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Management of complications following bowel surgery (13HDC01590)

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(13HDC01590, 24 June 2016) 

General surgeon ~ District health board ~ Laparoscopy ~ Right 4(1)

Following a colonoscopy, a 60-year-old man was diagnosed with cancer of the rectum. He underwent a laparoscopic anterior resection performed by a general surgeon. The laparoscopic anterior resection involved removing a section of the large bowel. The two ends of the large bowel were re-joined together (anastomosed) and a colonic J-pouch was created, which involved constructing an internal reservoir to retain functionality of the anus.

About two months later, the man developed a raised temperature and a CT scan was performed, which queried whether there was an anastomotic leak. Antibiotics were commenced. Initially the man showed some improvement, but a few days later he again developed a fever and pelvic pain. He underwent a second CT scan, which suggested that the anastomosis had leaked and a large pelvic abscess had developed.

The following day the surgeon returned the man to theatre and determined that the anastomosis was intact, but there was a rent (a tear) in the J-pouch, which was allowing faecal contamination of the man's pelvis. The surgeon decided to preserve the J-pouch and anastomosis, so he laparoscopically inserted a catheter into the hole in the J-pouch, and a suture was used to close the rent around the catheter. The surgeon was going on leave and he asked another surgeon to take over the man's care.

The second surgeon reviewed the man and found that he had deteriorated overnight. There was ongoing obviously feculent drainage from the pelvic drain. The second surgeon booked the man as an urgent case for theatre. A rectal examination revealed a pelvis full of soft faeces, and there was a complete dehiscence of the anastomosis.

It was held that the first surgeon's persistence with the laparoscopic approach, in all of the circumstances, was suboptimal. Accordingly, the first surgeon was found to have breached Right 4(1).

The district health board was found not to have breached the Code.

It was recommended that the first surgeon provide a formal written apology to the man's family for his breach of the Code, and that the Medical Council of New Zealand consider conducting a competence review.

It was also recommended that the district health board perform a credentialing review of the first surgeon and report back to HDC on its findings, and provide HDC with the findings from an audit of the first surgeon's rectal surgery for the past three years.

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