Monday, October 20, 2008

Soroka surgeons removed wrong organ in faulty op

From http://www.haaretz.com/hasen/spages/1029926.html

By Ran Reznick

Surgeons at Soroka Medical Center in Be'er Sheva earlier this year erroneously removed part of a patient's pancreas instead of his adrenal gland, which is located above the kidneys. They later discovered the operation had been based on a faulty diagnosis and had been unnecessary from the start, Haaretz has learned. The patient suffers from Cushing's syndrome, an endocrine disorder caused by high levels of cortisol in the blood.

After the operation, the man was admitted to intensive care, where he became stricken with diabetes. He has since received daily insulin injections, the dosage of which he says continues to increase on a daily basis. As a result of the mishap, the patient's pancreas became infected and the 32-year-old Be'er Sheva man had to undergo a second operation.

Last week, seven months after undergoing the wrong procedure in March, he underwent the brain procedure he should have originally undergone at Tel Aviv's Assouta Medical Center. During that procedure, it became clear the root of the man's medical problems indeed lay in the pituitary gland in the brain.

The faulty operation was carried out on March 30 at Soroka, and Haaretz obtained the details surrounding it from a team of senior physicians at Soroka and Maccabi.

An investigation into the matter revealed that the Soroka management, led by Dr. Michael Sherf, never reported the unusual incident to the Health Ministry.

Failed to report

The procedure was carried out by a surgical team led by Prof. Salim Suli Mizrahi, Dr. Eliezer Avinach and Dr. Abd al-Rahman Abu Ghanim. The hospital told Haaretz that it did not report the matter because the incident did not represent the "erroneous removal of an organ," which ministry regulations demand be reported, but rather the partial removal of part of an organ.

A senior health system official told Haaretz that Soroka management was required to report the incident to the ministry, and that the incident called for a thorough investigation by an investigative committee to examine the conduct of the physicians involved in the faulty procedure.

The hospital management did report the incident, however, to the insurance company that handles malpractice lawsuits against physicians.

A senior surgeon who looked into the incident said, "the operation should not have been carried out until the medical examination was complete. There is a chain of mistakes here which apparently stems from a lack of sufficient experience among surgeons to carry out such procedures, or from a lack of caution in doing the operation."

"The pancreas is located next to the adrenal gland, and here the surgeon's experience should come into play, and he should identify the organ and not cut into another one close to it. The suspicion of a mistake should have come up in the operating room, due to the size of the organ that was removed," he added.

A senior internal medicine specialist said he also believed the operation should only have been conducted after a comprehensive check of the man's medical problems.

"This was poor medicine, and there is a basic, systemic medical failure which includes the way in which the patient was transferred from the HMO to the hospital. This is a serious incident that led to unnecessary surgery, which endangered the patient's life and the outbreak of severe diabetes," the official said. "The incident demands a thorough investigation, arriving at systemic conclusions and a personal examination of responsibility of the physicians involved at both Soroka and Maccabi."

Two days after the erroneous operation, the patient was examined by Prof. Yair Liel, the head of Soroka's endocrinology unit. Liel determined that in contrast to the initial diagnosis, the patient's medical problems had their roots in the brain. He also recommended that the man be referred to Dr. Jonathan Arbel, the head of endocrinology in the HMO's Negev district.

The patient underwent the second, correct surgery on his brain last Thursday. His family told Haaretz the procedure was carried out successfully, and was able to determine the root of the man's symptoms.

A response from Soroka Medical Center said the hospital "has successfully carried out dozens of laparoscopic surgeries to remove the adrenal gland, the majority by Prof. Suli Mizrahi and Dr. Eliezer Avinach, senior surgeons with vast experience in the field."

"Placing a report with the Health Ministry is required when dealing with the removal of an essential organ in an erroneous manner," said spokeswoman Inbar Darom-Gutter. "The portion of tissue removed was marginal, and does not affect the function of the pancreas or influence its operation."

Maccabi HMO spokesman Ido Hadari said "this is an unfortunate incident and we hope the patient's condition improves soon. Maccabi operates in a transparent manner with the Health Ministry and reports every incident required by law."