Gastroenterology Expert Evaluates Untreated Duodenal Perforation

This case involves a man who retained a stone in his bile duct following a surgery on his gallbladder. An endoscopic visualization procedure known as an ERCP was performed, after which physicians noted that there may have been a perforation in the patient’s duodenum. Despite the fact that the perforation was identified, it was not treated directly, with doctors orders for conservative monitoring and antibiotics. Nevertheless, the patient continued to suffer difficulties related to the perforation that necessitated additional surgeries, an extended hospital stay, a months-long rehabilitation period, as well as disfiguring scarring from the repair procedures. It was alleged that the patient’s duodenal perforation should have been treated more aggressively, and that earlier intervention would have prevented his negative outcome.

Question(s) For Expert Witness

1. Do you routinely perform ERCPs?

2. Have you ever had a patient develop the outcome described in the case?

3. Do you believe there may have been a deviation in the standard of care that contributed to this patient's poor outcome?

Expert Witness Response E-035088

I routinely perform ERCP procedures, including over 300 last year alone. I have had a patient develop a perforation related to an ERCP procedure before. Generally speaking, perforations can be duodenal or periampullary. Duodenal perforations are managed through surgery; however, periampullary perforations can be managed medically. As such, it is difficult to say if there has been a deviation in the standard of care without knowing the specifics of the perforation and the details of the care administered. Similarly other questions include whether there was anything other than antibiotics administered, such as nasogastric tube suction, an attempt at endoscopic perforation closure using an OTC clip, or other varieties of intervention. I am an advanced endoscopist who routinely performs hundreds of advanced endoscopic cases (ERCP, EUS) annually at a high volume reputable academic center. I have published extensively and have extramural funding on ERCP related complications.