[Legal aspects of conflict situations from the hospital physician's perspective]. / Rechtliche Konfliktsituationen aus Sicht des Krankenhausarztes.

The majority of hospital physicians have already adapted to "normal conflict situations". Standards in patient information, diagnosis, treatment and follow-up have become established practice as have the resultant consequences of the failure to observe these standards, possibly on the basis of guidelines and directives. The legal developments in recent years make organisational shortcomings and mistakes in taking on patients without any requisite specialisation a liable offense. Similarly, faulty documentation is a much-discussed medical and legal issue. New fields of legal dispute arise from the growing financial pressure and the increasing managerial responsibilities placed on senior physicians. Likewise, budgeting requirements and legal claims of employees based on working time legislation may also bear legal consequences. With the introduction of a flat-rate remuneration system for hospital services (DRGs: diagnosis related groups), liability claims against senior physicians due to coding errors have been included in the contractual agreements. Serious new conflicts essentially arising from time pressure and the overloading of physicians with bureaucratic, financial and administrative tasks can only be satisfactorily resolved if doctors are allowed to do what they are intended to do and if they are provided with the time and financial resources their every day work and continuing medical education require.

[Malpractice in laparoscopic cholecystectomy. Results of cases recently considered by the Expert Commission]. / Arztliche Behandlungsfehler bei der laparoskopischen Cholezystektomie. Ergebnisse der gutachterlichen Bearbeitung der von der Kommission behandelten Fälle laparoskopischer Cholezystektomie.

The Expert Commission for medical malpractice which is part of the Medical Chamber of Nordrhein received about 60 applications in connection with laparoscopic cholecystectomy; as of August 1998 5 complaints were let off and 11 of them are still being considered. So far 44 complaints have been considered and in 25 of them medical malpractice has been established. The medical malpractice detected laparoscopic cholecystectomy cases were mainly bile duct injuries of which 13 required a biliodigestive anastomosis for reconstruction, four cases required and end-to-end anastomosis and in one case a T-tube drainage was needed. The youngest one of these patients was 21 years old, the oldest one was 61 years old. Four times the bile duct injury was not considered as malpractice, because it could be intraoperatively made out and immediately treated. Trocar injuries were twice a cause for malpractice and once it was not. Each of the following cases was also recognized as a malpractice. One lost gallstone one dislocated Roedersnare, one electric injury, one delayed reintervention and one insufficient information. The following cases were decided as non-malpractice: in two cases a slipped clip, in five cases subhepatical hematoma/abscess, in three cases a secondary bleeding, once a lesion of the splenic capsule and finally a running sore with subsequent incisional hernia. Three courses of treatment with consequence of death also contained mistakes: one electric injury of the bowel, one bile duct lesion and one information rebuke. The bile duct injury is the most considerable risk for laparoscopic cholecystectomy and implies also a high risk for the future health. The experienced surgeon distinguishes himself by the fact that he is right about the situation and converts sooner that later to conventional cholecystectomy if there's any doubt. In open surgery the principle is applied that structures may be only divided when they are clearly identified. The same goes even on a wider scale for laparoscopic surgery too.

[Special problems of confidentiality in the hospital from the physician's point of view]. / Spezielle Probleme der Schweigepflicht im Krankenhaus aus ärztlicher Sicht.

Professional discretion is a result of the individual rights of the patient and the increasing right of self-determination. It is very difficult to follow these rules because of the necessity for precise documentation, electronic dommentation, and the medical and administrational necessities in the hospital. How to assure the discretion in an ambulatorium, in the room with several beds? Where to place the operation-schedules with all their details? How to assure the discretion, when a lot of people in the hospital are involved in the therapy and the diagnostic procedures? A lot of questions: everybody has to do his best, keeping in mind the professional discretion as an important human right.

[The employment schedule act: temporal and economic limits]. / Arbeitszeitgesetz: Zeitliche und wirtschaftliche Grenzen.

This Employment Act is designed to decrease the stress burden for hospital doctors by removing avoidable night and shift work and is supposed to lead to an improved working environment. This act will also leave room for family and professional commitments as well as for social activities. Despite continuous efforts within clinical work, there is huge information deficit for detailed handovers and the information given to succeeding colleagues. Operations may need to be deferred, and misunderstandings between patients and relatives are likely to arise. Good co-operation with the nursing staff is suffering. A doctor is likely to miss around 60 days per annum through training. Legal consequences may arise through gaps and negligent paperwork.

[Work distribution and cooperation in surgery--horizontal and vertical decision and responsibility fields]. / Arbeitsteilung und Zusammenarbeit in der Chirurgie--Horizontale und vertikale Entscheidungs- und Verantwortungsebenen.

Horizontal delegation of labor in medicine means independent cooperation of medical specialties. Careful division and confidence in other physicians is very important. Vertical delegation of labor means cooperation between physicians in respect to hierarchical systems in the hospital or between physicians and nurses or medical technical staff members. Special problems have to be solved in the cooperation between the medical staff, on the other hand, and administration or nurses, on the other.

[Medical expert assessment in civil and criminal law--stand for evaluating medical expert assessment]. / Arztliche Begutachtung in Zivil- und Strafrecht--Beurteilungsmassstab ärztlicher Begutachtung.

The standard for the assessment of the medical expert opinion is defined by the high demands expected from the judgement of a high court: Objectiveness, solid knowledge, self-criticism, in contestability in diction and firmness in the argumentation. From the legal point of view, the knowledge of the medical expert witness has to clearly go beyond the knowledge of his profession. The obligation for objectiveness is the basis of expert witness' activity. From the medical point of view, the physician has to take into account during the preparation of his expert assessment that structural deficiency of the personnel and surgical equipment of a department for surgery frequently plays a role due to the development of surgery to high tech medicine and the hospital physician cannot affect this. It is necessary for a physician as an expert witness to have basic knowledge about the evidence law and the medical liability process. On the other hand, judges and lawyers should basically know the medical way of thinking.

[Mesenteric panniculitis]. / Panniculitis mesenterica.

We report three cases of mesenteric panniculitis in which the disease took different courses. The first case clinically mimicked an acute diverticulitis and consequently laparotomy was performed. During this operation a large space-occupying tumour was found in the lower abdomen. After resecting this tumour mass of uncertain classification (benign or malignant) a preternatural anus of sigmoid colon was formed. Histological exploration revealed mesenteric panniculitis. Six months later we restored continuity of large bowel by end-to-end anastomosis. No residues of the preexisting panniculitic alterations were seen. The second case concerned a female patient who again complained of discomfort after surgical treatment of colon carcinoma. We measured an elevated erythrocyte sedimentation rate and suspected a relapse of the malignant disease. Notwithstanding radiological and endoscopic diagnostics, the origin and classification of an intra-abdominal tumour could not be determined preoperatively. Laparoscopically we took a biopsy of the local mass, but a definite diagnosis was not found. Postoperatively undulant fever occurred, uninfluenced by cortisone treatment. Finally the patient died because of unstoppable hemorrhage under coagulopathy. Mesenteric panniculitis was identified as causative disease by autopsy.

[Medical malpractice in ambulatory surgery]. / Arztliche Haftung bei ambulantem Operieren.

Due to the structural reform of the public health service on Jan. 1, 1993, totally new conditions are generated for the hospital and partially for the surgical practice to extend the outpatient surgery, especially to transfer stationary tasks to the ambulant area. Additionally, to the basic contract according to SGB V for ambulant surgery, a special agreement about procedures for quality control in ambulant surgery according to sec. 14 of the contract regarding sec. 115b par. 1 SGB V has been added since June 13, 1994. Minimal requirements of quality are demanded to achieve a high quality in the outpatient area and maintain the standards of the stationary surgery. However, any detail has to be prospectively and more intensively considered, discussed and documented since the patient will not be available for supervision or discussion before and after surgery. The preoperative setting has to be checked carefully to avoid a situation where an elective surgery has to be postponed due to other pathologic findings or a faulty organization. The principle of trust may be applied when findings from other physicians are adopted but the final liability has the physician undertaking the surgery. The information of the patient after surgery has to be adapted to the symptoms. Thus, the symptoms of any problem or complication after surgery have to be explained to the patient that he can act properly if such problems occur. Actually, the patient's information after surgery is very important: pain, bleeding, prophylaxis of thrombosis, immobilization, transport problems and the availability of the surgeon at any time as well as a regular attendance during the consulting hours have to be clarified and discussed to maintain the demanded expert status of the physician and the valid medical standards as well as to meet the legal requirements for liability.

[Can endoscopic methods decrease the mortality and complication rate of bleeding stomach and duodenal ulcer? A study of the literature]. / Kann durch endoskopische Methoden die Letalitäts- und Komplikationsrate des blutenden Ulcus ventriculi bzw. duodeni gesenkt werden? Eine Literaturstudie.

Bleedings from gastroduodenal ulcers still pose a major threat to health and life of a patient. Recent technical developments have provided the endoscopist with several methods for achieving hemostasis. In the present paper the results from clinical studies concerning interventional endoscopy shall be discussed. Criteria for the therapeutic approach for an individual patient shall be presented. Optimal results are possible if diagnosis and initial treatment are handled quickly by an experienced endoscopist. Early cooperation with the surgeon will further improve the outcome.

[Isolated traumatic dislocation of the fibula head. A rare injury in soccer]. / Isolierte, traumatische Luxation des Fibulaköpfchens. Eine seltene Verletzung beim Fussball.

The case presented of a rare injury of the left knee joint underlines the necessity for meticulous examination. We report on isolated dislocation of the head of the fibula in a 25-year-old football player; the diagnosis and therapy for this rare injury are presented.

[Preventive operations of the gallbladder and bile ducts]. / Prophylaktische Operationen an der Gallenblase und an den Gallenwegen.

Prophylactic cholecystectomy is indicated for cholelithiasis in diabetic patients, in hemolytic anemias, before transplantations for focus treatment or implantation of a cardiac valve and also before travelling to countries with poor infrastructure; or for precancerous lesions like GB papilloma, porcelain gallbladder or cystic choledochus. Furthermore one can consider prophylactic indication for cholecystectomy for asymptomatic cholecystolithiasis in young patients in order to prevent complications in future.

[Gastrointestinal leiomyosarcoma]. / Das gastrointestinale Leiomyosarkom.

The clinical course of 12 patients was analyzed in a retrospective study; all of these patients were operated on a gastrointestinal leiomyosarcoma. The most common site of metastasis was the liver (33%). These data confirm that histologic grade, size and the extent of resection are the most important prognostic factors. Because the differential diagnosis between benign and malignant smooth muscle tumors is often quite difficult and a high risk of local recurrence the enucleation of these tumors is insufficient.

[Diffuse eosinophilic gastroenteropathy]. / Die diffuse eosinophile Gastroenteropathie.

Eosinophilic gastroenterocolitis is a very rare disease of the gastrointestinal tract. As a result, frequently the diagnosis is missed and/or symptoms get misinterpreted. Histological examination and blood analysis however support the finding of the correct diagnosis in most cases. We report here the case of a 47 year old female patient with diffuse gastroenterocolitis and we will comment the diagnostic problems.

[Primary non-Hodgkin lymphoma of the stomach: diagnostic and therapeutic procedure]. / Das primäre Non-Hodgkin-Lymphom des Magens: Diagnostisches und therapeutisches Vorgehen.

It is reported on 13 patients with gastric non-Hodgkin's lymphoma, who underwent surgery between Jan 1st, 1984, and Sept 1st, 1987. Common symptoms included abdominal pain, weight loss and decline in health and strength. Endoscopy or barium studies had established the diagnosis of a gastric neoplasma in 12 cases. A total gastrectomy (n = 4) or a distal resection (B I n = 3, B II n = 5) was performed, depending on the size of the tumor and its location. Potentially curative resection was followed by radiotherapy in patients with high-grade lymphoma (stage I E). Patients with involvement of regional lymph nodes and advanced gastric lymphoma (stage II E1-IV E) underwent postoperative chemotherapy. So far follow-up (mean 25.3 months) revealed one case of relapse. These results confirm the value of surgical treatment in diagnosis, staging and treatment of primary gastric lymphoma. Survival in patients with advanced lymphoma and high-grade malignancy can be improved significantly by radical tumor resection, followed by multiagent chemotherapy and radiation.

[Chemolitholysis of gallstones as ambulatory treatment by the established physician]. / Chemolitholyse von Gallensteinen als ambulante Behandlung beim niedergelassenen Arzt.

General Surgeons and physicians for internal medicine were asked for their results of dissolution-therapy of gallstones. 405 physicians were asked, 283 (69.9%) answered; 33.6% of these had some experience with the dissolution therapy. Data from 100 patients could be gathered completely: from 72 women (mean age 48 years) and from 27 men (mean age 53 years). The age-distribution resembled those of surgical gallstone-patients. In 27 cases the dissolution was successful (mean duration of therapy 49.6 weeks), in 25 cases there was a partial success (mean duration of therapy 54.8 weeks), and in 48 cases the dissolution-therapy failed (mean duration of therapy 55.5 weeks). In 60 cases therapy was stopped, but only 25 of these patients underwent cholecystectomy. In summary there is some evidence, that many collegues are sceptical against dissolution of gallstones, that the preoperative diagnostic procedure is ineffective, that the results of dissolution therapy in a common praxis is not as effective as in controlled studies, that dissolution therapy mainly is forced in patients at a normal risk--and not in high-risk patients, that only few patients are ready to take the pills longer than 1 year, and that in the case of stopping the therapy not all patients undergo consequently cholecystectomy.

[The solid-cystic pancreas tumor]. / Der solid-cystische Pankreastumor.

Solid-cystic pancreas neoplasia is a rare condition mostly observed in young adults and women. We report three cases of this rare tumor. In all three instances the patients were young, slender women. The tumors were removed by total resection of the pancreas. In two cases these tumors were very large. In two cases we also observed criteria which could indicate that these tumors were malignant: the tumors had infiltrated the adjacent spleen and adjoining lymphnode or displayed a destroyed capsula. Until now, such infiltrative or malignant qualities have not been reported. That such criteria can be conclusively evaluated as an indication of malignancy, remains, however, unclear.