2012 Report of Colorectal Surgery at Noble's

Summary

The request sought a confidential 2012 investigative report by Mr. Stevan George Stojkovic regarding complications in elective colorectal surgery at Noble's Hospital, which was fully disclosed by the Department of Health and Social Care. The report details a specific case of unnecessary surgery and post-operative sepsis, leading to recommendations for improved clinical guidelines and monitoring.

Key Facts

• Elective colorectal resections at Noble Hospital were suspended following a run of complications.
• The investigation was conducted by Mr. Stevan George Stojkovic, a Consultant Colorectal Surgeon from York Teaching Hospitals NHS Foundation Trust.
• Case 1 involved a 72-year-old man who underwent a right hemicolectomy despite no cancer being found in the resected specimen.
• The report criticizes the failure to perform a pre-operative colonoscopy and the use of abdominal ultrasound instead of CT for investigating post-operative sepsis.
• Recommendations include establishing a Colorectal MDT and using invasive monitoring techniques like oesophageal Doppler.

Data Disclosed

• 2012
• November 28th-29th, 2012
• 72 year old
• 2004
• 6/11/12
• 78 minutes
• 90mmHg
• 21,000
• 38.2 C
• 500mls
• 15 pages
• 2 documents
• 4149293

Original Request

I would like a copy of the report issued by Steven George Stojkovic in 2012 on colorectal surgery at Noble's. This report is not publicly available, but is cited in the recent report from Sir Jonathan Michael.

Data Tables (1)

Full Response Text

Investigative report of elective colorectal surgery at Noble Hospital, Isle of Man November 28th-29th, 2012

Private and Confidential

Author: Mr Stevan George Stojkovic MB, ChB, FRCS (Eng), MD

Consultant Colorectal Surgeon, York Teaching Hospitals NHS Foundation Trust, York, UK GMC no: 4149293

Background

Following a recent run of complications after elective colorectal surgery performed by Mr , colorectal surgeon at Noble Hospital, the Medical Director and Hospital Manager have suspended elective colorectal resections pending investigation. This situation was brought to light, as I understand, by fellow health professionals involved with the patients concerned.

I am a peer investigator giving an “opinion” on recent events and am not a representative of an official institution. My experience within my own colorectal department has included the role of Lead Clinician for Colorectal Cancer (CRC), Service Improvement Lead for Colorectal Cancer. I also assimilate and report on performance data for Colorectal Cancer resections on behalf of my department and colleagues and have done for the last 6 years. This includes specifically, 30 and 90 day mortality, anastomotic leaks, permanent stoma rates and post operative length of stay. I am currently the Vice Chairman of the Yorkshire Cancer Networks Site Specific Group for CRC.

Methods

This report has been produced using the following methods: • case note review
• one-on-one discussions
• visiting the wards, ICU and theatre complex
• review of historical data

Case note review

Case 1

Summary

72 year old man referred as an out patient with iron deficiency anaemia and no bowel symptoms. Previous history of a D1 Gastrectomy in 2004 for gastric cancer. A smoker with a history also of “mild” ischaemic heart disease. Investigations arranged included an Upper GI Endoscopy which was normal followed by a Ba enema where there was a suggestion of a cancer in the right colon. Staging CT was then performed and this also suggested a possible cancer in the right colon. There was no evidence of metastatic disease. The patient was recommended to have surgery and this took place on the 6/11/12. Surgeon – , Anaesthetist – . At surgery no tumour was found to be palpable in the right colon however there was quite a degree of stool present making palpation of a small tumour difficult. On table colonoscopy was attempted but unsuccessful beyond the sigmoid colon due to stool. A decision was made to perform right hemicolectomy with side to side stapled anastomosis (no histological evidence of cancer in the resected specimen). Operatively the operation appeared to be straightforward. Length of operation 78 minutes. From the anaesthetic side there were no obvious adverse events other than pan- operative hypotension with the patient never achieving a systolic greater than 90mmHg according to the anaesthetic chart. No evidence of invasive monitoring with oesophageal Doppler or arterial line. PCAS was used for postoperative pain relief. The patient was well for the first three post op days however on the fourth day there was some concern raised regarding the colour of the drain fluid which was thought to be possibly faeculent. Inflammatory markers were noted to be raised (WBC 21,000) and i.v. antimicrobials were commenced. On day five the drain was noted to be blood stained and an abdominal USS was requested. This showed a possible collection in the left iliac fossa. Continued conservative management with antimicrobials. Inflammatory markers remained raised and the patient developed diarrhoea. This was treated with Imodium. On day ten post op the antimicrobials were stopped. However the following day the patient developed a temperature of 38.2 C. At this point a CT abdomen was requested. This showed a collection in the right iliac fossa and the following day radiological drainage was performed revealing approx. 500mls of purulent fluid. Continued conservative management then on day eighteen post op the drain fluid was noted to be faeculent. Continued conservative management. The patient remains in hospital.

Comments

Patient had an unnecessary operation (no cancer). The Association of Surgeons of GB and Ireland clearly state in their guidelines for CRC that colonoscopic evaluation and biopsy should be obtained prior to surgery whenever possible. This patient should have had a colonoscopy pre operatively.
Recommendation: a Colorectal MDT that provides and agrees an operational policy for CRC based upon national and local cancer network guidelines. Pan-operative hypotension. This should not occur with modern anaesthesia and attempts should be made to prevent intra operative hypotension as much as possible. Recommendation: use of invasive monitoring techniques such as oesophageal Doppler (LidCo) to monitor cardiac filling which will guide targeted fluid therapy as well as invasive blood pressure monitoring particularly in moderate/high risk patients. Judicious use of vasoconstrictors. Failure to investigate the post op sepsis appropriately. There is absolutely no role for abdominal USS in assessing the post operative abdomen. At day 6 post op (hypotensive and raised WCC) a CT should have been requested. Recommendation: departmental policy that if a patient who is seven days post resection and is not progressing as expected should have cross sectional imaging. This is where the window of opportunity lies for patients who have leaked. This has worked well in our own department. Lack of any pre operative objective assessment of fitness. The comment on the anaesthetic chart of “general health, fair” in my opinion falls short of current standards for pre op assessment. Recommendation: develop Cardiopulmonary Exercise (CPEX) testing for all patients who are perceived to be moderate/high risk undergoing major resections. Epidural anaesthesia. I accept that this issue is very debatable however in an elderly patient with mild IHD who is a smoker this is probably the better option particularly if used in combination with the invasive monitoring techniques described above. Speaking to the nursing staff in ICU and the wards there appears to be variation amongst the anaesthetists regarding this issue. Recommendation: departmental policy on post operative pain relief which is delivered based on the needs of the patients rather than the personal preferences/competency of the anaesthetist. This should preferably be done in a setting of ERAS (enhanced recovery after surgery)

Cause of leak

Difficult to say in this case; surgical technique as far as I can tell from the op notes appeared sound. Pan operative hypotension could have been a contributory factor. The surgeon made the correct decision to proceed with hemicolectomy even though he could not feel a cancer.

Case 2

Summary

71 year old lady, smoker with a history of type II diabetes (diet controlled) and hypertension. Admitted with abdominal pain whilst under going bowel prep for a Ba enema. Ba enema suggested a diverticular abscess. Subsequent CT showed a diverticular stricture with a degree of diverticulitis and paracolic fluid collection. The left ureter was potentially compromised by the inflammatory process. The possibility of a cancer at the recto sigmoid junction was raised. The patient was treated conservatively initially and elective surgery scheduled for 13/11/2012. Surgeon – , Anaesthetist – . A sigmoid colectomy was performed for a large inflammatory mass adherent to pelvic sidewall, vaginal vault and ureter. This appeared relatively straightforward. Anastomosis was performed using a circular stapling device. Donuts (sic) were noted to be intact and the air-leak test normal. The patient went to HDU post op. There were issues with pain relief that evening and a spinal with intrathecal morphine was used as the PCAS was not effective. Day 1 post op there was an issue with flipped T waves and epigastric pain. A transthoracic echo was performed which was normal. Vasoconstrictors were started to maintain BP. Day 2 they were stopped and day 3 the patient returned to the main ward. Day 5 the patient opened their bowels and passed flatus. Day 6 the patient became unwell, with low sats and left iliac fossa pain. The following morning the patient was seen by Mr who arranged an urgent CT abdomen which suggested an anastomotic leak. A laparotomy was performed that day. The anastomosis was found to be ischaemic (proximal). A Hartmanns performed. The patient did well following this operation and whilst still an inpatient continues to improve as far as I am aware.

Comments

Adequate pre op planning. Complicated diverticular disease in this setting can be challenging. In an elderly patient with co morbidity there needs to be careful thought about how to proceed with the various options being discussed with the patient in particular the option of whether to anastomose or not and also whether to persevere with a more expectant approach. Given the CT findings I would have certainly considered involving the Urologists at the start of the procedure to stent the left ureter to aid identification and minimise risk of injury. Again CPEX would have likely highlighted this patient as high risk and invasive monitoring would probably have helped. Adequate post op analgesia. Poor pain relief post op invariably results in basal atelectasis and periods of hypoxia which could threaten an anastomosis. Recommendation: see earlier section re: use of epidurals Surgical technique. There is no documentation that the splenic flexure was mobilised and that flow in the marginal artery was confirmed. Considering that the mid descending colon was divided and anastomosed to the mid rectum it is unlikely that this could be done without tension unless the flexure had been fully mobilised. Recommendation: intra op documentation of marginal blood flow (usually for 10secs) as well as a low threshold to mobilise the splenic flexure

Avoid criticising colleagues in the notes. The documentation from Mr
regarding his belief that the inotrope usage caused the leak is not helpful and not relevant in the setting of the notes. This is a sign of lack of communication within the team. There are better ways and better forums in which to discuss this contentious issue. E.g. Junior presenting the research and evidence on the use of vasoconstrictors and leaks in a joint M and M session with the anaesthetists followed by debate

Cause of leak Probably a combination of poor surgical technique as well as the patients’ co-morbidities. Early post op hypoxia and inotrope usage may have contributed. The good points in this case are the early recognition and treatment of the leak by the surgical team.

Case 3

Summary 64 year old lady with a past history of a hysterectomy as well as mild hypertension and hypercholesterolaemia admitted with RUQ pain. CT performed which showed a necrotic mass in the transverse colon with possible localised perforation. Patient treated with antimicrobials. Symptoms settled to a degree. Patient discharged and given date for elective surgery on 18/09/2012. Surgeon – , Anaesthetist – . Laparotomy revealed a locally advanced transverse colon cancer involving a loop of small bowel. An en-bloc resection was performed which was described as a transverse colectomy with colo-colic anastomosis (handsewn PDS) a well as an entero-enteric anastomosis (handsewn PDS). No adverse anaesthetic events. Some intra op hypotension. Day 1 to day 3 no problems. Patient developed a temperature, tachycardia and reduced sats on day 4. CXR showed free air under the diaphragm. CT findings consistent with a probable leak. It was decided to treat conservatively at this point with antibiotics as clinically and biochemically she was reasonably well. Day 6 postop it was noted that her pain was still present and her pulse rate was 110. A decision was made to start parenteral nutrition. When the anaesthetist saw the patient (for a central line) he was concerned that she had signs of sepsis and asked for surgical review. A CXR revealed a left sided pleural effusion and possible consolidation – it was postulated by the surgical team that this may be responsible for her symptoms. The anaesthetist however felt that his was not the case and that intra abdominal sepsis was the cause. Patient was reviewed by Mr
who felt that the sepsis was not surgical and suggested CTPA to exclude PE and continue with TPN. Cons anaesthetist reviewed the patient and documented in the notes “there is clearly intra abdominal pathology here” and asked for an abdo CT to be added to the CTPA. CT showed no PE and a small collection in the abdomen. Conservative treatment was continued. The following day it was noted that faeculent material was coming from the wound. A CT guided drain was inserted into the collection which was also faeculent. Laparotomy that day revealed a large leak from the colo-colic anastomosis. The descending colon was cross stapled and a colostomy fashioned. The following post op period was smoother with eventual recovery. The patients care was taken on by Mr
as the family had lost confidence in Mr . The patient was lucky to survive. Pathology showed Dukes C1 cancer.

Comments

Conservative management of a leak was a very risky approach in this lady. The patient had two anastomoses, it was difficult surgery, I gather she was overweight and the leak occurred early in the post op course. I accept that on occasions extra pelvic leaks can sometimes be managed successfully but it is a dangerous course to take. Recommendation: if it is felt that an extra pelvic leak is to be managed conservatively then a second opinion should be sought from a surgical colleague and there should be unanimous agreement with daily review of the decision. Obvious discord between surgeon and anaesthetists. It becomes very clear reading the notes that there are quite clear differences between the anaesthetists and the surgeons assessment of this patient and this is reflected in the notes by some rather “awkward” comments. This lack of agreement and communication was to the detriment of the patient in my opinion. Recommendation: agreement for a “joint” assessment of a patient where disagreement occurs with the surgeon, seeking independent review from a colleague. We do this not infrequently in our hospital as such patients can be incredibly complex. A “fresh” review from an uninvolved impartial colleague is often the best! Surgical technique. An anastomosis between the ascending colon and descending colon is a terrible anastomosis in my opinion and should be avoided. Sacrifice of the IC

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