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 The endoscope was noted to be slowly withdrawn.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 from 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 are as follows:
1. Was there a medical error by the first surgeon? If so, did it cause injury?
2. Was it appropriate for the first surgeon to divide the bowel 8cm proximal to the ink tattoo when the GI MD noted that the ink tattoo had been placed distal to the 15cm mass?
Files:
Q: Did the first surgeon perform a colonoscopy on the operating table? Also, did he/she have the CT scans available in the room?
A: A colonoscopy is not mentioned anywhere in his OP report. I do not believe he did. He had the report sent to him a couple of months before the surgery. No mention that he had them in the OR. In fact, the CT had been done at another hospital system.
Do you believe there might have been medical error?
I Don’t believe there was a medical error on the part of the surgeon. It is strange that the mass would be 15 cm and he would have divided the colon 8 cm proximal to that. You wonder if he transected part of the mass. However, if he would have done this, then he wouldn’t have been able to fashion and anastomosis appropriately, so I don’t believe this actually happened. I believe that the obstructing lesion was a second lesion. Where thebsurgeon divides the colon anatomically is decided upon by multiple factors, including the blood supply to that segment. I think the bigger concern here is if there was an additional polyp not identified by the gastroenterologist in the report And the surgeon would not have been aware of this and that could have been what caused the obstruction. If the surgeon was aware of this, then they could have moved their anastomosis appropriately. It is surprising, however that this large polyp was not identified at the time of surgery . One wonders if the surgery had been done open. Perhaps the surgeon may have felt this large mass that was creating the obstruction.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This is a very odd case, and that there are discrepancies in the surgical findings and the endoscopy report. It’s difficult to ascertain whether medical era contributed to this complication, because there are conflicting perspectives. Was there a second polyp or did the surgeon not taken off of the colon out, and divide/transact the colon where there was still mass. It would be important to see any CT scans postoperatively and preoperatively to compare.
What makes you a good expert for this case?
I’m a complex surgical oncologist who specializes in complex G.I. surgery and take care of patients with both benign and malignant processes of the colon.
How often do you encounter cases similar to this one in your practice?
Multiple times weekly. I stated above, I am a complex Gastro enterology, surgeon, and surgical oncologist, who cares for patients with both benign and malignant processes of the colon.
Do you believe there might have been medical error?
Unfortunately, there was medical error. A GI physician's estimation of where a lesion is not always accurate because of the redundancy of the bowel and the "according" that occurs when the scope is advanced. The tattoo making is more accurate and should be seen when a scope is placed in the patient's abdomen. If not, then an on-table colonoscopy should be performed or the case converted to open. In this case the CT scan clearly identified the area of thickening in the proximal sigmoid colon which corresponded to the second surgeons findings and the pathology report. A surgeon cannot solely rely on a report. They must review the images and be prepared convert this type of surgery to open or re-scope the patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The error caused the patient to undergo a second surgery with associated risks.
What makes you a good expert for this case?
I have been in practice for 16 years and have competed hundreds of laparoscopic and open colon resections. In addition, I do expert cases for law firms on both the defendant and plantiff's side.
How often do you encounter cases similar to this one in your practice?
I have never had this happen in my practice, but I am aware of similar cases. Especially with advances in laparoscopic and robotic surgery. I suspect we will see more.
Do you believe there might have been medical error?
There are several problems with the conduct of the operation. There is no mention of the first surgeon opening the specimen within the operating room in order to confirm the intended target has been excised. Had he opened the specimen, he would have found the cluster of small polyps, none of which measured anywhere close to 15 cm as described in the colonoscopy report. This would have alerted him that he had missed the polyp. Secondly, dividing the colon proximal to the tattoo is appropriate but should have been performed well beyond 8 cm from the tattoo. If the tattoo is placed distal to the polyp, you have to transect the bowel proximal to the tattoo but far enough away from it that you incorporate the target within the resection. In this case 8 cm was insufficient. Finally, the surgeon performed what appears to be a segmental resection of the colon that included a section of distal transverse colon, splenic flexure and descending colon. This is an inappropriate operation for colon cancer and even though there was no knowledge of cancer prior to surgery, a 15 cm polyp that occupies one third of the circumference of the colon is going to be cancer in a substantial number of cases. Therefore, the correct operation should have been a cancer operation, namely an extended left hemicolectomy with lymph node resection.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The complication was caused by the unresected polyp that occluded the anastomosis. Had the polyp been removed, there would not have been a polyp to occlude the anastomosis.
What makes you a good expert for this case?
I'm a board certified general surgeon and surgical oncologist with extensive experience in open colectomies, laparoscopic colectomies and robotic colectomies.
How often do you encounter cases similar to this one in your practice?
Up until 2020 I encountered this problem between 50 to 75 times a year. Since 2020 I no longer perform colonic surgery
Do you believe there might have been medical error?
The mass in question is noted to be 15cm long in the GI note with a tattoo at the distal end. The surgeon resected 8cm proximal to the tattoo. While a 15cm long mass is abnormal and grounds for question, at least by report the mass is incompletely resected. Therefore, when the ball-valve like mass was later found this is not unexpected. If there was question of the accuracy of the colonoscopy report an on-table scope could have been performed or a more in-depth evaluation of the colon proximal and distal to the resection points should have been performed intra-operatively. The subsequent complications all stem from this initial event. I am curious at the second operation if anything was done to confirm the vascular viability of the anastomotic site as the initial resection likely took a large amount of the colonic vasculature.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Not completely resecting the causative site led to the subsequent events-as above.
What makes you a good expert for this case?
I am a board certified general surgeon in practice for over 10 years and treat patients with both the initial surgical problem and as an acute care surgeon also with the subsequent complications.
How often do you encounter cases similar to this one in your practice?
The initial GI report is unusual, I suspect few surgeons encounter such unusual reports regularly. I do encounter patients with colonic masses and obstructions regularly (several times per month).
Do you believe there might have been medical error?
In this case, appropriate pre-operative screening was done. The colonoscopy described is appropriate and helps guide future surgical intervention. Following the colonoscopy, the appropriate pre-operative workup was performed and in reading the description of the first operation, I would agree with the approach taken including the margin of 8cm and the locations to do the anastomosis.. The decision of distance to go proximal and distal to the tumor are well defined and are both to minimize the chance of a positive margin but must also take into account how the anastomosis is functionally performed. Sometimes more margin is taken to allow for a safer anastomosis, such as in this type of case where the transverse colon is involved. Attempting to anastomose the transverse colon end to end can typically be a location where there is both tension and/or watershed blood supply and lead to post-operative complications. It is not routine to do another colonoscopy in the OR as long as the lumen of the bowel was inspected prior to completing the anastomosis, therefore allowing direct visualization for any poylps, tumors, or technical problems to be seen prior to completion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
With a hand sewn anastomosis during the index operation, there was adequate opportunity to inspect the lumen and ensure no obstructions prior to completion. That said, it is likely that patient disease (AJCC) was a major factor that was responsible for the index complication as well as the delayed complication 4 months later.
What makes you a good expert for this case?
I have performed many colonic anastomoses in my career both in the elective and emergent setting from cancer or in the setting of inflammatory bowel disease. The approach for a transverse colon resection in the setting of cancer is a common board question and I have encountered this type of case many times in my career.
How often do you encounter cases similar to this one in your practice?
Although this is an overall rare complication (anastomotic breakdown), I have encountered many of these cases during my career and it is often a point of discussion at M&M regarding what could be done differently to prevent anastomotic leaks and how the index surgery can help prevent that.
Do you believe there might have been medical error?
According to the records provided, the ink tattoo is placed 15 cm distal to the mass and the proximal colonic transection point was done 8 cm proximal to the tattoo. This was followed by a postoperative large bowel obstruction at the level of the anastomosis. The intraoperative findings from the on the anastomotic takedown indicate obstruction due to the intraluminal mass. This leads to the reasonable conclusion that a surgical error had occurred as the mass was not resected and anastomosis was created with immediate subsequent postoperative colon obstruction.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The fact that an immediate postoperative colon obstruction occurred at the site of the anastomosis indicates that a surgical error has occurred and the fact that it required a return to the operating room and colostomy creation indicates that the error did cause harm to the patient.
What makes you a good expert for this case?
I am an academic surgeon in active clinical practice who performs routine intraabdominal surgery including bowel resections, anastomosis and ostomy creation on a daily basis. I have nearly a decade of experience of elective and emergency general surgery.
How often do you encounter cases similar to this one in your practice?
I encounter cases similar to this in my practice on a daily basis.
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