Revision of Gastric Bypass Surgery Kills Patient

Case Overview

This case takes place in Louisiana and involves a middle aged patient with a past medical history of morbid obesity. The patient had undergone a vertical banded gastroplasty before, but failed to lose weight following the procedure. He was also suffering from severe acid reflux and was taking Nexium regularly. As a result, he sought revision surgery several years after the initial procedure. The patient underwent laparoscopic revision of open vertical banded gastroplasty, laparoscopic Roux-en-Y gastric bypass and partial gastrectomy and hiatal hernia repair. The surgery was complicated by subcutaneous emphysema (SE. The patient was intubated for airway protection and sedated. The patient subsequently developed extensive bilateral pulmonary emboli and was started on anticoagulant therapy with a combination of anticoagulants.

Following the initial procedure, she was extremely short of breath and her functional status was limited. The patient recovered and was discharged on Coumadin and Lovenox. The patient returned to the hospital shortly after discharge with severe shortness of breath. Investigations revealed the patient had suffered a large GI bleed due to a large gastric intramural hematoma and was suffering from acute blood anemia as a result of the bleed. The patient’s anticoagulants were discontinued and she received blood products to reverse the anemia. She made a good recovery and was discharged again. The patient presented to the ER one week following discharge with hypotension, weakness, nausea and vomiting. She underwent thrombectomy but developed respiratory failure during the procedure. Post-operatively, the patient became acidotic, hypotensive and suffered a cardiac arrest, She was also found to be in acute renal failure. The patient’s condition continued to decline and she became comatose. The decision was made to stop life support and the patient was not resuscitated when she coded again.

Questions to the General Surgery expert and their responses

Do you treat bariatric patients? If so, how often?

I am a fellowship trained bariatric surgeon, and I currently work at one of the top medical institutions in the country. Over half of my practice is bariatric surgery.

Could you review the medical records for this patient and opine as to whether the treatment he received was within the standard of care?

In reviewing the brief description, there may have been a few points of care where the standard of care was not fully met. The timing and dose of anticoagulation is important to prevent DVT/PE. Once diagnosed, the appropriate treatment of DVT requires a balance of anticoagulation, and preventative therapies such as an IVC filter to be placed before a PE occurs.

About the expert

This expert is a board certified general surgeon who earned his BS and MD from UC Davis. He completed internship training at UCSF, residency training at UCSF, and fellowship training in minimally invasive and bariatric surgery at Johns Hopkins Medical Institution. This expert is a member of numerous prestigious societies in the surgical field, most notably as a fellow in the American College of Surgeons. He is currently an Assistant Professor of surgery and the Director of the comprehensive hernia center at one of the world's top university medical centers.

E-001161

Specialties:

General Surgery