Page 47 - WALS Journal

Lalwani S et al
Medicine ICU. A diagnosis of cholangitis with septicemia and DISCUSSION
associated pancreatitis was made. Computerized Tomography Professional negligence is defined as absence of reasonable
of abdomen did not reveal any leakage from the T tube as the care and skill or willful negligence of a medical practitioner in
dye was passing smoothly from CBD into duodenal loop without the treatment of a patient, which causes bodily injury or death
any extravasation. Patient was kept on intravenous fluids, of patient. A doctor is not liable if he exercises reasonable skill
antibiotics, vasopressor support and was placed on ventilator. and care, provided that his judgment conforms to accepted
Central line was inserted. Blood was sent for culture and medical practice and does not result in an error of omission.
sensitivity test, Serum amylase and serum Lipase. ECG and The doctor cannot be sued for professional negligence, when
X-rays were done. Arterial Blood Gas analysis showed severe statistics show that accepted methods of treatment have been
metabolic acidosis. employed on the patient and that the risk and injury which
The investigations revealed deranged clotting parameters
and high level of Serum amylase and Serum Lipase. A resulted are of a kind that may occur even though reasonable
care has been taken.
vasopressin infusion was started and sodium bicarbonate was In the present case, the patient was admitted with diagnosis
administered to correct acidosis. Consultation was sought from of acute cholecystitis. Laparoscopic cholecystectomy, which
senior nephrologists. Non-contrast Computerized Tomography is the treatment of choice for gallbladder diseases was
1
of abdomen was done which was normal. Patient was on dalacin, performed by the treating surgeon. During the surgical
amikacin and vancomycin. The coagulation abnormality was procedure injury to common bile duct occurred. Bile duct
corrected with one unit of Fresh Frozen Plasma and one unit of injuries result in high morbidity, long-term hospitalization and
platelets. He was started on Xigris (Activated Protein C) on may be life threatening. The incidence of bile duct injury
1
fourth postoperative day. Despite these measures the patient’s reported varies in different studies. Gronroos et al (2003)
condition continued to deteriorate. In the morning hours of the reported that the risk of bile duct injury was 0.86% in total
fifth postoperative day, the patient developed cardiac arrest. patient population. Krahenbuhl et al (2001) reported that
2
Cardiopulmonary resuscitation was attempted with adrenaline, overall bile duct injury incidence was 0.3%; 0.18% for
atropine and sodium bicarbonate but was unsuccessful and symptomatic gallstones, and 0.36% for acute cholecystitis. In
the patient was declared dead. case of severe chronic cholecystitis with shrunken gallbladder
The relations of the deceased lodged a complaint at the incidence was as high as 3%. Calvete et al (2000) reported
5
police station alleging negligence in the treatment by the that overall incidence of bile duct injury was 1.4% and Huang
6
doctors. The inquest was conducted by police and autopsy et al (1997) reported that bile duct injury accounted for 0.32%. 7
was performed the body by the board of doctors. Richardson et al (1996) has mentioned that severe
Autopsy findings revealed stitched wounds on right and left inflammation, aberrant anatomy and poor visualization as
8
side of chest with injection marks (Therapeutic Central Venous contributory factors for CBD injury. This complication may
5,6,9
Line insertion site), Stitched wound 24 cm in length on anterior occur even when the operating surgeon is well experienced.
abdominal wall (Stitched Surgical Incision), stitched wound Francoeur et al (2003) reported that these injuries could not
around umbilicus (Therapeutic) and injection marks in both be anticipated and as such it is an inherent risk of this procedure
side inguinal and both side cubital fossa. Internally, stitched thus, it is unavoidable and uniformly first concerned of surgeon
9
surgical wound on first part of duodenum. CBD was attached after injury is about the patients well being.
to first part of duodenum. Gallbladder was absent. Gel foam The bile duct injury in this case was immediately recognized
present in gallbladder fossa. Both lungs were congested and by the operating surgeon. Injury to common bile duct was
edematous. Petechial hemorrhages were seen on surface of lungs repaired by using T-Tube and converting the procedure of
and liver. Heart shows subendocardial petechial hemorrhages. laparoscopic cholecstyectomy to open procedure. Other senior
surgeon was also consulted and involved in operation. The
There was no evidence of pericardial, pleural effusion or procedure adopted was in conformation to that as reported in
hemoperitoneum.
5,6
literature. Kienzle (1999) had reported that bile duct injury
cannot be considered as malpractice, because it could be
Histopathological Examination
10
intraoperatively made out and immediately treated. Carroll
Histopathological examination indicated congestion in spleen, et al (1998) concluded that factors that predisposes to lawsuits
fatty change in liver, severe pulmonary edema and hemorrhage include treatment failures in immediately recognized injuries,
in lungs and acute tubular necrosis of proximal tubules of complications that result from delays in diagnosis and
11
kidneys. misinterpretation of abnormal cholangiograms. Low et al
Cause of death was attributed to multiple organ failure due (1997) reported that in Germany the main reasons for
to septicemia following cholecystectomy. acceptance of a case of common bile duct injury in laparoscopic

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