A landmark study, potentially a trigger for malpractice litigation, was published in the January 2012 journal Gastroenterology (click here for link) is very disturbing. Doctors at two major medical centers in the Northeast got patients with recently resected neoplastic polyps — those with a propensity to undergo malignant degeneration to a true cancer — to agree to a second colonoscopy for the purpose of determining the adequacy of the original resection. For a resection to be complete the margins around the polyp had to be free of abnormal polypoid material; otherwise the cancer risk from the polyp is not eliminated. What they found was a 10% rate of incompletely resected polyps removed by an experienced group of university-based gastroenterologists. Certain types of polyps, especially so-called serrated polyps, were associated with the highest rates. The comments within the article and in the accompanying editorial are sobering. First of all the gastroenterologists doing the highest number of colonoscopies had the lowest rate of incomplete resection. Secondly, the largest polyps — those at the highest risk of becoming truly malignant — had the highest rate as well. Those polyps that had to be removed piecemeal (in chunks, not all at once) also were most likely to have an incomplete resection.
Left unsaid by the article and its editorial is whether the incomplete removal of a neoplastic polyp is negligent. If the overall rate of error is 10% does this mean something, i.e., is that number high enough to excuse the behavior as within the standard of care? More importantly, what should the well-informed health-care consumer do? A) Ask his or her prospective colonoscopist how many procedures he or she does in a year?; B) Ask that the margins of polyp resection be examined carefully by an experienced pathologist? C) Ask that he or she have another colonoscopy say in three months with biopsies at the margins of resection of the prior polyp? Whatever else happens this study by Pohl et al does a tremendous service to the medical community by pointing up a problem which to date has gone largely unrecognized.
Whether the incompletely resected polyp that goes on to become a cancer and kills someone should be or will be the basis of future litigation is unclear at present. Once the first case is filed, if ever, expect the plaintiff’s bar to take notice.