Patient was a 71-year-old male with a history of diverticulitis and, sometime in the remote past, an abdominal or pelvic gunshot wound which required surgery.
On 10/25/2021, he underwent what was supposed to be an elective laparoscopic sigmoidectomy for his diverticulitis.
The surgeon encountered a lot of adhesions and converted to open.
Specifically, the surgeon noted that significant attachments of the omentum to the spleen and abdominal wall throughout the left upper quadrant had to be taken down. The splenic flexure was mobilized in order to get a tension-free anastomosis.
The anastomosis was created with a 30-mm EEA, then tested with flexible sigmoidoscopy.
The patient was admitted after the surgery, and in the days following, he "didn't do as well as expected," and had a hard time tolerating an advancing diet. He did not have fevers, and his white blood cell count was elevated but trending down from a high of 17.7 before surgery. Most of his pain and tenderness seemed to be around his incision, and his abdomen was described as soft and non-distended. He had a small BM on 10/28/2021, and was passing flatus. On 11/1, he had multiple episodes of loose stools, but was up in the halls with a walker. He was eating a regular diet, but complaining of some hiccups, nausea and vomiting. His abdomen was still soft, but now described as distended. On 11/2/2021 (POD #8), a CT abdomen showed a "large fluid collection or abscess consistent with a leak adjacent to the colocolic anastomosis," along with evidence of a small bowel obstruction and an anterior abdominal wall hernia containing bowel loops. The patient was taken back to the OR for an emergent exploratory laparotomy, where he was found to have a complete anastomotic breakdown and peritonitis. The surgeon did a partial colectomy with an end colostomy, described as a "Hartmann's type procedure," with an abdominal washout and wound VAC placement. The patient had not been kept NPO as ordered, and aspirated a large amount of stomach contents during induction. After the surgery, he was taken to the ICU on a ventilator. He was diagnosed with aspiration pneumonia, but slowly recovered and was weaned off the ventilator.
On 11/9/2021, an abdominal CT showed a possible subtle leak and surgical reassessment was recommended, but it's not clear if any was done. On 11/18/2021, the patient underwent surgical debridement of the abdominal wall for dehiscence and infection. By 12/10/2021, a CT found no evidence of residual intra-abdominal fluid or abscess, and on 12/22/2021, the patient was discharged to a rehab facility.
Nine days later, on 12/31/2021, the patient was brought back to the ED for concerns of possible septic shock. He still had a wound VAC to his center abdomen, and his colostomy was leaking. He was lethargic, with low blood pressure, weakness, dehydration, and anemia, but no fever. A CT abdomen showed a "suboptimally characterized" "fluid pocket" which had "enlarged from the prior study." The patient was admitted with diagnoses of sepsis and acute kidney injury, and was also COVID-positive, although he wasn't having any severe respiratory symptoms. On 1/2/2022, a CT abdomen was described as "most characteristic of a progressing large multiloculated complex abscess/leak" and a surgical evaluation was recommended. The following day, 1/3/2022, the patient underwent a CT-guided aspiration and drain placement, with grossly purulent fluid. The fluid cultures eventually grew mixed gram positive cocci and gram negative rods. A CT on 1/7/2022 showed a possible new, additional abscess. Another CT on 1/11/2022 showed that the initial area was smaller but the new one was "slightly more apparent" and the radiologist believed the two probably communicated. On 1/12/2022, the patient underwent a second CT-guided drainage, along with catheter replacement and repositioning. The drain catheter was repositioned again on 1/21/22, and the patient was discharged back to rehab the following day, 1/22/2022.
On 1/26/2022, the patient was sent from rehab back to the hospital for an outpatient CT, and the impression was: "Left-sided abdominal abscess overall looks unchanged wiht drainage catheter in place in appropriate position, concern for possible enteric versus colonic fistulous communication given persistence. Recommend surgical reassessment. May consider follow-up CT fistulogram." It does not appear that any surgical reassessment or fistulogram were done at that time.
On 2/1/2022, the patient was sent from rehab back to the ED with complaints of increased abdominal pain, swelling, and ostomy drainage for the past 3 days, worsening. It was also mentioned that his "surgical drain fell out of abdomen." Abdominal CT showed that the preexisting parts of his abscess were enlarged, and there was a new periumbilical component. At that point, the surgeon recommended the patient be transferred to a larger teaching hospital at a nearby university "for potential drainage of his persistent intra-abdominal abscess." The patient was transferred accordingly, and the next day, on 2/2/2022, he had 2 CT-guided drains placed, with almost 500 mL of grossly purulent fluid drained. It was also felt at this hospital that he might have a colonic fistula, but it does not appear that a fistulogram was done to confirm it. On 2/12/2022, the patient was discharged to rehab for the third time.
On 2/26/2022, the patient was readmitted to the university hospital after an outpatient CT apparently showed a new abscess. On 2/28/2022, another drain was placed by interventional radiology, and contrast instilled through it confirmed a fistula to the colon. Not long afterwards, the patient was diagnosed with a multidrug-resistant Klebsiella infection, and he continued to worsen in the ICU despite antibiotic therapy. The family eventually agreed to comfort measures and hospice, and the patient passed away on 3/10/2022. His death certificate listed "enterocutaneous fistula" as the primary cause of death, followed by heart failure and coronary artery disease.
Files:
Q: How was the Hartmanns pouch closed and was a drain placed at the take back operation?
A: —
Q: Was a leak test performed at the initial operation?
A: —
Do you believe there might have been medical error?
Sounds like a bad outcome. Leaks are common (7-12%), sounds like it was found in a timely fashion, and all of the subsequent issues are related to the leak. Outcome is not relevant in assessing the standard of care. It seems like when there were enough clinical signs/symptoms of a leak, A CT was done, the problem was found and repaired appropriately.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above. Surgery seems indicated, correct surgery, had a known complication, fixed appropriately.
What makes you a good expert for this case?
This would be a good case to defend. I have reviewed many cases like this and continue to perform this type of surgery.
How often do you encounter cases similar to this one in your practice?
several per month. Still active clinically.
Do you believe there might have been medical error?
The first error in this case was an error in judgement. Clearly the patient should have had a diverting loop ileostomy at the same time of his initial operation. Diverting loop ileostomies have been shown to reduce mortality associated with anastomotic complications. The second error is not making the patient NPO and the patient aspirating during induction. There was no mention of whether a nasogastric tube was placed prior to intubation to decompress the stomach. The patient likely had an ileus as I'm sure it would have been shown on the CT scan, which may have additionally shown significant gastric distension tipping everyone off to this. In addition, if he was placed on vasopressor agents after his aspiration event, this could have contributed to any additional anastomotic complications and wound healing issues. In addition there were several delays in getting source control for his abdominal fluid collections. This should have been addressed aggressively within 12 hours or less of the CT scan based on surviving sepsis guidelines lastly the use of a wound vac in the situation is very controversial and may have contributed to the enterocutaneous fistula formation. How the wound vac was placed the type of sponges that were used and how often it was replaced as well as how the wound was examined and how frequently it was examined would have been vitally important period it is shocking that the patient survived as long as they did. Clearly he had good Physiology but he left the house could only withstand so much.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Specifically, not creating a diverting loop ileostomy the first operation in the setting of such inflammation as manifest by a white blood cell count of 17.7 resulted in the patient requiring reoperation. He also developed an ilias from this and aspirated. This event set the spiral of events that the team clearly failed to rescue. Surgical complications do happen, but when they do it's the failure to rescue and get the patient back on the track that ultimately led to this patient's demise. This was the result of sequential events and poor care that when taken together was too much for him to overcome.
What makes you a good expert for this case?
I'm a very detailed surgeon who takes very good care of complex patients. There are important nuances in caring for patients and their complications, especially elderly patients. There are many details that need to be further investigated into this case including how the patient's nutrition was managed this entire time, the use of vasopressor agents in the perioperative. As well as the use of any steroids, and lastly how the hartmanns pouch was oversewn or stapled slash managed and whether a drain was placed at the time of surgery.
How often do you encounter cases similar to this one in your practice?
We very frequently manage patients with colon resections from outside hospitals who developed complications due to the complexity of care we provide as a tertiary referral center.
Do you believe there might have been medical error?
Unfortunately anastamotic breakdown and leaks are more Common than we want. It is one of the risks that should be discussed when booking any colorectal surgery. I don’t think that is a “medical error” here. It’s just an unfortunately known complication
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As mentioned above this is a known complication. On this case it lead to multiple abscesses and further complications. Very unfortunate but not something we haven’t seen before
What makes you a good expert for this case?
I have performed open colon operations and anastomoses and work in a very busy surgical practice where we do see this occasionally happen. Not to the point of death very often at all but anastamotic leaks happen
How often do you encounter cases similar to this one in your practice?
Hard to say and wouldn’t have the denominator. Rare but not super rare
Do you believe there might have been medical error?
This seems to be a long and complicated case and would need to look over records completely. I believe the question is was it appropriate for him to be transferred back and forth to rehab with the intraabdominal abscesses and if they were completely controlled. Should there have been more work up to determine the etiology of these recurrent infections. This was major complication; however, this is a risk of this operation for diverticulitis. The patient also has other co-morbidities that puts him at increased risk of anastomotic leak, and it appears the surgeon recognized the initial complication and treated it in a timely fashion. It is unclear if they initially left drains in the abdomen at the time of the Hartmann's procedure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If there was opportunity to address the abdominal collections or a delay this could have prevented sepsis. Again would need to see all the records.
What makes you a good expert for this case?
Professor of Surgical Oncology at large tertiary cancer center. 15 year experience performing complex colorectal surgery as part of my surgical oncology practice.
How often do you encounter cases similar to this one in your practice?
I manage anastomotic leaks 1-2 every few years.
Want to open a case or submit response?
Comments are accepted only from Surgery (General Surgery) experts.