by Gracie Awalt, Marketing Associate, and
Kassie Toerner, Senior Risk Management Representative
Presentation
A 35-year-old man consulted with a general surgeon regarding bariatric surgery. The patient was 5 feet 8 inches tall and weighed 295 pounds; his body mass index (BMI) was 46.
Physician action
The surgeon considered the patient to be a good candidate for bariatric surgery, and a sleeve gastrectomy and duodenal switch was performed on August 3.
On September 8, the patient experienced difficulty swallowing and nausea. After reporting his symptoms to the general surgeon, the patient was directed to the nearest emergency department (ED).
The next day, the general surgeon performed an esophagogastroduodenoscopy (EGD) on the patient. It showed a narrowing of the mid-part of the sleeve gastrectomy. The duodenal-jejunal anastomosis was widely patent, and the patient received balloon dilation of the narrow area. Due to continued symptoms, the patient received another EGD and balloon dilation on September 12.
The patient was still nauseated, but the narrowing of the mid-part of the sleeve gastrectomy had improved. A non-functioning gallbladder was revealed after a HIDA scan.
On September 17, the general surgeon performed a laparoscopic cholecystectomy. During the procedure, the efferent limb of the duodenal switch was sutured to the lateral abdomen wall. The patient was discharged on September 18.
On September 23, the patient returned to the ED experiencing increased neurological symptoms of nystagmus and dizziness. After admission, the patient’s symptoms improved when he was given thiamine and other vitamins.
While still hospitalized on September 28, the patient developed abdominal symptoms and an elevated white blood count (WBC). The general surgeon requested a cardiology consult due to the patient's increasing heart rate. A cardiologist saw the patient and diagnosed ileus, tachycardia, obesity, hypertension, and history of murmur. Her exam of the patient did not suggest a surgical abdomen. The cardiologist ordered the patient transferred to the ICU and started him on anticoagulants.
The cardiologist saw the patient the next morning. She documented that he had increased abdominal pain and was restless and agitated. When the cardiologist palpated the patient’s belly, the patient reflexively grabbed the cardiologist’s hand to stop her.
The cardiologist believed the patient had an acute abdomen and told the nurses to immediately contact the general surgeon to come see the patient. The cardiologist never personally tried to contact the general surgeon. The cardiologist later testified that she believed the patient’s tachycardia was a result of the acute abdomen and not an indication of pulmonary embolism, dissection, or heart attack.
At 2:30 p.m., the patient experienced cardiopulmonary arrest before the general surgeon was able to evaluate the acute abdomen. The patient received CPR and was revived; however, he sustained an anoxic brain injury and had increased lactic acid levels.
On September 30, the general surgeon performed an exploratory laparotomy and found that the patient had a necrotic small bowel and colon. The necrotic areas were resected, but the patient showed no sign of brain activity post-surgery. The patient died later that day.
The lactic acid levels suggested the patient’s organs were not adequately perfused. According to the autopsy report, the cause of death was complications of gastric sleeve duodenal switch surgery. Findings included ischemia of pylorus and small and large bowels.
Allegations
A lawsuit was filed against the general surgeon. The allegations included:
- failure to complete the hospital’s DVT risk factor screening form on August 3, September 8, and September 23;
- failure to administer blood thinner during the patient’s admissions on August 3, September 8, and September 23;
- failure to evaluate the patient’s mesenteric vessels before surgery on August 3 and September 17; and
- practicing and caring for the patient when he should have known that the patient’s complications were beyond the scope of his abilities.
Legal implications
The patient’s treating cardiologist was critical of the care provided by the general surgeon and hospital nurses. She thought the nurses should have noticed the patient had an acute abdomen on September 29 and taken her urgent request to notify the general surgeon more seriously. She was shocked that no one had evaluated the patient’s acute abdomen before he experienced cardiopulmonary arrest.
Expert consultants for TMLT were generally supportive of the care provided by the general surgeon. One consultant did not understand why the duodenal switch procedure was performed on the patient, as there are complications related to this procedure. They believed the patient’s autopsy did not explain what caused the bowel ischemia and that portomesenteric venous thrombosis (PMVT) was the possible cause of death, but it could not be certain without a second autopsy. This same consultant believed the patient’s death was related to the initial bariatric procedure or the subsequent cholecystectomy.
All of these consultants agreed that deep vein thrombosis (DVT) prophylaxis was indicated to treat the patient, but that literature did not definitively support that it would prevent PMVT or death.
The plaintiff consultants believed the surgeon violated the standard of care by failing to provide DVT prophylaxis after the patient’s bariatric surgery. However, the American Society for Metabolic and Bariatric Surgeons states that “the ideal method of prophylaxis for VTE complications bariatric surgery has yet to be elucidated.” (1)
Both plaintiff consultants thought that the lack of chemical prophylaxis and the duodenal switch caused intestinal vein blood clots to form. They believed the patient died of intestinal ischemia that could have been helped or prevented by using blood thinners.
Defense consultants were generally supportive and thought the claim was defensible. They agreed that DVT prophylaxis should have been administered more often, but noted that the patient did not die of DVT or pulmonary embolism. They also did not believe it would have prevented PMVT because there is a lack of evidence that it does.
Disposition
This case was settled on behalf of the general surgeon.
Risk management considerations
A study published in The Journal of Clinical Endocrinology and Metabolism states that “although the mortality rates are low, probably due to the standardization of bariatric surgical care, the complications after bariatric surgery can be deadly and must be treated promptly by surgeons familiar with these problems.” (2)
Comprehensive documentation and effective communication remain essential to ensure continuity of care, patient safety, and successful outcomes. These are crucial when unforeseen complications arise that require timely interventions. Documentation needs to be thorough and contemporaneous, as this is essential for effective treatment by all those involved in a patient’s care. It is equally important to document clinical rationale for not following hospital protocols, not prescribing recommended medications, or not ordering standard diagnostic testing.
Complete and concise documentation is not limited to the surgical procedure or hospital course. Documentation of follow-up visits and post-ops visits after hospital discharge are also critical. The documentation of office visits provides an opportunity to document, among other items, any post-op concerns, response to the surgical procedure, care instructions, and compliance with treatment plans.
Documenting conversations with consultants that may impact a medical or treatment decision is crucial. All communications that impact a medical decision must be documented in the patient’s medical chart and available to other members of the care team. The documentation of communications or consults should also be reviewed by the care team to ensure informed decision-making and appropriate treatment is being delivered.
Sources
- ASMBS updated position statement on prophylactic measures to reduce the risk of venous thromboembolism in bariatric surgery patients. Surgery for Obesity and Related Diseases. American Society for Metabolic and Bariatric Surgery. 2013. Available at https://asmbs.org/app/uploads/2013/04/VTEupdate-July2013.pdf. Accessed March 5, 2021.
- Pories WJ. Bariatric surgery: Risks and rewards. The Journal of Clinical Endocrinology and Metabolism. November 2008. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729256/. Accessed March 23, 2021.
