70 y/o male underwent appendectomy. Friable appendix perforated upon extraction causing spillage which was contained. Pathology revealed moderately differentiated adenocarcinoma of vermiform appendix, tumor invaded through the serosa into the mesoappendix. Appendix orifice was positive for involvement by the tumor. No evidence of any distant spread. Patient remained in the hospital and 8 days later, without any additional studies, surgeon elected to perform laparoscopic right hemicolectomy. On post op day 1, patient suffered massive PE and died from DVT.
Files:
Q: Was the patient on prophylactic heparin or Lovenox before the appendectomy and during his hospitalization?
A: —
Do you believe there might have been medical error?
While cancer can cause a hyperinflammatory state which can cause hypercoagulability the presence of the tumor is unlikely to have caused a PE. Even less likely if the patient had been on prophylactic heparin/lovenox post-operatively.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Not sure how the two are connected. True, true but unrelated. Yes a DVT and PE occurred. Yes surgery for appendicitis that found cancer. The follow up operation was appropriate and the complication unfortunate but not caused by the care listed above.
What makes you a good expert for this case?
I have treated several patients in this situation and routinely treat patients that have sustained pulmonary emboli.
How often do you encounter cases similar to this one in your practice?
This has not occurred in my practice but I do encounter patients with appendiceal cancer and patients that have had PE regularly as a surgical intensivist.
Do you believe there might have been medical error?
Postoperative VTE is more frequent in patients with known cancer than in the general population, occurring in as many as 40 percent of patients in clinical trials employing venography for diagnosis. As a result, individuals with cancer should be considered high risk for development of postoperative VTE. This increased risk is reflected in the Caprini score for VTE in surgical patients, which assigns two points for the presence of malignancy SCORE (%) Very low 0 <0.5 Low 1 to 2 1.5 Moderate 3 to 4 3.0 High ≥5 6.0 Would need to review to see score and what was done to prevent the PE. Anticoagulation, Sequential hose on the patient prior to induction of anesthesia and/or filter
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
BAsed on the timing of event, the PE more likely than not started with a DVT. Was there any anticoagulation for the 8 days? was the patient ambulatory? Was there any prevention attempted prior to the colectomy?? What was his Caprini score AND surgical risk for a PE based on the NSQIP Lot of questions need to be answered
What makes you a good expert for this case?
Experience with both plaintiff and defense. Decades of chart review. Ability to look at a complex issue and explain it in a simple fashion. Will give you an honest answer of what happened in this case, more likely than not
How often do you encounter cases similar to this one in your practice?
Yes, Have had similar cases like this. Work in an academic setting where complication like this are not uncommon. This one may have been preventable. Although, everything may have been done correctly and the PE still could have occurred. Massive fatal PE can occur in about 3% of patients even when all the preventative measures are taken.
Do you believe there might have been medical error?
There may have been two issues with this case- 1- spillage of an appendix cancer can happen but increases risk of peritoneal metastases. 2- It is unclear when they determined to perform the laparoscopic right hemicolectomy. Were there any perioperative factors that increased risk of PE/DVT?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There may have been two issues with this case- 1- spillage of an appendix cancer can happen but increases risk of peritoneal metastases. 2- It is unclear when they determined to perform the laparoscopic right hemicolectomy. Were there any perioperative factors that increased risk of PE/DVT?
What makes you a good expert for this case?
I am a national expert in surgical oncology with an expertise in GI and colorectal surgeries and a NCI designated cancer center.
How often do you encounter cases similar to this one in your practice?
I perform many colectomies per year and also treat patients with appendiceal carcinoma.
Do you believe there might have been medical error?
Of note, I am a board certified surgical oncologist as well as general surgeon. From the brief description above, there may be negligence. Following the diagnosis of appendiceal cancer, this patient should have underwent an extent of disease workup including contrasted cross sectional imaging (CT) of the chest, abdomen and pelvis. If there was no evidence of metastatic spread, the patient would then be consented for right hemicolectomy. However, at the age of 70, with some comorbidites, there should have been consideration to medical and possible cardiac clearance. Additionally, since the patient expired from a PE, we would have to review the medical record to ensure he received the appropriate peri-operative chemical and mechanical DVT prophylaxis. I would need to do a thorough chart review to answer these questions.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As stated above, if the patient did not have a medical clearance and was not on the appropriate DVT prophylaxis by the Caprini risk stratification index, there may have been causation. Was the patient on chemical DVT prophylaxis during his hospital stay? Did he receive immediate chemical DVT prophylaxis prior to the induction of general anesthesia? This needs a chart review.
What makes you a good expert for this case?
I am both board certified in surgical oncology as well as general surgery. Additionally, I was recently an expert witness on another case which was a death following surgery due to DVT and PE and I have recently reviewed the literature and written expert summary on the use of pre and post op DVT prophylaxis using risk stratification guidelines.
How often do you encounter cases similar to this one in your practice?
Often. I am a high volume Gastrointestinal surgical oncologist practicing within the highest volume surgical oncology group in my state. I was formerly at Memorial Sloan Kettering Cancer Center. Happy to provide my CV if needed.
Do you believe there might have been medical error?
I would have to believe that the patient was not on prophylaxis for deep vein thrombosis and that he developed a blood clot during his hospitalization. If in fact, the patient was not on heparin or Lovenox before and after his appendectomy then there is a definite deviation from the standard of care. However, if he was placed on heparin or Lovenox prophylactically before his appendectomy and if it was continued during his hospitalization then there is no deviation from the standard of care. I would also need to know whether the patient had other comorbid conditions that would make him more likely to have a blood clot.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the patient was not on prophylactic heparin or Lovenox then definitely that omission caused the massive pulmonary embolus.
What makes you a good expert for this case?
General surgeon with extensive experience in colorectal surgery, and laparoscopic surgery.
How often do you encounter cases similar to this one in your practice?
Appendiceal carcinoma is not a very common disease so it is not a frequent case in anybody's practice. However the issue of prophylactic anticoagulation is pertinent to every operation performed so from that respect I encounter this situation multiple times a week.
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