Abstract

This research paper explores the professional responsibility and forensic implications of complications arising from digestive endoscopy procedures, with a particular focus on case studies from Italy, Spain, Japan, and the USA. The study highlights the lack of homogeneous data in the literature, especially in legal contexts where only a fraction of adverse events is documented. Two Italian case studies are presented, involving patients who suffered severe complications following colonoscopy and esophagogastroduodenoscopy, including bowel perforation and the need for subsequent surgeries. These cases underscore the significant risks associated with procedural errors and the psychological impact on patients. The analysis emphasizes the crucial role of operator expertise and adherence to best practices in reducing the risks of such complications. Furthermore, the paper discusses the medico-legal implications, including the assessment of damages and the role of medical negligence in the observed adverse outcomes. The findings stress the importance of an expert specialist in endoscopic techniques when evaluating potential professional liability. It also underscores the need for a thorough medico-legal assessment of both physical and psychological damages, including maladjustment syndrome, to ensure proper compensation. Ultimately, the study calls for improved regulatory frameworks and training standards to enhance patient safety and professional accountability in digestive endoscopy.

Keywords: Forensic implications; Medico-legal implications; Medical negligence; Professional responsibility; Adverse events; Damages assessment; Expert specialist

Introduction

There is a fair amount of case history in the literature on the subject of professional responsibility in digestive endoscopy with descriptions of experiences especially in Spain, Japan and the USA. However, the data is generally not very homogeneous in the forensic field because it comes from judicial cases or registers in which only a percentage of cases is noted. In particular, a study in Catalonia highlighted between 1987 and 2009, 66 complaints, of which 46 (70%) after colonoscopy with a number of complaints due to fault of 27%, which progressively increased during the study period with a greater number of complaints about private clinics versus public hospitals [1].

In Japan, an investigation consisted of a retrospective review of cases adjudicated in the civil justice system over 21 years from 1985 to 2005, identifying eighteen malpractice cases and a total of 30 charges, of which 8 (44%) were malpractice-related. in performing esophagogastroduodenoscopy, 4 (22%) colonoscopy, 4 (22%) endoscopic sphincterotomy and 2 (11%) endoscopic retrograde cholangiopancreatography. 94% of cases involved complications and the remainder (6%) involved misdiagnoses [2]. Some studies have evaluated the quality of care in anesthetic facilities related to digestive endoscopy taking inspiration from the Controlled Risk Insurance Company (CRICO), a database that represents approximately 30% of annual medical malpractice cases in the United States. Data which highlighted a total of 58 claims in the gastrointestinal endoscopy suite between 1 January 2007 and 31 December 2016 [3]. Almost all recent studies report that gastrointestinal endoscopy, including colonoscopy, esophagogastroduodenoscopy and Endoscopic Retrograde Cholangiopancreatography (ERCP) is safe and effective even in elderly patients [4].

The two cases described in this report were collected in Italy in 2021 by a legal association that protects consumers and relate to complications arising following endoscopic interventions on the colon related to operational imperfections and procedural errors. In both cases the outcome was quite favorable after reoperation but requests for compensation arose for the prolongation of the illness and the resulting permanent disability.

Materials and Methods

The first case: an intestinal tumor

The first case refers to a 64-year-old retired woman with essential thrombocytopenia being treated with antiplatelets, with previous hysterectomy operations, parotid adenoma (2017), cataract and subscapular fibroelastoma (2018). In March 2020 he had undergone - in good general condition and with only modest painful dyspeptic syndrome - a gastroenterological check-up and endoscopy with deep sedation, at a private nursing home, for the study of the upper digestive and recto-colic tracts. After discharge, on the same day, rectal bleeding appeared at home. Admitted to the emergency room there was evidence of “peritonitis due to probable bowel perforation after colonoscopy, indication for surgical exploration”. She then underwent a right hemicolectomy, histological findings of the perforated right omentum and colon were examined with the outcome of “mucinous adenocarcinoma of the large intestine, superficially ulcerated, moderately differentiated, focally infiltrating the tunica muscularis proprio with low-grade tumor budding...moderate peritumoral inflammatory infiltrate, acute peritonitis..” after the period of hospitalization, already during the convalescence and in the following period he presented bowel disorders characterized by pressure and urgent evacuation, insomnia, state of anxiety.

A few months after the ablative colectomy procedure, the subject appeared in a good general state of nutrition with a treatable abdomen but painful on deep palpation, with the presence of a median scar on the xyphombilical, pink, partially retracted, 18 cm, slightly painful on palpation. Accentuated ileocolic typanism, absence of abnormal intra-abdominal masses, no superficial venous network, hypochondriac organs within limits. At the interview he showed signs of anxiety with reported insomnia, nervousness, health concerns and feelings of depression. He relived the emergency episode with persistent sadness, irritability and complained of loss of energy and fatigue, difficulty concentrating, memory loss, difficulty making decisions.

Clinical course and discussion

In this first case the problem was essentially centered on the performance of a colonoscopic examination and the resulting sequelae. The operator decided to proceed with an endoscopic polypectomy and to facilitate the exercise of the lesion he carried out a submucosal infiltration, at the base of the polyp, of an (unspecified) quantity of adrenaline diluted 1:20,000, so as to increase the degree of elevation of the polyp and facilitate its capture with the diathermic loop. The maneuver does not appear to have been carried out correctly and therefore was not successful. The polypectomy was postponed after the attempts made and the surgeon decided to perform simple biopsies of the lesion also trying to proceed with marking the polyp (tattooing) by infiltrating an (unspecified) dose of dye (Kina ink?). The endoscopic examination concluded without immediate complications and the patient was told, upon discharge from the clinic (4.20 pm on 2/3/20), that the polypous formation in the colon could not technically be removed endoscopically, that it could be a polyp already cancerized and ileo-colic resection surgery was recommended after confirmation by histology. The operator and structure where to carry out this intervention were also suggested.

After a few hours, and on the same day, approximately 4 hours after the endoscopic procedure, the patient was hospitalized urgently for severe rectorrhage and abdominal pain that progressively appeared shortly after returning home. Clinical and instrumental investigations (CT scan) made it possible to diagnose a peritonitis picture due to perforation of the right colon, corresponding to the polypoid lesion seen at endoscopy. Transferred to surgery, the clinical picture was stabilized and at 2.30 pm the following day 3/3/20 right hemicolectomy was performed, with ileocolic reconstitution. The intraoperative diagnosis was stercoraceous peritonitis due to perforation of the right colon. The patient was discharged on the 9th post-op day (12/3/20) for surgical recovery. The diagnosis on the surgical specimen was “perforation of the colon, mucinous adeno-k of the right colon, ulcerated on the surface. G2, pT2, pN0”.

The second case: sigmoid diverticulosis and angiectasia

A second case involved a 78-year-old man suffering from moderate anemia with Hb values ranging from 10 g/dl to 12 g/ dl, starting from the first quarter of 2021. Symptomatic due to asthenia, dyspepsia and modest bowel irregularity, being treated with traditional gastric protectors and folin associated with iron. For several years he had suffered from arterial hypertension, atrial fibrillation, prostatic hypertrophy, osteoporosis, diverticulosis of the left colon, and wore a right hip prosthesis. For chronic pathologies he was under continuous treatment with: cardioprotectors, anti-aggregating antihypertensives, Vitamin D.

Due to the poor response to hematological therapy, an endoscopic examination of the upper and lower digestive tract was recommended but he was not informed about a possible suspension of pre-endoscopic anticoagulant therapy. Subjected to Esophago Gastro Duodenoscopy and Colonoscopy, under superficial sedation, after regular intestinal preparation, nothing significant was revealed, nor did any lesions appear suspicious for hemorrhagic sources. The endoscopic picture was completely comparable to a previous endoscopy performed in the same hospital and by the same specialist in 2018.

The colonoscopy confirmed the presence (already known since 2018) of diverticular formations of the sigmoid colon, which were neither inflammatory nor deforming the intestinal lumen. No presence of free or coagulated blood or mucus, nor signs of focal or diffuse inflammation of the recto-colic mucosa. No complications or difficulties with the progression of the instrument were reported but in correspondence with the ileocaecal valve, “small blood clots coming from late angiectasia” were described, without description of the extent of the lesion, appearance and submucosal depth. A targeted washing of the suspected haemorrhagic area was not carried out to define the clot/angiectasia ratio. We immediately proceeded with photocoagulation with Argon laser (APC), at “mild” (sic!) power, of “some thin vessels”. The procedure concluded without any reported incidents and the patient was discharged.

On the same day, a few hours after discharge, the painful symptoms became more intense, making it necessary to be admitted to the emergency room again. The admission report described a suspicious clinical picture for intestinal perforation, post gastric and colic endoscopy, in stable conditions but with possible short-term compromise of vital parameters. A first standard x-ray of the abdomen confirmed the presence of free air in the peritoneal cavity and the CT scan confirmed the perforative nature of the picture. However, the presumed site of the perforation, whether gastric or rectocolic, was of uncertain interpretation. In the hospital, close monitoring was carried out, and 24 hours later, a CT scan was repeated, which did not favor the diagnosis of the location of the perforation but highlighted a clear worsening of the peritonitis. It was therefore decided to intervene surgically.

After a preliminary laparoscopic diagnosis of purulentfibrinous peritonitis, we proceeded with the xiphopubic laparotomy which highlighted a frank perforation of the colonic wall, the location of which was reported “at the level of the proximal transverse colon”. The characteristics of the iatrogenic lesion were not defined but the The surgical repair procedure adopted, i.e. the simple raffia with detached and introflecting stitches, suggests that the extent of the loss of substance was minimal, such as not to require a segmental resection. The operation, as usual, concluded with the adoption of a transitional, non-exclusive, preternatural iliac anus to protect the raffia. Finally with the addition of 2 separate drains: right shower and Douglas. The post-op course, after a short stay in the Intensive Care Unit, was regular and the patient was discharged on the 16th day with the plan to return for the definitive closure of the stoma after approximately 4 weeks. On August 3, the patient was hospitalized, according to plan, for the closure of the stoma and then discharged for surgical recovery having re-established intestinal continuity. After some time, symptoms persisted, referred to as “fear” or “fear” of complications, anxiety and nervousness, mood alteration.

Medico-legal discussion and evaluation

The first case report was characterized by an adverse event due to iatrogenic injury. The chronological sequence of events, starting from the endoscopic procedure on the colon to the intraoperative evidence, testifies that the endoscopic maneuvers with the associated techniques practiced (infiltration of fluids into the colic wall and tattoo) were in all probability responsible for the perforation of the wall of the right colon, precisely in correspondence with the 2 cm sessile polypoid formation, on which attempts were made to remove it and then to mark and stain.

It has been reported in the introduction that colonoscopy is a fairly safe examination even in the elderly [5]. However, the method still has a percentage of procedural-related complications (almost all immediate), which about 50 years after its diffusion of the method, are now globally stabilized from 0.2 to 0.3%. Complications are burdened by a very low mortality, not exceeding 0.07%. If, however, only the operative use is taken into consideration, then endoscopy has a higher incidence of morbidity (5-fold increase compared to the standard); for example, for the common polypectomy with diathermic loop, the data are now stable in the literature for an incidence of complication, from perforation and perforation/hemorrhage, ranging from 0.7% to 1.2%, but however, it can reach up to 5% if polyp excision is associated with more complex manoeuvres such as submucosal dissection.

Among the risk variables (type of patient, anatomy of the colon, lesion, technology used, etc.), the variable: “operator’s expertise” is important since it has been defined as the incidence of complications of Operative Endoscopy changes significantly depending on the number of procedures performed by an Operator /year : at least 800 or less than 800. In the case in question, given the low general risk of the endoscopic method, the appearance of a perforation of the colonic wall seemed unusual, especially if we bear in mind that the procedure of exercises of the polypoid lesion was not even performed. The cause of the perforation can only be related to the infiltration maneuvers of both the epinephrine liquid and the dye liquid. Such infiltrations, if not carried out impeccably, are evidently at play in the trauma of the intestinal wall.

Moreover, observing the endoscopic photos, it is first noted that the wheal produced by the submucosal infiltration has a volume of at least 3 times greater than that of the lesion itself and how, moreover, its site is very off-center with respect to the implant base infiltrations. If the purpose of the injection manoeuvre, in the submucosa at the base of the implant, was the dual one of raising the polypoid formation from the mucosal plane and then dropping the section line of the diathermic loop on ischemic tissue, in order to minimize the risk of bleeding, then we must state by photographic evidence that none of the purposes has been achieved. In fact, the polyp then appears to be all dislocated on one side of the wheal, in close contiguity with the angle of the mucous plane, thus making it much more difficult to close the loop over the entire formation than it was already without the wheal. To make the possible attempt at excision even more complex, there was also the size of the wheal, due to excess of injected ischemic fluid; In fact, the photos document an area of submucosal imbibition, in contiguity with the polyp, which almost takes on the appearance of another smooth proliferative lesion, the diameter of which would have contraindicated the use of the common loop for polypectomy. It is clear that in the face of the operative error, i.e. the inadequate injection of ischemic fluid in an unsuitable location, the decision to postpone the planned polypectomy was consequential, since only an endoscopist with extensive experience and adequate technology could have proceeded in those conditions. at the end of the operating procedure.

As far as the direct cause of the colon perforation is concerned, it is likely that several factors contributed. First of all, the excessive ischemization (adrenaline 1:20,000) of the wall of the right colon, responsible for a subsequent weakening of the integrity of the muscle tones. Then, an excessive penetration of the infiltrating needle, below the submucosal lamina, into the layer of the musculature propria, such as to reach perhaps the stratum of the musculature. , perhaps reaching the layer of the lamina serosa. In addition, as an aggravating factor due to a decreased resistance of the colic cassocks, the thinning due to distension of the thickness of the wall of the ascending colon, which in itself is the thinnest of the entire colon, caused by the insufflation of air for a prolonged time, due to the endoscopic maneuvers carried out during the colonoscopy. Finally, the subsequent infiltration of dye (Kina), may also have had a share of the responsibility. due to the difficulty of calibrating the depth of penetration of the needle through tissues that are almost disrupted by what has been practiced previously.

A further consideration concerns the tattoo of the lesion. The manoeuvre does not seem to have been coherent and appropriate. In fact, the prediction for the definitive treatment was to resort to intestinal resection. And it had been anticipated to the patient that the polyp had the characteristics of the cancerization (pending histological confirmation from biopsies) and therefore it would have been necessary to perform a right hemicolectomy, according to the standard protocol.

This statement and the future resection obviously implied that the polypoid lesion was largely understood in the operative piece. In fact, tattooing would have been used only when, by providing for further endoscopic access, it was intended to facilitate the finding of the previous site of a lesion or outcomes. In this case, when she underwent colectomy, a histological examination was carried out on the surgical piece which showed that the malignant lesion, i.e. a mucinous adenoK, had already infiltrated the muscular tissue of the colon even if with low-grade ‘tumor budding’. The grading of the lesion was G2 and the final staging was pT2 N0.

Emergency colectomy surgery was therefore indicated as a result of what had happened previously. It would certainly have been better implemented “in elective” without the danger of infection as usually occurs in stercoraceous peritonitis. However, the size of the surgical scar and the fact that it caused a situation of serious danger to the patient are facts that must be taken into account in the assessment of the damage. Following the intervention, the patient was also subjected to blood transfusion risk and has suffered an understandable psychic trauma such as to determine an anxiety syndrome with a discreet impact on relationship life.

Ultimately, the cause of the perforation of the right colon was the inadequate technical maneuver implemented by the operator, the marked ischemia of the parietal cassocks, including that of the muscular proper due to excess inoculation of chemical compound , The excessive thinning of the tunics due to endoscopic insufflation in the right colon during the manoeuvres and the prolonged duration are attributable to a lack of operational prudence that should have limited the time of execution; There was also, in all likelihood, a lack of or poor control in the advancement of the infiltration needles (adrenaline and dye) through the plasters of the wall (again due to inexperience and imprudence). The perforation was characterized by a loss of substance at the full thickness of the wall, of not modest dimensions to the point of not giving time to the physiological attempt of peritoneal reaction of “covering” with mesenteric fat. This may be compatible with the early failure of a necrotized parietal area due to concentrated and prolonged ischemia.

It should be noted that when the rectum-colon polyp is cancerous, the indication for resection surgery must be based on the balance: patient-specific operative risk (morbidity-mortality) / risk of metastasis, specific as defined in histology. Therefore, if a polyp has cancerized (invasive capacity for: contiguity, lymphatic, blood) but the neoplastic nest is still completely contained in the a) mucosa (ancient Ca in situ), then the endoscopic resection alone may be sufficient. If b) the lesion has invaded the submucosa, then it becomes essential to define the aforementioned balance for the most correct treatment. Finally, if c) the lesion has infiltrated the colon muscles, then the risk of metastasis is very high and therefore the indication for surgical colectomy is absolute IF there are no high operative risks. In the case of the PC, the Histology (performed endoscopically and in any case arrived only after surgery) gave only partial information since the study was performed only on biopsy fragments and NOT on the entire formation, since the Endoscopist did not perform the radical polypectomy.

If there had been no urgency, it is highly probable that a different and more correct way of proceeding could have been determined. But the surgeon was forced to proceed with the right hemicolectomy, including the malignant lesion in the resection, since the perforation was located right at the base of the cancerous polyp.

On the basis of the definitive histology (operative piece) the malignant lesion was defined as T2 (small to medium tumor size); N0 (absence of lymph node metastases on 11 lymph nodes examined); grading 2 (moderate differentiation); moderate tumor budding (neoplastic nests on the margin of the Ca not exceeding 10). This situation put the patient at low risk of lymph node metastases, i.e. 7-10% within a 3-year follow-up window.

And, although surgical resection is still indicated, both on the basis of histology (even if obtained after surgery) and on the basis of the low operative risk of the patient due to low comorbidity, immediate intervention in critical situations has determined a very serious risk of death due to the complication of the disease. (stercoraceous peritonitis). In addition, the dimensions of the field of intervention were in all probability different from those of an elective surgery with after-effects of an anatomical-functional and scarring nature. The greatest damage consists in the fact that the emergency surgery required a laparotomy approach, while an elective one would most likely have involved a laparoscopic intervention with evidently less tissue involvement. And the larger scarring outcome that was achieved coexists with the weakening of the abdominal wall far greater than that which would have remained from the laparoscopic outcomes with all the implications of adhesion as a consequence of stercoraceous peritonitis.

From the point of view of the after-effects, it can be said that they consist of a partially retracting post-operative abdominal scar, moderately painful and of substantial size, weakening of the abdominal wall, as well as a form of anxiety, depression similar to that which appears in the case of adjustment disorder due to the stress suffered due to emergency treatment and the anxieties suffered. The resulting damage can be estimated at 11-12% (eleven/twelve percent) of biological damage. A period of partial disability of 50% has also been assumed, which can be determined in 25 days (quantifiable difference between elective and emergency hospitalization).

The second case also involved one of the most feared adverse events in the course of endoscopic colorectal operative procedures, namely perforation of the intestinal wall. The sequence of events, in fact, for the patient, begins with the outpatient colonoscopy and continues with emergency surgery for purulent peritonitis, up to a second operation to reconstitute intestinal continuity. In this case, the reason for the drilling seems to have been attributed from the beginning, to the use of the thermal energy of the Argon Laser on a “fine angiectasia” of the cecum. In fact, this is how the endoscopist describes the modest vascular lesion, identified at the ileocecal valve and which probably due to the presence of “small clots”, was considered the real cause of the anemic state. This led the Specialist to proceed with his photocoagulation for the resolution of the case. Now, angiodysplasias of the colon, angiomatous microvascular lesions of the superficial arteriovenous network (mucosa and submucosa) formed by chronic sclerotic/ inflammatory processes, almost always have a limited diameter (0.5 cm-2 cm) and do not go deep beyond the submucosal tunic or have a thickness that does not exceed 7 mm. Such microvascular changes are typical of elderly subjects and are accidentally detected during a colonoscopy (asymptomatic lesions) in 3-5 %. On the other hand, in elderly patients with symptoms of small recurrent emetic discharge, these rectal colonic lesions are responsible for chronic anaemisation in 2.6-6 %. In these cases, once the nature and location of the hemorrhagiparous source have been identified by colonoscopy, the treatment of choice is photocoagulation of the angiomatous area both in elective (almost always) and in emergency. The success of the procedure, for angiectasias of the colon, is achieved in almost all cases. The incidence of complications of this type of treatment is included in that described above for general complications of operative procedures in the colon.

In particular, however, it must be borne in mind that the photocoagulation procedure (Argon Laser), although it can guarantee for safety purposes, the exact millimeter depth of coagulation action (on the colic wall) set on the flow dispenser, also has two other fundamental variables: Laser flux application time and energy power. Therefore, Depth, Time and Power must be pre-set by the Operator for the purpose of correct, safe and effective coagulation treatment. It is quite clear that the area to be treated must be well identified with appropriate targeted washing, stripping as much as possible of the lesion from coagulated or active blood material. In the case in question, it can reasonably be deduced from the evolutionary sequence of symptoms (operative colonoscopy-discharge-hospitalization P.S.) that the perforation occurred during or within a very short time (max 1 hour) from the procedure, in this second case due to failure of the integrity of the wall due to coagulative necrosis. First of all, it is legitimate to assert that the experience of the endoscopist should be considered good, since he is structured in a hospital-university specialist center (seat of the School of Specialization) in which no less than 10/15 endoscopies are performed daily (200 pcs/month). And again, in the examination of the fact, it must be emphasized that in a Center with such a high flow of pcs, it does not seem likely to suspect maintenance deficiencies, lack of availability of instrumentation. Nor does the Specialist seem to have made any errors in terms of the correct execution of the endoscopic diagnostic examination, having been able to clearly identify the small angiodysplastic lesion, presumed to be the cause of the blood loss, as the only pathological finding. Even for the indication of principle to laser treatment, according to Doctrine, there seem to be no doubts. But it is also true that a series of critical considerations can be advanced on the specific indication to perform photocoagulation of that small lesion immediately.

First of all, the certainty of holding her responsible for bleeding; The reported presence of small clots on the lesion, in fact, is not evident from the photos of the report, nor is it evident that there is live blood coming from it, while generally due to the standard intestinal preparation the eventual material Free or coagulated blood would have to dislocate from the lesion and then dilute in the colonic contents. A diagnostic doubt would have been legitimate about the real source of bleeding. In this case, it would have been advisable to proceed with targeted washing of the lesion, uncovering its edges and bottom; This would have made it easier to assess the diameter and degree of superficiality of the lesion and, above all, it would have been possible to identify the real degree of bleeding, if existing. In the scientific field regarding the treatment of digestive hemorrhages. ESGE recommends that in the presence of a hemorrhagic lesion with an adherent clot it is appropriate to evaluate the possibility of removing this clot (targeted washes or mechanical removal) in order to have a finding of active or inactive bleeding, on which the choice and modalities of coagulation treatment may depend. The endoscopist, on the other hand, proceeded directly to the laser procedure on an area of the mucosa of the cecum, in his opinion free from diagnostic ambiguities. He reports that he applied a “slight” coagulation energy, but does not attach the printout indicating the Joules dispensed nor are they reported; moreover, the time of application of the energy used is not specified. In the (poor quality) photo of the report you can only see multiple confluent punctiform areas of coagulation surrounded by an edematous halo. Taking into account the sequence of events after endoscopic treatment and the intraoperative characteristics of the perforation of the colon wall, it is entirely plausible to believe that laser photocoagulation and its methods of execution are the cause of the complication. In this regard, what actually led to the perforation can be attributed to an excessive time of application of the laser probe on the mucous membrane or to an excessive use of thermal energy, or finally to an excessive use of thermal energy, or finally to the association of both. In the final analysis, the operator’s mistake of having neglected the anatomical features of the ascending-caecal colon could also be considered plausible; The wall of this colic segment, in fact, is rather thin compared to the others and therefore under prolonged insufflation (time for treatment) the resulting dilation makes the wall even thinner. The Time and Laser Energy parameters, therefore, not only had to take into account the anatomical-pathological characteristics of the lesion but also had to be related to the anatomical ones of the wall of the cecum, where the heat treatment took place.

The patient reports a long and painful wait before the reparative surgery is performed. He also reports that he felt deeply discouraged by the packaging of an ostomy, an eventuality not explicitly envisaged before the surgery. A long post-operative convalescence is also reported determined by the sharp deterioration of psycho-physical conditions, weight loss of 13 kg, worsening of the anemic state, impossibility of independent walking. It was therefore necessary to activate home rehabilitation care through the CAD with sessions on a three-weekly basis until October 2021. Currently, there are meteorism, bowel disorders with constipation, pain in the periumbilical region, itching of the scar. The pz reports that he is no longer able to take long walks, as was usually the case before the events in question.

From a clinical-objective point of view, the subject is in a fairly good general condition: height 178 cm, weight 89 kg with slight skin pallor and moderate muscular hypotonotrophy of the 4 limbs. In the abdomen, there is a slightly diastased and reddened laparotomy scar in the central tract, 18 cm long, with the presence of hazelnut-sized nodularity in the sub-umbilical region; presence of another scar on the right side, reddish, 7 cm long as a result of previous ostomy packaging. The abdomen is also treatable but widely painful on deep palpation with hypochondriac organs within limits. From a lucid, oriented, collaborative psychic point of view, polarized conception on health issues with a vindicative attitude, notes of anxiety, deflected mood.

The critical findings can be summarized as follows:
1) failure to perform the angiodysplasia lesion lavage during the colonoscopy, which would have allowed the edges and fundus to be uncovered in order to verify the actual presence of bleeding; 2) excessive application time of the laser probe on the mucosa and/or excessive use of thermal energy, also in consideration of the peculiar characteristics of the colic wall section thinned by air insufflation.

The identification and quantification of the damages that can be compensated as a result of the negligent conduct of the medical staff appeared to be rather easy. As far as temporary biological damage is concerned, it should be noted that the course of a colonoscopy examination not characterized by adverse events consists of an almost immediate resumption of daily activities, with at most a generic abdominal pain symptomatology remaining in the hours immediately following the procedure. In the present case, the iatrogenic lesion led to the need for hospitalization and two surgeries: the first of colic raffia and temporary ileostomy on 26.06.2021, the second of closure of the stoma on 6.08.2021. Between the two surgical acts in question, it is worth mentioning the need for specific care also for the management of the stoma, as well as physiotherapy therapies for the recovery of muscle tone and After prolonged bedridden: it should be noted in particular that upon access to the nursing record on 3.08.2021, the doctors noted that the then patient arrived in the ward in an orthopedic wheelchair, walking with difficulty with the aid of a walker after the last hospitalization: it also resulted in the inability to manage the ostomy independently. The physiotherapy care of the CAD was extended until October 2021 as shown by the geriatric certificate issued on 8.06.2022 by the health professionals of the UOC nonself- sufficiency and adult disability.

It is therefore possible to identify precise periods of illness and convalescence that can be quantified globally, on the basis of the medical documentation examined and the normal course of the injuries in question, as 50 (fifty) days of absolute temporary incapacity and 50 (fifty) days of 50% absolute temporary incapacity. Permanent after-effects, on the other hand, consist of a post-peritonitis syndrome with bowel irregularities as well as abdominal scarring that weakens the wall and at the same time constitutes aesthetic damage.

The most recent medico-legal barèmes include:
i. For milder forms of colon disease (Stage I) percentages between 5% and 10%;
ii. For scars with weakening of the abdominal wall, 2% for every 10 cm;
iii. For scarring outcomes, which can be classified from a purely aesthetic point of view in a class of mild-moderate damage, an evaluation between 6% and 15%.

Ultimately, taking into account the available documentary elements, the objective findings and the evaluative references proposed by the commonly used guides, the permanent aftereffects, including the aesthetic damage related to the scarring outcomes, are were quantified to the extent of 14% (fourteen percent). It is also easy to understand how these impairments have led to moral suffering in temporary disability, due to the long duration of the clinical process, the presence of an ostomy, the need for surgery under general anesthesia and the temporary loss of personal autonomy; of lesser magnitude, but still appreciable the moral suffering in the permanent disability to be traced back mainly to the evidence of the aesthetic impairment as well as the qualitative and quantitative renunciations in everyday life related to the lack of restitutio ad pristinum.

Conclusion

As mentioned in the introduction, the evidence of adverse events during endoscopic maneuvers is still present and, in some ways, not completely evaded, despite the refinement of techniques and the progress of the endoscopists’ learning curve.

The cases reported attest that overlapping lesions occurred as a result of the same procedure (iatrogenic intestinal perforations during colonoscopy) can find completely different motivations to be scrupulously analyzed also through the vision of the iconographic finds. For the purpose of identifying possible profiles of professional liability, far from applying an automatism between damage and liability, the support of an expert specialist in the field who has specific and practical knowledge of endoscopic techniques therefore appears to be decisive. In the same way, while not discussing (at least in the cases analyzed here) particularly significant permanent impairments, the medicolegal assessment must be equally accurate in defining the extent of the damage or greater damage of an iatrogenic nature. In this context, very often aspects of psychic suffering can take over, substantially attributable to maladjustment syndrome, which should be adequately diagnosed and evaluated, in order to obtain full compensation for the damage.

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