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An unnecessary operation or two

01 September 2009

Mrs R, aged 40, was referred to consultant general surgeon, Mr P, complaining of long-standing abdominal pain, abdominal distension and severe hiccups. Mr P performed an upper gastrointestinal endoscopy and found a small sliding hiatus hernia, but no oesophagitis. Mrs R had already been treated with proton pump inhibitors by her GP, but had experienced no improvement in her symptoms.

According to the medical notes, Mrs R was keen to consider surgical treatment of her hiatus hernia. Mr P subsequently undertook a laparotomy and Nissen fundoplication. A naso-gastric (NG) tube was inserted at the time of surgery, but this was removed during the early postoperative period as it was not tolerated. Mrs R made an otherwise uneventful recovery and was discharged home symptom-free. A few months later Mrs R experienced a recurrence of her symptoms and saw Mr P again.

A barium swallow demonstrated a recurrence of the hiatus hernia. A new operation was discussed. Mrs R was agreeable, but warned Mr P that she did not want an NG tube whatever the circumstances. Mr P agreed, and a further laparotomy and revision Nissen fundoplication was carried out. Mrs R experienced abdominal distension post-operatively, but refused an NG tube.

Following discharge, the patient complained of epigastric pain and difficulty in swallowing. A chest x-ray revealed a large irreducible hiatus hernia. Eventually, Mrs R required further major thoraco-abdominal surgery for correction of a large hiatus hernia and subsequently made a complaint against Mr P.

Expert opinion

Experts agreed that the first operation was not indicated. The patient’s symptoms were not classical of gastro-oesophageal reflux (GORD) and the finding of a small hiatus hernia at the time of endoscopy did not require surgical intervention. The lack of any response to protein pump inhibitors and the absence of any oesophagitis should have prompted further investigation in the form of oesophageal manometry and 24-hour pH monitoring.

Questions were also raised about the reasons for performing an open operation (via a laparotomy) when minimally invasive (laparoscopic) Nissen fundoplication can be carried out with decreased morbidity, shorter hospital stay and faster return to normal activities. There was also criticism regarding the consent for both the first and second operations, specifically relating to the documentation of the risks of surgery and the long-term results.

Experts were in agreement that primary and revisional anti-reflux surgery are complex procedures which should only be undertaken by appropriately specialised and experienced upper GI surgeons. Although NG tubes are not routinely required, all upper GI procedures carry the risk that they might be required. Patients should be counselled accordingly. The claim was settled for a moderate sum.

Learning points

  • Most common elective procedures have a requisite list of appropriate pre-operative tests (often supported by guidelines from learned societies). Preoperative oesophageal physiology investigation can confirm or refute GORD and help identify patients unsuitable for surgery.
  • It is imperative to ensure that there are clear indications for surgery before proceeding.
  • The options for medical versus surgical management of their problem must be discussed with patients.
  • All discussions regarding treatment options must be recorded, including any differences of opinion. In this particular case, it was unclear how much pressure the patient had put on the surgeon to perform the first operation.
  • If an operation may require a particular intervention, eg, an NG tube, it needs to be made clear to the patient that this is a possibility.
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