowship. In response to the question “Would you perform a laparoscopic fundoplication in a patient with medically refractory GERD and a BMI of ‘X’?” surgeons were less likely to offer fundoplication at a higher body mass index (BMI). The majority of respondents felt that laparoscopic Roux-en-Y gastric bypass was the best option (91 %), followed by laparoscopic sleeve gastrectomy (6 %). Many had a morbidly obese patient with a primary surgical indication of GERD denied a bariatric procedure by their insurance company (57 %), and 35 % of those surgeons chose to do nothing rather than subject the patient to a fundoplication. Respondents uniformly felt that bariatric surgery should be recognized as a standard surgical option for treating GERD in the obese (96 %).

Conclusion

When surgical treatment of GERD is indicated in an obese patient, bariatric surgery is the optimal approach, in the opinion of surgeons responding to our survey. Unfortunately, third-party payers often decline to provide benefits for a bariatric procedure for this indication. Additional data is necessary to confirm our belief that the opinions elicited through this survey are consistent with the standard of care as defined by the medical community.     

The Relationship between Volume and Outcome after Bariatric Surgery: A Nationwide Study in Taiwan

Background

This study purposed to explore the impact of hospital volume and surgeon volume on hospital resource utilization after bariatric surgery and to identify the predictors of length of stay (LOS) and hospital treatment cost in a nationwide population in Taiwan.

Methods

This population-based cohort study retrospectively analyzed 2,674 bariatric surgery procedures performed from 1997 to 2008. Hospitals were classified as low- and high-volume hospitals if their annual number of bariatric surgeries were <35 and ??35, respectively. Surgeons were classified as low- and high-volume surgeons if their annual number of bariatric surgeries were <15 and ??15, respectively. Hierarchical linear regression models were used to predict LOS and hospital treatment cost.

Results

The mean LOS was 7.67?days and the LOS for high-volume hospitals/surgeons was, on average, 28%/31% shorter than that for low-volume hospitals/surgeons. The mean hospital treatment cost was US$2,344.08, and the average hospital costs for high-volume hospitals/surgeons were 10%/13% lower than those for low-volume hospitals/surgeons. Advanced age, male gender, high Charlson co-morbidity index, and current treatment in a low-volume hospital, by a low-volume surgeon, and via open gastric bypass were significantly associated with long LOS and high hospital treatment cost (P?Conclusions The data suggest that annual surgical volume is the key factor in hospital resource utilization. The results improve the understanding of medical resource allocation for this surgical procedure and can help to formulate public health policies for optimizing hospital resource utilization for related diseases.     

Assessing Patterns of Practice of Sentinel Lymph Node Biopsy for Breast Cancer in Latin America

Introduction

There is a lack information regarding how sentinel lymph node biopsy (SLNB) for breast cancer is carried out today in developing countries and how it was adapted. To rectify this situation we performed a pattern-of-practice survey amongst practicing surgeons in Latin America (LA).

Methods

A survey was developed to assess current surgical practice in breast cancer, use of SLNB, limitations to the implementation, training, technique variations, and observed adverse events. A total of 30 surgical associations and breast surgery societies in 18 Latin American countries were invited to participate. Surveys were distributed among member of these associations and 76.7 % of those contacted answered the survey. Responses were limited only to those who reported treating breast cancer patients.

Results

A total of 463 surgeons who manage breast cancer responded. Over 53 % of surgeons do not have sub-specialty training. Only 47.7 % have a high-volume case load, of which 87.8 % routinely perform SLNB. The main limitations perceived to the implementation of SLNB were a lack of resources/equipment (48 %) and training opportunities (33 %). Over 60 % reported that fewer than half of their patients were eligible for SLNB and 67.8 % reported that they were involved in teaching this technique to residents.

Conclusions

A significant proportion of surgeons that treat breast cancer cases in LA have not had sub-specialty training or manage a low volume of cases. Among those surgeons with a high-volume caseload, SLNB is routinely performed. SLNB training during residency represents an opportunity for improvement in the region.