California – Vascular Surgery – Hypotension, Hypoxia, And Acute Kidney Injury After Partial Gastrectomy And Cholecystectomy For Gastric Adenocarcinoma And Gallstones

On 7/22/2010, a 74-year-old male was seen by a vascular surgeon for a recently diagnosed gastric adenocarcinoma (cancer of the digestive tract).  A follow-up CAT scan revealed a “3.5 cm polypoid mid gastric cancer” and gallstones. There was no obvious metastatic disease. The plan was for the patient to undergo a partial gastrectomy (removal of the lower portion of the stomach) to address the gastric adenocarcinoma with cholecystectomy (surgical removal of the gallbladder) to address the patient’s gallstones.

On 8/5/2010, the patient was admitted for his scheduled surgery that was performed on the same date by the vascular surgeon.  The surgery was uneventful with findings of a more extensive tumor than expected, but with accomplishment of the subtotal gastrectomy with a B1 (gastroduodenostomy) anastomosis and the cholecystectomy to address the gallstones.

On 8/7/2010, the patient’s post-operative course became unstable with hypotension (low blood pressure) and respiratory difficulties associated with oxygen desaturation and worsening acute renal insufficiency.  A CT scan of the abdomen and pelvis without contrast was ordered by the vascular surgeon at approximately 5:19 p.m. with the physician’s order listing “sepsis” as the reason for ordering the CT scan.

On 8/8/2010, the results of the CT scan were electronically signed by a radiologist with findings of “gas collected in the operative bed” with “[a] large amount of free intraperitoneal air is also present.”  The CT impression section noted, among other things, that there was “[g]as collected at the operative site. This has somewhat unusual appearance and an infected collection cannot be absolutely excluded.”

On 8/10/2010, the patient underwent a Gastrografin UGI (upper gastrointestinal) study (radiological study of the gastrointestinal tract) that was ordered by the vascular surgeon, which revealed a leak above the gastroesophageal (GE) junction.  At this point, the patient was stable with improved overall renal and pulmonary parameters using conservative therapy, which included NGT suction, TPN, and antibiotics.

On 8/14/2010, a repeat Gastrografin UGI study was completed, which showed a larger leak and collection of fluid, which was drained.  Thereafter, the patient’s condition steadily declined. On 8/15/2010, the patient was seen by another surgeon, who was covering for the vascular surgeon, with the covering surgeon documenting a possible return to the operating room for exploratory surgery and lavage with a notation that the patient and family were “hesitant regarding re-exploration and washout.”

On 8/16/2010 at 4 a.m., the patient’s clinical condition was noted to “have gotten progressively worse by the hour” with the patient having “agonal breathing.”  The attending physician confirmed the patient’s DNR and DNI status with the patient’s son, who was at bedside. The patient was placed on morphine for comfort and expired at 4:30 a.m.  The discharge summary prepared by the vascular surgeon listed the patient’s complications as leak from gastric anastomosis, acute renal insufficiency, bronchopneumonia, and severe sepsis.

The Medical Board of California judged that the vascular surgeon’s conduct departed from the standard of care because he failed to respond in a timely and appropriate manner to the patient’s anastomotic leak, which delayed the expeditions and effective treatment of the anastomotic leak.

For this case and others, the Medical Board of California ordered the vascular surgeon to surrender his license.

State: California

Date: July 2015

Specialty: Vascular Surgery, General Surgery

Symptom: Shortness of Breath

Diagnosis: Post-operative/Operative Complication, Cancer, Acute Abdomen, Sepsis

Medical Error: Delay in proper treatment

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

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