A 73-year-old woman was referred to a general surgeon for surgical management of a gastric outlet obstruction, gastric stasis, and erosive esophagitis, secondary to pyloric stenosis, which were discovered during an endoscopy in May 2010.
After conducting a preoperative evaluation, the general surgeon scheduled the patient for surgery on 6/24/2010.
On 6/24/2010, the general surgeon performed an exploratory laparotomy, excision of a mass around the pylorus, distal gastrectomy, and placement of drains.
The mass was not biopsied prior to being excised. In addition to the mass, the general surgeon also removed a portion of the patient’s pancreas.
On 6/29/2010, the patient was discharged.
On 7/5/2010, the patient returned to the hospital with abdominal pain and green colored discharge from her abdominal incision and drain. Test results showed fluid collection under the liver.
On 7/8/2010, the patient was taken back to the operating room for a second surgery. The general surgeon performed an exploratory laparotomy, abdominal washout, lysis of adhesions, and an oversew of a presumed duodenal hole and application of glue.
Postoperatively, the patient continued to have copious output from her drains and was not doing well clinically.
On 7/14/2010, she returned to the operating room. The general surgeon performed another exploratory laparotomy, abdominal washout, presumed duodenal hole oversew and placement of glue and drains.
The patient’s condition still did not improve after the third surgery on 7/14/2010. The patient was seen by multiple consultants and additional studies were performed, which revealed a bile leak at the distal common bile duct and inability to cannulate the duodenum, consistent with a common bile duct injury.
The patient was then transferred to a higher level of care. Numerous procedures were performed on the patient but her clinical condition continued to deteriorate and she ultimately died on 11/20/2010 while in hospice care.
The Board judged the general surgeon’s conduct as having fallen below the standard of care for several reasons. The standard of care, when presented with an unexpected mass, is to biopsy the mass prior to resection. Biopsying the mass is even more warranted when the mass is in a part of the body close to a number of vital structures, as was the patient’s mass.
The patient’s mass was determined to be pancreatic tissue. Had the general surgeon performed a biopsy instead of removing the mass along with part of the patient’s pancreas, major injury to the pancreatic head, and what eventually turned out to be the adjacent common bile duct, could have been avoided.
The general surgeon’s notes did not mention the unintended removal of a significant segment of the pancreas. The Board notes that the standard of care when a patient shows signs of possible major intra-abdominal injury is early intervention. After the patient returned to the hospital on 7/5/2010, there was evidence of copious drainage from the implanted drain and the incision would itself, indicating a possible uncontrolled intra-abdominal leak.
The general surgeon did not intervene surgically and instead ordered a series of tests that pointed to a biliary leak and possible bile duct injury. Per the Board, the standard of care would have called for immediate surgical exploration. The general surgeon did not intervene until 3 days after admission.
The Board also notes that the general surgeon performed the same operations on 7/8/2010 and 7/14/2010. During both surgeries, he oversewed a presumed duodenal hole without clearly identifying its location and correlation with adjacent structures. After the 7/8/2010 surgery failed to correct the problem, the standard of care required that the general surgeon study the hole intra-operatively to properly identify its anatomy. Further, given the location of the hole, the general surgeon should have considered whether the hole was in the common bile duct and not the duodenum. Per the Board, the general surgeon committed a simple departure from the standard of care when he blindly oversewed a hole without knowing its anatomy amidst post-operative inflammatory changes and in an anatomically dangerous area.
The general surgeon was placed on probation for three years. Stipulations included enrolling in the Physician Assessment and Clinical Education Program and undergoing monitoring.
Date: December 2016
Case Rating: 4
Link to Original Case File: Download PDF
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