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A restoration problem

01 January 2014

Mr A, a 46-year old accountant, had a long history of biopsy-confirmed ulcerative colitis. Because of escalating medication, he was referred by his gastroenterologist for consideration of surgery after repeated exacerbations. He saw Mr C, a colorectal surgeon, who discussed the options available.

Mr A had been unable to work for several months. He had done some independent research on the internet and concluded that he wished to undergo a restorative procto-colectomy to avoid a permanent stoma. Mr C documented the risks of this complex procedure and warned Mr A of possible leaks, pelvic sepsis and possible future pouchitis. He planned to perform the operation laparoscopically, which would carry the advantages of a quicker recovery, fewer adhesions and minimal scarring.

Mr A underwent a laparoscopic proctocolectomy with complete intra-corporeal ileo-anal pouch formation and a covering loop ileostomy. He made a slow but straightforward recovery. He remained in hospital for ten days, requiring a course of intravenous antibiotics for presumed urinary sepsis and training in the management of his ileostomy.

Two days after discharge he re-presented with urinary retention requiring urethral catheterisation. Mr A subsequently developed increasing perineal and pelvic pain. Digital rectal examination revealed separation at the anastomosis, and a subsequent CT scan demonstrated a 6x7cm pelvic abscess adjacent to the anastomosis. A CT-guided drainage of the area was successfully carried out, and a week later Mr A was discharged home with the drain in situ.

There was a four-month period of ongoing review by Mr C, with a series of CT scans and contrast enemas demonstrating a slow but steady resolution of the abscess cavity with removal of the drain. After such frequent reviews the patient and surgeon were wellacquainted with one another and were on first-name terms.

Mr A was desperate for his ileostomy to be closed so he could return to work and, following a normal water soluble enema, Mr C decided to close the loop ileostomy. Preoperatively he documented the “high risk of pelvis sepsis if there is a persistent anastomotic dehiscence”. Before surgery Mr C performed an examination under anaesthesia, which showed a very small dehiscence posteriorly at the pouch-anal canal anastomosis. Nevertheless, Mr C proceeded with closure of the ileostomy, in the hope that this would ultimately heal.

Mr A then suffered a recurrence of his previous problems with urinary retention, pelvic pain and sepsis. A further 12-month period of repeated hospital admissions ensued, with radiologically-guided drainage of the pelvic collections and treatment with antibiotics. The relationship between surgeon and patient gradually broke down and Mr A was referred to Professor X, who undertook a revision open procedure to refashion the pouch, which eventually produced a satisfactory outcome.

Mr A initiated a claim against Mr C, citing that he had insufficient experience in undertaking laparoscopic procto-colectomy and ileo-anal pouch formation, and should instead have undertaken an open procedure. He also complained that he provided negligent postoperative care, performing a closure of ileostomy whilst an anastomotic defect remained.

Expert opinion agreed that the decision to perform a restorative procedure was correct and Mr C had sufficient experience and training to undertake the procedure laparoscopically. They were, however, in agreement that closure of the covering ileostomy – despite the operative finding of a persistent anastomotic defect – was not defensible. Mr C accepted the criticism, but noted that on a personal basis he had felt responsible for the patient’s complications, and had been influenced by a desire to help the patient back to a normal life as rapidly as possible.

The case was settled for a substantial sum.

Learning points

  • Clinicians should always maintain objectivity in the advice given to a patient. Shared decision-making is very important, with a balance between ensuring patient autonomy and making good clinical decisions. MPS’s workshop, Mastering Shared Decision Making, shows such a model is an effective way to ensure that patients make appropriate and informed choices.
  • Restorative procto-colectomy is a demanding surgical procedure with a high complication rate. Patient expectations should be matched with a frank discussion regarding complications and outcomes. When working within a multidisciplinary team, the ability to ask for second opinions and advice from colleagues in the event of problems is a strong medicolegal defence, as well as good medical care.