This case takes place in Maine and involves complications following a percutaneous endoscopic gastronomy. The patient, an 80-year-old female, was admitted for elective cardiac catheterization. She had previously suffered from an ascending aortic aneurysm. The patient was noted to need CABG, AVR and MVR. On the day of surgery, the patient was taken to the operating room for an aortic valve replacement with a 25mm manganese bioprosthetic aortic valve and a complex mitral valve repair with a 30mm Carbomedics AnnuloFlex ring. After the procedure, the patient was transferred to the cardiovascular intensive care unit in stable but critical condition. The patient was extubated on post-op day 1. However, the patient became acidotic and was subsequently reintubated. The patient remained critical throughout the rest of her stay with multiple postoperative complications. The patient required 20-hours of Levophed and was placed on a renal dose of dopamine for 3 days. All pressors were discontinued on post-op day 5. It was noted on post-op day 7 that the patient had ischemic of her right index finger, left 3 lateral fingers and bilateral pads of the toes. Vascular surgery was consulted and subsequently Dopplers were ordered and there was no acute thrombus or embolic clot noted in any great vessels. The patient was placed on a heparin drip. The patient had consultations to nephrology, infectious disease, endocrinology, nutritional, dietary and the intensivist. All cultures that were drawn remained negative. The patient was taken for a tracheostomy and PEG tube placement on post-op day 9, performed by the defending surgeon. The patient was noted to have stool coming from around the PEG tube site. On post-op day 12 while performing an x-ray, the patient was turned and became hypoxic leading to a respiratory arrest and PEA. Subsequently, the patient was coded, however, despite all efforts after about 25-minutes the patient expired. It was discovered the PEG tube perforated her transverse colon. The plaintiff alleges that although she had a lot of comorbidities, the tracheostomy was the event that caused death.
Question(s) For Expert Witness
1. Do you routinely treat patients and perform procedures similar to the one described in the case?
2. Have you ever had a patient develop the outcome described in the case?
3. Do you believe this patient may have had a better outcome if the care rendered had been different?
Expert Witness Response E-001161
I routinely perform PEG's and have never had a patient develop the outcome described in this case. There are specific steps that a surgeon must take to make sure that this complication does not occur. One such step is to transilluminate, or to see if the light within the endoscope inside the stomach is visible on the skin. This minimizes the risk of perforating a structure that can be caught between the stomach and the abdominal wall, such as the colon. This patient most likely would have had a better outcome if it were not for this complication with the PEG tube.
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