A 57-year-old male with a history including TIA, chronic neck and back pain, benign prostatic hyperplasia, essential tremor, and mood disorder underwent an outpatient colonoscopy for family history of colon cancer and first-time screening/surveillance. The procedure note documents diffuse diverticulosis, a near-stricture in the sigmoid colon, and removal of seven polyps using cold snare, hot biopsy, and hot snare techniques. The report states the scope was advanced to the ileum, the examination was completed, the polyps were removed atraumatically, and no procedural complications were identified at the time.
**PLEASE SEE ATTACHED OP NOTE FOR REFERENCE**
Later the same day, the patient developed abdominal pain, distention, and swelling/crepitus extending into the upper chest and neck, prompting return for emergency evaluation. Imaging obtained after presentation was reported as showing pneumoperitoneum, subcutaneous emphysema, and mild pneumomediastinum, raising concern for bowel perforation following colonoscopy. Surgical consultation was obtained, and the patient was admitted for management of a perforated viscus in the setting of recent endoscopy.
The following day, the patient underwent exploratory laparotomy with bowel resection and anastomosis. Hospital documentation describes a full-thickness colonic perforation with contamination, including pus/feculent material, requiring operative repair. Later summary documentation attributes the bowel perforation to the colonoscopy and notes postoperative treatment with IV antibiotics, pain control, bowel rest, and gradual advancement of diet. The patient reportedly improved during the admission, regained bowel function, and was discharged home several days later with surgical follow-up.
For expert review:
-Was the colonoscopy technique and polypectomy methods appropriate under these circumstances.
-Whether the subsequent perforation is more consistent with mechanical injury, thermal injury, barotrauma, or another mechanism.
-Whether the procedure note and subsequent hospital documentation adequately explain the location and cause of the perforation.
Thank you in advance, questions welcome.
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Do you believe there might have been medical error?
While this appears to be an indicated procedure, there are a few findings in the report that call into question, whether or not the use of hot biopsy forceps, which have a known higher risk of perforation, was the right approach for three small benign appearing polyps. Typically this technique is used to ablate residual tissue when other, less traumatic options have already been exhausted or in other specialized scenarios. The use of cold snare polypectomy has become standard of care for otherwise small diminutive polyps that cannot reasonably be fully excised with cold biopsy forceps. It is possible that the perforation was missed and that the patient had no evidence of a problem until they were discharged and back at home, but this would require a review of the PACU notes and any other files.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
see above The use of electrocautery is associated with a higher risk of bowel wall injury, and perforation, and needs to be applied selectively and with caution. This is likely the mechanism of injury, the use of hot biopsy, forceps, or possibly from stretching of the colon wall in the setting of a narrowed colonic segment in the setting of severe diverticulosis, it would require a review of the colonoscopy and surgical pathology reports to sort out.
What makes you a good expert for this case?
20 years of endoscopy and colonoscopy experience, including advanced training in interventional, endoscopy and familiarity with all of the techniques used in this case.
How often do you encounter cases similar to this one in your practice?
The need to remove polyps at colonscopy is a routine matter in my practice.
Do you believe there might have been medical error?
use of hot biopsy technique has been abandoned a long time ago due to risk of perforation. multiple devices used t remove small polyps? should not be the case--only cold snares
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
use of hot biopsy technique has been abandoned a long time ago due to risk of perforation. multiple devices used t remove small polyps? should not be the case--only cold snares
What makes you a good expert for this case?
extensive endoscopy expertise, professor, medical director and long history of legal reviews, extensive publication record
How often do you encounter cases similar to this one in your practice?
a few a year --colonoscopy related perforations are rare in good hands but in a busy practice can be seen
Do you believe there might have been medical error?
First of all, the endoscopist notes "hot snare" used for at least one polyp, but doesn't mention the specific one being removed with that method. Second, the "hot biopsy" technique was proved to be of unacceptably high risk at least 10 years ago, and discarded as a standard technique, that is currently inappropriate in the U.S. - not the standard of care. Lastly, a 5 year interval as recommended is incorrect for that many polyps - first one needs the path report, but in general it should be 3 years at the most. The biggest egregious error though, is the hot biopsy technique - never done nowadays, and is a breach, as the perforation risk is too high.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Clearly, the colonoscopy led to the perforation - there's no other explanation.
What makes you a good expert for this case?
I've performed 30,000 endoscopic procedures, and have reviewed about 150 legal cases, about 50/50 plaintiff defense, including multiple cases of complications.
How often do you encounter cases similar to this one in your practice?
I encounter patients with polyps multiple times a day during procedures, and remove them with standard techniques. In terms of perforations, as I'm in a group of 11 doctors, we may have 1-2 perforations a year out of 12-14,000 cases. However no one has used hot biopsy in over 10 years.
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