This case involves a 59-year-old female patient that underwent a complicated spinal fusion surgery to repair severe spinal cord deformity, osteoporotic changes, and multilevel neuro foraminal stenosis. As a result of the surgery, the patient developed evidence of mesenteric ischemia. The operative reports of the subsequent exploratory laparotomy revealed progressive and extensive full-thickness necrosis of the duodenum, near complete ischemia of the liver with portal vein thrombus and full thickness ischemia of the stomach. The impression by the surgeons who performed the second exploratory laparotomy stated that all conditions were not compatible with survival. The doctors caring for the patient concluded that this was a clotting issue in her arterial system and unlikely due to the reconstructive surgery itself including her recreation of normal posture out of kyphosis. They also mention other possibilities for her hypercoagulable states including underlying blood dyscrasia, which had been undetected as well as the postoperative state such as immobilization and multiple transfusions.
Question(s) For Expert Witness
1. Could the pre-operative labs have demonstrated how the surgeons should have anticipated such adverse events and if anything may have been done to alter the outcome in this case?
Expert Witness Response E-000855
Hypercoagulability from protein C and S deficiency, antithrombin III deficiency, dysfibrinogenemia, abnormal plasminogen, polycythemia vera (most common), thrombocytosis, sickle cell disease, factor V Leiden mutation, and pregnancy are all predisposing factors for developing an acute mesenteric ischemia. There are no pre-op labs that the surgeon could have checked unless this patient was suspected of having a rare blood disorder but it seems as if there was no reason to think along those lines in this case. The surgeon is not to blame in this case for causing the bowel ischemia but he does have a responsibility to recognize and treat the condition as soon as possible. Survivors of extensive bowel resection face significant long-term morbidity because of the reduced intestinal mucosal surface available for absorption. However, with rapid treatment, the mortality rate can be reduced considerably, and patients may be spared bowel resection.
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