Citation Nr: 21002583 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 15-33 748 DATE: January 14, 2021 REMANDED The claim for compensation for irritable bowel syndrome (IBS) and/or double colon disorder (DCD) as additional disability under 38 U.S.C. § 1151 resulting from VA surgery and treatment in July-August 2011 is remanded. REASONS FOR REMAND The Veteran served in the United States Navy on active service from January 1989 to January 1993. In addition, she served in the National Guard and U.S. Reserves. This matter comes before the Board of Veterans’ Appeals (Board) from a May 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This claim was previously before the Board in October 2018, when it was remanded for clarification of conflicting information in the 2015 VA medical opinion. Unfortunately, additional remand is required for two reasons, as explained below. First, despite the VA examiner in 2019 stating that the records of the 2011 surgery and 2015 examination and medical opinion were re-reviewed, conflicting information remains concerning the events of the July 2011 hysterectomy remains. The VA treatment at issue is the July 2011 surgery for hysterectomy and August 2011 readmission to the hospital for treatment of an ileus. The Veteran argues that symptoms of gastrointestinal disorder, currently diagnosed as IBS and DCD, are the result of the July 2011 operation, in particular, a tear in her bowel which required surgical repair. The 2015 VA examiner opined that the Veteran’s bowel symptoms were less likely the result of VA surgery. The VA examiner’s rationale was that the bowel was not perforated during the surgery and no surgical correction was required. Rather, the ileus for which she required additional hospitalization in August 2011 was more likely the result of pain medications causing constipation, and the diagnosed IBS, was more likely caused by triggers and risk factors including her service-connected psychiatric disability symptoms. However, the VA examiner further indicated that the serosa in the bowel was oversewn during the operation, and that stitches were required in more than one location. Given the conflicting statements about how many and in what location stitches were required to repair what manner of injury during the surgery, the 2018 Board remand asked the VA examiner to re-review the records and resolve any discrepancies. The 2019 VA review and revised medical opinion was provided by the same VA examiner who conducted the 2015 review and VA examination. The VA examiner in 2019 again opined that the Veteran’s bowel symptoms were less likely than not the result of VA surgery. In pertinent part, the VA examiner stated that removal of adhesions in the 2011 surgery was completed intraoperatively. After review of the evidence, the Board points out there are two operative reports for the July 2011 surgery. They operative report for gynecology, July 28, 2011 (9:21) and the general surgery operative report, July 28, 2011 (18:23). The gynecology operative report documents adhesions so numerous and extensive as to obstruct access to the operative field. In addition, the surgeon observed numerous dense bowel adhesions to the anterior abdominal wall and adhesions from the posterior aspect of the uterus to the rectum. The gynecology surgical team requested assistance from general surgery due to the extensive lysis required and concern for the small bowel, a portion of which had become partially denuded. The report states that the general surgeon took over and completed lysis of adhesions, including those from the posterior aspect of the uterus to the rectum, and oversewed multiple areas of the small bowel. It was noted to take over 30 minutes to mobilize the small bowel alone. This operative report refers the reader to the second, general surgery operative report. The general surgery operative report details lysing a small segment of sigmoid colon densely adherent to the abdominal wall. Approximately 4 centimeters of the serosa was injured and repaired. The general surgeon further lysed additional dense adhesions of the anterior sigmoid from the posterior portion of the uterus and from the colon along the lateral abdominal wall, requiring additional sutures to the sigmoid colon. The general surgeon notes that the gynecology surgical team reassumed control and completed the remainder of the hysterectomy. The two operative reports together demonstrate a much more complicated and involved surgery than that related by the 2019 VA examiner, with more than one area of the colon sutured. While it is true that the repairs were made intraoperatively, the surgery as a whole required the intervention of another surgical team expressly due to the initial team’s concern at the complexity of the surgical repairs required in the areas of the bowel and rectum. As the VA examiner made no mention of the two separate operative reports in either 2015 or 2019, but refers to a 2008 (sic) surgery in which no special surgical intervention or incidents occurred, the 2019 VA review cannot be seen to adequately clarify the 2015 opinion As such, the 2019 VA medical review and opinion continues to provide an inadequate basis upon which to adjudicate this claim. Remand is required to obtain a thorough review with medical opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following action: 1. Obtain a medical opinion from an appropriate examiner who has not already reviewed the Veteran’s case. If deemed necessary by the reviewer, schedule the Veteran for appropriate VA examination by an examiner that has not already examined the Veteran to address the claimed intestinal and bowel disorders to include IBS and DCD. The claims folder must be reviewed in conjunction with the examination. The examiner must identify all currently diagnosed intestinal and bowel pathology. Based on a review of the claims file, the examiner must provide an opinion as to whether the intestinal and bowel disorders to include IBS and DCD was caused or hastened by VA carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing treatment, or was an event not reasonably foreseeable. The examiner must indicate that the entire medical record concerning the July 28, 2011 hysterectomy (with both gynecological surgery and general surgery operative report) and subsequent August 2011 re-hospitalization and intensive care treatment has been reviewed. A complete rationale for any opinion must be provided. 2. Readjudicate the claim. If any matter remains denied, issue a supplemental statement of the case and return the appeal to the Board for further consideration. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Bakke, Lila J. The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.