Practice of Medicine
Don’t Complicate your Complications
November 29, 2017
A 64-year-old woman presented to the emergency room (ER) with right sided abdominal pain. Her ER evaluation revealed cholelithiasis with thickening of the gall bladder wall. The patient was admitted by the surgical team on call and underwent laparoscopic cholecystectomy. Approximately 12 hours after surgery, the patient developed fever and tachycardia followed by tachypnea and abdominal rigidity. On evaluation by the surgical team, a decision was made to take her back to the operating room (OR) for an exploratory laparotomy. During her exploratory laparotomy the surgeon discovered a transection of her common bile duct and decided to perform a repair. The complication was addressed using a technique that included a choledochoduodenostomy.
Post-operatively, the patient developed septic shock complicated by multi-organ failure and her condition rapidly declined. On hospital day 4, the surgeon had a discussion with the patient’s family and a decision was made to transfer her to a tertiary care center. At the time of transfer, the patient was on mechanical ventilation and required several vasopressors to maintain her blood pressure. Following transfer to the tertiary care center, concerns were raised about breakdown of her common bile duct anastamosis. A second exploratory laparotomy was then performed, at which time she was noted to have separation of her choledochoduodenal anastomosis with leakage of bile and duodenal contents into the peritoneal cavity. A hepaticojejunostomy was then performed, along with placement of a gastrostomy-jejunostomy tube and percutaneous transhepatic cholangiography (PTC) drain. Following surgery, the patient recovered from severe sepsis but her renal failure persisted, warranting initiation of hemodialysis. In addition, she had difficulty being weaned from mechanical ventilation and had to undergo a tracheostomy.
The patient’s family was angry because they were not notified of the surgical complication until the option of transferring her to a tertiary facility was being considered. The family sued, stating that, 1) there was a delay in recognizing and appropriately treating her surgical complication, and 2) the delay in transferring the patient to the tertiary center resulted in her severe sepsis and renal failure.
Doctors feel a sense of responsibility to their patients and often want to personally manage complications that arise from the procedures they perform. However, physicians should be cognizant of their capabilities and recognize when the intervention required to address a complication is beyond their scope. In instances where a higher skill level is required to address a complication, the physician should seek to expeditiously transfer the patient to a facility where they can receive the appropriate level of care. Any delay in doing so puts patients at risk for worse outcomes related to their procedural complications and exposes physicians to the risk of litigation.
When a physician recognizes that a complication has occurred, it is crucial for him or her to inform the patient, and/or the patient’s family, in a timely manner. Delays in informing the patient/family about the complication may be perceived by the patient/family as an attempt to hide or misconstrue information. In the clinical case presented, the surgeon may have averted litigation had he:
- Informed the patient/family of the complication at the time it was recognized
- Discussed the options for handling the complication with the patient/family
- Involved the patient/family in the decision-making process regarding management of the complication
Instead, the surgeon attempted to correct the complication on his own, even though the ideal approach would have been to transfer the patient to a tertiary care center to address the complication. One of the claims against the surgeon included the allegation that the ideal, more technical, surgical procedure required to repair the common bile duct transection was beyond the surgeon’s scope. Although the surgeon felt confident in his skills because he had used this alternative surgical approach before, his delay in transferring the patient was perceived as an attempt to avoid discovery of the complication. The case was settled for a significant amount of money.
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