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Patient was ill-informed

01 February 2004

During a balloon dilation of Mr P’s oesophagus at the site of previous surgery, Dr U, a specialist in general surgery, noticed bleeding as he removed the gastroscope. He could not see any perforation because blood in the oesophagus was obscuring his view.

Mr P complained of pain after returning to the ward; he was given analgesia and Dr U arranged for a plain chest x-ray, advising Mr P to stay in the hospital for the time being.

Mr P declined, saying that he had obligations at work that he needed to deal with. Dr U told him to drink only clear fluids and to contact him if the pain persisted.

Mr P phoned the next day. He was still in pain and his voice seemed to be affected. Dr U asked him to come to the hospital, but Mr P said he’d come the next day.

When he examined Mr P, Dr U noted surgical emphysema of his neck and face, decreased air entry and dullness in the chest. A chest x-ray showed air in the mediastinum so he ordered a gastrograffin swallow, which showed a perforation.

Dr U called in Dr J, a cardiothoracic surgeon. They took Mr P to theatre that night and Dr J operated, with Dr U assisting him.

They found an oesophageal laceration with resultant purulent mediastinitis and empyema of both pleural cavities. They stapled closed the gastro-oesophageal junction and inserted a jejunostomy feeding tube as a temporary measure.

Six weeks later Dr J carried out a transthoracic pull-through of the stomach and cervical oesophagogastrostomy.

Mr P continues to need occasional dilation of the oesophago-gastric anastomosis. He also experiences heartburn, regurgitation and choking when supine; he is not able to eat a normal diet.

Expert opinion

The expert we asked to report on the case was supportive of Dr U’s choice of procedure, but thought that he should have recognised the complication much earlier than he did.

According to this expert, the seriousness of perforation of the thoracic oesophagus increases if the diagnosis is delayed – ‘a period in excess of 24 hours post-injury is generally associated with an exponential rise in morbidity and, if the patient survives, residual disability’.

The chest x-ray taken immediately after the operation showed free air in the mediastinum, but Dr U apparently did not view the film or the report.

Dr U thus missed an opportunity to make a timely diagnosis.
Another expert asked to consider causation advised us that Dr U’s failure to diagnose the perforation at the first opportunity was the cause of most of Mr P’s subsequent problems.

We settled the claim.

Learning points

  • Although Mr P was not helping matters by insisting on going home after the procedure, and delaying his return, Dr U bore most of the responsibility for the delay in recognising the perforation. He had access to an x-ray film that he himself had ordered, but failed to check. Had he done so, he would no doubt have contacted Mr P and impressed on him the urgency of the situation.
  • If a patient is intent on going home early, the implications of doing so should be carefully explained to them. If Mr P had been warned of the risk of perforation, he may not have gone home or, if he did, may have been more alert to the significance of his symptoms and returned promptly for assessment.
  • Mediastinal air on x-ray is a subtle sign which has to be specifically looked for and positively excluded.