Monday, December 10, 2018

Dr. Peter Salomon Delves Into Colonoscopy Details to Clear Doctor at Trial Over Patient’s Colon Cancer

The Trial: Kazandjian v. Vastola, a Florida medical malpractice trial in which a physician is accused of rushing a colonoscopy and missing a patient’s colon cancer.

The Expert: Dr. Peter Salomon, a gastroenterologist, testifying for the defense on the standard of care and in colonoscopies and the likelihood that plaintiff had a visually detectable cancer at the time of the colonoscopy at issue.

The Verdict:  For the defense.


 By Gary F. Gansar, MD, FACS; Senior Medical Director, AMFS

Testifying for the defense in a medical malpractice case out of Florida’s 15th Judicial District, Dr. Peter Salomon, an expert in gastroenterology, clarified and endorsed the exam observations of defendant, Dr. David Vastola, and helped clear the physician at trial over a patient’s colorectal cancer.  

The plaintiff claims Vastola performed a colonoscopy so quickly that he missed a primary carcinoma (or its precursor) in 2011, which was found in the transverse colon when the patient was again examined in 2013. The patient was ultimately discovered to have metastatic colon cancer along with the transverse colon primary in 2013.

But Salomon’s unequivocal testimony proved to be instrumental in obtaining a verdict for the defense.

In this clip, Salomon begins with a discussion of the relative importance of CEA, the carcinoembryonic antigen, a chemical tumor marker for colon cancer. Salomon points out that only 30 to 40% of colon cancers produce this tumor marker, and this is an intrinsic characteristic specific to each tumor itself. Because a cancer may not be the type that produces the chemical marker, the marker is not considered a reliable screen in every case. In other words, while an elevated marker may be useful information, a non-elevated marker does not rule out cancer, since so many colon cancers will not produce enough CEA to register as a positive screen.

In this case, Salomon notes that, in 2010, the plaintiff’s CEA was documented as normal. However, the tumor found in 2013 was a CEA producer. Since the patient’s tumor produces CEA, but plaintiff’s CEA was not elevated in 2010, Salomon concludes the patient did not have colon cancer in 2010.

The expert then explores the use of CT scans and colonoscopies as screening tests for colon cancer. A CT scan may show a mass or inflammation around a colon cancer, dilation of the bowel, or bowel wall thickening to indicate the possibility of a cancer being present. The patient’s 2010 CT did not reveal any such clues. Along with the normal CEA, this is strong evidence that there was no cancer present at that time. In 2013, concurrent with the elevated CEA, the CT scan presented evidence of a colon neoplasm causing focal bowel wall thickening in the transverse colon. Still, Salomon says, despite such strong evidence, colonoscopy would be the ultimate gold standard for determining whether such a lesion was actually cancerous.

Vastola’s colonoscopy in 2011, when the plaintiff claimed that the cancer must have been missed, was critically examined by Salomon. In response to the plaintiff’s allegation that Vastola did not adequately describe the bowel preparation, the expert affirms that it is not the standard of care to comment on the quality of the bowel prep for the procedure unless there is reason to do so. Further, and without hesitation, the expert states that the 8 minutes it allegedly took to perform the 2011 procedure is enough time “to perform a valid and reasonable colonoscopy.” The fact that the procedure was performed with such speed, Salomon says, should not necessarily imply that anything was missed.

Salomon further states that the fact that Vastola could rule out the presence of angiodysplasias, or blood vessel abnormalities that can cause bleeding, is an indication that the bowel prep in this case was good, since these are flat lesions that can be very hard to see if the prep is inadequate.

Later, Salomon stresses how unlikely it would be to miss a cancer during the colonoscopy. Benign tumors have a different appearance than cancers. He explains the colonoscope lens magnifies the lesion and sends the image to a big screen monitor that magnifies it even further so that details of the lesion can be examined closely. It “would be extraordinarily difficult” not to see a 1 cm cancer in the transverse colon.

He concludes, “I believe that Dr. Vastola more likely than not performed an adequate colonoscopy, and I do not believe that he missed a colon cancer.” His testimony was entirely plausible as presented and based on sound reasoning.

The jury concurred in under 90 minutes.

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Gary Gansar, MD, is residency trained and Board Certified in General Surgery. He previously served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Mercy Hospital and Touro Infirmary in New Orleans, LA. Dr. Gansar also served as Clinical Instructor and Professor of Surgery at Tulane University. He received his MD and served as Chief Resident at Tulane University Medical School. Dr. Gansar joined AMFS as a consulting medical expert in 2011 and has served as Medical Director since Nov. 2015. In this capacity, Dr. Gansar provides consultation, review and guidance to attorney clients.