Fehler und Gefahren: Tonsillektomie und andere Standard-Eingriffe

Zusammenfassung

Hintergrund:

Die Standardeingriffe Septumplastik, Tonsillektomie, Adenotonsillektomie und Halslymphknotenentfernung zählen zu den 50 häufigsten stationär durchgeführten Operationen in deutschen Krankenhäusern. Zunehmend häufig werden Tonsillotomien vorgenommen. Insgesamt handelt es sich um etwa 380 000 Eingriffe im Jahr. Diese Abhandlung soll sich mit Fehlern und Gefahren von Tonsillektomie (TE), Adenotomie (AT), Tonsillotomie (TT), Septumplastik (SP) und Halslymphknotenentfernung (LK) auseinandersetzen.

Methoden:

Es wurden sämtliche Gutachterkommissionen, Medizinische Dienste der Krankenkassen und Institute für Rechtsmedizin in Deutschland um anonymisierte Datenübermittlung zu Fällen nach TE, TT, AT, LK und SP per Anschreiben gebeten. Die Resultate sollten vor dem Hintergrund der aktuellen medizinischen Literatur und publizierten Gerichtsurteilen im Zusammenhang mit diesen Operationen diskutiert werden.

Ergebnisse:

Die Antwortrate auf unsere Umfrage lag insgesamt bei 55,9%. Insgesamt wurden 9 Fälle aus der Rechtsmedizin (Sektionsprotokolle), 49 von den Gutachterkommissionen und kein Fall vom MDK genannt. In allen 9 Fällen der rechtsmedizinischen Institute handelte es sich um tödlich verlaufene Blutungskomplikationen nach TE. Hierunter befanden sich 2 Kinder im Alter von 5 und 8 Jahren sowie 7 Erwachsene im Alter zwischen 20 und 69 Jahren. Die zum Tode führenden Blutungsereignisse hatten sich durchschnittlich nach 8,7 Tagen ereignet, in 4 Fällen zuhause (5., 8., 9., 17. Tag). In 6 Fällen war den Blutungen mindestens eine revisionsbedürftige Blutungskomplikation vorausgegangen. Die von den Gutachterkommissionen bearbeiteten 49 Behandlungsfehlervorwürfe betrafen TT (1), AT (4), LK (3), SP (16) und TE (25). Letale Verläufe befanden sich nicht darunter, nur in 3 Fällen wurden überhaupt Behandlunsgfehler bejaht (6,1%). Hierbei handelte es sich um eine N.accessoriusläsion nach LK, eine falsche OP-Indikation und einen Zahnschaden nach TE. Die Recherche in den juristischen Suchmaschinen ergab 71 publizierte Urteile. Hierunter fanden sich 29 nach AT und TE, 28 nach LK und 14 nach SP. Von den 71 Verfahren führten 37 zu Verurteilungen wegen Behandlungsfehlern nach LK (16; 57%), TE (11; 41%), SP (8; 57%) und AT (2; 100%). Unter den 27 TE-Verfahren finden sich 16 wegen Blutungskomplikationen, nur 2 davon hatten sich am OP-Tag ereignet. Wegen der Blutungskomplikationen verstarben 5 Patienten, 5 behielten ein apallisches Syndrom zurück. Die Klagegründe nach SP waren sehr heterogen, am häufigsten wurden Aufklärungsmängel (6), Riechstörungen (4), Septumdefekte (2), Schädelbasisverletzung (2) und Austrocknung der Nase (2) vorgeworfen. Die 28 Verfahren nach LK befassten sich ausschließlich mit Accessoriusschäden, Aufklärungsmängel wurden in 19 Verfahren vorgeworfen. Zu Schmerzensgeldzahlungen wurden die beklagten in 7 von 29 AT/TE-Verfahren, 9 von 28 LK-Verfahren und 6 von 14 SP-Verfahren verurteilt. In keinem Fall nach AT/TE führten Aufklärungsmängel zur Verurteilung, wohl aber in 11 Verfahren nach LK und 2 SP-Verfahren.

Schlussfolgerungen:

In Deutschland ist eine zufriedenstellende Übersicht zur Komplikationsdichte und Häufigkeit juristischer Auseinandersetzungen der genannten Standardeingriffe nicht erhältlich. Es muss davon ausgegangen werden, dass nicht jede Auseinandersetzung oder jede Komplikation in medizinischen oder juristischen Publikationsorganen veröffentlicht wird. Ein Behandlungsfehlervorwurf ist bei den untersuchten Standardeingriffen außergerichtlich in weniger als 6%, gerichtlich in etwa der Hälfte der Fälle begründet. Medizinische Beratung, Indikationsstellung, Aufklärungsgespräch, Operationsausführung und Nachsorge müssen lückenlos dokumentiert werden, um als Operateur bei juristischen Auseinandersetzungen bestehen zu können. Vor allem bei der TE muss für ein adäquates Komplikationsmanagement Sorge getragen werden. Dies beinhaltet auch Verhaltensmaßnahmen der Patienten(eltern) im Fall der Nachblutung, transparente Anweisungen für die Abläufe in der Abteilung, Bereithalten von Instrumentarium und Airway-Management. Die stationäre Behandlungsdauer darf individualisiert werden. Operative Techniken beeinflussen die Charakteristik der Nachblutungen, die jährlich einer Analyse unterzogen werden sollten. Das Fehlen von definierten medizinischen Standards zur Schonung des N.accessorius führt gelegentlich zu widersprüchlichen Einschätzungen der Gutachter, denen die Gerichte in den Urteilverkündungen in der Regel folgen.

Abstract

Faults and Failure 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 alleged medical malpractice, technical traps and pitfalls 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 or medico legal implications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published verdicts in Germany.

Results:

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed 9 cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including 2 children (5 and 8 years of age) and 7 adults (aged 20–69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; 4 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. 3 Conciliation Boards submitted expert opinions concerning cases TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only 3 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 (11; 41%), 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 based on LN 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 thorough 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, readily available surgical instruments and appropriate 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.

Schlüsselwörter

Tonsillektomie - Tonsillotomie - Septumplastik - Halslymphknoten - Fehler - Gefahren - Behandlungsfehler - Nachblutung - Komplikationen - Septumdefekt - Accessoriusläsion - Chylusfistel

Key words

tonsillectomy - tonsillotomy - adenoidectomy - septoplasty - cervical lymph node - malpractice - litigation - complication - negligence - death - fatality

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