On 6/17/22 at 1825, 54 year old male patient presents to the ED complaining of rectal bleed. Patient had robotic colostomy takedown one week prior to presentation. (The anastomosis did not reveal bubbling or leak before closure at that time) Patient reported to ED MD that he had been straining for a bowel movement when suddenly a lot of bright red blood came out. His presenting bp was 67/45, pulse 121 and RR 22. Abdomen was noted to be soft, nontender with distension on exam. Initial labs drawn revealed WBC of 13.2, Hmg of 8.7, BUN 7 and Creatinine of 1.4.
A CT of the abdomen/pelvis with contrast was completed. The interp reads as follows: Abnormal appearance of the large bowel which may represent ileus, intraluminal blood not excluded; Abnormal appearance of loop of bowel directly proximal to an area of previous anastomosis where there may be perforation or abscess and there is extravasation of contrast consistent with active bleeding. No free air.
ED MD call surgeon who performed previous takedown. Surgeon recommends admission to medicine and serial H/H.
Surgeon sees patient at noon on June 18th. Surgeon notes that patient complains of abdominal pain although appears quite comfortable. Patient also denies further bleeding that day. Latest WBC from that morning was 21.0. Hgb is 9.4. Surgeon reviews CT from previous evening and notes that it "essentially shows fluid-filled small bowel loops and no free air". He does not mention the abnormality noted by the radiologist proximal to the anastomosis. His assessment was lower GI bleed, ileus, AKI and blood loss anemia. His plan was to continue conservative measures and supportive care with IV antibiotics and transfusions as indicated.
At 0850 on June 19th, rapid response was called related to patient's sever abdominal pain. Surgeon was called by hospitalist who was noted to urge the surgeon to come and reassess the patient for surgical revision. Surgeon ordered a repeat CT of the abdomen and pelvis. Hospitalist ordered ICU upgrade.
The CT was interpreted as showing "again, there is amorphous collection of gas noted just prosimal to the sigmoid colon anastomosis". The collextion of gas "could either represent stasis versus an abscess collection". There was also a moderate amount of free fluid mainly collecting in the lower abdomen. The radiologist's impressesion notes "interval intra-abdominal free air".
Surgeon takes patient for exploratory laparotomy that same day. Notably, he charts in his Op note that the initial CT did not show evidence of an anastomosis leak although did show a vascular blush. He further noted that the second CT "now showed evidence of air at the site of the anastomosis suspicious for a leak." During surgery he found a defect in the anastomosis and a visible bleeding vessel within the defect. There was a moderate amount of old appearing blood in the abdominal cavity which he aspirated. The defect was closed with several interrupted sutures and fibrin sealant. A diverting loop ileostomy was also performed.
On June 24th, patient was experiencing increased abdominal pain and increasing WBC. A CT completed that day demonstrated a large fluid collection with air fluid trapped in the mesentery most suggestive of a bowel dehiscence or perforation. Patient returns for exploratory surgery on June 25th with same surgeon.
Surgeon describes significant amount of clotted blood within the peritoneal cavity. The air fluid pocket was foul smelling and aspirated and evacuated. No actual purulence noted. Surgeon then attempted to examine anastomotic closure. He noted there to be brisk bleeding at the base of the bowel mesentery. The patient was not clotting after attempt at packing. Surgeon applied additional hemostatic agents, wound packing and application of ABthera device. Peritoneal cavity was left open. Plan was to reevaluate surgically in 24-48 hours.
Patient was taken back to surgery for washout four more times. On July 6th after washout, coverage of exposed viscera with Vicryl mesh and application of wound VAC was completed.
Patient discharged on July 17, 2022. His diagnoses during his admission included septic shock and acute hypoxemic respiratory failure. Patient has since had multiple surgeries with another surgeon to rebuild the abdominal wall.
I am interested in opinions regarding the timing of the first exploratory laparotomy. The CT scan as interpreted by the radiologist on June 17th suggested a defect proximal to the anastomosis, yet the surgeon did not find it significant nor mention it when he saw the patient at noon on June 18th.. In fact, he was aware of it the evening of June 17th and did not come in to see the hospital. The defect is seen again on June 19th but now demonstrating free air. The patient also clearly deteriorated. Therefore, did the surgeon deviate from the standard of care by not coming in on June 17th to emergently explore the abdomen? Same question as it relates to June 18th when he sees the patient?
If the standard of care required emergent exploration on the 17th, does the patient avoid the terrible outcome of septic shock, repeat washouts and multiple surgeries? Same question if the surgery takes place on the 18th.
Files:
Q: What was the hemoglobin on the day of discharge from the first operation? This is important to note if the patient came in with a significantly reduced hemoglobin, and the patient is in hemorrhagicum shock no.
A: —
Do you believe there might have been medical error?
This is a potentially challenging case. The patient definitely presented with signs and symptoms of hypovolemic shock and you have to assume it’s coming from your anastomosis. A plain CAT scan is not the procedure of choice for bleeding… more likely than not, a CTA would’ve shown the blush which would’ve led to surgery based on objective data when he presented to the emergency room. On the other hand, the patient did respond to medical management, but you still have to assume it’s a surgical problem and the quicker you operate to fix the problem more likely than not many of the downstream operations would not have occurred
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the way, this patient presented, the standard of care would have been a CTA, which would’ve led to emergency surgery, and re-doing the anastomosis or colectomy with colostomy. That would’ve eliminated all the other nonsense that the patient had to suffer.
What makes you a good expert for this case?
Involved in teaching training and educating medical students and residents for the past three decades. This is the kind of operation I do on a monthly basis.
How often do you encounter cases similar to this one in your practice?
Colectomy 1 to 2 times per month. Partial bowel resection and the management of postoperative patients after surgery is the mainstay of my current practice.
Do you believe there might have been medical error?
The patient presented in stage 3/4 hemorrhagic shock and should’ve been taken to the operating room or to interventional radiology or to the G.I. endoscopy suite immediately. The fact that this patient was admitted to a Medicine service and no intervention was performed despite radiographic imaging showing active bleeding is concerning.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Anastomotic bleeding is a known complication as is a Perry anastomotic abscess. The biggest issue was a failure to rescue this patient and in a significant delay, in an intervention, to save their life and prevent significant morbidity.
What makes you a good expert for this case?
I’m a board-certified surgeon and complex general surgical oncologist, who takes care of patients with complex abdominal surgeries. I’ve published nearly 100 publications and run an active practice in addition to a basic science laboratory.
How often do you encounter cases similar to this one in your practice?
I deal with these types of patients on a weekly to monthly basis as an active practicing surgeon in complex general surgical oncologist.
Do you believe there might have been medical error?
Sometimes the CT is inconclusive and : or there is a contained perforation and can be drained by IR. The patient has a high white count and could be observed for a bit with IV abx with a plan to explore the patient or drain the collection. The issue with repeat explorations and anastamotic leaks and abscesses are unfortunate but not unheard of. It happens. Sometimes patients need multiple washouts to get this done and patients access free.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I don’t think there were medical errors that led to the Anastamotic leak and abscess formation
What makes you a good expert for this case?
I have done plenty of GI surgery and anastamoses over a career of nearly 20 years since fellowship.
How often do you encounter cases similar to this one in your practice?
Thankfully very very rarely! Actually I cannot remember the last time I had. A patient with an anastamotic leak.
Do you believe there might have been medical error?
This is an unusual case in that the anastomotic breakdown should occur so late. The error included in this information however likely does not lie at the feet of the surgeon. I do not believe that the patient should have undergone an emergent re-exploration 6/17 unless he did not respond to resuscitation to suggest uncontrolled ongoing bleeding. I would have to review the entire record to determine this. I am surprised that the patient was not admitted to the ICU for closer monitoring given the presentation of hypotension, tachycardia etc suggestive of hemorrhagic shock. To not be admitted to the ICU here is troublesome at best and suggests error. If the patient had a complete and hemodynamically appropriate response to hemorrhage then emergent re-exploration would not be warranted, especially as the patient is in a time-frame during which re-exploration is fraught with risk due to the typical post-operative hyperinflammatory period adhesions. The risks exceed the benefit with the information known on 6/17.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above, exploration on 6/17 would not be warranted from the information provided. If I reviewed the entire record I may find information to the contrary. I am deeply troubled that the patient was not admitted to the ICU initially which would have led to closer clinical monitoring and may have uncovered the change in clinical status/abdominal exam sooner allowing for more immediate intervention.
What makes you a good expert for this case?
I have been in clinical practice for over 10 years and I work as an acute care surgeon specializing in the management of acutely ill patients with surgical emergencies. As a general surgery division chair and surgical ICU/ACS department medical director one of my duties is medical records review and determination of errors and/or opportunities for improvement. I encounter patients with emergencies like these on a monthly basis.
How often do you encounter cases similar to this one in your practice?
As an acute care/emergency surgeon I am called upon to help manage surgical emergencies regardless of source (ie institution or surgeon). I encounter problems such as post-operative hemorrhage and/or anastomotic leaks at least once per month.
Do you believe there might have been medical error?
The patient presented to the emergency department one week after robotic colostomy takedown with bright red blood per rectum; in shock (tachycardia and hypotension); and with acute kidney injury (creatinine 1.4). There was also acute blood loss anemia with hub 8.7 (although this is harder to interpret in the absence of the patient's hgb at time of discharge from the colostomy takedown). While it is not uncommon for there to be some bleeding from a fresh anastomosis, the critical part of the emergency department workup is a CT with contrast that demonstrated extravasation of vascular contrast -- there was active bleeding associated with the anastomosis that was bad enough to put the patient into Class III hemorrhagic shock. The summary does not state that the patient received blood products; it would not be unusual to transfuse the patient and see how they respond, but overall, a bleeding anastomosis bad enough to result in such severe shock warrants aggressive action. Bleeding that severe runs the risk of disrupting the anastomosis, leading to dehiscence, contamination and intra-abdominal abscess, which is what seems to have happened. I think the error is not acknowledging the evidence of active bleeding (history, vital signs, labs and radiographic findings of extravasation) at time of admission via the ER. By the time of the rapid response and transfer to ICU, I think there was a clear indication for return to OR for ex lap rather than delay for a repeat CT scan. Notably, the summary does not describe why the patient initially needed a colostomy nor the timing from initial ostomy and the takedown. An earlier return to OR for takedown of a colostomy, depending on the patient's previous course, carries with it more risk of complications such as anastomotic breakdown, fistula or abscess. Furthermore, the degree to which the patient's physiologic reserve was compromised by the index operation is important for the ability to tolerate the takedown operation. Such information would be helpful to know whether the patient was frail or robust at the time of presentation to the ER. With a more robust patient, one might be able to try non-operative management at first, whereas a more frail, debilitated patient may not have the physiologic reserve to tolerate complications -- a small leak may propagate to an intra-abdominal catastrophe.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The question is whether an earlier ex lap may have resulted in fewer intra-abdominal abscesses and the series of multiple operations, open abdomen and associated complications. I can imagine that the surgeon did not wish to go back to the OR because it would entail investigating the colorectal anastomosis, possibly taking it down, and being obligated to at least perform a diverting loop ileostomy (which would be reversible) if not a repeat colostomy (with a greater risk of not being able to reverse). However, an early return to the OR may have allowed intervention before frank dehiscence of the anastomosis and/or improved washout. When the patient returned to the OR on the 24th, the tissue would be inflamed and friable, and this likely led to the mesenteric bleeding that required packing and temporary abdominal closure. I do think an earlier ex lap may have mitigated the subsequent complications.
What makes you a good expert for this case?
I am a surgeon practicing acute care surgery, trauma surgery, and surgical critical care. I am the medical director of the Surgical ICU at an academic, Level 1 trauma center. I perform damage control surgery and reoperative surgery nearly every week. I perform colostomy procedures as well as takedowns. I am referred a wide variety of surgical complications both as a surgeon and an intensivist.
How often do you encounter cases similar to this one in your practice?
I manage patients similar to this one probably once per month
Do you believe there might have been medical error?
The initial presentation can be interpreted as an anastomotic bleed based on the patient presentation (bleeding per rectum), initial vital signs (indicative of hemorrhagic shock), and lab values (low hemoglobin, anemia). While not every anastomotic bleed will need immediate return to the OR, it is reasonable to expect that a patient who is one week postoperative and returns to the ED in hemorrhagic shock be seen by their surgeon and admitted under the care of that surgeon. There is a finding of a “defect” near the anastomosis - there needs to be more details around this and the surgeons response to it. Having said that, failing to address this finding - imminently clinically significant, as the patient is one week postoperative and there is mention of abnormality of the anastomosis - is a deviation in the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
While the patient initially presented as an anastomotic bleed, the patient developed a leukocytosis (elevated WBC) up to 21 the following day, concerning for a leak. There needs to be more information around the CT scan findings of the “defect” at the anastomosis on the initial CT scan and how is it addressed by the surgeon. If this clinically significant radiographic finding is left unaddressed, as it appears that it was, it caused the patient to continue to leak from the colon for well over 24 hours while sitting in the hospital. Timely surgery would encounter less contamination, and less postoperative complications and reoperations, prolonged hospital stay, and additional morbidity.
What makes you a good expert for this case?
I am truthful and objective. Academic Trauma Medical Director and medical expert witness. I am in active clinical practice of general surgery with nearly a decade of experience.
How often do you encounter cases similar to this one in your practice?
I see this on a weekly basis. I also take care of them in the icu, as I am specialized in surgical critical care as well.
Want to open a case or submit response?
Comments are accepted only from Surgery (General Surgery) experts.