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Mishandling major surgery

01 May 2013

Mr A, a 63-year-old retired farmer, had suffered from severe gastro-oesophageal reflux disease for many years. His symptoms were partially controlled with long-term anti-secretory medication but after a number of years he had reached the point where his gastroenterologist recommended antireflux surgery.

He saw Dr X, an upper gastrointestinal surgeon, who arranged a repeat endoscopy. This demonstrated a 10cm area of Barrett’s oesophagus with no obvious macroscopic abnormality above a 5cm sliding hiatus hernia. Dr X went on to perform a laparoscopic Nissen fundoplication, after which the patient made an uneventful recovery.

At a review appointment three months later Mr A reported a significant improvement in his symptoms and no longer required his medication. He next saw Dr X for a surveillance endoscopy seven months later. The fundoplication was intact and the long segment of Barrett’s appeared unchanged.

On this occasion multiple biopsies were taken and were subsequently reported by pathologist Dr H as demonstrating high grade dysplasia (HGD). Dr X reviewed the patient shortly thereafter and explained that the findings were likely to indicate the development of cancer. He recommended that Mr A should undergo an oesophagectomy.

Postoperatively the patient was managed jointly by Dr N, a respiratory physician, and Dr X on the intensive care unit. Dr X had arranged to go on holiday the day after the procedure and spoke to a colleague, Dr B, about managing the patient in his absence. Details regarding the handover and cover arrangements were subsequently disputed. Specifically Dr B allegedly told Dr X that he could not look after the patient until the following day.

In the afternoon after Dr X had departed, the patient developed intra-thoracic haemorrhage. Another surgeon, Dr F, was called to perform an emergency right thoracotomy and successfully stopped the bleeding by ligating an aortic bleeding point.

Postoperatively, the patient developed severe gastric distension and pneumonia. Dr B (who was now available) inserted an NG tube to decompress the stomach, confirming its position by chest x-ray. However the NG tube failed to drain any fluid and Dr N subsequently discovered that it had been placed in the right main bronchus when performing a bronchoscopy. Dr N placed it correctly into the stomach under direct vision.

There then ensued a protracted period of ventilation and multi-organ support on the intensive care unit. Dr X returned from leave and continued the patient’s care. A stepwise deterioration occurred with worsening pneumonia, sepsis and multi-organ failure and Mr A died on the intensive care unit 14 weeks after the operation. The final pathology report from the specimen demonstrated multi-focal HGD with no signs of invasive carcinoma and all margins clear.

Mr A’s family made several claims of negligence by the clinicians involved in his care. They alleged that Dr X had failed to biopsy the Barrett’s segment at the patient’s initial endoscopy leading to an unnecessary fundoplication and delay in the finding of high grade dysplasia. They also complained that Dr X had failed to adequately discuss alternative management options for HGD other than surgery and that he had also not arranged adequate cover for his planned absence after the operation.

Allegations of negligence also centred on Dr H and Dr X relying on a single pathologist’s assessment for the diagnosis of HGD. Criticism was made of the other surgeons involved in Mr A’s care for failing to place a nasogastric (NG) tube at the time of each operation to prevent gastric distension.

Expert opinions for MPS and the claimant agreed that biopsies of the Barrett’s segment should have been obtained at the initial endoscopy performed by Dr X, although they accepted that previous endoscopic biopsies did demonstrate entirely benign Barrett’s epithelium.

They also agreed that the standard approach to the finding of HGD should warrant further independent pathological review and assessment of biopsy material before acting upon the findings. However, it was noted that the diagnosis here was correct, as several pathologists confirmed the findings of HGD in the resected oesophageal specimen.

It was accepted that at the time the case occurred, the finding of HGD in Barrett’s in a fit patient was an indication for consideration of oesophagectomy. Other therapies, including endoscopic mucosal resection and radiofrequency ablation, have now become more accepted treatments as an alternative to surgery.

There was considerable criticism of Dr X’s decision to schedule such major surgery a day before he was on holiday and his subsequent arrangements for colleagues to cover. The absence of an NG tube placement at the initial operation and subsequent procedure was also criticised, as was Dr B’s misplacement of the tube and his misinterpretation of the X-ray findings. The case was eventually settled for a moderate sum.

Learning points

  • The diagnosis and management of HGD in Barrett’s oesophagus remains a controversial area with a number of different therapies available. It is now common practice for specialist multidisciplinary teams that include surgeons, gastroenterologists and pathologists to manage these patients. This approach may improve the accuracy of diagnosis and staging, and facilitates a consensus on the optimum management for each patient.
  • It is not always possible for a surgeon to be constantly available for the postoperative management of a patient. In periods of extended absence, robust arrangements must be made for adequately qualified colleagues to cover the care of a patient. The patient, relatives and all relevant staff involved should be informed.
    Even so surgeons undertaking major or high risk elective surgery before a planned holiday are likely to be at risk of criticism when something goes wrong in their absence. The duration of time that can elapse between events and subsequent litigation, as highlighted in this case, demonstrates the need to maintain accurate and detailed notes as the cornerstone to any medicolegal defence.
  • It is common practice to place an NG tube after oesophagectomy. In this case it may have prevented gastric distension, aspiration and pneumonia. Misplacement of an NG tube is a common error and a potential source of morbidity, mortality and medicolegal problems. See Casebook 20(3), September 2012, for an article on NG tube errors.