This is a PC who had a long history of abdominal issues, including colon cancer with some metastatic growth in the liver in 2019. PC has had colon resection with colostomy, subsequent reversal, small bowel obstruction repair, cholecystectomy, and a liver tumor resection in the subsequent time.
This particular case is for the PC arriving to the emergency room with abdominal pain and new onset large bowel obstruction. He had multiple days of abdominal distention and lack of bowel movements. Once admitted for observation, PC was given laxative and IV fluids and some of his symptoms were relieved. Colonoscopy was done and revealed stricture at the colorectal anastomosis. Surgeon recommended metal stent placement. Surgeon informed PC that the stent could be kept permanently unless he had discomfort post-operatively.
Two days later, the stent was placed. In the surgical notes, the surgeon noted that the only stent they had available in the hospital was 120 mm in length.
Surgical notes seen below:
“A ********** (redacted company name) 25mm x 120 mm wall flex stent was advanced over the wire through the stricture. Stent deployment was initiated high in the colon and the stent brought down intermittently across the stricture with an effort to have the distal most aspect of the stent just past the stricture to avoid stent low in the rectum and resultant proctalgia. Unfortunately, the only stent available in-house was a 120 mm length. Regardless, stent deployment was successful. The flare was just beyond the stricture. The delivery device was withdrawn. I again advanced the colonoscope. As stated the flare was just beyond the stricture. The stricture was already significantly improved. The colonoscope was withdrawn. The patient tolerated the procedure well. Patient was taken to the post anesthesia care unit in stable condition.”
PC was discharged and on multiple follow-ups over the next 6 months, PC complained of pain on most every bowel movement. Surgeon did a digital exam and found that the stent was palpable and was sitting in the rectum. It should be noted that the surgeon warned of proctalgia being a concern for the stent size.
2 months after this discovery, a colon resection was scheduled. No CT scan was done prior to the procedure. PC was healthy, had no colostomy, had no other significant health issues. PC was very active and providing full-time support for family.
Post resection, PC had continual abdominal pain, lack of appetite and generalized weakness while in patient. No CT scan was done in the hospital until 8 days post op. By this time, PC was very edematous, had acute kidney injury, showed two anastomotic leaks with multiple abdominal abscesses. Specimens obtained from the colon resection had firmly embedded stents with necrosis. Stent appeared to fail due to the fact that the stricture was occluded with copious amounts of abnormal red-brown mucosa and that tissue sampling was difficult due to mangled stent wiring.
PC was brought back for exploratory laparoscopic procedure and washout. Had colostomy and mucus fistula. Also had four drains placed at this time. No complications notated.
PC hospitalized for an additional 3 to 4 weeks and was subsequently discharged. PC now has permanent colostomy and mucus fistula that requires multiple dressing changes a month.
PC reports approximately 50% reduction in energy levels, having difficulty providing for family and now has continual follow-ups and subsequent abdominal complications.
This case would be for a colorectal surgeon who is experienced in stricture cases and/or abdominal stenting.
Our concern is that the stent appears to be meant for terminal patients, however our PC was fully active and did not show any clinical signs of being a terminal in nature. In addition, we have apprehension about the size of the stent and its placement. Thirdly, we are concerned about a lack of CT scan prior to the procedure and the eight days post procedure.
Attached imagine is the ABD XR immediately post-stent placement. (Can be opened with Windows Photo Viewer or Paint app)
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Do you believe there might have been medical error?
I believe the choice to put a stent at the initial procedure was I’ll conceived. Typically, with a anastomotic stricture, a balloon dilation, or even an Axios stent would be a viable option. However, a metallic stent is permanent and it cannot be removed and does cause proctalgia and anorectal pain. The subsequent issues are all related to the choice of stent placement. Even in a terminal patient this would not have been the best choice.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As stated above the choice to place the stent led to the subsequent issues.
What makes you a good expert for this case?
I’ve reviewed many cases similar to this one concerning missed injuries and malpractice. I am a dual board certified colorectal and general surgeon and perform colonoscopies as well.
How often do you encounter cases similar to this one in your practice?
I see similar cases on a weekly basis.
Do you believe there might have been medical error?
The indications for stent placement in patients with malignant colonic obstruction include: ●Palliation of surgically incurable colorectal cancer. ●Stenting as a bridge to surgery to avoid an emergent, two-step procedure and to allow for optimization of medical status and for preoperative staging including colonoscopy. ●Management of some patients with extracolonic pelvic tumors Stent placement to treat distal rectal lesions (ie, within 5 cm of the anal verge) is usually avoided because a stent in this location can induce severe pain, tenesmus, and rectal bleeding. However, some patients who wish to avoid an ostomy can undergo stent placement very low in the rectum with good tolerance.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Colorectal self-expanding metal stents (SEMS) may be uncovered (meshwork is bare wire) or covered (meshwork is covered to decrease tissue growth into the stent). All colorectal SEMS function very similarly. ●Only uncovered stents are available for the treatment of colonic obstruction in the United States, and include the following: ●Through-the-scope (TTS) stents: •WallFlex Colonic Stent (Boston Scientific) – This uncovered nitinol TTS stent expands to mid-body diameter of either 22 or 25 mm and proximal flange of 27 or 30 mm. It is available in lengths of 6, 9, and 12 cm. Foreshortening, which is the reduction in stent length from the crimped to the expanded condition, occurs up to 30 to 40 percent during deployment. •Evolution Colonic Controlled-Release Stent (Cook Medical) – This uncovered nitinol TTS stent has a mid-body diameter of 25 mm and proximal and distal flanges of 30 mm. It comes in lengths of 6, 8, and 10 cm. Foreshortening occurs during deployment. •HANAROSTENT LowAx Colonic Stent (Olympus) – This uncovered nitinol TTS stent has a patented "hook and cross" design to promote ideal radial and axial force at the site of obstruction. It is available in lengths of 6, 9, and 12 cm, with mid-body diameters of 22 and 25 mm. This stent demonstrates limited foreshortening during expansion in comparison to other commercially available colon stents. ●Non-TTS deliverable stent: •Ultraflex Precision Colonic Stent (Boston Scientific) – This nitinol stent has a proximal flange of 30 mm and body diameter of 25 mm. It is available in lengths of 5.7, 8.7, and 11.7 cm]. It differs in that the delivery system is too large to be passed through the channel of the endoscope (non-TTS deliverable), it cannot be re-constrained during deployment, has a string release mechanism, and opens from the distal end (closest to the endoscopist, below the tumor, unlike the other stents that open from the proximal end, above the tumor). It also has less foreshortening than the previously mentioned stents.
What makes you a good expert for this case?
Decades of experience with colon surgery/obstruction. Most colorectal surgeons do NOT place stents, but GI physicians do this all the time. Have experience with placing stents, the indications, and when they are not useful.
How often do you encounter cases similar to this one in your practice?
Large bowel obstruction is common. Why wasn't this patient offered surgery?
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