A perforation in the bowels, “missed” during emergency surgery, is most likely to have precipitated the infection that ultimately caused the death of Hugo Chetcuti, a forensic doctor testified.

Mario Scerri was one of several medical professionals who testified during two lengthy sessions on Thursday at the trial by jury of 39-year-old Bojan Cmelik, a Serbian national accused of causing the death of the 52-year-old businessman, whom he allegedly stabbed on July 6, 2018.

The stabbing took place at Paceville, outside a seafood bar that Hugo had just launched that evening. 

The medico-legal expert ran the jury through his report, supplementing his technical explanation with photos of both the victim and his alleged aggressor who had suffered various bruises and lacerations that were still fresh.

Those injuries had evidently been sustained on account of the struggle Cmelik had put up when resisting arrest, explained the expert, adding that Cmelik had “immediately accepted” to undertake a drug test telling the doctor that he did not take any drugs.

A urine sample test subsequently confirmed that.

Images of Chetcuti after surgery and also post-mortem were shown in court after parte civile lawyers Joe Giglio and Mario Spiteri informed the court that the victim’s family was granting permission.

As the images flashed on screen, relatives of the victim who were following proceedings in court were visibly moved. 

Given the current medical scenario, a patient is “not supposed to die of stab wounds to the abdomen, but complications do arise,” the medico-legal physician explained when asked by defence counsel Simon Micallef Stafrace whether death had been a direct result of the stabbing.

The victim was a healthy man who suffered two stab wounds and that was when the crisis started, said Scerri, pointing out that the decision to rush Chetcuti to emergency surgery upon admission to Mater Dei minutes after the stabbing, was a “good” one.

There was no time to waste and were it not for that timely decision the patient “would have died immediately”.

When he visited Chetcuti at the ITU after surgery, the patient was still sedated.

So he returned the following day, finding him alert, oriented and even “joking”.

A negative turn

But hours later, on Saturday evening, the situation took a negative turn when Chetcuti’s initially stable condition suddenly deteriorated rapidly as septicemia set in. 

The most plausible cause for infection was a perforation in the small bowels that might have been “missed” during the first emergency intervention, explained the expert, adding that the hole might not have been there during surgery or was not visible to the naked eye and might have become enlarged due to normal bowel movement. 

The decision to re-operate the patient on Sunday was a “wise” one that ought to have been taken immediately, said Scerri, explaining that symptoms had set in hours after the first surgical intervention.

“Every hour makes a difference,” he stressed, prompting the defence lawyer to ask whether death was inevitable given the lapse of some 12 hours for the decision to operate again. 

“A second urgent laparotomy would have been advisable. In my opinion it took a lot of time to be performed,” Scerri replied, remarking that it was deemed “blasphemy in this day and age for a person to die because of bowel perforation”.

On the Saturday morning after the stabbing, Chetcuti was “fine” but later that evening he was “almost unresponsive” “confusional” and showing signs of hypotension and toxicity. 

Next day, the second operation confirmed not only a perforation in the small bowel that was leaking but also clear signs of infection.

The consultant surgeon who performed the second operation also took the witness stand on Wednesday.

Alex Attard explained that Chetcuti had been his patient “for quite a number of years” ever since the entrepreneur had undergone some minor surgery years ago.

“He trusted me with any other physical complaints” and so, when visiting the patient early on Saturday morning following the knife attack just as he woke up after surgery, Chetcuti had expressed his wish for him to take care, Attard recalled.

Later that day, the patient was still stable when the surgeon returned to his bedside.

But a call from one of his assistants the next day signalled some concern and suspicions were confirmed by Attard himself soon afterwards.

“I was worried. His abdomen was distended. That indicated some perforation in his intestines which clinically needed surgery,” explained the witness, adding that a CT scan soon confirmed those suspicions.

The second operation conducted by Attard himself located a hole in the first 12 inches of the small intestines, close to the area where the other holes had been sutured in the first surgery.

“The previous suturing was intact,” said Attard.

But to avoid future complications in the healing process that segment of bowel containing the “missed” hole and the stitched up area, was removed and sent to the lab for histological testing.

That “hidden” perforation was what caused the patient’s condition to deteriorate after the first operation, Attard explained when asked about the further medical complications.

Darko Babic, consultant histopathologist at Mater Dei, confirmed that he had found a 10 millimetre laceration in one of the two segments of bowel sent for analysis in the lab.

Macroscopic (with the naked eye) and microscopic examination of the 25cm and 17cm-long segments confirmed signs of inflammation, said the witness who had sent his report on the findings back to the consultant surgeon on July 20.

“Were you asked to treat the matter with urgency,” asked the defence lawyer.

“No,” came the reply. 

Thursday’s evening’s session was wrapped up by pathologists Marie Therese Camilleri and Ali Salfraz who carried out the autopsy confirming that the cause of death was septicemia caused by bowel perforation due to stab wounds.

The trial resumes on Friday. 

Mr Justice Aaron Bugeja is presiding. AG lawyers Kevin Valletta and Maria Francesca Spiteri are prosecuting.