Gunma University Hospital’s final report on the deaths of eight patients following laparoscopic liver surgery gives an appalling picture of what happened at the institution. It brings to light the lack of common sense and professionalism on the part of the hospital, the surgeon and his boss to ensure the safety of their patients. Yet the report comes up short: Investigators apparently failed to interview the surgeon and his superior sufficiently on why such a mess continued. The hospital should delve into questions left unanswered.
The report issued in early March focused on laparoscopic liver operations that the surgeon performed from 2010 to 2014 on the eight patients, who died within two weeks to four months after their operations.
It concludes that in each of the operations, the surgeon was negligent. The most problematic behavior was his failure to determine the size of the patient’s liver before operating and decide the maximum portion of the liver that could be excised. This is an indispensable procedure before such operations.
Compared with conventional abdominal surgery, a laparoscopic operation requires a smaller incision and causes less pain to patients. But a high level of surgical skill is required because the procedure carries the risk of damaging tissues and blood vessels outside the camera’s visual field. Laparoscopic surgery on livers is said to be particularly difficult because of the concentration of numerous blood vessels in the organ.
Although the operations in question were considered so difficult that they were not covered by public health insurance, the surgeon performed the operations without first applying for screening by the hospital’s ethics committee.
The measures the surgeon took during the operations were inappropriate, leading to either the rupture of sutures or to unnecessarily large excisions that eventually caused liver failure.
Some of the deaths were caused by a series of bungles in post-operative treatment. The surgeon’s explanations to the patients before the operations were also inadequate, and the medical reports kept by him were incomplete.
The surgeon, who is in his 40s, belonged to the liver, gallbladder and pancreas team of the hospital’s second surgery section, which was in charge of laparoscopic liver operations. The team, composed of only the surgeon and his supervisor, carried out 93 such operations from December 2010 to June 2014, including the eight operations that led to the deaths of the patients.
It is deplorable that there are no signs that the team paid adequate attention to patient safety. Four patients died within one year after the team started laparoscopic liver operations. By that point, the hospital should have at least halted further operations of this type until they could assess the reasons for the unusually large number of deaths.
The surgeon’s superior did not appear to grasp what was actually happening on his own team. The report leaves it unclear whether the surgeon reported the deaths to his supervisor. Nor does it answer the big question of why the surgeon was allowed to continue such operations.
Clearly communication within the hospital was severely flawed. High-ranking officials of the hospital were not aware of the deaths in question. The hospital authorities should sincerely listen to what lawyers for the families of the patients have said: “If the first death had been reported, the seven other deaths might have been averted. But the report fails to adequately address this point.” The lawyers charge that the deaths were caused by the surgeon’s reporting failure and his supervisor’s lack of oversight.
Of 58 laparoscopic liver operations carried out at the hospital outside the coverage of public health insurance, eight of them — or 13.8 percent — led to patient deaths. That rate is much higher than the 2.3 percent reported among some 1,200 such operations carried out across the country. Ordinary abdominal operations by the surgeon in question to excise part of the liver resulted in the deaths of 10 patients in five years beginning in 2009. One wonders whether the surgeon is fit to serve as a medical doctor.
The hospital needs to fully interrogate the surgeon and his supervisor, and make them account for their actions. It also must overhaul its internal communication to prevent recurrences.