Surgeon not liable for recurrence of HCC in transplanted liver: Rs 5 crore Relief to Medanta, its doctor in medical negligence case

Dr S M Kantikar, Presiding Member, NCDRC clarified that it was a case of recurrence of Hepatocellular Carcinoma (HCC) and not due to any residual tumour, for which the surgeon was not liable.

The case concerns a non-smoker and non-alcoholic person, who was suffering from off-and-on fever, weakness, loss of weight and appetite, and approached a doctor. After triphasic CT Scan of abdomen and other investigations, it was diagnosed as multifocal hepato cellular carcinoma (liver cancer). Therefore, for further treatment, the patient consulted the surgeon at Medanta who confirmed the liver cancer and advised immediate liver transplant.

It was alleged that the surgeon assured that after liver transplant patient would be able to lead normal life without any complications. Accordingly, patient was told to arrange liver donor. As commercial donor was not available, therefore, the patient's daughter-in-law agreed to donate her liver.

The surgeon issued certificate and subsequently, NOC was obtained from Punjab State Authorization Committee under the Transplantation of Human Organs Act, 1994. The approval was subject to Surgeons being doubly sure that no metastasis of HCC are present in the patient’s body at the time of transplant surgery.

The patient underwent liver transplant and was discharged with follow-up advice. Later he visited the hospital and the surgeon, underwent blood test, which revealed high AFP value i.e. 4780 as compared to 2120 seen in the report dated 05.04.2012. Thus, it was clearly indicative of presence of cancer cells in the body. After four months, the patient’s condition deteriorated.

For a second opinion he consulted another doctor, who advised MRI Dorso Lumbar Spine. The MRI revealed cancer cells spread in the spinal cord of the patient.

It came as a complete shock to the patient and his attendants, as the surgeon allegedly misled them that after transplant surgery all cancer cells had been successfully removed from the body. Aggrieved, the (daughter-in-law) and two sons of the deceased patient filed a complaint alleging negligence of the surgeon who never removed the cancer cells, but it spread to spine and subsequently the patient died, and sought a compensation of Rs 5 crore.

Meanwhile, the surgeon and the hospital denied the allegation and submitted in order to mislead the Commission, the Complainant in the pleadings has suppressed the material fact that the surgeon conducted a whole body PETTriphasic CT Scan, 99m Tc-MDP Bone Scan and a biopsy. As there was no extra hepatic spread, the patient was considered for Liver transplant. It was the Complainant's own case that the cancer re-occurred in the spine.

They further submitted that no medical treatment can prevent the recurrence of cancer cells and failure to prevent the recurrence of cancer does not constitutes medical negligence, when there are no pre-emptive treatment proved to be effective in preventing such recurrence.

Taking note of the allegation of complainant that the AFP value in April 2012 was 2120, which after transplant increased to 4780 in August 2012, meaning thereby the cancer cells were still present in the body; and doctor's response, the Commission observed;

"In my view it was wrong and contrary to medical literature. Increased or decreased values of AFP are not an indicator of a successful or unsuccessful Liver Transplant but it is an indicator of recurrence. Since early recurrence of liver cancer is known, thus it is incorrect to assume that due to residual cancer after 3.5 months of transplant AFP was raised. It was demonstrative of reoccurrence, and follow up was advised with the Surgeon. In 18% of patients recurrence is known. It is clear from the record that the entire liver was explanted (removed) and a healthy liver from a healthy donor was transplanted in the Patient, therefore, there was no residual cancer in the Patient after the Surgery."

The Commission further perused medical literature on HCC and concluded that;

"In the instant case there was recurrence of HCC in the transplanted liver, but it was not due to any residual tumour. It appears the Complainant wrongly alleged that the HCC was developed due to Residual tumour after liver transplant, but it was ‘recurrence’ of HCC."

It also referred to the case of Kusum Sharma & Ors. V. Batra Hospital and Medical Research Centre & Ors[5], the Hon'ble Supreme Court applied certain standard principles to establish that the doctors in the said case were not guilty of medical negligence. The Supreme Court specifically held that:

“As long as the doctors have performed their duties and exercised an ordinary degree of professional skill and competence, they cannot be held guilty of medical negligence.”

The Commission eventually dismissed the complaint against the surgeon and the Gurgaon hospital. It held;

"Based on the foregoing discussion, to conclude, I do not find any dereliction of duty from the OP-1 (Surgeon) at OP-2 (Medanta Institute of Liver Transplantation and Regenerative Medicine). It was unfortunately a case of recurrence of HCC, for which the OP1 was not liable. The team of doctors performed their duties with standard skills and competence. No case of medical negligence is made out.