Confidential

Facts

The patient, a generally vigorous and healthy 74-year-old man, experienced recurrent rectal bleeding. A sigmoidoscopy revealed cancer in the sigmoid colon. On admission to defendant hospital, he was assigned an attending physician and a senior surgical resident. The physician defendants decided to perform a laparoscopic removal of the sigmoid cancer, and performed this procedure. Following the procedure, the patient did not recover quickly, with significant abdominal pain, ileus, distension, and eventually developed new free air in the abdomen. The defendant surgeons, with a classic incision, performed a second surgery, the leaking anastomosis from the initial laparoscopic surgery was found and closed, and a colostomy was fashioned. Following this surgery, the patient continued to drain fluid from his wound drains, eventually draining well over 1000 cc of clear fluid a day. Creatinine measurements of the drainage fluid revealed that this was probably urine, and radiographic studies appeared to show an obstructed right ureter. Plans were made for a third abdominal surgery when the patient abruptly died.

At autopsy, the decedent's immediate cause of death was found to be massive saddle pulmonary embolism. Also noted was a massive abscess in the pelvis, the site of origin of the pulmonary embolism, with massive adhesions involving the colon, bladder and ureters. A new leakage from the colon was noted, as was an avulsion of the left ureter, so that both fecal matter and urine had contributed to the pelvic abscess.

PLAINTIFFS' CONTENTIONS:
The plaintiffs contended that the decedent did not require laparoscopic colectomy, since he was healthy and the procedure was done laparoscopically more as a teaching tool than as reasonable therapy for the decedent. It was uncertain whether any attending physician was even present for the initial laparoscopic surgery, and even if he was, the "hands" doing this procedure were those of the surgical resident, not the attending physician. This procedure left an anastomic leak behind.

The plaintiffs also contended that the defendant physicians was tardy in recognizing developing peritonitis in the decedent, and failed to perform laparotomy timely, permitting the fecal leak to cause a pelvic abscess. When the second surgery was finally done, it left behind an avulsed left ureter and another leak from the colon, causing a massive pelvic abscess in which multiple areas developed phlebitis. After this, it took almost a week for clinicians to recognize that urine was filling the abdomen and draining from the abdominal wound, and by the time a third surgery was scheduled, a fatal pulmonary embolism had left the pelvis and killed the patient.

DEFENDANTS' CONTENTIONS:
The defendants contended that the laparoscopic procedure was reasonable as a way to minimize the morbidity of the initial segmental resection of the sigmoid. The attending physician attended this surgery, and the resident who did the procedure was a senior resident and was experienced in the technique. Anastomotic leakage is a known complication of the procedure and did not in and of itself prove negligent surgery.

The defendants also contended that the diagnosis of peritonitis was uncertain in the few days following initial surgery and the signs and symptoms were ambiguous. The second surgery was done as soon as it was clear it was needed.

The defendants further contended that the second surgery, closure to the initial leak and creation of an ileostomy was performed in compliance with the standard of care. No explanation for the later leak from the colon or for the avulsed ureter was known.

Finally, the defendants contended that the final operation was scheduled as soon as it became clear that there was a urine leakage into the abdomen. The decedent was kept on prophylactic low dose heparin to avoid phlebitis, but full doses of anticoagulants were too dangerous to give. The final pulmonary embolism was the result of known complications of necessary procedures.

Result

After informal settlement discussions, the case settled for $175,000.

Other Information

The decedent, in his 70s, had no source of income, and was supported by his son. His life expectancy, at 74 with colon cancer, was not materially affected by his colon cancer, as the pathology specimen showed it to be a superficial cancer, Stage I, with a cure rate in the range of 90 percent.