Cancer patients 2 years after the operation of the wound does not heal because of the gauze left during the operation? Family claims of 880,000

Brief facts of the case

The patient, Mr. Pang (62 years old), was admitted to the surgical department of the municipal hospital for more than 1 month due to distension with blood in the stool, and was admitted to the hospital for diagnosis: malignant tumor of the rectal canal and hypertension. After admission, patients undergo laparoscopic radical resection of rectal cancer (L-APR) + extensive abdominal adhesion decomposition + special treatment of abdominal malignancy under general anesthesia.

Intraoperative hemostatic cotton and 5 compressive strips of yarn were given due to presacral bleeding to stop bleeding. Pathological manifestations (rectal) invasive ulcerated tubular adenocarcinoma, high-medium differentiation, tumor size 4 cm× 3.5 cm× 1.5 cm, invasion of the deep muscle layer of the intestinal wall. Metastasis of 1/12 cancer in the paracortic lymph nodes. One week after the operation, the patient's perineal wound was obviously painful, and during the treatment period, he had a fever of 39 ° C twice and was discharged from the hospital after one month of treatment. Discharge diagnosis: malignant tumor of the rectal canal (T2N1M0).

Six months after discharge, the patient was admitted to the municipal hospital surgery again, and was admitted to the hospital for physical examination to show that the wound had a small amount of bloody secretion. Pelvic enhanced CT shows rectal cancer after thickening of presacral soft tissue with uneven intensification, except for tumor metastasis or recurrence. After colonoscopic rectal surgery, there are no abnormalities in the artificial anus and residual colon.

In the following year, patients went to the city hospital several times to prescribe traditional Chinese medicine. One year later, the patient went to the provincial hospital for repeated swelling and pain, and performed an incision and pus removal of abscess around the rectum and anus;

After 5 months, he was admitted to the provincial hospital again, admitted to the hospital for diagnosis, pelvic tumor, rectal malignancy. General anesthesia descending perineal foreign body removal + perianal tissue resection. According to the surgical records, the lump can be seen at the original perineal incision and puffed out, which is removed and sent to pathology;

Necrotic tissue can be seen at the original perineal incision, and local debridement is found to have a complete piece of large gauze in the incision, which is completely removed. Intraoperative pathology shows adenocarcinoma tissue in exudates of inflammatory necrosis.

Postoperative pathology shows adenocarcinoma infiltration with massive necrosis and purulent inflammation in fibrous connective tissue, and the combination of immune enzyme labels is consistent with rectal adenocarcinoma metastasis/infiltration. The patient died 7 months after discharge without an autopsy.

The family believes that the municipal hospital left gauze in the patient's body, resulting in aggravated death of the patient's condition, and the lawsuit went to the court to demand that the municipal hospital compensate for various losses totaling more than 880,000 yuan.

Court hearings

According to the appraisal opinion of the Medical Association, the medical prescription was negligent in postoperative treatment: according to the surgical records, the doctor gave a hemostatic cotton and 5 compressive yarns to stop the bleeding due to presacral bleeding during the operation.

The postoperative dressing process does not describe in detail the amount of indwelling tamponade removed. Pelvic enhancement CT shows rectal surgery, the presacral soft tissue thickens with uneven strengthening, and high-density shadow with multiple small air cavities can be seen, indicating that foreign body residue cannot be excluded. At this time, it is half a year after the rectal cancer surgery, and the patient's wound has not healed for a long time, and the doctor should pay attention to it and further examine to determine the nature of the local lesion. Until a year and a half later, a foreign body (a large piece of gauze) was found during the debridement of the perineal wound in the outer courtyard.

According to the patient's clinical course, it is considered that the residual gauze is caused by the perineal operation of the municipal hospital. The residual gauze of the doctor during the medical process is causally related to the perineal wound after the patient's rectal cancer surgery. Due to the inability to heal the patient's perineal wound, it affects the standardized treatment of tumors to a certain extent. There is also a causal relationship between the doctor's fault and the patient's death (shortened survival). With reference to the "Medical Malpractice Grading Standards (Trial)", the patient's personal injury level is First Class A, and the degree of responsibility of the doctor is secondary liability.

The court of first instance held that, according to the appraisal opinion, there were gauze residues in the medical activities of the municipal hospital, which affected the medical fault of the standardized treatment of the tumor, and there was a certain causal relationship with the personal injury result of the patient's death, and determined that the municipal hospital should bear the liability for medical damage compensation in accordance with the proportion of 40%, and ruled to compensate the patient for medical expenses, death compensation, funeral expenses, psychological damage and other losses totaling more than 560,000 yuan. The municipal hospital appealed against the appeal, and the court of second instance ruled to reject the appeal and uphold the original judgment.

Brief analysis of the law

Patient safety is related to the lives and health of the people, is the core of medical management, and is also an important foundation for the smooth progress of the construction of a healthy China and the deepening of the reform of the medical and health system. After surgery, the consequences of foreign body residue in the body are serious, metal instruments can be determined by fluoroscopy, X-ray examination, and gauze remaining can not be found and diagnosed in time, often patients with serious clinical symptoms can not be confirmed, laparotomy exploration only found that the body left gauze, to the patient brought great pain and economic losses, and even because of this improper treatment caused by patient death.

In order to ensure medical quality and medical safety, the relevant national authorities have formulated a number of laws and regulations and industry norms. With the continuous improvement of the medical quality system, the medical disputes caused by death have been greatly reduced due to the foreign bodies left in the body after surgery, which in turn have caused infection, adhesions, fistula formation, etc..

Surgical safety verification is carried out by qualified surgeons, anesthesiologists and operating room nurses, who jointly verify the identity of the patient and the surgical site before the anesthesia is implemented, before the operation begins and before the patient leaves the operating room. Before the patient leaves the operating room, the above three parties need to jointly verify the patient's identity (name, gender, age), actual surgical method, intraoperative medication, blood transfusion verification, inventory of surgical materials, confirmation of surgical specimens, check skin integrity, arteriovenous access, drainage tubes, and confirm the patient's whereabouts. Moreover, the "Surgical Safety Verification Form" of inpatients should be classified into the medical records for safekeeping, and the surgical safety verification system is also one of the eighteen core systems of medical quality and safety, as a medical institution, it should establish a surgical safety verification system and standardized process to improve medical quality and protect patient safety.

In this case, the foreign body removed was located in the patient's perineum, and the doctor's surgical record recorded that "due to presacral bleeding during the operation, a hemostatic cotton and 5 compressive strips of yarn were given to stop the bleeding", and the identification agency determined that the foreign body was the gauze left over from the doctor's operation. In practice, the use of gauze compression by medical institutions to stop bleeding is widely used in clinical practice, but it is generally removed 24-48 hours after surgery. At this time, medical staff should fulfill a high duty of care, communicate and inform the patient or relatives, and remove the gauze in time after the patient's bleeding situation improves to avoid secondary injuries to the patient.

Half a year after the rectal cancer surgery of the patient in this case, the wound was not healed for a long time, the pelvic enhancement CT showed that the soft tissue thickened before the sacralum was thickened with uneven strengthening, and it was visible that the high-density shadow was accompanied by multiple small air cavities, and the doctor did not pay attention to and further examine to clarify the nature of the local lesions, causing damage to the patient, and therefore bear the corresponding compensation liability.

The medical behavior involved in medical damage liability dispute cases is a very specialized scientific issue, and it is often difficult for the affected party to produce evidence to prove whether the medical behavior of the medical party is at fault, and in trial practice, it is often necessary to entrust a third-party forensic appraisal institution to conduct an appraisal and complete the burden of proof through appraisal.

At present, there are two kinds of institutions undertaking medical damage appraisal, forensic appraisal institutions and medical associations, and unlike most regions in the country, the courts in Shanghai are entrusted by the court to organize experts from the medical association to conduct appraisals in accordance with their authority, and the medical association believes that it is impossible to identify, and the court will entrust a qualified forensic appraisal institution to organize appraisals in accordance with the "Provisions on the Administration of Judicial Appraisal Entrusted by the People's Courts to The Outside World". At the end of 2021, the Shanghai Municipal High People's Court issued the Opinions on Further Promoting the Work of Medical Damage Appraisal in The Municipal Courts, which clarified that to promote the work of medical damage appraisal in medical disputes in the city, we should adhere to the principle of "attaching equal importance to the appraisal of medical associations and judicial appraisals, parallel to the judicial appraisal institutions of The City and the judicial appraisal institutions of Jiangsu and Zhejiang, and strengthening the unified centralized management of medical forensic appraisal institutions and strengthening the trial management of medical dispute cases".

Strengthen the docking with the municipal health commission and the municipal and district medical associations, and continue to play an important role in the identification of medical damage by the municipal and district medical associations. As a result, Shanghai is still mainly focusing on the identification of medical damage in order to achieve the goal of "juxtaposing system" of identification by medical associations and appraisal by forensic identification institutions. Surgical item inventory and surgical safety verification is an important measure to ensure surgical safety, is one of the most basic and important systems in the operating room, and standardizing the inventory of surgical items is the guarantee to eliminate the surgical products left in the patient's body.

For personal injuries caused by the failure to formulate and implement a medical quality and safety management system in accordance with regulations, in addition to bearing civil compensation liability, if the circumstances are serious, the health administrative department will also give or order the directly responsible supervisors and other directly responsible personnel to give the punishment of demotion of the post level or dismissal, and the relevant medical personnel may be ordered to suspend the practice activities for 1 month to 6 months; if it constitutes a crime, criminal responsibility shall be investigated according to law. Therefore, the implementation of the pre-operative safety verification system can not only effectively reduce the rate of surgical errors, prevent and reduce the occurrence of medical disputes, but also effectively guarantee the safety of patients and medical staff themselves. (This article is the original of Medical Law Hui, based on real cases, and adopts pseudonyms to protect the privacy of the parties)

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