DR DEEPAK GOVIL, APOLLO HOSPITAL, NEW DELHI

#1
Sub: Medical complaint against Dr Deepak Govil (surgeon), Apollo Hospital (Delhi)

Re: Rajendra P Mittal ( UHID : APD1.1054406 , IP Number: 315704)

I am Rajendra Mittal, resident of Sidharth Extension, New Delhi 110014. I was suffering from functional obstruction in residual sigmoid colon, confirmed by Nuclear Medicine Transit Study and Gastrographin (Administered orally) study. I had previously undergone left hemicolectomy but residual sigmoid colon was still causing functional obstruction and I had to spend 20-25 minutes twice a day, to defecate. Though this was a mild problem, I did not want to live with it for whole life and wanted it to be resected. I had consultation with several colo-rectal surgeons and opinions received were “no surgery justified”, “illeo-rectal anastomosis” and “high anterior resection”. I decided to go for “high anterior resection” on the basis of my experience with the symptoms and test reports.

In this regard I met Dr Deepak Govil, G I Surgeon at Apollo Hospital, New Delhi and discussed my problem with him. He studied all my previous test reports. During the course of reviewing my reports he asked about an illeo-rectal anastomosis recommendation by a surgeon at Royal Melbourne Hospital. I told Dr Govil that I do not want to undergo this radical procedure to get rid of my current symptoms but to suffer worse symptoms post-surgery. Though medically a surgery was not justified in my case it was up to the surgeon to accept or refuse to do the High Anterior Resection. Dr Deepak fully shared my concerns and agreed that there was no need for total colectomy (illeo-rectal anastomosis ). However he said that it’s your risk if the symptoms continues after High Anterior Resection. I fully accepted that risk. He wrote a consensus letter which was signed by Dr Deepak Govil and me on 12 August 2011 ( a copy enclosed). Admission to hospital was planned for 16 August and Surgery for 17 August 2011.

He send me for Barium Enema test which was done at Apollo Hospital on 10 August 2011. Test reported normal colon except moderately dilated colonic segment.
On the day of admission Dr Deepak Govil’s assistant gave me ‘Request for Admission form’ to be taken to Admission Department for admission, on which Dr Govil had changed the procedure name to ‘illeo-rectal anastomosis’. I thought that this was just a casual mistake, I took that form to Dr Govil to correct the name of procedure. He changed the name of procedure on admission form from ‘illeo-rectal anastomosis’ to ‘Anterior Resection’ (a copy of admission form enclosed).

In the evening before day of surgery I was asked to sign formal consent form for ‘Anterior Resection’.

On the day of surgery (17/08/2011) when I was lying un-conscious, Dr Deepak came out of OT in midst of procedure and resorted to un-ethical means to get my relatives’ signatures. He said, “If I do, want Mr Mittal wants, he will continue suffering from current symptom”. My wife told him that “you just cancel the surgery if you cannot do the planned surgery”. He intimidated my relatives saying “If you cancel this surgery now, Mr Mittal would not be fit for any surgery in the future”. There were some more disturbing facts about conversations; during the conversations he told my relatives that the patient would have roughly 8 bowel motions/day after 1 year of surgery- why was he doing a surgery which was increasing my bowel motions to 8/day from 2/say? Did I have cancer? Or just relatives signatures justifies everything?

He told my relatives that the patient may need another surgery (two stage surgery) after few weeks. I want to ask the doctor and hospital, who would have paid another 2 lakh rupees? My relatives? Certainly not – they would not pay even Rs 1000. How can an educated doctor take such extreme decisions on the basis of my relatives signatures, specially when there is no emergency or danger to life of patient. None of my relatives was involved in any of my consultations with this surgeon.

Finally he was successful in getting my ignorant and not-so-concerned relatives’ signatures on a procedure they didn’t know about.

Now he went on a rampage. He took out whole large bowel; resected 40% of rectum and on top of that he joined a 15 cm long J-pouch. This is a surgery which is only considered in serious conditions like Upper rectal cancer, FAP or Colitis, that too only as a last option. I had a healthy rectum, where was the need for any pouch? Even after knowing all the complications associated with illeal pouch, he went ahead with this absurd arrangement.

I compare my condition before and after surgery:
Before Surgery: Bowel motions -2, Bleeding (pouchitis)- never, Normal sex life
After Surgery: Bowel motions -10, Bleeding (pouchitis)- frequent, Retrograde ejaculation, Host of likely future complications
Problems does not end there; he has used pouch sutures which have not dissolved even after 1 year causing sharp pain, restricting my body movement.
Recent report from radiologist: “Extensive anastomotic sutures within the pelvis”.

I have some serious questions to Apollo management:
How can a doctor force a surgery on a patient after repeated and categorical refusal by patient? Is it hospital policy to use these un-ethical means to change the procedure by taking signature from relatives? Are relatives competent to give consent to this kind of radical procedures?

Is it a hospital or a jungle where a doctor can force his wild imagination on a patient? I am in a disabled condition but what’s my fault? I went to largest private hospital in the country expecting a high quality service but instead got a permanent disability; not as a result of negligence or an accident but it was forced on me, knowingly.
Rajendra P Mittal

A relevant clip of an article from The Times of India, January 17, 2008
“The Supreme Court has stated that doctors must seek consent from patients before conducting any procedure additional to the scheduled surgery for which they have received consent. Justices B N Agrawal, P P Naolekar and R V Raveendran stated that only in an emergency, when the life of the patient was in danger without immediate surgery, would the consent of the patient’s relative suffice. In all other cases doctors may not conduct additional surgery until after the patient regained consciousness, was informed of the need for additional surgery, and gave consent”.
 

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#2
Dear Sir,

We are in receipt of your letter regarding the treatment at Indraprastha Apollo Hospitals.

At the outset, we wish to inform you that the contents of your letter have been viewed with concern and the matter has been discussed with the treating doctor.

Sir, you were having functional obstruction in the residual sigmoid colon as was evident according to the report of nuclear transit study done in Australia which showed a hold up in sigmoid colon. A barium enema study at our hospital showed a distended colon.

As per treating doctor, after clinical examination and study of all your records, the treating doctor was quite reluctant to operate upon you inspite of your insistence. He agreed to operate after detailed discussion before surgery as you were insistent with your symptoms and were willing to take all risks and agreed on to give consent for anything related with this matter as you were disturbed significantly by the symptoms. Preoperative investigations did not mention the length of available colon so he did not anticipate that at surgery he would find such a short length of colon. Due to this intraoperative unexpected finding of very short residual colon, discussion was held with family members and with consent of wife and two other relatives, surgical procedure i.e. anterior resection (which is also a resection of segment of colon) was modified to to resection of residual colon with restoration of continuity by ileal J pouch rectal anastomosis.

We wish to inform you that this is not an additional or different procedure but modification of the same procedure for which you consented and this was done in the best interest of the patient.

We wish to further reiterate that the treating doctor have explained all the details to the patient and relatives at every stage and taken signatures and informed consents for everything explained to the patient and the relatives wherever needed and possible.

We apologise for an unintentional overwriting happened in the admission request paper.

We would like to assure you that at Indraprastha Apollo Hospitals we are committed to ensure provision of appropriate health care to our patients. We would be available for further clarifications, if any.

With warm regards
For Indraprastha Apollo Hospitals
 
#3
[attachment=31][attachment=32]Dear Sir,
Thanks for your reply to my complaint.
Distension: As I had functional obstruction in sigmoid colon there is bound to be some distension in proximal colon due to constipation. It was moderate distension, nothing alarming.
In my very first meeting I had told this doctor that I am not interested in illeo-rectal anastomosis and that I am better off in present condition than go for resection of whole colon. He had then written a note agreeing that there was no need for total colectomy and he shared my concern that there will be frequent motions post total colectomy. There was no question of ever agreeing to anything different from high anterior resection. Why would there be any need to discuss such a radical surgery for mild symptoms that I had? I never asked his opinion in my case, I went to him for a specific procedure.
He was initially reluctant to do high anterior resection and had asked for more information which was duly provided to him. Only when he was satisfied and willing to do high anterior resection, I had signed consent form. If a person is not accepting illeo-rectal anastomosis, how can he accept J-pouch surgery? Do you even an iota of evidence that he discussed J-pouch surgery with me?
You have disregarded the note written by Dr Govil, that was attached by me with my complaint, clearly outlining what was discussed and what was consented to. Discuss my case with any doctor (of sound mind) in the country and ask him, will he consider J-pouch surgery for mild constipation symptom such as mine?
I had worked for nearly two years on my problem; had consultations with large number of specialists both in India and Australia; underwent all relevant tests e.g. nuclear transit study, barium enema, colonoscopy, rectal biopsy, rectal manometry, barium meal follow through etc. not because I had risk of any kind or had some serious problem, but because I wanted to have best outcome for my problem; I wanted to save my colon, however small it may be. I was successful in my efforts and was able to identify this unconventional, but not risky, problem. After this diagnosis I was referred to a surgeon at Royal Melbourne Hospital who advised illeo-rectal anastomosis, totally free of cost, which I did not agree to (details in my case file with you).
You have said that the two procedures are similar in outcome and anatomically. This is really unfortunate that you cannot distinguish between these two vastly different procedures. Presuming that you understand importance of body organs, high anterior resection is just resection of small segment of recto-sigmoid while what this misguided doctor has done is- taken out whole colon, 30% of rectum, caecum, and changed the function of ileum for the worse. Complications of J-pouch are well known to everybody so there is no point in repeating them here.
If I had known that the surgeon would change the procedure when I am unconscious I would never have accepted to be operated by him. I never knew that you have a policy of taking consent from ignorant relatives. Are relatives better informed than specialists in this field? Is 5 minutes of intraoperative briefing to relatives sufficient to take such an important and complicated decision. Unfortunately some unscrupulous doctors are using this practice of relative’s signatures to justify their wild, misguided and otherwise untenable decisions. A shameful incidence of un-ethical practice by a PhD from AIIMS working in largest private hospital which claims to provide high quality medical services. High quality medical services without ethics?
The only risk I accepted was that the surgery that I consented to, may not improve my symptoms. But I never agreed to change of procedure. I never asked him for his opinion on my symptoms or opinion on suitability of any other procedure.
He always had the option of cancelling the procedure even while operating. A short colon does not mean that it was not useful. It was so important that taking it out has taken me from 2 motions/day to 10 motions/day in addition to developing host of other complications. Is the false claim by the doctor that he had explained the risks to patient and relatives, sufficient to justify a surgery which, it is known, will make a patient’s condition worse? When I did not agree, then you use a fool proof method of getting signature from ignorant visitors. Has anyone talked about J pouch in my case history available with you; has anyone ever tried such an absurd and extremely radical procedure for such mild symptoms?
None of my relatives was ever present in any of consultations with this doctor; my relatives came only on the day of surgery just as mark of formality.
I am re-enclosing a letter written by this un-ethical doctor in my second meeting with him.
Rajendra Mittal

Apollo Hospitals said:
Dear Sir,

We are in receipt of your letter regarding the treatment at Indraprastha Apollo Hospitals.

At the outset, we wish to inform you that the contents of your letter have been viewed with concern and the matter has been discussed with the treating doctor.

Sir, you were having functional obstruction in the residual sigmoid colon as was evident according to the report of nuclear transit study done in Australia which showed a hold up in sigmoid colon. A barium enema study at our hospital showed a distended colon.

As per treating doctor, after clinical examination and study of all your records, the treating doctor was quite reluctant to operate upon you inspite of your insistence. He agreed to operate after detailed discussion before surgery as you were insistent with your symptoms and were willing to take all risks and agreed on to give consent for anything related with this matter as you were disturbed significantly by the symptoms. Preoperative investigations did not mention the length of available colon so he did not anticipate that at surgery he would find such a short length of colon. Due to this intraoperative unexpected finding of very short residual colon, discussion was held with family members and with consent of wife and two other relatives, surgical procedure i.e. anterior resection (which is also a resection of segment of colon) was modified to to resection of residual colon with restoration of continuity by ileal J pouch rectal anastomosis.

We wish to inform you that this is not an additional or different procedure but modification of the same procedure for which you consented and this was done in the best interest of the patient.

We wish to further reiterate that the treating doctor have explained all the details to the patient and relatives at every stage and taken signatures and informed consents for everything explained to the patient and the relatives wherever needed and possible.

We apologise for an unintentional overwriting happened in the admission request paper.

We would like to assure you that at Indraprastha Apollo Hospitals we are committed to ensure provision of appropriate health care to our patients. We would be available for further clarifications, if any.

With warm regards
For Indraprastha Apollo Hospitals
 

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#4
In response to your letter, we have again discussed with the treating doctor and we would like to clarify that the doctor discussed all the details with the patient before operation, but did not anticipate such a short colon at operation which was also distended. In such a situation, after doing an anterior resection the length of the remaining colon would have been 5-10 cm, which would have been really of no consequence.

That is the time the option of leaving him alone versus doing a colonic resection was thought and the relatives were called. They were very clearly explained about the options.

Since the patient was so disturbed by the symptoms that he had previous surgical procedures for the same symptoms and had recurrent symptoms and hence was willing to go ahead with another procedure accepting all conditions, the doctor did not consider that he is having minor symptoms as he is stating now.

Leaving this distended colon would have again made him suffer with the previous symptoms which were worrying him for so long. That is why in good faith and in order to help the patient the procedure was performed.
The surgeon had given a big incision and only then could he realize that the length of colon was so short. If he would have left him alone at that stage, then also the patient may have complained that he had been suffering from the problem for so long and he had to suffer the pain and agony of this incision without doing anything.

After doing anterior resection the amount of remaining colon would have been worse than the pouch which was made, as it adapts to the functions of the colon with time. So the best available option was given to him considering all the circumstances. The attendants were also explained the possibility of a temporary Ileostomy which is often required for these pouch procedures, but it was not done as the surgery and the anastomosis was technically fine and fortunately patient did not have a leak and recovered well.

I think all our steps were in line with medical ethics and in good faith. It is unfortunate that he is having some symptoms at present. He is most welcome to consult any of our physicians at any time for his complaints.

We at Apollo hospitals are committed to good patient care.
 
#5
You are lying again and again. If a single sensible doctor in this whole universe says that he would consider IPRA (Illeal pouch rectal anastamosis) for my symptoms, I would put this matter to rest. If he had discussed this particular surgery with me I would have become aware of his level of knowledge or his vested interests in choosing this particular surgery.
It’s not the question of just length of colon (which was 40 cm as per previous colonoscopy and also visible in barium enema), but also the system as a whole. I had a complete system in place i.e. large bowel, ceacum, rectum. He has mercilessly removed ceacum, large bowel and even 40% rectum – an act of sheer madness.
You are stressing again and again that the patient was disturbed; what don’t you clearly write here, what were his symptoms? Do you go by patient’s words or by evidence based on test reports? If a person comes to Apollo hospital and says he is troubled by pain in his leg, would you just amputate his leg or conduct tests to make a proper diagnosis.
‘Good Faith’ is the word you doctors and hospitals use to justify all wrongdoings, your random actions and mal-practices. I came only for a specific procedure, not for anybody’s good faith. If ‘good faith’ was sufficient for appropriate treatment then no one need to come to Apollo or AIIMS, it is available in plenty even in rural areas.
Complications of J-pouch are known to everybody who performs this kind of surgeries or patients who have to have J-pouch. It is possible that this particular doctor did not know anything about that.
Incision heals in a matter of few weeks but organ once taken out, can’t be placed back.
You didn’t even bother to take a second opinion even from within Apollo. Or you have an employment policy to protect the erring doctor, no matter what happens?
Going by your response in this case it is very clear that there is nothing like medical ethics in your organization (or you have it but don’t practice it), but yes, you have a doctor protection policy in place and also practice it.

Rajendra Mittal
Apollo Hospitals said:
In response to your letter, we have again discussed with the treating doctor and we would like to clarify that the doctor discussed all the details with the patient before operation, but did not anticipate such a short colon at operation which was also distended. In such a situation, after doing an anterior resection the length of the remaining colon would have been 5-10 cm, which would have been really of no consequence.

That is the time the option of leaving him alone versus doing a colonic resection was thought and the relatives were called. They were very clearly explained about the options.

Since the patient was so disturbed by the symptoms that he had previous surgical procedures for the same symptoms and had recurrent symptoms and hence was willing to go ahead with another procedure accepting all conditions, the doctor did not consider that he is having minor symptoms as he is stating now.

Leaving this distended colon would have again made him suffer with the previous symptoms which were worrying him for so long. That is why in good faith and in order to help the patient the procedure was performed.
The surgeon had given a big incision and only then could he realize that the length of colon was so short. If he would have left him alone at that stage, then also the patient may have complained that he had been suffering from the problem for so long and he had to suffer the pain and agony of this incision without doing anything.

After doing anterior resection the amount of remaining colon would have been worse than the pouch which was made, as it adapts to the functions of the colon with time. So the best available option was given to him considering all the circumstances. The attendants were also explained the possibility of a temporary Ileostomy which is often required for these pouch procedures, but it was not done as the surgery and the anastomosis was technically fine and fortunately patient did not have a leak and recovered well.

I think all our steps were in line with medical ethics and in good faith. It is unfortunate that he is having some symptoms at present. He is most welcome to consult any of our physicians at any time for his complaints.

We at Apollo hospitals are committed to good patient care.
 
#6
You did not bother to talk to another experienced surgeon to put facts in right perspective. I think you are too busy- because of number of cases in hospitals - to give required attention to this particular case. However I am sending some information about this particular procedure.
Attached research paper (or information from any reliable source) brings out these facts:
IPRA (Illeal Pouch Rectal Anastomosis) is done only as an alternative to illeostomy;
A pouch surgery ( IPRA or IPAA) is never considered when a person has a healthy rectum; For patients having healthy rectum and requiring sub-total colectomy, Illeo-rectal anastomisis is done, universally.
Pouch surgery becomes necessary when rectum is diseased (cancer or Crohn’s disease);
I did not have any disease. I never had any bleeding before this absurd surgery then why this surgery on me, that too in complete defiance of patient’s consents and other doctor’s recommendations.
If you have to resect everything then what is the need for any testing? If a person has problem in a finger, then according to you cut away his leg because he may develop problem in other fingers. According to you all doctors who prescribed me so many tests - nuclear transit study, rectal manometry, rectal biopsy, defecography, barium enema, CT scan, colonoscopy - were just wasting resources.
 

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