This case involves a female patient with a history of Crohn’s disease who underwent a colectomy for excision of a neoplastic polyp. After surgery, her diet was immediately advanced from liquid to a regular soft diet. Several days after the surgery, the patient developed extreme nausea and vomiting. She returned to the hospital and it was noted that fluid was leaking from her incision. The decision was made to return the patient to surgery for a suspected bowel obstruction. However, the surgeon did not order an NG tube to be placed. When anesthesia was started, the patient aspirated a significant amount of her stomach contents. An NG tube was then placed and more than a liter of fluid was removed. The patient suffered severe lung injury and was placed on life support.
Question(s) For Expert Witness
- 1. How frequently do you treat patients with suspected obstructions requiring surgical treatment?
- 2. When should an NG tube be placed in such a patient?
Expert Witness Response E-075438
It will be important to distinguish whether the patient had developed an early anastomotic leak as the indication for her deterioration and her need for an unplanned return to the operating room, or whether she had a mechanical bowel obstruction with or without other factors, such as an anastomotic leak. One way to circumvent this distinction is to ask “How often do patients with emesis, who also require emergent abdominal surgery, need to have a nasogastric tube?” The answer is “always,” but this situation would be exacerbated if there were also preoperative radiographic evidence of gastric distention, a significant ileus, or a mechanical small bowel obstruction. A nasogastric tube would ideally be inserted prior to transportation in the operating room to begin decompressing the stomach for as long of an interval prior to intubation as possible. The key would be to decompress the stomach prior to the induction of anesthesia when the risk of aspiration is highest.