Interventional gastroenterology

Coroner calls for better training after angiodysplasia treatment death

A coroner has recommended updated training in argon plasma coagulation (APC) technique following the death of a Victorian man who sustained full thickness burns and colonic perforations due to prolonged application of APC in cauterising bleeding lesions.

In January 2017, Kevin O’Keeffe was diagnosed with angiodysplasia in the caecum and ascending colon with actively bleeding lesions, after a colonoscopy at Ballarat Base Hospital. The 82-year old, who had multiple co-morbidities including pulmonary hypertension, pulmonary fibrosis, COPD, paroxysmal atrial fibrillation and bowel polyps, underwent argon plasma coagulation to treat the vascular malformations the same day.

The procedure took longer than was usual and Mr O’Keeffe became uncomfortable, so the gastroenterologist stopped, with plans to resume in two days.

The next day, the man’s condition deteriorated and a colonic perforation was discovered. An emergency laparotomy revealed several injuries to his bowel, and despite emergency surgery Mr O’Keeffe became critically ill, was palliated and died a few days later.

The cause of death was found to be cardiomelagy, myocardial fibrosis and ischaemic coronary artery disease in the context of large bowel resection for argon plasma coagulation perforations during colonoscopy.

A subsequent investigation revealed that prolonged application of the machine used to perform the argon plasma coagulation during the final third of the procedure had left full thickness burns and perforations in Mr O’Keeffe’s bowel.

In her findings, Victorian coroner Audrey Jamieson noted that machine – the CONMED CE200 Beamer Electrosurgical System – appeared to have been used with the correct settings and the manufacturer found no faults with it.

She noted that the gastroenterologist  – Dr Mohammed Al Ansari – was experienced in performing the procedure, but had not received specific training from CONMED in the technique to be used for large areas of angiodysplasia called the “spotwise technique”.

The Ballarat Health Service noted a second patient had an adverse reaction to the same procedure for angiodysplasia in the right colon, however it was non-fatal.

In its review, the service found that the right colon setting was in an acceptable range, but the intervals used in the third part of the procedure were long and the bowel injuries probably occurred then. The service recommended a new protocol for the machine.

In her comments, Coroner Jamieson highlighted the recommendations from the health service review to improve education, training and applications in relation to the APC procedure.

“I … find that Ballarat Health Service has responded appropriately to the death of [Mr O’Keeffe] by its investigation and has implemented restorative and preventative measures with the aim of preventing like complications and like deaths,” she noted..

Read the full case here

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