Avoiding unnecessary surgery

Mrs A, 50, had initially consulted her GP with heartburn and some minor weight loss. A gastroscopy was performed and demonstrated Grade A oesophagitis with a small hiatus hernia. Mrs A was started on a proton pump inhibitor; however, her symptoms persisted and she asked to see a specialist.

There was no documented evidence of a discussion regarding the role of further medical management and lifestyle measures. At the end of the consultation, Mrs A agreed to proceed with surgery

She subsequently saw a consultant surgeon, Mr B, who discussed the further management of Mrs A’s hiatus hernia and her gastro-oesophageal reflux disease. Mr B placed heavy emphasis upon the need for anti-reflux surgery to repair the hiatus hernia and prevent further reflux. There was no documented evidence of a discussion regarding the role of further medical management and lifestyle measures. At the end of the consultation, Mrs A agreed to proceed with surgery and, after the appropriate pre-operative work-up, Mrs A underwent an open Nissen fundoplication.

Surgery was carried out uneventfully, but postoperatively the patient developed an ileus and acute gastric dilatation. Attempts were made to decompress this with a naso-gastric tube but this was not tolerated, and the patient refused to allow it to remain in situ. After a prolonged hospital stay and slow recovery, Mrs A was eventually well enough to be discharged home.

Unfortunately within a few months, Mrs A’s symptoms became increasingly worse and were not controlled with high doses of antacid medication. Investigations at this stage demonstrated a disruption in the fundoplication and a breakdown of the repair to the diaphragm with a larger recurrent hiatus hernia. Mr B advised on further surgery, documenting the complexity and potential risks of the procedure, but made no mention of the need for a further naso-gastric tube.

A difficult further revisional operation was carried out by Mr B, repairing the recurrent hiatus hernia and performing a further wrap. Mrs A again developed postoperative problems with abdominal distension and gastric dilatation and again refused the naso-gastric tube. Within weeks of the operation she developed significant problems with worsening symptoms. A CT scan now demonstrated evidence of a huge recurrent complex hiatus hernia. Mrs A had lost faith in Mr B and sought further attention from a different surgeon, who required the help of a thoracic surgical colleague to carry out a major thoracoabdominal operation to repair the hernia.

After a prolonged but full recovery, Mrs A made a claim against Mr B for inadequate management. Expert opinion considered that there was a failure to adequately consider nonsurgical management in the form of medical treatment with antacid medication and lifestyle measures. Although the repeated postoperative complications were unfortunate, they were well recognised events and Mr B had clearly documented the risks of surgery when taking consent from Mrs A for the procedures.

There was agreement amongst the experts, however, that Mr B should have specifically warned Mrs A of the potential need for a naso-gastric tube, especially before the second operation. The case was eventually settled in full because of Mr B’s failure to exhaust conservative management before proceeding with surgery. This case was settled for a moderate sum.

Learning points

Clinicians should discuss all the treatment options available to a patient and document the discussion

  • When advising on a course of action, clinicians should discuss all the treatment options available to a patient and document the discussion. In situations where there is an alternative strategy to an operation, or a patient is unsure whether to proceed, a period of reflection or a second opinion from another clinician can be useful.
  • Appropriately detailed consent, ensuring that the patient understands the risks of a surgical procedure and the chances of failure, with good documentation of the discussion, are important cornerstones of a good defence when things go wrong.
  • When a patient’s postoperative management may be disrupted by their inability to comply with or tolerate a particular aspect of their care (such as a naso-gastric tube) surgeons should pay particular attention to this with any further procedure. The patient should be counselled about maintaining the naso-gastric tube postoperatively.
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