This case involves an elderly patient who underwent a colonoscopy. During or after the procedure, the gastroenterologist allegedly caused an injury involving the bladder, after which the patient developed hematuria and signs of infection. Urology was reportedly consulted to assist with repair of the bladder injury, though it is unclear from the available information whether that repair was completed.
The patient’s condition subsequently worsened, and the patient underwent surgical intervention for a bowel perforation, including exploratory laparotomy, enterolysis, enterotomy, and bowel resection. Despite treatment, the patient developed intra-abdominal sepsis and respiratory failure and ultimately died.
From a legal perspective, this case may turn on whether the complication was timely recognized, whether appropriate specialists were involved, and whether surgical intervention occurred within the applicable standard of care. Although perforation and injury to adjacent structures are known risks of colonoscopy, the key issues may include the timing of diagnosis, escalation of care, bladder repair, management of bowel perforation, and whether earlier intervention could have prevented sepsis and death.
Questions to the General Surgery expert and their responses
What care is taken to avoid perforation during a colonoscopy?
Care must be taken to understand the anatomy and understand when advancing the colonoscope might lead to a perforation. Operator experience is important in avoiding a perforation.
About the expert
This expert has over 35 years of experience in the field of general surgery. He earned his BS from the University of California, Irvine, and his MD from Vanderbilt University Medical School. He completed an internship in surgery at the University of Southern California and a residency in surgery at Louisiana State University. Today, this expert is board certified in general surgery and is a member of the American Society of General Surgeons and the Society of American Gastrointestinal Surgeons. He previously served as an instructor of surgery at Louisiana State University and was a surgeon in private practice in Louisiana during this time. He also held the prestigious role of clinical chief of colorectal surgery at Cedars Sinai Medical Center. Currently, he serves as an attending physician and instructor of colorectal surgery as well as an attending surgeon at a renowned academic medical center in California. He also is a surgeon for a private surgical practice in California.
E-174447
Specialties:
Questions to the Gastroenterology expert and their responses
What are the accepted standards of care for performing a colonoscopy in terms of minimizing the risk of internal bleeding or perforation?
There are technical approaches to reduce the risk of bleeding and perforation. Perforations are associated with removal of large polyps, adhesions and tortuosity, and colonoscopy loopy. It is important, not to use excessive air or excessive force during the colonoscopy procedure. Bleeding risk could be reduced by Using appropriate pottery settings and intervening with a clip.
What is the potential mechanism of the initial colonoscopy causing the subsequent complications the patient experienced?
The mechanisms by which complications occur are outlined in the prior response. What is challenging is proving that these practices occurred or dismissed during the colonoscopy procedure. At times, what is left is to examine post complication management, and awareness and intervening appropriately and in a timely fashion.
About the expert
This expert has over 15 years of experience in the field of gastroenterology and hepatology. He earned his BA in chemistry from Pomona College, his MS in epidemiology and statistics from the University of California, San Francisco, and his MD from Harvard Medical School. He then completed a residency in internal medicine at the University of California Los Angeles Harbor Medical Center and a fellowship in gastroenterology and hepatology at the University of California, San Francisco. Today, this expert is board certified in gastroenterology and is an active member of several professional organizations, including the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. He previously served as an associate professor of medicine at the University of California, San Francisco. Currently, he serves as an endowed professor of gastroenterology and as the director of the gastrointestinal mucosal biology core at a top university-affiliated medical center in California.
E-019680
Specialties:
Questions to the expert and their responses
What care is taken to avoid perforation during a colonoscopy?
Identification of patients at increased risk of perforation (diverticulitis, colitis, IBD, frailty, history of prior surgery) and procedures with greater risk (large polypectomy, EMR, ESD, etc.). Avoiding application of excess force or tissue trauma during the procedure. In some cases, knowing when to abort a difficult procedure is crucial.
About the expert
This board-certified general and colorectal surgeon is based in California and has extensive academic, clinical, and research experience in colorectal surgery, anorectal physiology, and general surgery. They earned a BS in Biology and Human Physiology, an MS in Physiology and Biophysics, and an MD before completing a general surgery residency and fellowships in anorectal physiology and clinical research as well as colorectal surgery. Their background includes prior roles in sports physiology research, clinical practice with a major Southern California medical group, and academic surgery, and they currently serve as an Assistant Professor of Surgery at a California university.
E-1124831
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