Select country
Membership information
0800 561 9000
Medicolegal advice
0800 561 9090
Refine my search

A restoration problem

Post date: 20/01/2014 | Time to read article: 3 mins

The information within this article was correct at the time of publishing. Last updated 19/07/2018

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.

Share this article

Load more reviews

You've already submitted a review for this item

New site feature tour

Introducing an improved
online experience

You'll notice a few things have changed on our website. After asking our members what they want in an online platform, we've made it easier to access our membership benefits and created a more personalised user experience.

Why not take our quick 60-second tour? We'll show you how it all works and it should only take a minute.

Take the tour Continue to site

Medicolegal advice
0800 561 9090
Membership information
0800 561 9000

Key contact details

Should you need to contact us, our phone numbers are always visible.

Personalise your search

We'll save your profession in the "I am a..." dropdown filter for next time.

Tour completed

Now you've seen all of the updated features, it's time for you to try them out.

Continue to site
Take again