This case involves a sixty-nine-year-old male patient who died of a hemoperitoneum following complications of a right hepatectomy. The procedure was performed due to the presence of a liver mass. The patient has a past medical history of autoimmune pancreatitis and chronic obstructive pulmonary disease. The patient presented to his primary care physician with a two week history of jaundice and unintentional weight loss. The physician referred the patient for further investigations. Following a hepatology consult the patient was diagnosed with a liver mass it was recommended that he undergo surgery to resect it. The procedure was completed without any apparent intraoperative complications, however within a few hours of surgery the patient became very hypotensive and was emergently taken back to the operating room for surgical exploration of the abdomen. During the laparotomy a large volume of blood was found in the patient’s abdominal cavity and the bleeding site was identified as the right hepatic artery which was injured during the initial surgery. Examination of the removed portion of the liver revealed a final diagnosis of immunoglobulin associated G4 cholangiopathy with no evidence of malignancy which was perhaps related to his autoimmune pancreatitis. The injury was believed to be linked to improperly placed sutures. The patient was not able to recover and ultimately died as a result of these complications. According to the autopsy report there was evidence of a dislodged suture at the right hepatic artery which led to the hemoperitoneum.
Question(s) For Expert Witness
Can you determine from the medical record if the improperly placed sutures contributed to this patients untimely death? Was this procedure absolutely necessary given that the mass was non-malignant, could the outcome have been different if surgery was not pursued?
Expert Witness Response E-005040
Massive bleeding is a known complication of liver surgery. Generally the hepatic artery is suture-tied (so that the suture does not slip) or (even better) stapled. Immunoglobulin G4 associated cholangiopathy is a rare condition that can involve any level of the biliary tree which exhibits sclerosing cholangitis or pseudotumorous hilar lesions. Most cases are associated with autoimmune pancreatitis, an important diagnostic clue. In many cases the diagnosis of IgG4-cholangiopathy is very challenging. Indeed such cases have been treated surgically. A thorough review of the patient’s history and pre-op tests and imaging, as well as any pre-op biopsy that was performed, would help to determine whether liver resection could have been indicated or not. If there was no evidence that the mass was in danger of rupturing or degenerating in any way the procedure may have not been absolutely necessary.
This expert is board certified in Surgery with additional Fellowship training in Surgical Oncology. He trained at the University of Chicago for residency and at the Moffitt Cancer Center in Tampa, Florida for his Oncology fellowship. He is currently the Clinical Professor in the Department of Surgery at a Major University Medical Center in New York. Furthermore, he is on two advisory committees in his university and is a member of the Society of American Gastrointestinal and Endoscopic Surgeons.
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Michael Morgenstern
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