Allegation
Plaintiff alleged the defendant physician incorrectly noted the location of a tumor resulting in the unnecessary removal of a portion of the colon and a temporary colostomy for the patient.
Case Details
The patient, a 73 YOM (5’10”, 161 lb), with a history of polyps, sigmoid resections for diverticulitis, and a patent end-to-side ileo-colonic anastomosis, was seen by the defendant gastroenterologist (GI) for a routine colonoscopy. The defendant found one 10-mm semi-sessile polyp at the hepatic flexure. The polyp was resected and retrieved. He also discovered a polypoid non-obstructing medium-sized mass at the hepatic flexure, which was partially circumferential, involving one third of the lumen circumference. The mass measured 3 cm in length and 3 mm in diameter. No bleeding was present. The defendant physician took biopsies for histology and injected the area with 2 ml India ink for tattooing.
The pathology report revealed the hepatic flexure polyp as fragments of tubular adenoma, and the hepatic flexure mass biopsy as invasive adenocarcinoma, moderately differentiated. The patient saw a general surgeon prior to scheduling an extended right hemicolectomy. The patient obtained preoperative clearance from his PCP, including PT, PTT, chest x-ray, CEA, and a skull to thighs PET scan, which showed no scintigraphically worrisome lesion.
The patient underwent an extended right hemicolectomy and transverse colectomy. Since the tumor had been noted in the hepatic flexure preoperatively, the surgeon made a careful search of the entire right colon. Prior to dividing anything, the surgeon palpated the entire right colon and transverse colon past the middle colic vessels. After repeat palpations, he found no obvious abnormalities. The omentum was also densely stuck to the colon toward the splenic flexure, which made palpation difficult in this region. No tumor was noted, but since it had been reported to be a small tumor that might not be palpable, the surgeon mobilized the right colon along the white line of Toldt. The surgeon divided and ligated the mesentery up to the middle colic vessels with the colon divided.
The surgeon sent the colon to pathology. While the colon specimen was being examined, he completed an ileocolic anastomosis. Pathology reported there was no tumor in the specimen. The surgeon explored the remainder of the omentum from the transverse colon, and the tumor was found toward the splenic flexure region. He mobilized this portion of the colon out of the splenic flexure, and removed the greater omentum. There were no obvious bleeding vessels, so he removed a good portion of the omentum by ligating the pedicles and dividing them. Once the surgeon discovered the appropriate location, the colon was divided and anastomosis was performed after taking down or removing the previous anastomosis to fresh terminal ileum.
The patient remained hospitalized for approximately one week before being discharged home. The next day, the patient woke up during the night with severe abdominal pain, nausea, and vomiting. He went to the emergency department where they called the general surgeon who had performed the prior procedure. The surgeon admitted the patient. When the surgeon returned in the afternoon, the patient was feeling better, but was not free of pain or in the same condition as his preoperative state. The surgeon discussed the plan to take the patient back to the operating room, and the patient consented.
The surgeon performed a re-exploration of the abdomen. Upon inspection, the small bowel was somewhat edematous and swollen. The colon itself and colonic anastomosis were somewhat ischemic. The report noted ulceration, focal acute peritonitis, and fat necrosis with a possible microperforation.
While the patient was still hospitalized, lab abnormalities and a CT scan showing free air and possible leaking of the anastomosis necessitated a second re-exploration. The surgeon confirmed a leaking anastomosis and performed an ostomy. The patient’s total hospitalization lasted 19 days. Since the colon cancer was at an early stage, the patient did not need chemotherapy; he had the ostomy reversed six months later.
Expert Testimony
Plaintiff experts stated the defendant physician deviated from the standard of care by erroneously identifying and marking the location of the plaintiff’s tumor as being in the hepatic flexure; the tumor was actually located near the splenic flexure, resulting in unnecessary removal of the right colon/hepatic flexure. The additional removal of the right colon led to subsequent ischemic bowel surgery and subtotal colectomy.
Defense experts testified the defendant physician’s treatment fell within the standard of care. They agreed the plaintiff’s surgical history would make describing the position of the tumor with precision more difficult, which is why the physician tattooed the area where the mass was located. Additionally, the surgeon stated he would have taken the other section of bowel to increase the chances of success even if the defendant had identified the tumor as being more toward the splenic flexure region.
Resolution
The case resulted in a defense verdict at trial.
---
If you have questions on this topic, please email RiskAdvisor@ProAssurance.com or call 844-223-9648.