A 72 year old male patient undergoes an EGD/Colonoscopy for epigastric pain and colon cancer screening on 5/10/22. The endoscope was advanced to the cecum. The cecum was indentified by the presence of the light in the right lower quadrant, the ileocecal valve and appendiceal orifice. The terminal ileum was intubated. The endoscope was noted to be slowly withdrawn. The following were found to be normal: terminal ileum, cecum, ileocecal valve, ascending colon, hepatic flexure, splenic flexure and rectum. Diverticulosis was noted to be present in the descending colon and sigmoid colon. GI MD identified what he described as a 15 cm mass located between 45 - 60 cm in the transverse colon. He further noted that the mass was occupying approximately one third of the circumference of the colon. An India ink tattoo was placed distal to the mass. The mass was not removed. Multiple biopsies obtained. The quality of the prep was described as excellent.
The biopsy revealed a tubular adenoma. GI MD documented that there was a high likelihood of malignancy within this "very large polyp". He referred patient to colorectal surgeon.
A CT of the abdomen and pelvis is obtained on 5/18/22. The radiologist interpretation includes focal area of wall thickening involving the proximal sigmoid colon which may reflect segmental colitis versus underlying mass. Recommend correlation with colonoscopy findings. Also notes there to be submucosal fatty deposition throughout the colon which can be seen in setting of metabolic or chronic inflammatory bowel disease.
Robotic resection of transverse, splenic flexure and descending colon with two layer handsewn end to end transverse to sigmoid colo-colostomy was performed on July 5, 2022. After laparoscopically exploring the abdomen, the surgeon found the tattoo to be located within the distal transverse colon right at the splenic flexure. The surgeon mobilized the entire transverse splenic flexure and descending and sigmoid colon. Once this was done, he noted that "a proximal division point was selected 8 cm proximal to the edge of the tattoo". He further noted that "a distal division point was selected in a similar manner proximally 8 cm distal to the distal-most aspect of the tattoo". This was roughly the mid sigmoid colon. Continuity was performed by a hand-sewn double layer end-to-end anastomosis. The specimen was submitted to pathology.
The gross description of the specimen was described by the pathologist as an intact segment of colon with two stapled end margins that measured 12 cm in length and had a large amount of attached mesocolic fat. The proximal and distal stapled end margins could not be determined as received. The colonic lumen revealed four tan-to-red brown polyps. Three of the polyps were clustered near each other, were exophytic and varied in size from 1.5 cm to 3.7 cm in maximum dimension. Two of these polyps were closest to one stapled end margin with both 1.5 cm away. These three polyps were greater than 5 cm away form the remaining stapled end margin. The fourth polyp was flat, measuring 0.7 cm in maximum dimension and was closer to the stapled end margin furthest away from the other polyps which was 1 cm away from the stapled end margin. On sectioning, each of the polyps were confined to the mucosal aspect of the bowel wall. Diagnosis was adenocarcinoma arising within a tubulovillous adenoma invading into submucosa. Tumor summary included AJCC pathologic stage: pT1, pN0.
Following his discharge, the patient returned to the hospital two days later via EMS for abdominal pain x few days. A CT of the abdomen/pelvis w/contrast was obtained and demonstrated a colonic obstruction at the level of the colonic anastomosis within the left abdomen. The patient was taken to surgery on 7/9/22 for laparoscopic takedown of anastomosis, end colostomy.
The surgeon who performed this second surgery noted that the small bowl and large
bowel to be grossly dilated. A stapler was used to divide the ascending colon distal to the anastomosis and the anastomosis grasped with a locking grasper. The anastomosis and transverse colon were then brought through the ostomy site and the distal transverse colon was opened adjacent to the anastomosis, excising the anastomosis entirely. The surgeon noted that "at this point a polyp was found within a cm of the anastomosis and appeared to be acting like a ball valve precipitating the obstruction. The distal transverse colon was then fashioned as an end colostomy.
The specimen was sent to pathology. The pathologist described there to be a 2.6 x 2.0 x1.4 cm dark red polypoid lesion which was 0.9 cm from the open margin. Sectioning near the polyp reveals multiple intramural staples and a focally fatty cut surface.
Four months later the patient underwent a takedown procedure following which he developed sepsis. A CT was performed and showed significant intra-abdominal free air/fluid. He was taken back to surgery during which an anastomic leak with ischemia of the ascending and transverse colon were identified. A subtotal colectomy with end ileostomy was performed.
My questions related to the foregoing are as follows:
1. Was it reasonable for the GI MD to fail to identify the polyp during the colonoscopy which was ultimately described as 2.6 x 2.0 x 1.4 cm? In other words under the circumstances of this case, did he fall below the standard of care?
2. Given the size and proximity of the missed polyp to the :large "lesion" that he did ink, would it not have been his responsibility to closely inspect those areas in close proximity to the lesion given the fact that a surgeon would be relying on such identification?
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Do you believe there might have been medical error?
1. Was it reasonable for the GI MD to fail to identify the polyp during the colonoscopy which was ultimately described as 2.6 x 2.0 x 1.4 cm? In other words under the circumstances of this case, did he fall below the standard of care? From the information provided I do not know if the GI MD traversed the 1/3 circumferential mass. If the GI MD went beyond the mass, the other polyp should have been noted in the report. If GI MD was limited and unable to get by the mass, then GI MD is within standard of care. If details to the extent of exam (cecum identified?) were not documented that is not meeting standard of documentation. 2. Given the size and proximity of the missed polyp to the :large "lesion" that he did ink, would it not have been his responsibility to closely inspect those areas in close proximity to the lesion given the fact that a surgeon would be relying on such identification? Yes, details about the extent of exam are not provided in the reviewed case. Based on the provided documentation it is not stated what was or was-not visualized proximal to the mass. The length of 15cm was stated, but there is not a description of the mucosa proximal to the mass. Unless the GI md and surgeon discussed the case directly the endoscopy report has limited information.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
First, the colonoscopy report appears to be missing essential information, specifically extent of exam with mucosal description proximal to the mass. Second, why was a division point selected 8cm proximal to the tattoo? The colonoscopy reported a 15cm mass. The division point 8cm proximal to the tattoo would be in the middle of the 15cm mass. This would leave residual mass/polyp tissue behind. The proximal division point should be greater than 15cm proximal to the tattoo for clear margins. Thus it is not clear if the ball-valve lesion was actually a polyp not mentioned or incorrect math for the surgical margins. Poor documentation, communication, and assumptions might have been causation for the injury.
What makes you a good expert for this case?
I have ten years experience as a gastroenterologist in the Texas medical center. I specialize in colon cancer screening. I am a member of quality review for adverse events and m&m related to endoscopy.
How often do you encounter cases similar to this one in your practice?
Communication related medical errors are not uncommon. I have not ever encountered this case specific chain of events.
Do you believe there might have been medical error?
Colonoscopy is our best test for polyp detection and colon cancer detection but it is not perfect. Interval colon cancers have been well described in the literature and are presumed to be related to missed polyps. Usually this is smaller polyps than the one described here but polyps can hide behind folds and detection can be more difficult in areas with a lot of diverticula.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Polyps do not generally cause obstruction in the large intestine and unlikely to have caused obstruction at that size. One could easily argue that the obstruction was not related to this polyp and it was fortuitous that it was identified
What makes you a good expert for this case?
I am a gastroenterologist and routinely perform screening colonoscopies with polypectomies and refer patients for surgery if indicated. I review about 8-10 cases a month for an expert witness company as preliminary review for attorneys.
How often do you encounter cases similar to this one in your practice?
This is an unusual situation. I deal with large polyps that may require surgery but have not encountered a case where a missed polyp was attributed to post op obstruction.
Do you believe there might have been medical error?
Granted the bowel preparation was adequate (in this case there does not seem to be reason to think that it was not), failure to identify a polyp of these dimensions (2.6 x 2.0 x1.4 cm) is extremely difficult to justify except for in very extenuating circumstances. This would be highly unusual. it’s possible that with the other polyp findings and the diverticulosis, the endoscopist became visually and/or mentally fatigued and didn’t pay adequate attention (I.e. became negligent)
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It’s written that “The surgeon noted that "at this point a polyp was found within a cm of the anastomosis and appeared to be acting like a ball valve precipitating the obstruction..” This would seem to indicate causation, especially if there is further corroboration of this in the resected specimen.. It appears the patient endured a tremendous amount of morbidity and suffering, a substantial amount of which probably could have been avoided.
What makes you a good expert for this case?
Colorectal cancer screening, polyp detection, endoscopic resection, and collaborative care with surgeons, radiologists, and pathologists are pillars of my clinical practice and published research.
How often do you encounter cases similar to this one in your practice?
I encounter cases similar to this a few times per year (fortunately my my own cases). This one is somewhat unique in the number of polyps, surgeries, and so forth, but the principles are the same.
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