Presentation and physician action
A 61-year-old woman with a history of colon polyps was referred to General Surgeon A for a colonoscopy.
The surgeon performed the procedure and found a small polyp at 30 cm in the descending colon and a larger lesion at 125 cm in the ascending colon. Both areas were biopsied. To mark the lesion in the ascending colon, the surgeon tattooed it during the procedure.
The polyp in the descending colon was benign per pathology, but the lesion in the ascending colon was diagnosed as invasive adenocarcinoma.
General Surgeon A reviewed the results with the patient at a follow-up visit and recommended a right hemicolectomy. The risk and benefits, as well as alternatives to excision, were discussed and documented.
Before surgery, a CT scan of the pelvis and abdomen were completed for further evaluation. The results revealed an apple core lesion in the right colon, compatible with colon cancer. There were no signs it had metastasized to the abdomen or caused a bowel obstruction.
Twelve days after the colonoscopy, the patient was admitted to the hospital for surgery. The general surgeon performed the right hemicolectomy without complications.
After surgery, the specimen was sent to pathology. The pathologist reported the specimen was not malignant and did not include any tattoo-inked tissue. The pathologist reviewed the previous biopsy and confirmed adenocarcinoma. Repeat colonoscopy was recommended.
The patient was referred to Oncologist A, who reviewed treatment options with her. Oncologist A thought it was possible the tumor was so small that it had been removed, but not found or noted in pathology. He recommended repeat colonoscopy to take place in several months. The patient was released from the hospital four days after surgery, and cleared to return to work on light duty two weeks later.
The patient elected to see another physician to discuss her pathology results and treatment options. Oncologist B ordered a CT scan of the abdomen and pelvis. The results did not show evidence of metastatic disease.
A repeat colonoscopy was performed, and the biopsy results revealed invasive moderately differentiated adenocarcinoma of the transverse colon. Benign polyps on the descending colon, sigmoid colon, and rectum were also biopsied.
General Surgeon B was consulted and recommended surgery in a few months, allowing acute inflammation from the patient’s previous surgery to settle.
Three and a half months after the first surgery, General Surgeon B performed abdominal exploration; extensive lysis of adhesions; resection of the previous ileocolonic anastomosis with right hemicolectomy with ileocolonic anastomosis; partial ometentectomy; and intra-abdominal pedicle omental advancement flap.
A malignant mass was noted to be approximately 19 cm proximal to the original anastomotic site. During the procedure, the ink that was injected by the first surgeon at the time of the colonoscopy was visible to the new surgeon. The postoperative diagnosis was T3N0 transverse colon adenocarcinoma.
About six months later, a CT scan of the abdomen, pelvis, and chest revealed no evidence of pulmonary or hepatic metastasis or local recurrence.
Allegations
A lawsuit was filed against General Surgeon A. Allegations included failure to identify and remove the malignancy and failure to verify that the excised specimen was malignant.
The lawsuit also alleged that these failures caused the patient to undergo a second procedure to remove the malignancy and put the patient at greater risk of bowel obstruction, incisional hernia, and adhesions.
Legal implications
Defense consultants stated that General Surgeon A performed below the standard of care. They were critical of him for failing to note that there was no ink in the specimen removed, and stated that he should have identified where the ink was before resection.
One consultant stated that the specimen should have been opened in the operating room to confirm removal of the tumor, or that pathology should have been consulted for confirmation of adequate tumor resection. Another consultant was critical that the surgeon did not attempt to palpate the tumor. This consultant felt it was a weakness that General Surgeon A’s documentation did not mention searching the abdomen for possible metastatic disease; for instance, examining the liver and peritoneal surfaces.
Another consultant noted that the surgeon could have been misled by the preoperative CT scan, which indicated the lesion was in the mid-ascending colon. Subsequent events demonstrated it was more distal.
Ultimately, the primary tumor was left in the proximal transverse colon during the first surgery. All consultants agreed that the patient was subjected to a second unnecessary procedure. The consultants felt a transverse partial colon resection would have been a more appropriate procedure.
Disposition
This case was settled on behalf of General Surgeon A.
Risk management considerations
According to consultants reviewing this case, General Surgeon A’s actions fell below the standard of care.
The surgeon failed to document certain processes, such as reviewing the specimen for ink, assessing the abdomen, and palpating the tumor, which made it uncertain if these were performed. If any of these procedures were done, it was not noted in the medical record.
There were concerns that during the interval between surgeries, the tumor could have progressed to a higher stage, putting the patient at increased risk of distant relapse. All defense consultants agreed that the patient underwent an unnecessary surgery that could have caused increased morbidity and attendant complications.
There also appeared to be breakdowns in communication between General Surgeon A, the patient, and other providers. The patient was in the hospital for four days after surgery, and there is no documentation that a conversation occurred between General Surgeon A and the patient about the possibility that the excised tissue did not include the malignancy.
