Surgery
18. Mrs S complains that the Trust performed his bowel resection poorly on 3 November 2022, resulting in the need for emergency surgery to stop a serious bleed and leading to an anastomotic leak.
19. We asked our surgical adviser whether there is any indication the operation was performed to a poor standard. They explained that our consideration of this will be limited as we can only rely on the notes made by the surgeons at the time. There is no video recording of the surgery that took place, and so this is the only evidence we have of what happened during surgery.
20. Our surgical adviser explained that that a serious bleed and anastomotic leak are both recognised complications of the surgery Mr E had. This means that the fact these happened does not, in and of itself, indicate something went wrong. Up to 19% of patients experience an anastomotic leak after bowel surgery (Zarnescu et al. 2021). Serious bleeding is much less common but is still a recognised complication of surgery. Mr E was advised of these risks, which were included on the consent form he signed, prior to undergoing surgery.
21. The notes of Mr E’s operation indicate that the bleeding arose ‘technically’. This means it was not likely caused by underlying medical conditions but, rather, due to the surgeon causing damage to a blood vessel. The blood vessel that was damaged was within the surgical area, and the fact this happened is not necessarily an indicator that something went wrong. Unfortunately, damage to the surrounding areas can still happen even when good surgical technique is used.
22. After the surgeons recognised the serious bleed, our surgical adviser explained they took the correct steps to rectify this by converting the surgery to a laparotomy and repairing the damaged blood vessel. They also replaced the blood lost with a blood transfusion. This was in line with the Royal College of Surgeons’ Good Surgical Practice guidelines, which state that surgeons should take prompt action when patient safety is compromised.
23. We can understand why Mrs S would have serious concerns with regards to her brother’s surgery given these complications. Whilst we cannot comment on the surgical technique used beyond that which is documented in the clinical notes, we can say that the fact these complications arose does not indicate poor technique nor that something went wrong. They are, unfortunately, complications that can happen during this type of surgery.
24. We have seen no indication that the serious bleed and anastomotic leak arose due to poor surgical technique and there is no indication of service failure.
Drain
25. Mrs S complains the Trust delayed in placing a drain to remove fluid from Mr E’s abdomen, following his surgery.
26. The fluid that built up in Mr E’s abdomen and which was leaking from the incision in his abdomen was ascitic fluid. This was most likely caused by Mr E’s liver cirrhosis, rather than it being a complication of surgery. This fluid did not begin to visibly accumulate until several days after surgery, which is important when considering when the drain should have been inserted.
27. The consent form completed by the Trust, and signed by Mr E, did include consent to insert a drain following surgery. Our surgical adviser explained that, in line with NICE Technical Appraisal TA105 (laparoscopic surgery for colorectal cancer) and NICE guideline NG151 (colorectal cancer) a drain is not explicitly indicated during this type of surgery and would be inserted at the discretion of the surgeon, based on clinical need. Our surgical adviser confirmed there was nothing within the operation notes that indicated there was a clinical need for a drain to be inserted at that time. Therefore, the fact a drain was not inserted at that time appears to be in line with NICE TA105 and NICE guideline NG151.
28. Following surgery, Mr E was physically stable for the first few days, before showing signs of deterioration. He began accumulating ascitic fluid which was causing his abdomen to distend and swell. The pressure from this fluid build-up caused fluid leakage through the incision site on Mr E’s abdomen, which was very concerning for Mrs S at that time.
29. The British Gastroenterology Society’s guidelines on managing ascitic fluid do not recommend inserting a drain in the first instance. This is only recommended when other interventions to treat the accumulation of fluid have not worked or when the fluid is extensive.
30. Mr E did not have a build-up of ascitic fluid in the days following his surgery. This was first documented on 8 November, and the clinician noted that the distension in his abdomen was ‘mild’. From 10 November, the clinicians began collecting and measuring the fluid that was draining through his incision. This continued until 14 November, when the clinicians treating Mr E sought specialist advice from gastroenterology colleagues. The specialist advice, received on 15 November, recommended inserting a drain. The following day the Trust inserted a drain.
31. The evidence indicates that there no delay in inserting a drain following Mr E’s surgery. Insertion of a drain at the time would have been dependent on clinical need, and our surgical adviser has confirmed there is nothing within the operation notes to indicate this was needed.
32. Following this, the Trust monitored Mr E’s ascitic fluid build-up and the decision not to initially insert a drain appears to be in line with the guidance from the British Society of Gastroenterology. Once gastroenterology colleagues recommended a drain, this was inserted the following day. There are no indications of service failure because the time it took to insert a drain appears to be in line with the relevant guidance.
Anastomotic leak
33. Mrs S complains the Trust delayed in identifying and treating the anastomotic leak in Mr E’s bowel.
34. In line with the Good Surgical Practice guidelines, surgeons must take prompt action when patient safety is compromised. Similarly, the General Medical Council’s Good Medical Practice guidelines state that doctors must adequately assess a patient’s condition and promptly arrange suitable treatment where necessary.
35. Our surgical adviser explained that an anastomotic leak is a recognised complication of the surgery Mr E had. They also explained that diagnosing an anastomotic leak can be challenging and, often, it is not until a patient becomes very unwell that clinicians suspect an anastomotic leak.
36. Following surgery on 3 November, Mr E initially appeared to be recovering well and his physiological observations were stable. He began leaking fluid from the incision on his abdomen a few days after surgery; however, this fluid arose due to his liver disease and was as a direct result of the surgery. Our surgical adviser explained that this fluid retention would not have indicated an anastomotic leak.
37. Mr E had a CT scan of his upper torso on 13 November. The purpose of this CT scan was to check for a pulmonary embolism, which is a blockage in the artery in the lung. This meant that the CT scan focused primarily on the lungs and only captured the upper part of Mr E’s abdomen.
38. This CT scan noted there was some free gas within the upper abdomen that could be related to the surgery, but an anastomotic leak could not be ruled out. Our surgical adviser explained that free gas within the abdomen commonly occurs during abdominal surgery and does not necessarily indicate a problem. The advice from this CT scan report was to undertake a CT scan of the abdomen if Mr E’s clinical condition indicated there was any acute intra-abdominal pathology (such as an anastomotic leak). This means that at this stage, whilst a leak could not be ruled out, the recommendation was to undertake further tests if Mr E’s clinical condition indicated this was needed.
39. Mr E’s clinical observations were stable at the time of this CT scan. His blood results indicated a slight elevation in inflammatory markers and his white cell count; however, this was within the expected deviation from the normal range that occurs in post-surgical patients.
40. It was not until 18 November that his National Early Warning Score, which is a tool used to help clinicians recognise when a patient is deteriorating, began to escalate. This prompted a review from clinicians and on 19 November they decided to undertake a CT scan of his abdomen. This CT scan took place the same day. The CT scan identified the anastomotic leak and the Trust proceeded to undertake corrective surgery later that day.
41. Based on the evidence available, there is nothing to indicate a delay in identifying or treating Mr E’s anastomotic leak. Anastomotic leaks can be difficult to identify, and the evidence indicates that when Mr E began to show signs of deterioration from 18 November, the clinicians quickly undertook a CT scan of his abdomen and proceeded to exploratory surgery the following day. There are no indications of service failure because the actions taken by the Trust appear to be in line with the GMC’s Good Medical Practice guidelines, and the Royal College of Surgeons’ Good Surgical Practice guidelines.
42. We recognise that this was a very distressing experience for Mrs S and she has understandably had serious concerns about the complications that arose after her brother’s surgery. We hope our work helps to reassure Mrs S that his care appears to be in line with the national guidelines.