This case involves a 46-year-old female patient who presented to the hospital for elective cholecystectomy. The patient was admitted to the hospital for almost a week to rule out the possibility of gall bladder carcinoma and was kept NPO for 7 days. Lab work showed that she was dehydrated and had severe electrolyte imbalances at which point the house staff aggressively gave fluid resuscitation. The surgery was less than 24 hours away when the lab work showed the dehydration and electrolyte disturbances but the surgery was continued anyway. The physicians experienced great difficulty intubating the patient.

There are several steps the physicians in charge should have taken to properly workup this woman once gallbladder cancer was suspected. Tumor marker studies can be reavealing if the clinical suspicion is high. Additionally, several of the following tests should have been reviewed before surgery. Liver function tests: Elevated alkaline phosphatase and bilirubin levels are often found with more advanced disease. BUN, creatinine, urinalysis: Assess renal function prior to performing an enhanced CT scan. CBC: Anemia may be an indicator of more advanced disease. I believe this case warrants further review in light of the fact that the initial workup of the patient involved suspected cancer, therefore I think the physicians giving care to this patient should have looked into a few other venues before sending this woman into surgery.

1. Was this patients surgery necessary given her status right before surgery and the fact that it was elective in nature, could it have been delayed until she was more stable?

Location: Maryland B.S., University of California, Davis M.D., University of California, Davis School of Medicine Internship, University of California, San Francisco Residency, University of California, San Francisco Fellowship, Minimally Invasive and Bariatric Surgery, John Hopkins Medical Institution Board Certification: General Surgery, American College of Surgery Active Medical License: MD, CA Fellow, American College of Surgeons Member, American College of Surgeons Member, Society of American Gastrointestinal and Endoscopic Surgeons Member, American Hernia Society Current A******** P******** o* S****** a* a t** t** m****** i********** Current D******* C************ H***** C***** a* a t** t** m****** i********** Current A******** M****** D******* a* a m**** m****** r******* c*****

This expert is a board certified General surgeon with additional fellowship training in minimally invasive surgical techniques. He was trained at the University of California Davis School of Medicine for residency and at Johns Hopkins for fellowship. He is the Director of a surgical hernia center at a prestigious medical university in Maryland and treats a significant amount of cancer patients.

Mismanagement of Elective Cholecystectomy Causes Severe Electrolyte Imbalance

This case involves a fifty-six-year-old male patient who underwent a single incision laparoscopic cholecystectomy. The procedure was met with some complication as it was noted that the patient had an intrahepatic gallbladder with severe scarring at the triangle of Calot that proved to be a difficult dissection. Postoperatively, the patient was said to be recovering fine and was discharged soon after. The patient was readmitted to the hospital three weeks later for severe pain and jaundice and was noticed to have a large fluid collection that required drainage via ERCP along with a percutaneous left biliary drain placement. A cholangiogram was performed after the drainage which showed significant biliary damage that required referral for an extensive biliary reconstruction procedure.

The most dreaded complication of laparoscopic cholecystectomy is injury to the common bile or common hepatic duct. The estimated incidence of bile duct injury in cholecystectomies performed laparoscopically varies from 0.3-2.7%. In contrast, biliary tract injuries were noted to occur in 0.25-0.5% of open cholecystectomies. A major risk factor for bile duct injury is the experience of the surgeon and other risk factors are the presence of aberrant biliary tree anatomy and the presence of local acute or chronic inflammation.

1. How often is the bile duct injured during this procedure and what are the most likely causes?

Location: Indiana B.A., Texas Christian University M.D., Tufts University School of Medicine M.S., Health Care Policy, The University of Texas-Dallas, Southwestern Medical School M.B.A., The University of Texas-Dallas, Southwestern Medical School Internship, General Surgery, Naval Medical Center Residency, General Surgery, Naval Medical Center Postgraduate, Thoracic and Cardiovascular Surgery, University of Texas Board Certification: Thoracic and Cardiovascular Surgery Active Medical License: Indiana Award, Scholar in Health Policy, American College of Surgeons 2006 Former C******** M***** W******** o* H***** C*** P***** R***** a** A******* Former A******** S****** L*** T********* P****** M******** H******* Current S*** D******* A******* C****** o* S******* O******* G**** Current D******* T******* S****** M**** M****** C***** I******

This expert has been practicing for about 15 years. Aside from his medical degree, he hold a Masters degree in Health Care Policy and an MBA, which make him ideally suited for this case. He has been an ad hoc reviewer of various medical journals for the general thoracic surgery field. He's won many honors and awards and also served in the military. He's also extremely well published, gives invited presentations, and continues to perform research and investigations.

General Surgeon Fails to Protect Bile Duct During Gallbladder Surgery

This case involves a middle-aged male patient in Wyoming who was morbidly obese patient who suffered from an infected surgical incision following surgery. The patient presented to a general surgeon for what was initially supposed to be a routine gallbladder removal surgery performed with a traditional incision. The surgery proceeded without complications and the patient was discharged home. However, less than a week after the surgery was completed the patient returned to the hospital to have his stitches removed at which point the wound completely opened. Over the next few days, the wound became infected. The patient was forced to endure an extended stay in the hospital, and was left seriously disfigured.

I routinely perform this procedure, on average 1 to 2 cases per week. Closures on the abdomen should be left in on average 10 to 14 days, and a vigilant eye should be kept on the patient's progress in order to identify the development of infection. I have significant experience in both open and laparoscopic cholecystectomy. In addition, I have fellowship training in bariatric surgery dealing with patients like the one described here with morbid obesity. I am an assistant professor of surgery at a major teaching university hospital focusing on upper GI and general surgery. I am also an associate program director for the general surgery residency.

1. Do you routinely perform this procedure? 2. Do you frequently leave staples in longer than one week for such a procedure?

Location, CA BS, Ursinus College MD, Thomas Jefferson University Residency, General Surgery, Thomas Jefferson University Fellowship, Minimally Invasive and Bariatric Surgery, University of California, San Diego Board Certified: General Surgery, Laparoscopic Surgery, Endoscopic Surgery Fellow, American College of Surgeons Member, Society of American Gastrointestinal and Endoscopic Surgeons Current A******** P******** o* C******* S****** a m****** s***** i* C********* Current A******** P****** D******* G****** S****** R******** a m****** s***** i* C********* Current A******** P****** D******* A******* G***** F********* a m****** s***** i* C*********

West Coast

Wyoming

This expert earned his BS at Ursinus College and his MD at Thomas Jefferson University. He then went on to complete a residency in General Surgery at Thomas Jefferson University Hospital, and a fellowship in Minimally Invasive and Bariatric Surgery. He is board certified in General Surgery, Laproscopic Surgery, and Endoscopic Surgery, and is active in his field as a fellow of the American College of Surgeons and a member of the Society of American Gastrointestinal and Endoscopic Surgeons. He currently serves as an assistant professor of clinical surgery, as well as the associate program director of both the general surgery residency and the advanced GI/MIS fellowship at a medical school in California.

General Surgery Experts Discuss Surgical Wound Infection

This case involves a middle-aged male patient who suffered complications following gallbladder surgery. The patient required an endoscopic retrograde cholangio-pancreatography (ERCP) to determine proper treatment course. Within days of receiving the ERCP, the patient became infected with E. Coli. A microbiologist familiar with biofilm prevention, multi-drug resistant organism outbreaks, and with a working knowledge of automated endoscope reprocessors was sought to discuss best practices for infection control.

I am well qualified to serve as an expert on biofilms, medical equipment disinfection, and tracing infection sources using molecular epidemiological tools. I conducted research at the FDA on mixed-species biofilm and served as a reviewer of food additive petitions filed before the FDA for 6 years. The approximately 60 petitions I reviewed all dealt with the use of antimicrobial agents to control microbes in foods, on food processing machinery, in poultry chiller tanks, and clean-in-place disinfections. I was often called on by the petitioner to help them design the experiments to generate the data needed for the FDA to grant them approval for the intended use. I worked closely with FDA's general counsel and was prepped to serve as the agency's expert witness on compliance actions initiated against companies implicated in foodborne illnesses. I also served as the lead scientist for a national network of public health and food regulatory laboratories at the FDA for 13 years. In this capacity, I was involved with the outbreak analyses and traceback efforts of a number of pathogens, including pathogenic E. coli strains. During my years as a senior program officer at a major medical research center, I dealt extensively with research projects on multi-drug resistant organisms and nosocomial infections. I have received multiple awards for teaching and training from the Department of Health and Human Services, the FDA, and the Department of Agriculture. I have published on this topic and was invited to present findings at an international microbiology conference.

1. Please briefly describe your work with automated endoscope reprocessors.

Microbiologist Discusses Best Practices For Bacterial Control on Medical Devices

This case involves a 35-year-old male with a past medical history of fibromyalgia who had his gallbladder laparoscopically removed. The patient was discharged the same day but presented to the emergency room two days later in septic shock. Surgery was consulted and the patient went to the operating room for an exploratory laparotomy. He was found to have a perforated duodenum, which was repaired with a graham patch. An abscess was also discovered and subsequently drained. Postoperatively, the patient was continued on pressors but developed severe low blood platelet count. He remained intubated and also developed atrial fibrillation. The patient required additional drainages and was intubated for over a week. A hepatobiliary scan revealed the patient had suffered a duodenum leak.

As an assistant professor of surgery at a major university medical center, I routinely take general surgery calls and therefore perform laparoscopic cholecystectomies on a fairly routine basis. I would estimate 3-5 cases per month. I also teach other surgeons how to appropriately perform this operation. Duodenal injury is relatively uncommon if appropriate measures are taken to avoid it. One common source of injury is inappropriate take down of adhesions between the inflamed gallbladder and the duodenum. This can be minimized by appropriate surgical technique, and sometimes requires conversion to open surgery if the anatomy is not clear. Revision of the Graham patch depends on the clinical state of the patient, and objective evidence of an ongoing leak. If the patient is not clinically improving and a persistent leak is documented, then a revision Graham patch should be performed in circumstances where surgery does not substantially increase the risk of mortality. It would be interesting to look at the operation room notes to determine if the physicians followed the appropriate maneuvers for this procedure. I have reviewed similar cases regarding inadvertent injury to surrounding structures during gallbladder surgery, but I do not recall any duodenal injuries. Mostly they have been common bile duct injury. It is concerning that a young and relatively healthy patient would suffer such a catastrophic outcome from what should have been a routine operation. This suggests potential poor surgical technique, lack of recognition or understanding of clinical findings, or inappropriate follow up. It also appears that the patient was released too soon after the procedure, without appropriate vitals and monitoring. If he was in pain or his labs were not clear, he should have remained in hospital care.

1. How often do you perform laparoscopic cholecystectomies? 2. What care is taken to avoid injury to the duodenum? 3. At what point, if any, would you take a patient back to the OR to redo a Graham patch versus continue IR drainage?

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Gallbladder Removal Expert Witness Case Studies

Mismanagement of Elective Cholecystectomy Causes Severe Electrolyte Imbalance

General Surgeon Fails to Protect Bile Duct During Gallbladder Surgery

General Surgery Experts Discuss Surgical Wound Infection

Microbiologist Discusses Best Practices For Bacterial Control on Medical Devices

Surgeon Perforates Patient’s Small Intestine Causing Septic Shock

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