64 year old gentleman who came to ER for epigastric stomach pain after eating. PC has history of hypertension, prostate cancer, debulking surgery via laparotomy 20 years ago, fatty liver and BPH. PC was working in actively assisting family.
CT scan shows cholecystitis with new 1.5cm cystic lesion in the pancreas, dilation of biliary tree and distal obstruction. An attempt to do an ERCP was done, however was found to have “irregular anatomy” and coffee ground fluid in the stomach. This was aborted and an EGD was done. PC was then transferred to a more appropriate facility to investigate pancreatic mass.
January 4: The second facility attempted a biopsy with endoscopy and that procedure was complicated by a biliary tree rupture and transmural defect in the proximal jejunum. Operative notes state that two hemostatic clips were applied and the entire defect was closed with serial application of hemostatic clips and complete approximation of small bowel mucosa. They state that contrast was injected into the small bowel and it showed no leakage at the time. IV antibiotics were given and surgery was consulted post procedure. The decision was made to transfer patient to ICU and monitor closely. PC continued to have sharp and severe abdominal pain and was receiving IV Dilaudid and was NPO status. CT scan done same day (Jan 4) reveals pneumoperitoneum and/or bowel perforation. The decision was not to perform surgery immediately, just monitor.
2 days later (Jan 6), exploratory laparotomy was done in which they found “copious amounts of enteric contents in the abdominal cavity, multiple dents adhesions, a perforation just distal to the ligament of Treitz with a large perforation of the jejunal side wall with exposed mucosa and prior place middle clips. Bowel wall extensively thin and friable.”
A washout and repair was completed. PC on dialysis due to AKI and developed severe sepsis within a few days.
PC had complicated hospital course following this, mostly due to intrabdominal infection and renal failure. Was on long-term ventilator support and a tracheostomy was placed. PC had hospital stay extending longer than 3 months. Was eventually discharged to rehab and then returned to hospital in mid 2023 for elective laparoscopic takedown of fistula, bowel resection, hernia repair, possible cholecystectomy, poss appendectomy. By all accounts, these procedures went without any complications, however PC did become septic once again and over a course of 2 weeks had rapidly declining health and was placed on the DNR and passed in April 2023.
The purpose of this evaluation is to determine if the sequence of events between January 4th and January 6th we're detrimental to the PC's health. There's a concern that the bowel perforation and pneumoperitoneum was discovered post endoscopy on 1/4, however was not addressed with surgery until 2 days later.
I have had conferences with the family and they reveals that the patient's health rapidly declined after this time and never improved to a point of home discharge.
I have attached a word document that includes radiology reports that would be pertinent for your evaluation. We are looking for a gastroenterologist who would do various GI surgeries like these on a regular basis.
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Do you believe there might have been medical error?
The problem here is that perforation is a known complication, so it would depend on the nature of the indication for the procedure, and whether or not, there was gross negligence, which could be hard to prove. The management of this patient may not necessarily have been wrong after perforation, but will depend on a thorough review of the decision making. I don't see the attachment that was referenced.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Seems clear that the perforation led to his demise, see above. It appears there is adequate documentation of this perforation, and that it was recognized in a timely fashion. The problem here is that perforation is a known complication, so it would depend on the nature of the indication for the procedure, and whether or not, there was gross negligence, which could be hard to prove. The management of this patient may not necessarily have been wrong after perforation, but will depend on a thorough review of the decision making. I don't see the attachment that was referenced.
What makes you a good expert for this case?
Interventional endoscopist/academic The problem here is that perforation is a known complication, so it would depend on the nature of the indication for the procedure, and whether or not, there was gross negligence, which could be hard to prove. The management of this patient may not necessarily have been wrong after perforation, but will depend on a thorough review of the decision making. I don't see the attachment that was referenced.
How often do you encounter cases similar to this one in your practice?
Often The problem here is that perforation is a known complication, so it would depend on the nature of the indication for the procedure, and whether or not, there was gross negligence, which could be hard to prove. The management of this patient may not necessarily have been wrong after perforation, but will depend on a thorough review of the decision making. I don't see the attachment that was referenced.
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