Volume Two (June 2022): Better to have done a different procedure

A QASM June 2022 (Volume 2) Better to have done a different procedure A Queensland Audit of Surgical Mortality (QASM) assessor recently stated: “If something is not right – pause and reconsider the strategy. Be astute to potential problems when the clinical presentation has unexplained anomalies. Complex cases benefit from multidisciplinary assessment.”

BACKGROUND

Surgeons make complex decisions, often with time constraints and uncertainty, which have significant influence on patient outcomes.1,2 This QASM perspective includes QASM data for patients who died in hospital between 1 July 2016 and 30 June 2021. The data and case study presented give perspectives from QASM assessors regarding the choice of surgical procedures.

QASM PATIENTS (1 JULY 2016 TO 30 JUNE 2021)

QASM assessors reviewed 5,308 patients’ in-hospital deaths and noted that 19.1% of patients had clinical management issues (CMIs). Of the patients with CMIs, 13.2% were CMIs themed as ‘better-to-have-done-a-different-procedure’. QASM assessors noted that better-to-have-done-a-differentprocedure CMIs occurred in 3.1% of patients who had a procedure and that 0.5% of the patients who did not have a surgical procedure, should have.

The patients who had a procedure and a better-to-have-done-a-different-procedure CMI were elderly (median age of 73 [IQR 65–82 years]), mainly emergency admissions (70.2%), and more than half were male (55.7%). The association between surgical specialty and better-to-have-donea-different-procedure CMI was investigated using a multivariable logistic regression model adjusted for the potentially confounding variables admission status, hospital status, comorbidities, ASA grade and death risk. Fewer Orthopaedic Surgery patients who had a procedure had a betterto-have-done-a-different-procedure CMI (n = 1,076 procedures and 0.9% better-to-have-done-a-different-procedure CMI) compared to General Surgery patients (n = 1,357 procedures and 4.3% better-to-have-done-a-different-procedure CMI; odds ratio 0.2 [95% confidence interval 0.1 to 0.4), p < 0.001]). There was no statistical difference between General Surgery patients and Paediatric Surgery (98.4% had a procedure and 8.2% better-tohave-done-a-different-procedure CMI) or Cardiothoracic Surgery (94.4% had a procedure and 5.2% better-to-have-done-a-different-procedure CMI) (Figure 1).

Assessors noted that 66.9% of the better-to-have-done-a-different-procedure CMIs may have contributed to the death of the patient, 26.2% made no difference to the patient’s outcome and 6.9% caused the death of the patient who would have otherwise been expected to survive. More than half (59.5%) of the better-to-have-done-a-different-procedure CMIs were considered to be preventable.

Odds ratio (95% CI), p-value Paediatric Surgery, n=61/62

8.2%

2.3 (0.8 to 6.9), p=0.14

Cardiothoracic Surgery, n=442/468

5.2%

1.1 (0.7 to 2.0), p=0.63

General Surgery, n=1,357/1,893

4.3%

Reference

Plastic Surgery, n=48/51

4.2%

0.4 (0.1 to 2.9), p=0.35

Vascular Surgery, n=404/463

4.0%

0.9 (0.5 to 1.7), p=0.85

Neurosurgery, n=527/745

2.5%

0.7 (0.3 to 1.3), p=0.25

Urology, n=200/247

2.0%

0.4 (0.1 to 1.1), p=0.09

Orthopaedic Surgery, n=1,076/1,277

0.9%

0.2 (0.1 to 0.4), p<0.001*

Figure 1: Proportion of patients admitted by surgical specialty who had a procedure and a better-to-have-done-a-different-procedure CMI *Statistically significant; CMI = clinical management issue; 95% CI = 95% Confidence Interval; Odds ratio is a measure of association between an exposure (i.e. surgical specialty) and an outcome (i.e. surgery and better-to-have-done-adifferent-procedure CMI). It is the ratio of the odds of the outcome happening in one surgical specialty versus the reference group (General Surgery).

The odds ratio is used to report the strength of association between exposure and outcome. The larger the odds ratio, the stronger the association.

The smaller the odds ratio is than 1, the less likely the event is to be found with exposure. It is important to look at the confidence interval for the odds ratio, and if the odds ratio confidence interval includes 1, then the odds ratio did not reach statistical significance.

Surgical specialties not shown if no CMIs noted (Obstetrics and Gynaecology, Ophthalmology, Oral/Maxillofacial and Otolaryngology Head and Neck Surgery).

A QASM QASM CASE STUDY

A man (mid-60s) who required high care nursing in a residential aged care facility, was booked for elective laparoscopic cholecystectomy.

He had a prior admission for cholangitis successfully managed with endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy. He had limited-mobility right-sided hemiplegia, blindness and panhypopituitarism.

On admission day, he had a laparoscopic subtotal cholecystectomy. A fatty liver was noted. Hartmann’s pouch was controlled with an endoloop. No cholangiogram was performed.

FLOSEAL Haemostatic Matrix was used to control the oozing from the gallbladder bed.

On day 1, the surgeon noted 450 ml of blood in the drain. At prompt repeat laparoscopy, he was noted to be cirrhotic with 150 ml of blood-stained fluid and bile staining of the gallbladder fossa. The endoloop was intact. The source of the bile leak was not identified. No active bleeding was found. On day 2, there was 200 ml of bile in the drain. On day 3, he had an ERCP. Complete disruption of the bile duct with leak of contrast into the abdomen was noted.

That evening, he was transferred to a referral hepato-pancreatico-biliary (HPB) unit. At the referral centre, his liver function tests (LFTs) were normal. He was admitted to a general surgical ward.

On day 4, magnetic resonance cholangiopancreatography showed a fluid collection in the gallbladder fossa with a defect at the confluence of the right and left hepatic ducts. The portal vein was patent. No comment was made regarding the hepatic artery.

The HPB surgeon had a discussion with the patient and obtained consent for immediate biliary reconstruction.

On day 6, at open exploration a Strasberg E5 injury was identified: division of a right posterior sectoral duct and the common hepatic duct, at the confluence of right and left ducts. An endoloop was noted around the common hepatic duct. Roux-en-Y biliary reconstruction was performed.

In the intensive care unit (ICU), his LFTs were deranged with treating teams suspecting an ischaemic injury. This was not investigated at the time. On reoperation day 6 (due to rising bilirubin), a computed tomography (CT) scan showed a large subhepatic collection of fluid and gas and hypoattenuation within the right lobe, and biloma was queried. The patient was readmitted to ICU after a medical emergency team call for hypotension and abdominal pain.

He underwent percutaneous drainage the next day (infected bile was drained).

On reoperation day 11, there was a large drain output of blood and a haemoglobin drop. A repeat CT scan reported likely haemorrhage, although it did not show a defined source of bleeding, hypoperfusion of the right hemiliver and the development of gas within the intrahepatic portal veins.

At repeat laparotomy, large amounts of clot and bile were evacuated. There was no description of their source. The patient returned to ICU, and after two days the family requested no further active intervention should he deteriorate.

Plans were made for a percutaneous transhepatic cholangiography and stenting of biliary anastomosis due to ongoing high-volume bile leak.

Following a family meeting, a palliative care consultation was initiated, and the patient died that day.

SUMMARY

The decision to perform a laparoscopic cholecystectomy for this patient is of concern. An elderly multimorbid man with prior ERCP sphincterotomy suggests: (1) low risk of recurrent biliary sepsis and (2) difficult cholecystectomy. A strong argument exists not to perform a cholecystectomy.

Assessment of the patient’s undiagnosed liver disease (in the setting of other comorbidities) at the time of cholecystectomy should lead the surgeon to reconsider proceeding.

Inability to obtain a ‘critical view’ should prompt a surgeon to reassess the anatomy. A correctly interpreted intraoperative cholangiogram would enable earlier recognition of a major bile duct injury.

There was significant delay in diagnosing the biliary injury, which delayed the referral to a specialist HPB service. The patient sustained a significant ischaemic injury to the liver, which led to hepatic decompensation.

The cause of this is not clear; it could have occurred at the time of biliary reconstruction or cholecystectomy.

There was limited documentation of discussions with the patient before undertaking reconstruction regarding likely outcomes and his wishes. It would appear that no one enquired as to the presence of an advance health directive.

LESSONS

• Assessment needs to be made of the risk/benefit of every procedure: this high-risk patient had low-risk biliary pathology.

• Unexpected findings at commencement of laparoscopy (e.g. cirrhosis) require re-evaluation of whether to proceed.

• Biliary anatomy at the time of cholecystectomy must be clearly defined. This may be achieved by demonstrating the critical view of safety or performing intraoperative cholangiography.

• When post-cholecystectomy patients are not recovering as expected, early abdominal CT is of paramount importance. This avoids delays in diagnosis and management.

• Investigation of concomitant arterial injury in the setting of bile duct injury is needed.

• Accurate documentation of discussions with patients and families is essential, especially in high-risk scenarios.

DISCUSSION

The QASM findings show that most patients receive appropriate surgical procedures. The decisions made at the time of the operations usually occurred in emergency situations. Suggestions of what could be done differently are easier to make retrospectively.

Although more patients were admitted as general surgical patients, better-to-have-done-a-differentprocedure CMI was not significantly different across all the reported specialties, except for Orthopaedic Surgery. Decision-making is an integral part of surgical practice and is a skill that is as important as being able to operate. Sound decision-making can be seen to result from the acquisition of surgical wisdom, which is achieved through learning, experience and reflection. Surgical trainees must make every effort to extract maximal benefit from learning opportunities. We all make decisions that later can be viewed as suboptimal.1

RESOURCES

• Teaching surgeons about non-technical skills. https://doi.org/10.1016/S1479-666X(07)80059-X • Non-Technical Skills for Surgeons System Handbook. https://scholar.harvard.edu/files/ntsl/ files/notss_handbook_2012.pdf • Royal Australasian College of Surgeon’s (RACS) Clinical Decision Making course. https:// www.surgeons.org/Education/professionaldevelopment/all-professional-developmentactivities/clinical-decision-making • The 4 phases in surgical patient care where important clinical decisions are made include:  D eciding what to do (e.g. formulating a working diagnosis and management plan)  P reparing to do it – when an operation or procedure is involved (e.g. preoperative planning)  R eviewing progress while doing it (e.g. intraoperative decision-making in response to the operative findings); and  R eflecting, reviewing and responding to how it all went ( e.g. post-operative care, debriefing and audit). https://doi.org/10.1111/ans.15098 • Situational awareness in driving, and lessons for surgeons. https://www.bjoms.com/article/ S0266-4356(20)30888-3/fulltext • Deficiency in care following cholecystectomy. http: //dx.doi.org/10.1016/j.jviscsurg.2015.06.008 I

REFERENCES

1. Francis DMA. Surgical decision making.

ANZ J Surg. 2009;79(12):886-891. Available from: https://onlinelibrary.wiley.com/doi/ epdf/10.1111/j.1445-2197.2009.05139.x 2. Loftus TJ, Tighe PJ, Filiberto AC, Efron PA, Brakenridge SC, Mohr AM, et al. Artificial Intelligence and Surgical Decision-making.

JAMA Surg. 2020;155(2):148-58. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7286802/pdf/nihms-1559534.pdf

ACKNOWLEDGMENTS

QASM Assessors: The case study is edited from QASM first- or second-line assessments that have been generated by expert surgeons in the field.

Any recommendations relate to the case as it was presented.

Griffith University: Robert S Ware & Emily Young (statisticians)

Email feedback to QASM@surgeons.org. Copyright © 2022 Queensland Audit of Surgical Mortality. All rights reserved. Phone: +61 07 3249 2971.